YAJEM-159349; No of Pages 7

American Journal of Emergency Medicine xxx (2020) xxx

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: www.elsevier.com/locate/ajem

Skin tapes and tissue adhesive vs. either method alone for laceration
repair in a porcine model
Jennifer L. Brown, MD a, Dietrich Jehle, MD b,⁎, James Mayrose, PhD a, Lainie Schwartz, MD a,
Jennifer Pugh, MD a, Clay O'Brien, BS b,⁎
a
Department of Emergency Medicine, State University of New York at Buffalo, Buffalo, NY, United States of America
b
Department of Emergency Medicine, Grand Strand Medical Center, University of South Carolina, Myrtle Beach, SC, United States of America

a r t i c l e i n f o a b s t r a c t

Article history: Study objective: To determine whether the combination of skin tapes and tissue adhesive is superior to either
Received 11 July 2020 method alone for laceration repair.
Received in revised form 18 August 2020 Methods: This was a prospective, longitudinal experiment on six anesthetized swine. Thirty-six full-thickness
Accepted 24 August 2020 linear wounds were created using a metal template, then closed using one of three methods: skin tapes over ben-
Available online xxxx
zoin, tissue adhesive, or a combination of both. The study was done in two parts. Group 1 (immediate excision)
animals were euthanized at day zero for skin excision and tensile strength testing following wound repair. Group
Keywords:
Adhesive
2 (delayed excision) had initial wound repair; animals were euthanized at day 35 for skin excision and tensile
Tissue glue strength testing.
Wound closure Results: In Group 1, the combination of skin tapes and tissue adhesive provided the strongest immediate wound
Surgical tape closure. Average mean force for disruption immediately after wound repair was 19.9 lbs. for the tapes and tissue
Laceration repair adhesive group compared to 9.6 lbs. for adhesive alone and 8.9 lbs. for tapes alone. The difference in mean force
for combination repair vs. tapes alone was 10.3 lbs. (95% CI 4.1, 16.7), and combination vs. adhesive alone was
10.9 lbs. (95% CI 4.7, 17.3). In Group 2, the mean force required for laceration disruption for those repaired
with both tape and tissue adhesive was 188.9 lbs. The mean force until wound disruption for tape only was
165.6 lbs., and the mean force until wound disruption for tissue adhesive alone was 118.9 lbs. The difference
in mean force required for wound disruption for those repaired with adhesive alone vs. combination repair is
66.5 lbs. (95% CI 21.2, 111.9). The difference in mean force required for wound disruption between the other
two groups was not statistically significant.
Conclusions: This study demonstrates that the combination of skin tapes and tissue adhesive provides superior
immediate wound closure strength to either of these methods alone in a porcine model.
© 2020 Elsevier Inc. All rights reserved.

1. Introduction
1.1. Background
Traumatic wounds are a frequent problem managed in the emer-
gency department. They account for approximately 7% of all emergency
department visits in the US per year, for a total between 7 and 8 million
cases annually [1]. While some wounds may be managed conserva-
tively, the majority of lacerations require primary closure. There are
several different techniques available for wound closure [2]. Sutures
⁎ Corresponding authors at: Department of Emergency Medicine, Grand Strand Medical
Center, 809 82nd Parkway, Myrtle Beach, SC 29572, United States of America.
E-mail address: djehle@roadrunner.com (D. Jehle).
have been the time-honored gold-standard method used to repair lac-
erations. Sutures allow for meticulous wound closure and provide
good tensile strength, but can be painful to the patient, time consuming
to place, and often require a return visit for removal. Suture closure also
has the associated risk of needlestick injury, both from the suture needle
and from the injection of local anesthetic. Using staples for wound re-
pair is a technique that may allow for a faster closure; however, staples
usually also require an injection of local anesthetic as well as a return
visit for removal and may not be an acceptable method for use in cos-
metically important areas. Adhesive tissue glues and skin tapes are
other options for laceration repair that provide an acceptable, or even
preferable, alternative to suture closure in selected wounds. [3–7]
These techniques have several advantages over sutures and staples.
Both glue and tapes provide rapid wound closure without the potential

https://doi.org/10.1016/j.ajem.2020.08.081
0735-6757/© 2020 Elsevier Inc. All rights reserved.

Please cite this article as: J.L. Brown, D. Jehle, J. Mayrose, et al., Skin tapes and tissue adhesive vs. either method alone for laceration repair in a
porcine model, American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2020.08.081
J.L. Brown, D. Jehle, J. Mayrose et al.
risk of needlestick injury to the operator and can often be applied in
much less time than is required for a suture repair. Also, neither glue
nor tapes require a return visit to a physician for removal.
1.2. Importance
Multiple studies have concluded that tissue adhesives are an effec-
tive and an acceptable alternative to sutures and can provide similar
results with respect to cosmesis, and rates of infection. [3,4,6,8,9] In
addition, the tissue adhesives have performed well in strength testing.
[10,11] However, to ensure proper closure and epithelialization of
the wound when using tissue adhesives, meticulous alignment of the
wound edges is necessary to prevent seepage of the glue into the
wound, and to provide maximal bonding strength. If the skin edges
are not aligned correctly, seepage of adhesive into the wound may
prevent epithelialization, lead to a foreign body reaction, cause small
persistent scabs and wound widening or even lead to areas of wound
dehiscence. [8,9,12,13]
Skin tapes are another acceptable alternative for wound closure.
Tapes are easy and quick to apply, and can be excellent at aligning
wound edges, but do not always maintain wound integrity as well as tis-
sue adhesive, especially in areas subject to tension. [12,14,15]
One study by Chigira et al. compared the combination of adhesive
tapes and tissue adhesive against tissue adhesive alone for repair of
full thickness lacerations on porcine skin. [16] This smaller study looked
at the immediate outcome only in terms of tensile strength and only
evaluated five wounds per group. A larger investigation of tissue
adhesive, adhesive tapes, and their combination has not previously
been studied.
1.3. Goals of this investigation
The goal of this study was to determine if first using skin tapes to
align wound edges followed by application of tissue adhesive over the
tapes performs better than either method alone for wound repair. We
hypothesize that the combination of skin tapes and tissue adhesive is
superior to either method alone for laceration repair.
2. Methods
2.1. Study design
A prospective, longitudinal experiment was conducted in two
main parts. Skin incisions, 6 cm in length, were made on two groups
of three animals each. Three wounds were made on each side of the
upper back of each swine, for a total of six wounds per animal, and
thirty-six total wounds. Full-thickness linear skin wounds 6 cm in
length were created using a template to ensure uniformity of the
wounds. After incisions were made, wounds were closed using one
of three methods: ½ inch skin tapes (Steri-Strip, 3 M Health Care)
alone, 2-octyl cyanoacrylate topical skin adhesive (Dermabond,™
Ethicon Inc.) alone, or both tapes and adhesive together. The study
was conducted in two main parts: Group I (Immediate Excision –
Day 0) and Group II (Delayed Excision – Day 35). Photographs of
each wound were taken at the time of initial repair and again just
prior to excision in order to assess the visual appearance of the
wounds. Detailed methods for each of the two groups are described
below.
2.2. Selection of subjects
Six pigs weighing 55–70 lbs. were used in this study. Domestic pigs
were chosen as subjects because they are well accepted as one of the
best animal models for human skin healing. [17,18] The skin of pigs
closely resembles human skin in both structure and function, [17,18]
and the use of an animal model allowed for the creation of multiple
2
American Journal of Emergency Medicine xxx (2020) xxx
simultaneous uniform lacerations and controlled follow-up. Thirty-five
days was chosen as a time frame for the delayed excision group to
allow for wound healing.
2.3. Setting
This study was conducted in a University-based Laboratory Animal
Research Facility. The study protocol was reviewed and approved by
the Institutional Animal Care and Use Committee. During the course of
the study, animals were housed in the University Laboratory Animal
Facilities and cared for by trained veterinary staff.
2.4. Group 1 (immediate excision, day 0)
Skin incisions, 6 cm in length, were made on three euthanized
animals. Three wounds were made on each side of the upper back,
for a total of six wounds per animal, and eighteen total wounds. Hair
was removed with electric clippers just prior to the procedure.
Full-thickness linear skin wounds 6 cm in length were created with a
no.10 scalpel blade. A metal template was used to ensure uniformity
of the wounds. After the incisions were made, wounds were closed
using one of three methods: ½ inch skin tapes (Steri-Strip, 3 M Health
Care) alone, 2-octyl cyanoacrylate topical tissue adhesive
(Dermabond,™ Ethicon Inc.) alone, or both tapes and adhesive together.
It is important to note, that the entire length of the Steri-Strips must be
covered with glue in order to avoid premature removal. The order of
closure method for the three wounds was changed on each of the
three animals (front, middle, back) to control for potential variations
in skin on the different parts of the back.
Prior to the application of tapes, liquid compound benzoin tincture
was applied to the skin on either side of the laceration to enhance
strip adhesion. 2-octyl cyanoacrylate (Dermabond,™ Ethicon, Inc.) tis-
sue adhesive was applied in layers using the manufacturer recommen-
dations described in the package insert. For wounds closed using both
methods together, benzoin and tapes were applied as described above
to align the wound edges, and then tissue adhesive was applied along
the line of the wound over the top of the tapes.
After wound repair, 12 cm × 6 cm rectangular-shaped full-
thickness blocks of skin surrounding the linear 6 cm incision sites
were excised using a template. Tensile strength of all specimens
was tested within approximately one hour after excision. Each spec-
imen was clamped, at both ends, and tested using an 858 Mini Bionix
material testing system (MTS Systems Corp., Minneapolis MN) to de-
termine the maximum load to failure of the wound closure (see
Photo 1). Peak force values required to disrupt the wound repair
were determined for each individual wound specimen. This is a stan-
dard tensile strength measurement model which has been used and
validated in prior studies. [19,20]
2.5. Group 2 (delayed excision at day 35)
The animals in Group 2 received general anesthesia provided by
the veterinary staff at the University Laboratory Animal Facility. On
Day 0, eighteen wounds were made and repaired as described
above in Group 1 methods. The procedures were performed under
sterile conditions in the operating suite. All skin was prepared
prior to surgery with a topical iodine-based solution following hair
removal by electric clippers. After wound repair, animals were re-
covered from surgery, and then housed separately in raised flooring
cages without wood chips. There were no bandages applied, wounds
were left open to air during the healing phase. Animals were pro-
vided with analgesic medication following the procedure, and were
fed and cared for by trained veterinary staff according to usual Labo-
ratory Animal Facility procedures. Wounds were inspected daily for
signs of dehiscence or infection. Photographs to assess the visual
J.L. Brown, D. Jehle, J. Mayrose et al. American Journal of Emergency Medicine xxx (2020) xxx

Photo 1. 858 Mini Bionix material testing system with specimen.

appearance of each wound were taken on day 0 at the time of initial 3. Results (group 1 – immediate excision group)
repair and again at day 35 before final excision.
On postoperative day 35 after initial wound repair, the animals were 3.1. Strength testing
euthanized and full-thickness blocks of skin surrounding the repair
were excised using the template as described above in Group 1 For Group 1 (excision on Day 0 following initial repair) the force
methods. These excised blocks of skin were again tested as described required to disrupt the wound closure for skin tapes, tissue adhesive
above to determine the peak force required to disrupt each type of and the combination of both is listed in Table 1. The combination of
wound closure after healing. both skin tapes and tissue adhesive provided the strongest closure
with a mean force required for disruption of 19.93 lbs. The difference
2.6. Methods of measurement between the force required to disrupt the wounds closed with both
(tapes and adhesive) and the wounds closed with either skin tapes
The Mini Bionix material testing system was used to apply a loading or tissue adhesive alone is statistically significant (see Table 2).
rate of 2 mm/s to each specimen until the wound closure was pulled There was no statistically significant difference between closure
apart at the site of the incision. The data acquisition hardware was con- with skin tapes and glue. Patterns of failure differed between the
figured with 2 channels, one measured axial displacement (mm) and groups. The skin adhesive failed as a result of the disruption of the
the other measured axial force (kN). The data acquisition software skin-glue interface. The skin tapes failed as a result of the disruption
(LabView, National Instruments, Corp., Austin TX) was set to sample of the skin-tape interface or by breakage of the skin tapes at the
at a rate of 10 samples/s. Peak force required to disrupt the wound re- wound site. A sample of time to peak disruption force for each of
pair was determined for each individual wound specimen. Mean values the closure methods in Group 1 is depicted in Graph 1.
were calculated for the peak force required to disrupt each type of
wound closure in both the immediate and delayed excision groups. 4. Results (group 2 – delayed excision group)
Each animal was used as its own control. Statistical analysis was
performed using the General Linear Model procedure of SAS 9.1 (SAS 4.1. Strength testing
Institute Inc., Cary, NC, USA).
For Group 2 (delayed excision after 35 days of healing) the force in
pounds required to disrupt the wound closure for skin tapes, tissue ad-
Table 1 hesive and the combination of both is depicted in Table 3. The mean
Group 1 – disruption strength in Lbs (kN) by type of closure
force required for disruption of wounds increased more than ten-fold
Force – Lbs (kN) after healing. The combination of both skin tapes and tissue adhesive
Tape Adhesive Both also provided the strongest closure at delayed excision with a mean
force required for disruption of 188.9lbs, even after the tapes and glue
Pig #1
Left Side 6.29 (0.028) 8.77 (0.039) 26.53 (0.118)
Right Side 9.44 (0.042) 10.56 (0.047) 23.6 (0.105)
Pig #2 Table 2
Left Side 2.7 (0.012) 11.91 (0.053) 9.66 (0.043) Group 1 – statistical significance by type of closure
Right Side 15.74 (0.07) 13.71 (0.061) 14.16 (0.063)
Pig #3 60 Minutes 95% Confidence
Left Side 8.77 (0.039) 2.25 (0.01) 24.28 (0.108) interval
Right Side 14.61 (0.065) 6.52 (0.029) 21.36 (0.095)
N Mean Lower Upper p value
Mean 9.59 (0.043) 8.95 (0.04) 19.93 (0.089)
Median 9.11 (0.041) 9.67 (0.043) 22.48 (0.1) Tape vs Adhesive 6 0.6383 −6.03 7.31 .8154
Tape vs Both 6 −10.98 −18.12 −2.23 .0396
The bolded numbers represent mean and median of 6 measurements. Statistically signif-
Adhesive vs Both 6 −10.34 −20.88 −0.742 .023
icant is defined as p < .05.

3
J.L. Brown, D. Jehle, J. Mayrose et al. American Journal of Emergency Medicine xxx (2020) xxx

Wound Repair Strength

Skin Tape Tissue Adhesive Both

0.1
Graph 1 – Wound Repair Strength: Group 1 Pig #3 Right Side
0.09
0.08
Force 0.07
(kN) 0.06
0.05
0.04
0.03
0.02
0.01
0
0.13 5.13 10.12 15.12 20.12 25.11
Time (Sec)

Graph 1. – Wound repair strength: Group 1 pig #3 right side.

Table 3 differences in scar appearance in two of the patients in the glue only
Group 2 – disruption strength in Lbs (kN) by type of closure group. See Photos 2–5 below.
Force – Lbs (kN)

Tape Adhesive Both

5. Limitations

Pig #4
The wounds created in this study were surgical wounds that were
Left Side 191.1 (0.85) 181.4 (0.81) 197.9 (0.88)
Right Side 203.1 (0.9) 163.9 (0.73) 172.1 (0.76) prepared with an iodine-based skin solution. This is a difference com-
Pig #5 pared to wounds that are seen in patients presenting to the Emergency
Left Side 163.2 (0.73) N/A (slipped) 272 (1.21) Department with traumatic lacerations requiring wound care and clo-
Right Side 139.1 (0.62) 145.6 (0.65) 207.3 (0.92)
sure. Assuming that basic wound care principles are followed before
Pig #6
Left Side 151.1 (0.67) 41.5 (0.19) 132.7 (0.59) wound closure, the risk of infection using a combination repair for a
Right Side 145.9 (0.65) 62.1 (0.28) 151.5 (0.67) traumatic laceration is not likely to be higher than either of the methods
Mean 165.6 (0.74) 118.9 (0.53) 188.9 (0.84) alone, however, this remains to be studied. Although tensile strength
Median 157.2 (0.69) 145.6 (0.65) 185.0 (0.82) may be a marker of wound strength it is not an exact predictor of clinical
The bolded numbers represent mean and median of 6 measurements. Statistically signif- dehiscence. Tensile strength testing done ex vivo only looks at forces
icant is defined as p < .05. applied in one plane and is inferior to testing of bursting strength.
The use of an animal model allowed for the creation of multiple
simultaneous uniform wounds and resulted in no subjects lost to
were no longer present on the wounds. The difference between the follow-up, but there are several important limitations to consider.
force required to disrupt the wounds closed with both (tapes and Although pig skin has been shown to closely resemble human skin,
glue) and the wounds closed with adhesive alone was statistically sig- these mammals differ from humans in several important anatomical
nificant, even in the delayed group tested after healing (see Table 4). and physiological ways. Wounds were created on the backs of the ani-
A sample of time to peak disruption force for each of the closure mals, in an area that was least likely to be disturbed by the animal as
methods in Group 2 is depicted in Graph 2. the wounds were healing. The methods for wound closure described
here may produce different results in areas subject to more tension or
movement. Finally, due to considerations of cost, availability and ease
4.2. Cosmetic results
of handling, the sample size was relatively small, limiting the power
to detect small differences in strength between the different closure
There were no wound infections, and no wounds with complete de-
methods.
hiscence. All lacerations were completely healed at day 35, except for
two of the wounds that were closed with tissue adhesive alone. These
wounds occurred on two different animals. Both had several areas of 6. Discussion
persistent scabbing still visible at day 35, where small localized areas
of dehiscence occurred within the wound. While we did not utilize stan- Compared to suture and staple closure methods for laceration repair,
dardized scales to measure cosmetic appearance, there were obvious application of tissue adhesive and skin tapes saves time [10,12], de-
creases the risk of needlestick injury, and is more convenient for physi-
cians and patients since no return visit is necessary for removal.
Providing a rapid wound closure with good repair strength is important
Table 4
Group 2 – statistical significance by type of closure not only to ensure adequate healing and to prevent wound dehiscence,
but also to provide patients with a satisfying cosmetic result and opti-
35 Days 95% Confidence
mize the time spent on repairing the wound. Alternative methods of
interval
wound closure have been released in an attempt to achieve this effect.
N Mean Lower Upper p value
Dermabond Protape (Ethicon Inc., Somerville, NJ) is one example. One
Tape vs Adhesive 5 47.16 −13.62 107.94 .0975 study demonstrated a trend to better wound approximation 86% versus
Tape vs Both 5 −6.24 −53.66 41.18 .7333 78.1% with the use of mesh tape plus skin adhesive versus skin adhesive
Adhesive vs Both 5 −53.4 −102.28 −4.52 .0387
alone. [21] Prineo™ (Dermabond™; Ethicon, Inc., Somerville, NJ, USA)

4
J.L. Brown, D. Jehle, J. Mayrose et al. American Journal of Emergency Medicine xxx (2020) xxx

Wound Repair Strength

Skin Tape Tissue Adhesive Both

0.8
0.7
0.6
Force (KN) 0.5
0.4
0.3
0.2
0.1
0
0.13 10.12 20.11 30.11 40.10 50.09
-0.1
Time (Sec)

Graph 2. – Wound repair strength: Group 2 pig #6 right side.

combines 2-octyl cyanoacrylate tissue adhesive (Dermabond™) and ad-

Photo 2. (Group 2, Pig 4, Right side. Photo taken at day 0 following repair with tissue
adhesive alone.)
Photo 3. (Group 2, Pig 4, Right side. Photo taken at day 35.) Small area of persistant
scabbing at the left edge of the wound.
hesive (mesh) tape in one device, and the Zip® Surgical Skin Closure de-
vice (ZipLine Medical, Inc., Campbell, CA) uses a repeated zip-tie like
mechanism to connect polyurethane strips on each side of the wound.
Like the combined use of tissue adhesive and adhesive tapes, the appli-
cation of these devices has been shown to reduce operating times by
rapidly closing wounds and provide a relatively painless removal for
the patient. [22,23] However, Prineo and the Zip® Surgical Skin Closure
device do not come without limitations. Both devices are significantly
more expensive compared to alternative treatments; Prineo™ costs
$1166.49 for a box of two devices and the Zip® Surgical Skin Closure
costs $605.00 for ten devices. [24,25] Also, these devices are effectively
limited to closing straight wounds, and Prineo™ has been reported to
cause an allergic response which results in a rash where the device
has touched their skin. [23,26,27]
This study shows the application of surgical tapes to align wound
edges, followed by an overlying application of tissue adhesive, provides
superior immediate wound strength than either method alone in a pig
model. The overall wound strength for all types of closure after
35 days of healing in group 2 animals increased more than ten-fold.
Most wounds appeared to be completely healed after 35 days, and the
force required for disruption of the wound sites after healing averaged
over 100 lbs. There were no wound infections, and no wounds with
complete dehiscence. However, in two of the wounds closed with tissue
adhesive alone, there were several areas of persistent scabbing still vis-
ible at day 35, where small localized areas of dehiscence occurred
within the wound. See Photos 2–5.
The areas of localized dehiscence within two of the wounds as
depicted above in the photographs has also been described in other
studies of wound closure techniques using skin adhesive alone,

Photo 4. (Group 2, Pig 6, Left side. Photo taken at day 0 following repair with tissue Photo 5. (Group 2, Pig 6, Left side. Photo taken at day 35.) Several small areas of persistent
adhesive alone.) scabbing within the wound.

5
J.L. Brown, D. Jehle, J. Mayrose et al.
especially in longer and deeper wounds. [12] The incidence of wound
dehiscence in deeper wounds, or in areas of thicker skin can usually
be improved by placing a deep layer of absorbable sutures to improve
alignment of wound edges prior to the application of skin adhesive.
However, this adds time to the procedure and adds the risk of needle-
stick injury from both the injection of local anesthetic and the suture
needle. Using tapes to first align the skin edges, followed by the applica-
tion of tissue adhesive, provides superior immediate wound strength to
either of these methods alone, and may also decrease the dehiscence
rate by improving initial alignment of the skin edges.
7. Future directions
Many studies comparing surgical tapes, tissue adhesives and su-
tures have been done in both humans and in animal models in the
operating room setting on surgical wounds. Several studies have
found an increased rate of dehiscence in wounds closed with tissue
adhesive alone, especially in deeper longer wounds, or in wounds
in areas subject to tension. [8,12,28] This study demonstrates that
apposition of skin edges by application of tapes followed by overly-
ing application of skin glue provides superior wound strength as
compared to either method alone. This technique may also lead to
a decrease the incidence of wound dehiscence by improving the
strength of the initial repair. Anecdotal reports suggest that the com-
bination of skin tapes and glue performs better than either method
alone for closure of traumatic wounds. [29] Wound infection and de-
hiscence rates as well as both immediate and delayed cosmetic out-
comes using this combination method for repair of traumatic
lacerations remains to be studied. Since the time that this study
was conducted, new wound closure devices that incorporate both
tissue adhesive and adhesive tape have been approved by the FDA.
[27] As mentioned in the discussion, Prineo™ is one example that
uses 2-octyl cyanoacrylate tissue adhesive (Dermabond ™) and a
mesh tape. A complete assessment of Prineo™ against all alternative
treatments including tissue adhesive with adhesive tape, and the
Zip® Surgical Skin Closure has not to be studied.
8. Conclusions
This study demonstrates that the combination of skin tapes and
tissue adhesive provides superior immediate wound closure
strength when compared to either of these methods alone in a por-
cine model. Improving immediate wound closure strength using a
combination repair may lead to a decrease in wound dehiscence
and therefore improved cosmesis, especially in areas subject to
tension and movement.
Author statement
Conceptualization: DJ; Data Curation: JB, DJ, JM, LS, JP; Formal Anal-
ysis: JB, DJ, JM; Funding Acquisition: DJ; Investigation: JB, DJ, JM, LS, JP;
Methodology: JB, DJ, JM; Resources: JB, DJ, JM; Software: JM; Supervi-
sion: DJ; Writing - Original Draft: JB, DJ, JM; Writing - Final Draft: DJ, CS.
Funding sources
This study was funded in part by a grant from the Federal Highway
Administration No. DTFH61-98-X-00103 as awarded by the Center for
Transportation Injury Research (CenTIR) and the Calspan University at
Buffalo Research Center (CUBRC), Buffalo, New York.
6
American Journal of Emergency Medicine xxx (2020) xxx
Acknowledgments
The authors would like to thank Dr. Shirley Anain, Clinical Instructor
of Surgery at the University of Buffalo, for her involvement in project de-
velopment, and Fritz Sticht for his photographic contributions. Statisti-
cal consultation was performed by Aruna Priya, MS, Research Assistant
at the Department of Biostatistics at the University of Buffalo. This re-
search was supported (in part) by HCA and/or an HCA affiliated entity.
The views expressed in this publication represent those of the author
(s) and do not necessarily represent the official views of HCA or any of
its affiliated entities.
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