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Abstract
Introduction: Real-world evidence on the timing and efficacy of enteral nutrition (EN) practices in intensive care unit
(ICU) patients with circulatory shock is limited. We hypothesized early EN (EEN), as compared to delayed EN (DEN), is
associated with improved clinical outcomes in mechanically ventilated (MV) patients with circulatory shock.
Methods: We analyzed a dataset from an international, multicenter, pragmatic randomized clinical trial (RCT) evalu-
ating protein dose in ICU patients. Data were collected from ICU admission, and EEN was defined as initiating < 48 h
from ICU admission and DEN > 48 h. We identified MV patients in circulatory shock to evaluate the association
between the timing of EN initiation and clinical outcomes. The regression analysis model controlled for age, mNUTRIC
score, APACHE II score, sepsis, and Site.
Results: We included 626 patients, from 52 ICUs in 14 countries. Median age was 60 years [18–93], 55% had septic
shock, 99% received norepinephrine alone, 91% received EN alone, and 50.3% were randomized to a usual protein
dose. Forty-two percent of EEN patients had persistent organ dysfunction syndrome plus death at day 28, compared
to 53% in the DEN group (p = 0.04). EEN was associated with more ICU-free days (9.3 ± 9.2 vs. 5.7 ± 7.9, p = 0.0002),
more days alive and free of vasopressors (7.1 ± 3.1 vs. 6.3 ± 3.2, p = 0.007), and shorter duration of MV among survivors
(9.8 ± 10.9 vs. 13.8 ± 14.5, p = 0.0002). This trend was no longer observed in the adjusted analysis. There were no differ-
ences in ICU/60-day mortality or feeding intolerance rates between groups.
Conclusion: In MV patients with circulatory shock, EEN, as compared to DEN, was associated with improved clini-
cal outcomes, but no longer when adjusting for illness severity. RCTs comparing the efficacy of EEN to DEN in MV
patients with circulatory shock are warranted.
Keywords: Enteral nutrition, Vasopressors, EFFORT, ICU, Circulatory shock
†
Co-first author: Jayshil J. Patel and James Zelten
Introduction
Up to one-third of patients admitted to an intensive care
*Correspondence: jpatel2@mcw.edu
unit (ICU) are in circulatory shock, which is associated
3
Division of Pulmonary and Critical Care Medicine, Medical College with an increased risk of mortality [1–3]. Death from
of Wisconsin, Milwaukee, WI, USA
Full list of author information is available at the end of the article circulatory shock is often preceded by multiple organ
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Ortiz-Reyes et al. Critical Care (2022) 26:173 Page 2 of 12
separately on each data set and then combined the commenced at a low rate’ was observed in 47% of the
results using Rubin’s rules [20]. We first used MCMC cohort, while 2% received trophic feeds, [Additional
with 100 imputations to impute just enough of the miss- file 1: Table S1a]. Polymeric EN was the most common
ing mNUTRIC and APACHEII values to create a mono- formula used (81%), and indirect calorimetry was utilized
tonic missing data pattern [21]. We then used monotonic in 6.9% of the entire cohort. Overall, EN was initiated in
regression to fill in the remaining missing mNUTRIC a median of 16 [IQR 8–31] or (range 0.3–234.6) hours
(linear), APACHEII (linear), and sepsis status (logistic). A after vasopressors initiation (EEN: 13.5 [IQR 6.7–21] or
subgroup analysis that controlled for sites has been per- (range 0.3–60.8) vs. DEN: 59.4 [IQR 43.2–73.6] or (range
formed to evaluate the effect of EEN on PODS + death 2.3–234.6) hours, p < 0.0001).
at day 28 and 60-day mortality within the subpopulation The median time to initiate EN after ICU admission
of enrolled patients. All p-values are two-sided without in EEN and DEN groups was 15.5 [IQR 8.4–24.5] or
adjustment for multiple tests of significance. A p-value (range 0.0–47.8) versus 67.6 [IQR 57.6–85.3] or (range
less than 0.05 was considered statistically significant. All 48.1–434.3) hours, respectively (p < 0.0001). Patients in
analyses were conducted using SAS software version 9.4 the EEN group (n = 449), as compared to DEN (n = 83),
(SAS Institute Inc., Cary, NC, USA) [22]. during the first 12 ICU days a had greater calorie deliv-
ery while on vasopressor (61.5% of prescribed calories or
Results 13.5 kcal/kg/day [range 1.0–31.3] vs. 47.1% of prescribed
Participant characteristics calories or 10.6 kcal/kg/day [range 0.4–24.8], p < 0.001)
A total of 3362 patients in 88 ICUs across 16 countries and greater protein delivery while on vasopressors (53.2%
were screened between January 15, 2018, and Septem- of prescribed protein or 0.8 g/kg/day [range 0.1–2.2] vs.
ber 15, 2021, for inclusion in the main study. Of these, 39.2% of prescribed protein or 0.6 g/kg/day [range 0.0–
1144 were randomized. Among 792 finalized charts, 1.4], p < 0.001) [Additional file 1: Table S1a].
155 patients did not receive vasopressors and 11 did not
receive EN, with 626 patients from 52 ICUs in 14 coun- Primary outcome
tries included in the analysis; 50.3% (n = 315) patients In the EEN group, 42% (n = 220) of patients had
were randomized into the usual protein group. Of these, PODS + death at 28 days compared with 53% (n = 53)
526 received EEN and 100 received DEN (Fig. 1). in the DEN group (unadjusted odds ratio 0.64 [95% CI
Of the 626 patients, 56% were male with a mean and 0.42–0.98, p = 0.04]). This trend was observed at Day 14
standard deviation (±) age of 57.7 ± 17.0 years. Eighty- but not Day 60. After controlling for age, mNUTRIC,
seven percent of the entire cohort had a medical admis- APACHE II score, and sepsis, the adjusted odds ratio was
sion and 55% had septic shock. The EEN group, as 0.75 (0.43–1.28, p = 0.29), Additional file 2: Table S1b.
compared to the DEN group, had a higher mNUTRIC In addition, EEN was associated with more PODS-free
score (5.0 ± 1.9 vs. 4.3 ± 2.2, p = 0.006), a higher APACHE days, as compared to the DEN group (11.0 ± 10.2. vs.
II score (22.9 ± 7.9 vs. 20.9 ± 9.0, p = 0.04); and a higher 8.5 ± 9.2 days, p = 0.03).
day 1 SOFA score (9.6 ± 3.4 vs. 8.7 ± 4.9, p = 0.05),
Table 1. Secondary outcomes and subgroup analysis
The EEN group, as compared to the DEN, had more ICU-
Descriptive vasopressor and nutrition data free days (out of 28 days) (9.3 ± 9.2 vs. 5.7 ± 7.9 days,
Ninety-nine percent of the entire cohort received norepi- p = 0.0002), and more vasopressor-free days within
nephrine (n = 621) with an average dose of 0.3 ± 0.6 µg/ 28 days of ICU admission (16.9 ± 9.6 vs. 15.5 ± 9.2 days,
kg/min, and 90% received 1 vasopressor. The median p = 0.05) (Table 3). In addition, survivors had fewer days
time, interquartile range [IQR], and range to initiate any of mechanical ventilation (9.8 ± 10.9 vs. 13.8 ± 14.5,
vasopressor/inotrope were 2.5 [IQR 0.3–15.0] or (range p = 0.0002), a shorter ICU LOS (13.9 ± 11.1 vs.
0.0–478.0) hours after ICU admission (Table 2). The 20.3 ± 13.6 days, p = 0.0001), and a shorter hospital LOS
median time to initiate vasopressor(s) after ICU admis- (22.5 ± 13.3 vs. 28.2 ± 15.3 days, p = 0.02) with EEN com-
sion was significantly different between groups (EEN: pared to DEN. There were no significant differences in
2.3 [IQR 0.2–12.0] or (range 0–387.3) vs. DEN: 5.8 [IQR ICU or 60-day mortality rates between groups.
0.5–45.8] or (range 0–478.0) hours, p = 0.002). For the There were significant associations between EEN and
entire cohort, EN was initiated 18.7 [IQR 10.0–36.8] or both 60-day mortality and PODS + death at day 28 in
(range 0.0–434.3) hours after ICU admission. EN alone the high and low mNUTRIC groups (Fig. 2). In patients
was delivered to 91% of the entire cohort and 97% had with high mNUTRIC score (≥ 5), EEN was associated
EN delivery into the stomach (gastric feeding tube). with increased risk of 60-day mortality (odds ratio [OR]:
We identified 6 feeding practices to initiate EN and ‘EN 1.52, 95% confidence interval [CI] 0.91–2.54) while there
Ortiz-Reyes et al. Critical Care (2022) 26:173 Page 5 of 12
Fig. 1 Flow diagram for total ICUs and patients included in the study
was non-significant association in the opposite direc- EEN was associated with a reduced risk of PODS + death
tion for patients with low mNUTRIC (test for interaction at day 28 (OR: 0.59, CI 0.42–0.83) while there was no
p = 0.03). In patients with a low mNUTRIC score (< 5),
Ortiz-Reyes et al. Critical Care (2022) 26:173 Page 6 of 12
Table 1 (continued)
Variable All (n = 626) Early EN (Within 48 h from ICU Delayed EN (> 48 h from ICU p value
admission) (n = 526) admission) (n = 100)
association in patients with high mNUTRIC (test for initiating EN in patients with circulatory shock after
interaction p = 0.02). hemodynamic stability and EN initiation beyond 48 h
may be due to greater initial severity of illness [11, 24,
Safety outcomes 25]. However, our study found the EEN group had greater
The rate of enteral feeding intolerance (25% [n = 161]) baseline severity of illness, including higher mNUTRIC,
was similar between groups and two events of necrotic APACHE II, and SOFA scores. The significant delay,
bowel/gut ischemia (0.3%) occurred in the EEN group. beyond the recommended 48 h, may be due to a paucity
There were no differences in the serum creatinine, urea, of data on the optimal timing of EN initiation in circula-
phosphate, and triglycerides serum levels between EEN tory shock. Unlike the recommendation to initiate EEN
and DEN groups (Table 4). in the general ICU patient, which is supported by mul-
tiple RCTs (that did not include patients with circula-
Discussion tory shock), the evidence base informing timing of EN
In this observational study using worldwide data to in circulatory shock consists of pre-clinical and human
describe EN practices in mechanically ventilated patients observational and small RCTs, including a phase II pilot
with circulatory shock, we observed (1) significant varia- feasibility study demonstrating protocol compliance
bility in EN practices, (2) significant differences in cumu- and safety of early trophic EN in septic shock.24 Fur-
lative calorie delivery between EEN and DEN groups thermore, critical care nutrition guidelines recommend,
during the first 12 ICU days, and (3) the association based on expert opinion, to provide tropic EN (low dose)
between EEN and DEN groups and clinical outcomes when shock is controlled or that EN be withheld until
was no longer significant after adjustment for severity. the patient is fully resuscitated and/or stable [11, 26, 27].
Data from this pragmatic study found a significant dif- The definition of stability is unspecified and, therefore,
ference in initiating EN in nutritionally high risk critically ambiguous. The lack of an evidence-based recommen-
ill patients in circulatory shock. The time to initiate EN dation and, instead, an expert opinion that introduces
after ICU admission was a median of 18.7 h but ranged ambiguity may lead clinicians to delay EN out of fear of
from 0–434.3 h with 16% (n = 100) being beyond the rec- complications.
ommended 48-h window following ICU admission. In a Second, our study found significant differences in cal-
retrospective propensity matched analysis using a nation- orie (13.5 vs. 10.6 kcal/kg/day, p = 0.0005) and protein
wide dataset, Dorken et al. found similar results, with (0.8 vs. 0.6 g/kg/day, p = 0.0001) delivery between EEN
a median time to EN initiation in the late EN group of and DEN while on vasopressor support, and no differ-
79 h [23]. Major nutrition societal guidelines recommend ences were observed in the proportion of patients in the
Ortiz-Reyes et al. Critical Care (2022) 26:173 Page 8 of 12
Time (h) from ICU admission to start vasopressors (626) 20.3 ± 49.5 (526) 17.1 ± 43.1 (100) 37.0 ± 72.9 0.002
mean ± SD; median [range] 2.5 [0.0–478.0] 2.3 [0.0–387.3] 5.8 [0.0–478.0]
Total Duration (days) of vasopressors 5.7 ± 3.6 5.4 ± 3.6 6.8 ± 3.8 0.0006
mean ± SD; median [range] 4 [1.0–12.0] 4 [1.0–12.0] 6 [1.0–12.0]
First 48 h of treatment period
Dopamine, µg/kg/min (12) 9.3 ± 5.0 (10) 8.7 ± 4.4 (2) 12.0 ± 9.0 0.75
(n); mean ± SD; median [range] 7.6 [2.8–18.3] 7.6 [2.8–18.3] 12 [5.7–18.3]
Dobutamine, µg/kg/min (44) 4.6 ± 3.2 (38) 4.6 ± 3.2 (6) 5.0 ± 3.8 0.69
(n); mean ± SD; median [range] 4.4 [0.2–17.4] 4.5 [0.2–17.4] 4.2 [2.3–12.5]
Norepinephrine µg/kg/min (621) 0.3 ± 0.6 (523) 0.3 ± 0.5 (98) 0.3 ± 0.9 0.32
(n); mean ± SD; median [range] 0.2 [0.0–9.3] 0.2 [0.0–5.2] 0.1 [0.0–9.3]
Epinephrine, µg/kg/min (34) 0.2 ± 0.2 (24) 0.2 ± 0.3 (10) 0.2 ± 0.1 0.81
(n); mean ± SD; median [range] 0.1 [0.0–1.0] 0.1 [0.0–1.0] 0.1 [0.0–0.4]
Phenylephrine, µg/kg/min (6) 3.9 ± 3.8 (5) 4.5 ± 4.0 (1) 0.9 ± .und 0.24
(n); mean ± SD; median [range] 2.2 [0.9–10.5] 3.1 [1.2–10.5] 0.9 [0.9–0.9]
Vasopressin, units/min (159) 0.0 ± 0.0 (139) 0.0 ± 0.0 (20) 0.0 ± 0.0 0.68
(n); mean ± SD; median [range] 0.0 [0.0–0.1] 0.0 [0.0–0.1] 0.0 [0.0–0.1]
Milrinone, µg/kg/min (9) 0.2 ± 0.1 (8) 0.2 ± 0.1 (1) 0.3 ± .und 0.70
(n); mean ± SD; median [range] 0.2 [0.1–0.3] 0.2 [0.1–0.3] 0.3 [0.3–0.3]
Levosimendan, µg/kg/min (9) 0.1 ± 0.0 (7) 0.1 ± 0.1 (2) 0.1 ± 0.0 0.36
(n); mean ± SD; median [range] 0.1 [0.1–0.2] 0.1 [0.1–0.2] 0.1 [0.1–0.1]
Vasopressor’s dose (524) 0.3 ± 0.6 (444) 0.3 ± 0.5 (80) 0.3 ± 1.1 0.07
at start of EN 0.2 [0.0–10.0] 0.2 [0.0–6.0] 0.1 [0.0–10.0]
(n); mean ± SD; median [range]
Norepinephrine-equivalent dose μg/min (621) 0.3 ± 0.6 (523) 0.3 ± 0.5 (98) 0.3 ± 0.9 0.32
(n); mean ± SD; median [range] 0.2 [0.0–9.3] 0.2 [0.0–5.2] 0.1 [0.0–9.3]
Proportion of patients with 2 or more vasopressors 0.18
n (%)
1 564 (90.1%) 475 (90.3%) 89 (89.0%)
>2 58 (9.3%) 49 (9.3%) 9 (9.0%)
Numeric variables are represented as “n” and percentage (%); mean and standard deviation ( ±) and [ranges]; µg = microgram; hrs = hours; ICU: intensive care unit
DEN and EEN allocated to high and usual protein dose randomized to early EN had a greater EFI rate, including
groups in the main RCT. It is unclear if the difference NOMI rate (2 vs. < 1%, p = 0.007).32 However, the EEN
in the quantity of daily calorie and protein represents a group in NUTRIREA-2 received 17.8 kcal/kg/day while
clinically important difference. Critically ill patients with on 0.56 µg/kg/min of norepinephrine [9]. In our study,
circulatory shock who received DEN are more likely to the EEN group patients received an average of 13.5 kcal/
fail to meet their energy and protein requirements, which kg/day of calories while on 0.3 µg/kg/min of norepineph-
may expose them to unfavorable clinical outcomes, espe- rine. These findings align with results from Ohbe et al.,
cially those at high nutritional risk [16, 28–31]. However, which found EEN while on low (< 0.1 µg/kg/min) and
in our analysis, patients with lower mNUTRIC score medium-dose (0.1–0.3 µg/kg/min) norepinephrine was
receiving EEN had an increased risk of 60-day mortality associated with lower 28-day mortality as compared to
and PODS + death at day 28. Our study found EEN group DEN with no significant difference in NOMI between
had more days alive and free of vasopressors and surviv- EEN and DEN groups (0.2 vs. 0.3%) [31]. The Ohbe et al.
ing patients in the DEN group had a longer length of ICU study did not account for total calorie intake in reporting
and hospital LOS. Two patients in the EEN group devel- NOMI rate. Our findings suggest an EEN dose of up to
oped non-occlusive mesenteric ischemia (NOMI)/bowel 13.5 kcal/kg/min may be safe and tolerated while receiv-
necrosis (NOBN), and there was no significant difference ing up to 0.3 µg/kg/min of norepinephrine in patients
in EFI rate between EEN and DEN groups. Our findings with lower APACHE II and SOFA scores and those with
are discordant with the NUTRIREA-2 trial, which rand- lower nutritional risk (mNUTRIC score < 5).
omized mechanically ventilated patients with predomi- Third, our study found significant differences in clini-
nant septic shock to early EN or early PN [32]. Patients cal outcomes. The EEN group, as compared to DEN, had
Ortiz-Reyes et al. Critical Care (2022) 26:173 Page 9 of 12
a fewer proportion of patients with PODS + death at day Database, Dorken et al. found EEN, as compared to DEN,
28, shorter ICU and hospital LOS and duration of MV in was associated with shorter ICU LOS [23]. Ours is the
survivors, and more days alive and free of vasopressors. first study to find an association between EEN, days alive,
However, this signal was no longer observed when con- and time free of vasopressors. In preclinical and small-
trolling for severity. The rate of PODS + death was not scale human studies EEN has been found to preserve EBF
significant between groups at Day 60, as compared to [6, 7, 25, 34]. A post hoc analysis of the NUTRIREA-2
Day 14 and Day 28, and these data suggest an associated trial found the EEN group had higher plasma citrulline
early benefit to EEN which may diminish over time. Our levels, a marker of enterocyte mass and function, as com-
findings align with those from other observational stud- pared to the early PN group [9]. These findings suggest
ies. In a small retrospective study, trophic dose EN deliv- EEN may preserve EBF, which may mitigate gut-derived
ered within 48 h was associated with shorter ICU LOS pro-inflammatory immune responses. Clinically, these
[33]. More recently, using a national eICU Collaborative findings may manifest as more vasopressor free days. In
Ortiz-Reyes et al. Critical Care (2022) 26:173 Page 10 of 12
Fig. 2 Each horizontal line represents a subgroup analysis for PODS + death at day 28 and 60-day mortality, with means shown by black circles and
whiskers representing the 95% confidence interval
addition, we found significant associations between EEN improved clinical outcomes, but adjusting for severity
and both 60-day mortality and PODS + death at day 28 reduced this association. RCTs comparing the efficacy of
in the high and low mNUTRIC groups. We found EEN, EEN to DEN in mechanically ventilated patients with cir-
as compared to DEN, in those with a high mNUTRIC culatory shock are warranted.
score is associated with increased risk of 60-day mor-
tality, as compared to DEN. On the contrary, in patients
Abbreviations
with a low mNUTRIC score, EEN is associated with less EN: Enteral nutrition; ICU: Intensive care unit; EEN: Early EN; DEN: Delayed EN;
PODS + death, as compared DEN. The sample size of MV: Mechanically ventilated; RCT: Randomized clinical trial; PODS: Persistent
the DEN group was small, which limits the precision of organ dysfunction; mNUTRIC: Modified NUTRIC score; NOMI: Non-occlusive
mesenteric ischemia; EFI: Enteral feeding intolerance; PN: Parenteral nutrition;
results when comparing mNUTRIC risk groups and the NOBN: Non-occlusive bowel necrosis; LOS: Length of stay; OR: Odds ratio; CI:
test for interaction. The subgroup effects of mNUTRIC 95% Confidence interval; RRT: Renal replacement therapy; MCMC: Markov
on the outcome of PODS + death at day 28 and 60-day chain Monte Carlo method.
mortality may be real based on key criteria developed
to assess credibility of our findings and larger trials are Supplementary Information
needed to confirm these findings [35]. The online version contains supplementary material available at https://doi.
org/10.1186/s13054-022-04047-4.
Our study has several limitations. First, we included
mechanically ventilated patients receiving EN and vas- Additional file 1. Supplemental Table S1a: Nutrition practices.
oactive agents and cannot account for time intervals Additional file 2. Supplemental Table S1b: Multivariable modeling for
between the exposure and outcome of interest. However, Clinical Outcomes.
we included patients with a minimum of three evaluable
days of nutrition to ensure exposure and attempted to Acknowledgements
capture all time intervals before and after concomitant We gratefully acknowledge the support and contribution of all clinical and
EN and vasoactive support by defining day 1 as the first research staff from participating institutions.
ICU admission day, reporting time to initiate EN and Author contributions
time to initiate vasopressor, and including patients who JJP, LO, and DKH equally contributed to the conception and design of the
were expected to be mechanically ventilated for > 96 h. research; XJ, ACY, AD, FS, JZ, T-KM, TR contributed to the acquisition, analysis,
and interpretation of the data; and LO and JP drafted the manuscript. All
Second, we did not explore differences in EN initiation authors critically revised the manuscript, agree to be fully accountable for
practices based on geography. Nevertheless, despite the ensuring the integrity and accuracy of the work, and read and approved the
presumed heterogeneity of care that might exist across final manuscript.
sites around the world, we did observe a significant sig- Funding
nal of benefit from early EN. Because of the large sam- None.
ple from diverse real-world settings, our results are
Availability of data and materials
maximally generalizable to practices around the world. The dataset analyzed in the current study is not publicly available but is avail-
Third, although we found a statistically significant differ- able from the corresponding author on reasonable request.
ence in delivered calories and protein between EEN and
DEN groups, we are unsure if these differences repre- Declarations
sent a meaningful clinically important difference. Fourth,
Ethical approval and consent to participate
despite controlling for known variables that account for The study protocol was approved by the Research Ethics Board (REB) at
the severity of illness, residual confounding may still be Queen’s University ID#6021669. Every intensive care unit participating in the
present. Fifth, these results are hypothesis-generating main trial obtained local REB approval, and consent was obtained from each
participant.
and the findings should be confirmed in randomized
controlled trials. Consent for publication
Strengths of our study include reporting real-world Not applicable.
practice data from numerous ICUs worldwide that pro- Competing interests
spectively collected data following a specific protocol, JJP, XJ, AD, DKH, LAO, MTK, ACY, FS, and JZ have no conflict of interest to
which enhances the validity and generalizability of our disclose. TR has consultancy relationships with Baxter and Nestle.
findings. Author details
1
Clinical Evaluation Research Unit, Department of Critical Care Medicine,
Queen’s University, KGH Research Institute, Kingston Health Sciences Centre,
Conclusions Kingston, ON, Canada. 2 Clinical Epidemiology Program, Ottawa Hospital
Our prospective observational study of real-world nutri- Research Institute, Ottawa, ON, Canada. 3 Division of Pulmonary and Critical
Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA. 4 Depart-
tion practices in mechanically ventilated patients with ment of Critical Care Medicine and Department of Pulmonary Medicine,
circulatory shock found significant variability in EN ini- Respiratory Institute, Cleveland Clinic, Cleveland, USA. 5 Division of Pulmonary,
tiation, and EEN, compared to DEN, was associated with Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA.
Ortiz-Reyes et al. Critical Care (2022) 26:173 Page 12 of 12
6
Pulmonary and Critical Care Medicine, Spectrum Health, Michigan State requiring prolonged mechanical ventilation: a multicenter cohort study.
University, East Lansing, USA. 7 Division of Allergy, Pulmonary, and Critical Care Crit Care Med. 2015;43(8):1569–79.
Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA. 19. Heyland DK, Muscedere J, Drover J, Jiang X, Day AG. Persistent organ
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veys. Stat Pap. 1990;31(1):180.
21. Schafer JL. Analysis of incomplete multivariate data. London: Chapman &
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