Successful Fetal Tele-Echo at a Small Regional Hospital
Julianna Brown, MD, and Brian Holland, MD
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Introduction
P
Division of Pediatric Cardiology, Department of Pediatrics,
University of Louisville School of Medicine, Louisville,
Kentucky.
Abstract
Background: Prenatal diagnosis of complex congenital heart
disease (CHD) has been shown to improve newborn outcomes.
The rate of prenatal diagnosis and access to fetal echocardio-
graphy vary widely across the United States.
Introduction: A clinical fetal tele-echo service was estab-
lished at King’s Daughters Medical Center (KDMC) in Ash-
land, KY, a region in eastern Kentucky that is 3 h from the
nearest congenital heart surgeon. The aim of this study was to
determine if fetal tele-echo utilizing local sonographers at a
small regional hospital can accurately and efficiently identify
fetuses with complex CHD.
Methods: Medical records were reviewed for all mother–
infant pairs who had fetal tele-echoes performed at KDMC
and interpreted by University of Louisville pediatric cardi-
ology between March 2011 and December 2013. Findings on
fetal tele-echo were compared to newborn echo and clinical
course, and divided into four groups: (1) Correct—no differ-
ence between fetal tele-echo and newborn echo, (2) Likely
Correct—normal fetal tele-echo and benign newborn course,
(3) Major Difference—one that affected newborn clinical
course, and (4) Minor Difference—did not affect clinical
course.
Results: Seventy-five mother–infant pairs were analyzed.
Fetal tele-echoes were Correct in 21%, Likely Correct in
56%, showed Major Differences in 0%, and showed Minor
Differences in 23%. For identifying complex CHD, fetal
tele-echo had a sensitivity and specificity of 100%. The
average number of fetal echocardiograms per mother–
infant pair was 1.1.
Discussion: Fetal tele-echocardiography performed by local
sonographers at a small regional hospital can accurately and
efficiently identify fetuses with complex CHD.
Keywords: cardiology/cardiovascular disease, pediatrics, tele-
cardiology, teleradiology
DOI: 10.1089/tmj.2016.0141 ª M A R Y A N N L I E B E R T , I N C . ! VOL. 23
renatal diagnosis improves newborn outcomes for
patients born with serious congenital heart defects.
Congenital heart defects are the most common
birth defect, occurring in around 1 in 100 live
births.1 Some of these defects are mild, but others can cause
death in the newborn period if undetected or untreated.
Prenatal diagnosis of congenital heart defects allows for
planning and preparation, both with regard to location and
timing of delivery, and also availability of optimal newborn
care. Infants with a prenatal diagnosis can be optimized to
be in a more favorable physiologic state before operative
repair,2,3 resulting in less perioperative and long-term
morbidity4,5 and mortality.3,6–8 Patients without prenatal
diagnosis often require emergent medical care and trans-
port, both of which significantly increase the cost of care
for these patients.9
The rates of prenatal diagnosis of heart defects vary widely
in the United States and around the world. Obstetrical screening
has been shown to detect only 10–26% of heart defects, while
for those who are found and referred, a fetal echocardiogram in
experienced hands can identify the details of heart defects 90%
of the time.10 For patients undergoing newborn heart surgery,
previous published studies have found overall rates of prenatal
diagnosis of congenital heart defects from 28% to 67%.4,11 We
have previously shown that infants with heart defects requiring
surgery or intervention before 1 year of age at Kosair Children’s
Hospital (KCH) in Louisville, KY, had a prenatal diagnosis only
28% of the time.12
The state of Kentucky has many healthcare needs. Our
center, KCH, is the only center in the state where pediatric
patients can undergo cardiovascular surgery. The United
Health Foundation’s 2014 ranking of state health placed
Kentucky at 47 out of 50 overall.13 In an effort to improve the
rate of prenatal diagnosis of congenital heart disease (CHD) in
Kentucky, the University of Louisville (UofL) Division of Pe-
diatric Cardiology established a fetal tele-echocardiography
service at King’s Daughters Medical Center (KDMC) in Ash-
land, Kentucky. Compared to previous studies looking at fetal
tele-echo, the unique aspects of this program are: (1) the use of
local sonographers employed by the small regional hospital to
perform fetal echocardiograms rather than sending someone
NO. 6 ! JUNE 2017 TELEMEDICINE and e-HEALTH 485
 BROWN AND HOLLAND
from the pediatric cardiac center to obtain the scans,14 (2) the
geographic distance of 190 miles or 3 h by car between the
regional hospital and the cardiac center,14–16 (3) the use of
store-and-forward telemedicine to allow interpreting physi-
cians at the cardiac center to optimize workflow and effi-
ciency,14–16 and (4) the expectation that sonographers at the
regional hospital obtain all of the images for a complete fetal
echocardiogram to be sent for interpretation.17
Methods
This was a retrospective chart review. Our patient population
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was all mother–infant pairs who had fetal tele-echocardiograms
preformed at KDMC in collaboration with UofL Division of
Pediatric Cardiology between the dates of March 2011 through
December 2013. Mother–infant pairs for whom no newborn
information was available were excluded. All of the infor-
mation collected was documented in the electronic medical
record as part of routine peripartum and newborn care at KCH
and/or KDMC. No additional information was collected from
mothers or infants for the purposes of this study. This study
was approved by the Institutional Review Boards of the UofL,
KCH, and KDMC.
All fetal echocardiogram images were obtained by two
local sonographers in Ashland, KY, who were employed by
KDMC. One was a senior sonographer with extensive expe-
rience who was registered in obstetrical (OB) ultrasound and
the other was the technical director of the KDMC echo lab-
oratory and was registered in echocardiography for adults
and pediatrics. Neither of the sonographers had performed
fetal echocardiograms previously, but both had done ex-
tensive self-study before formal training using A Practical
guide to Fetal Echocardiography: Normal and Abnormal
Hearts by Abuhamad and Chaoui.18 Fetal echocardiography
training was provided by a pediatric cardiologist from UofL
over a 4-month period. Training consisted of formal lectures
with handouts and video examples and 6 days of life scan-
ning with the pediatric cardiologist, which alternated be-
tween KDMC in Ashland, KY, and KCH in Louisville. Then, a
series of practice scans were performed on volunteer patients
by the sonographers at KDMC and images were sent to KCH
where they were reviewed by the pediatric cardiologist
and detailed feedback was given. The images of volunteers
who were scanned as part of the training were de-identified
and no reports were generated as part of the medical record.
One of the sonographers became credentialed in fetal echo by
the American Registry for Diagnostic Medical Sonography
during the study period.
Complete fetal echocardiograms were obtained at KDMC
following the protocol (Supplementary Data; Supplementary
486 TELEMEDICINE and e-HEALTH J U N E 2 0 1 7
Data are available online at www.liebertpub.com/tmj) used
by UofL Pediatric Cardiology and KCH, where the echo lab-
oratory is accredited for fetal echo by the Intersocietal Ac-
creditation Commission (IAC) and the American Institute of
Ultrasound in Medicine (AIUM). The protocol was based
upon the American Society of Echocardiography (ASE) 2004
guidelines.19 Studies were performed using a Philips iE33
ultrasound machine and C5-1 curvilinear transducer. The
images were stored at KDMC and also sent via the Internet to
KCH for interpretation, using an encrypted Virtual Private
Network with network firewalls on both ends. The UofL fetal
cardiology team was notified that a study was ready for
interpretation, one of three pediatric cardiologists at UofL
reviewed and interpreted the images within 24 h, and a
typewritten report was faxed to the requesting OB or MFM
provider. For studies with inadequate images, the sono-
grapher at KDMC and referring provider were contacted by
phone to arrange follow-up. For studies with any abnor-
malities identified, the interpreting pediatric cardiologist
called and discussed the findings with the referring provider
by phone.
Prenatal echocardiograms were interpreted as normal if
they showed normal fetal cardiac anatomy and function.
Isolated fetal premature atrial contractions were classified
as normal. Abnormalities noted on fetal echocardiography
were classified as likely to require urgent intervention at
birth or not. Postnatal echocardiograms were interpreted as
normal if they showed normal newborn cardiac anatomy
and function; isolated patent ductus arteriosus and/or
small patent foramen ovale were classified as normal.20
Abnormalities seen on postnatal echocardiogram were di-
vided into critical and noncritical lesions, critical lesions
being those expected to require surgery or catheter inter-
vention within the first year of life.21 The infant’s newborn
clinical course was reviewed in the electronic medical re-
cord at KCH and KDMC, which included the newborn
hospitalization and any newborn outpatient visits, emer-
gency room visits, or subsequent hospitalizations at KDMC.
If there was no evidence of cardiac abnormality in the
electronic medical record, the infant was presumed to not
have complex CHD.
Since this is a retrospective review with descriptive data,
results were placed into two-by-two tables for analysis. No
further statistical analysis was done on this data set.
For patients with no postnatal echocardiogram, length of
follow-up was determined by the last available medical re-
cords. For patients with postnatal echocardiogram, date of last
follow-up was either the date of last clinical documentation or
echocardiogram, whichever came later.
ª MARY ANN LIEBERT, INC.
 SUCCESSFUL FETAL TELE-ECHO AT A SMALL REGIONAL HOSPITAL
Results
In the time between March 2011 and December 2013, 78
women had fetal tele-echocardiograms performed at KDMC
and interpreted by UofL Division of Pediatric Cardiology.
Three mother–infant pairs were excluded from the final
analysis due to the newborn records not being available in the
electronic medical record. The remaining 75 mother–infant
pairs were analyzed.
The median gestational age of the fetus at time of first
prenatal echocardiogram was 26 weeks 5 days, range 19–36
weeks of gestational age. If the gestational age was not in-
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cluded in the echocardiogram report, it was extrapolated from
gestational age at birth and date of echocardiogram. If there
was a discrepancy between biparietal diameter and age by last
menstrual period, biparietal diameter was used.
Indication for fetal echocardiogram was either stated on
the echo report or presumed based on the medical records
reviewed (Table 1). We did not have access to medical records
from the requesting obstetrician. For 21 mother–infant
pairs, there was no documentation of the indication for fetal
echo available, due to a problem transcribing handwritten
orders into the electronic medical record during the early
study period.
Two infants had prenatal diagnoses of complex CHD ex-
pected to require urgent intervention after birth, which were
confirmed on postnatal echocardiograms (Table 2). Fourteen
infants had normal pre- and postnatal echocardiograms,
giving a total of 16 mother–infant pairs with confirmed cor-
rect cardiac anatomy. Forty-two infants had normal prenatal
echocardiograms performed and did not have postnatal
echocardiograms but had benign clinical courses and no ev-
idence of cardiac abnormality in the electronic medical re-
Table 1. Patient Characteristics
Number of mother–infant pairs analyzed
Median gestational age at first fetal echocardiogram
Indication for fetal echocardiogram, n (%)
Maternal diabetes mellitus
Family history of congenital heart disease
Abnormality on routine prenatal ultrasound
Fetal arrhythmia
Not able to visualize heart on routine ultrasound
Mother–infant pairs with multiple indications, n (%)
Mother–infant pairs with no indication documented, n (%)
ª M A R Y A N N L I E B E R T , I N C . ! VOL. 23
cord, and so, they were presumed not to have complex CHD
and the prenatal echo was likely correct. There were no major
differences identified. Two infants had a minor abnormal-
ity identified on prenatal echocardiogram but a different,
noncritical, lesion diagnosed on postnatal echocardiogram.
Eleven infants had mild abnormalities on prenatal echocar-
diograms with benign postnatal course and no postnatal echo
performed. Four infants had mild abnormalities on prenatal
echocardiograms but had normal postnatal echocardiograms
and benign clinical courses, giving a total of 17 minor dif-
ferences note between the pre- and postnatal findings (Table 3
and Fig. 1).
Our primary goal was to determine whether prenatal tele-
echocardiography can adequately identify fetuses with complex
CHD, since a prenatal diagnosis affects the recommendations
for delivery location and care available at the time of birth. No
infant had a new postnatal diagnosis of complex CHD either
by echo or clinical course. For our study population, fetal
tele-echo was 100% sensitive and 100% specific for identi-
fying complex CHD with 100% positive and negative pre-
dictive values.
We further asked whether fetal tele-echocardiography
can identify all details of congenital heart defects, including
mild defects. With this broadened classification, we iden-
tified an additional 17 patients with possible CHD diag-
nosed by fetal tele-echocardiogram. In this analysis, four
patients with a diagnosis of CHD by fetal tele-echo also had
CHD by postnatal echo, which includes the two previously
mentioned patients with complex CHD. Fifteen patients
with abnormal fetal tele-echocardiograms subsequently
had either a normal postnatal echocardiogram or nega-
tive clinical course. No patient with normal fetal tele-
echocardiogram had either an abnormal postnatal echo
or clinical course suggestive of significant cardiovascular
disease. For our study population, fetal tele-echo had a
sensitivity of 100%, specificity of 79%, positive predictive
75
value of 21%, and negative predictive value of 100% for
26 + 5 weeks
identifying all aspects of CHD, including mild defects. The
minor differences between prenatal and postnatal diagnoses
21 (28) in our patient population were felt to be due to limitations
in image quality of the fetal tele-echoes.
13 (17)
As shown in Figure 1, two patients had minor CHD diag-
9 (12)
nosed by fetal tele-echo, but postnatal echocardiograms
9 (12) showed different minor lesions. One of these patients had
3 (4) prenatal diagnosis of ventricular septal defect (VSD) with
4 (5)
suspicion for coarctation of the aorta. Postnatal echo showed
multiple VSDs and a normal aortic arch. The other patient had
21 (28)
suspicion for coarctation of the aorta on fetal tele-echo, but
postnatal echo showed a small VSD and a normal aortic arch.
NO. 6 ! JUNE 2017 TELEMEDICINE and e-HEALTH 487
 BROWN AND HOLLAND
Table 2. Patients with Complex Congenital Heart Disease on Fetal Tele-Echo
FETAL ECHOCARDIOGRAM
PATIENT GESTATIONAL AGE
1 22 weeks (initial fetal tele-echo at KDMC)
28 weeks (follow-up fetal echo at KCH)
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33 weeks (follow-up fetal echo at KCH)
2 22 weeks (initial fetal tele-echo at KDMC)
22 weeks (follow-up fetal echo at KCH)
26 weeks (follow-up fetal tele-echo at KDMC)
34 weeks (follow-up fetal echo at KCH)
DORV, double outlet right ventricle; KCH, Kosair Children’s Hospital; KDMC, King’s Daughters Medical Center; VSD, ventricular septal defect.
Both patients had benign newborn courses without need for
intervention or surgery.
The average number of fetal echocardiograms for mother–
infant pairs was 1.1. Seven out of 75 mother–infant pairs
required follow-up fetal echocardiograms. Four of those
were subsequently determined to have normal cardiac
anatomy by follow-up fetal tele-echo done at KDMC. One
had a follow-up fetal tele-echo done at KDMC which showed
a suspicion for a membranous VSD. One infant with complex
CHD had follow-up fetal echocardiograms performed by
UofL pediatric cardiologists at KCH. The other infant with
complex CHD had follow-up fetal echocardiograms done
488 TELEMEDICINE and e-HEALTH J U N E 2 0 1 7
POSTNATAL ECHOCARDIOGRAM
FINDINGS FINDINGS
Large membranous VSD with inlet extension DORV with large inlet VSD
Straddling mitral valve
Aortic valve not well seen Malposed great arteries
Large inlet VSD Pulmonary atresia
Straddling mitral valve
Malposed great arteries
Pulmonary atresia
Large inlet VSD
Straddling mitral valve
Malposed great arteries
Pulmonary atresia
Balanced AV canal defect Tricuspid valve atresia
Large inlet VSD with membranous extension
Large inlet VSD with membranous extension Overriding and straddling mitral valve
DORV with normally related great vessels DORV with normally related great vessels
Balanced AV canal defect
Large inlet VSD with membranous extension
DORV with normally related great vessels
Tricuspid valve atresia
Large inlet VSD with membranous extension
Overriding and straddling mitral valve
DORV with normally related great vessels
Tricuspid atresia
Large inlet VSD with membranous extension
Overriding and straddling mitral valve
DORV with normally related great vessels
both via tele-echo at KDMC and also by UofL pediatric car-
diologists at KCH.
For this patient population, the average length of postnatal
follow-up, based on available medical records, was 41.8 days,
with a median follow-up of 28 days.
For the two patients with complex CHD identified on initial
fetal tele-echo, prenatal counseling was arranged. One family
had face-to-face counseling with a pediatric cardiologist in 1
week at the tertiary care center in Louisville. For the other
family, a counseling visit was arranged in 2 weeks at a local
outreach office in Ashland, based upon family preference.
After multidisciplinary consultation and discussion with the
ª MARY ANN LIEBERT, INC.
 SUCCESSFUL FETAL TELE-ECHO AT A SMALL REGIONAL HOSPITAL

Table 3. Patients with Minor Abnormalities on Fetal Tele-Echo

FETAL ECHOCARDIOGRAM POSTNATAL ECHOCARDIOGRAM

GESTATIONAL AGE FINDINGS FINDINGS

PATIENT MINOR ABNORMALITIES SEEN ON FETAL TELE-ECHO AND ON POSTNATAL ECHO

1 35 weeks Small midmuscular VSD Multiple muscular VSDs, largest medium sized

Suspicion for coarctation of the aorta Normal aortic arch

2 24 weeks Suspicion for coarctation of the aorta Small midmuscular VSD

Normal aortic arch

MINOR ABNORMALITY ON FETAL TELE-ECHO WITH NORMAL POSTNATAL ECHO

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1 21 weeks Suspicion for a membranous VSD PFO

No VSD seen

2 35 weeks Possible membranous VSD PFO

Small PDA

No VSD seen

3 34 weeks Suspicion for coarctation of the aorta PFO

Small PDA

Normal aortic arch

4 30 weeks Suspicion for coarctation of the aorta PFO

Small PDA

Normal aortic arch

MINOR ABNORMALITY ON FETAL TELE-ECHO WITH NO POSTNATAL ECHO

1 34 weeks Trivial circumferential pericardial effusion None

2 21 weeks Suspicion for a membranous VSD None

3 22 weeks Possible membranous VSD None

4 25 weeks Echogenic area in the left ventricle None

5 22 weeks Two echogenic areas in the left ventricle None

6 21 weeks Suspicion for a membranous VSD None

7 30 weeks Suspicion for coarctation of the aorta None

8 27 weeks Small apical muscular VSD None

9 20 weeks Echogenic area in the left ventricle None

10 26 weeks Possible membranous VSD None

27 weeks Possible membranous VSD

11 33 weeks Tortuous ductus arteriosus None

PDA, patent ductus arteriosus; PFO, patent foramen ovale.

families, both the patients with complex CHD identified by
fetal tele-echo at KDMC in Ashland chose to deliver at Norton
Hospital in Louisville, where the newborns were directly ad-
mitted to the NICU in the adjacent KCH. While both fetuses
had additional anatomic findings delineated on serial fetal
echoes done at the tertiary care center and also on follow-up
fetal tele-echoes, the overall counseling regarding the pres-
ence of complex CHD, recommendation for delivery at a ter-
tiary care center, and expected need for heart surgery did not
change from the initial diagnosis to delivery. Both had

ª M A R Y A N N L I E B E R T , I N C . ! VOL. 23 NO. 6 ! JUNE 2017 TELEMEDICINE and e-HEALTH 489

 BROWN AND HOLLAND
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Fig. 1. Comparison of prenatal tele-echocardiography with postnatal diagnosis.
newborn echocardiograms done immediately after birth,
which confirmed the final prenatal cardiac diagnoses. Both
newborns were hemodynamically stable throughout the NICU
stay, had successful palliative first-stage cardiac surgeries,
and were discharged home in good condition.
Discussion
Fetal tele-echocardiography, performed by local sonog-
raphers at a small regional hospital and interpreted by pedi-
atric cardiologists using store-and-forward telemedicine, was
able to accurately and efficiently identify patients in our
population with complex CHD. In this study, the fetal tele-
echo studies performed by local sonographers were of high
quality, such that repeat fetal echoes were performed on only a
small minority of patients, with an average of 1.1 fetal echo
per patient. No cases of complex CHD were missed by fetal
tele-echo, and no patient was referred to be delivered at a
cardiac center who ultimately would not have required such a
high level of care. None of the newborns with normal fetal
tele-echocardiograms had evidence of CHD after delivery.
This provides reassurance that those infants with normal fetal
tele-echocardiograms are at low risk to have significant car-
diovascular disease immediately following birth and those
identified likely benefited from delivery at a referral center.
Our results are similar to published reports of fetal echo-
cardiograms performed at pediatric cardiac centers. Overall,
23% of our patients had difference between prenatal and
postnatal findings, and differences found at pediatric cardiac
22,23
centers have ranged from 5% to 29%.
490 TELEMEDICINE and e-HEALTH J U N E 2 0 1 7
Our analysis differs from the
majority of previous studies on
fetal tele-echo, in that it com-
pares prenatal findings directly
to postnatal diagnoses, including
newborn transthoracic echocar-
diograms, surgical findings, and
clinical follow-up. Most previ-
ous studies of fetal tele-echo did
not assess accuracy of prenatal
diagnosis but focused on image
quality,14,17,24,25 interobserver
agreement,26,27 patient and staff
comfort, and satisfaction,28,29
cost,30,31 and impact on referral
patterns.16 Some studies did look
at the accuracy of fetal tele-echo,
but either first identified new-
borns with known CHD and then
had a blinded reader review the
fetal tele-echo to see if correct anatomic findings could be
identified27,32,33 or used traditional fetal echoes done at a pe-
diatric cardiac center as the gold standard.14,15 As mentioned
above, and highlighted by a recent study from Bensemlali
et al.23 fetal echoes done at a pediatric cardiac center can be
discordant from the postnatal diagnoses up to 29% of the time.
One study by Hishitani et al.16 did a partial analysis com-
paring abnormal fetal tele-echoes to postnatal diagnoses, but
there was no reporting of fetal tele-echoes that were read as
normal, limiting further analysis. A study by Gomes et al.34
analyzed 201 fetal tele-echoes and based on review of med-
ical records, ‘‘.diagnosis was confirmed in all cases after
birth.,’’ without further details or analysis reported, and so,
it is not clear if newborn echocardiograms were performed,
what was the length of newborn follow-up, and if there was
assessment for minor differences between prenatal findings
and postnatal diagnoses.
A potential impact of our study is that it describes a fetal
tele-echo model that has been successfully implemented
into the day-to-day workflow of a busy clinical practice. In
our model, the images are sent via a secure Internet con-
nection using store-and-forward telemedicine. This allows
the interpreting physicians at the pediatric cardiac center
to optimize workflow and efficiency by reading the scans
once all of the images are obtained rather than dedicating
longer periods of time to observe the entire scan via live
video feed.
Our study has several limitations. In the patient population
in this study, we were able to correctly identify all major
ª MARY ANN LIEBERT, INC.
 SUCCESSFUL FETAL TELE-ECHO AT A SMALL REGIONAL HOSPITAL
cardiac lesions and did not have any significant false nega-
tives. We had a relatively small sample size and reasonably
expect that in a larger sample size that would not always be
the case. Our review of medical records was limited to the
hospital at the telemedicine site and our pediatric cardiac
center, and so, if an infant had follow-up outside of these
systems, we would not know if they had subsequent diag-
nosis of CHD. To try to ensure that no CHD was missed,
studies with suspicion for coarctation or concern for a pos-
sible VSD were categorized as abnormal rather than ‘‘within
known limitations of fetal echo.’’ Fetuses with these findings
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accounted for the majority (66%) of the minor discrepancies
in our analysis and may not be categorized the same way at
other centers.
This model of fetal tele-echocardiography has the potential
to benefit families who do not have easy access to a pediatric
cardiologist by helping to decrease costs and travel time,
improving the rate of prenatal diagnosis of CHD, ensuring
appropriate expectant mothers deliver at a pediatric cardiac
center, and ultimately improving outcomes.
Disclosure Statement
No competing financial interests exist.
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Collaborative study of 4-dimensional fetal echocardiography in the first Received: June 23, 2016
trimester of pregnancy. J Ultrasound Med 2014;33:1079–1084. Revised: September 20, 2016
33. Espinoza J, Lee W, Comstock C, Romero R, Yeo L, Rizzo G, Paladini D, Vinals Accepted: September 21, 2016
F, Achiron R, Gindes L, Abuhamad A, Sinkovskaya E, Russess E, Yagel S.

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