Original Research ajog.

org

OBSTETRICS
Acidemia in neonates with a 5-minute Apgar score
of 7 or greater e What are the outcomes?
Bethany A. Sabol, MD; Aaron B. Caughey, MD, PhD

BACKGROUND: The Apgar score is universally used for fetal
assessment at the time of birth, whereas, the collection of fetal cord blood
gases is performed commonly in high-risk situations or in the setting of
Apgar scores of <7, which is a less standardized approach. It has been
well-established that neonatal acidemia at the time of delivery can result in
significant neonatal morbidity and death. Because of this association,
knowledge of the fetal acid-base status and detection of acidemia at the
time of delivery can serve as a sensitive and useful component in the
assessment of a neonate’s risk. Umbilical cord blood gas analysis is an
accurate and validated tool for the assessment of neonatal acidemia at the
time of delivery. Because the collection of fetal cord blood gases is not a
standardized practice, it is possible that, with such a varied approach,
some cases of neonatal acidemia are not detected, particularly in the
setting of reassuring Apgar scores.
OBJECTIVE: In a setting of universally obtained cord blood gases, we
sought to identify the rates of acidemia and associated factors in neonates
with 5-minute Apgar scores of
7.
STUDY DESIGN: This retrospective cohort study identified all term,
singleton, nonanomolous neonates with 5-minute Apgar scores of
7.
The incidence of umbilical artery pH 7.0 or 7.1 and base excess
e12 mmol/L or e10 mmol/L were examined overall and in associ-
ation with obstetric complications and adverse neonatal outcomes. Chi-
squared tests were used to compare proportions, and multivariable
logistic regression was used to control for potential confounders.
RESULTS: In this cohort, the incidence of an umbilical artery pH of 7.0
was 0.5%, of a pH 7.1 was 3.4%, of a base excess e12 mmol/L was
1.4%, and of e10 mmol/L was 4.0%. Rates of neonatal acidemia were
greater in the setting of meconium (4.3% vs 3.2%; P<.001), placental
abruption (13.2% vs 3.4%; P<.001), and cesarean deliveries (5.8% vs
2.8%; P<.001), despite normal 5-minute Apgar scores. Additionally,
umbilical artery pH 7.0 was associated with an increased risk of res-
piratory distress syndrome (adjusted odds ratio, 6.5; 95% confidence
interval, 2.9e14.3) and neonatal intensive care unit admission (adjusted
odds ratio, 10.8; 95% confidence interval, 6.8e17.4). Base excess of
e12 mmol/L was also associated with an increased risk of neonatal
sepsis (adjusted odds ratio, 4.7; 95% confidence interval, 1.9e12.1).
Finally, when examined together, neonates with both a pH of 7.0 and
base excess of e12 mmol/L continued to demonstrate an increased risk
of neonatal intensive care unit admission and respiratory distress syn-
drome, with adjusted odds ratios of 9.6 and 6.0, respectively. This risk
persisted in neonates with a pH of 7.1 and base excess of e10 mmol/
L as well, with adjusted odds ratios of 4.5 and 1.1, respectively.
CONCLUSION: Because neonates with reassuring Apgar scores have
a residual risk of neonatal acidemia that is associated with higher rates of
adverse outcomes, the potential utility of obtaining universal cord blood
gases should be further investigated.
Key words: acidemia, Apgar, neonatal outcome, umbilical cord blood gas

F etal and subsequent neonatal acid-

emia is associated with multiorgan
dysfunction, hypoxic ischemic enceph-
alopathy, seizures, cerebral palsy, long-
term neurologic deficits, and neonatal
death.1-6 Because of this association,
knowledge of the fetal acid-base status
and detection of acidemia at the time of
delivery can serve as a sensitive and
useful component in the assessment of a
neonate’s risk of morbidity and death.
Umbilical cord blood gas analysis is an
accurate and validated tool for the
Cite this article as: Sabol BA, Caughey AB. Acidemia in
neonates with a 5-minute Apgar score of 7 or greater e
What are the outcomes?. Am J Obstet Gynecol
2016;215:486.e1-6.
0002-9378/$36.00
ª 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2016.05.035
assessment of neonatal acidemia at time
of delivery.
The components of umbilical cord
blood gas, which most commonly are
used as a means of capturing neonates
who are at risk for adverse outcomes, are
pH and base excess. Studies have
demonstrated an increased risk of
neonatal morbidity when umbilical ar-
tery cord pH is 7.0.1,7 Recent studies
have also demonstrated that even mod-
erate degrees of fetal acidemia (pH
threshold of 7.10) may place neonates
at risks for adverse outcomes.2,8 Base
excess is an additional threshold value
that is used to indicate the severity and
duration of neonatal acidemia. At the
time of delivery, base excess levels of
e12 mmol/L (10%) and e16 mmol/
L (40%) are associated with moderate-to-
severe newborn infant complications.3,4
Although pH and base excess are
useful tools in the prediction of adverse
outcomes, universal umbilical cord
blood gas analysis at the time of delivery
is not a routine practice. The American
College of Obstetricians and Gynecolo-
gists recommends the use of selective
umbilical cord blood sampling.6,7
Common thresholds for obtaining
neonatal cord blood gases are a 5-minute
Apgar score of <7 and in patients who
are at high risk for neonatal asphyxia (ie,
cord prolapse, placental abruption).
Because the collection of fetal cord blood
gases is not a standardized practice, there
is great variation in collection practice
among institutions and among providers
within the same institution. It is possible
that, with such a varied approach, some
cases of neonatal acidemia are not
detected, particularly in the setting of
reassuring Apgar scores. Additionally, it
is unclear whether cases of neonatal
acidemia with a normal Apgar score by 5
minutes are clinically important.

486.e1 American Journal of Obstetrics & Gynecology OCTOBER 2016

ajog.org OBSTETRICS Original Research

The objective of our study was to meconium aspiration syndrome (MAS),

TABLE 1
assess the rate of neonatal acidemia that respiratory distress syndrome (RDS),
Maternal demographics
occurs in neonates with a 5-minute and neonatal sepsis.
Apgar score of
7. Additionally, we Chi-squared tests were used to pH, %
sought to determine factors that are compare proportions and multivariable
Demographic >7.1 7.1
associated with an increased risk of logistic regression was used to control
neonatal acidemia in this setting and for potential confounders. The potential Paritya
their associated outcomes. confounding variables that were exam- Nulliparous 96.9 3.1
ined were race/ethnicity, maternal age, Multiparous 96.2 3.8
Materials and Methods parity, insurance status, gestational dia-
Age, y b
This is a retrospective cohort study of all betes mellitus, chronic hypertension,
nonanomalous, term, singleton neo- and preeclampsia. A probability value of <35 96.8 3.2
nates who were born at Moffitt-Long <.05 was considered statistically signifi- >35 95.7 4.3
Hospital from 1990 until 2009 with a cant. Multivariable analyses are pre- Race b

5-minute Apgar score of
7 (N¼26,669) sented as odds ratios with 95%

in a setting where routine collection of
cord blood gases was attempted in every
delivery. Deliveries were excluded if the
5-minute Apgar score was <7 (n¼873)
or if a cord blood gas was not obtained,
was inadequate, or was only a venous
sample (n¼3385). Approval from the
institutional review board at Oregon
Health & Science University was
obtained. All diagnoses were made by
the providing clinicians. Detailed infor-
mation on all deliveries during the study
time frame were abstracted from the
medical records by trained abstractors
and recorded in an electronic database.
The abstracted data were reviewed
monthly by a Neonatologist and
Maternal Fetal Medicine specialist to
ensure accuracy.
Within the cohort of deliveries with a
5-minute Apgar score of
7, the inci-
dence of deliveries with an umbilical
artery pH 7.0, pH 7.1, base excess
e12 mmol/L, and base excess e10
mmol/L were then identified. To identify
risk factors for abnormal cord blood
gases in this setting, these groups were
then examined in a variety of maternal
subgroups that included mode of
delivery and those women with placental
abruption, presence of meconium,
shoulder dystocia, and preexisting
maternal conditions such as gestational
diabetes mellitus, chronic hypertension,
and preeclampsia.
Next, several neonatal outcomes were
compared between acidemic and non-
acidemic neonates who had 5-minute
Apgar scores of
7. Neonatal outcomes
that were examined included neonatal
intensive care unit (NICU) admission,
White 96.0 4.0
confidence intervals (CIs).
Black 96.4 3.6
Results Hispanic 96.3 3.7
Of the 26,669 deliveries that met the Asian 97.6 2.4
inclusion criteria, the overall incidence
Other 98 2
of an umbilical artery pH 7.0 was 0.5%
(n¼133), of umbilical artery cord pH Insurance type
7.1 was 3.4% (n¼906), of base excess Public 96.6 3.4
e12 mmol/L was 1.4% (n¼373), and Private 96.9 3.1
of base excess e10 mmol/L was 4.0%
Gestational diabetes
(n¼1067). Maternal characteristics mellitus
between those with and without a
Yes 96.6 3.4
neonate with an umbilical artery pH of
7.1 were similar with respect to No 96.0 4.0
insurance status and rates of gestational Chronic hypertension
diabetes mellitus and chronic hyperten- Yes 96.6 3.4
sion but differed in regards to maternal
age, parity, and rates of preeclampsia No 96.2 3.8
b
(Table 1). Women who delivered neo- Preeclampsia
nates with a pH of 7.1 were more likely Yes 96.6 3.4
to be nulliparous and >35 years old and No 94.6 3.4
to have preeclampsia. a
P < .05; P < .001.
b
The incidence of abnormal cord blood Sabol & Caughey. Neonatal acidemia with 5-minute
gases was compared with obstetric Apgar
7. Am J Obstet Gynecol 2016.
complications that included placental
abruption, presence of meconium,
shoulder dystocia, mode of delivery, RDS, MAS, and NICU admissions.
maternal gestational diabetes mellitus, Similarly, a cord blood gas base excess of
chronic hypertension, and preeclampsia. e10 mmol/L or e12 mmol/L was
Rates of neonatal acidemia (pH 7.1), also associated with these outcomes in
despite a normal 5-minute Apgar score, addition to increased rates of neonatal
were greater in the setting of meconium sepsis (Table 3).
(4.3% vs 3.2%; P<.001), placental Multivariable regression analyses were
abruption (13.2% vs 3.4%; P<.001), performed to control for potential con-
cesarean deliveries (5.8% vs 2.8%; founding variables that included parity,
P<.001), and pregnancies that were maternal age, maternal race/ethnicity,
complicated by preeclampsia (6.3% vs insurance type, chronic hypertension,
3.9%; P<.001; Table 2). gestational diabetes mellitus, and pre-
With regard to neonatal outcomes, a eclampsia. After we controlled for these
cord blood gas with pH of 7.0 and 7.1 variables, we determined that neonates
was associated with increased rates of with a pH of 7.0, despite an Apgar of

OCTOBER 2016 American Journal of Obstetrics & Gynecology 486.e2

Original Research OBSTETRICS ajog.org

>7 at 5-minutes, had a statistically sig-

TABLE 2
nificant increased risk of RDS and NICU
Incidence of neonatal acidemia with 5-minute Apgar scores of ‡7
admission with an adjusted odds ratio
(aOR) of 6.5 (95% CI, 2.9e14.3) and pH Base excess pH Base excess
10.8 (95% CI, 6.8e17.4) respectively Characteristic 7.0, % e12 mmol/L, % 7.1, % e10 mmol/L, %
(Table 4). Similarly, in neonates with Meconium
a pH 7.1 and normal Apgar scores,
Yes 0.7a 2.0b 4.3b 5.2b
there were also statistically significant
increases in rates of MAS, RDS, and No 0.4 1.2 3.2 3.7
NICU admissions (Table 4). Abruption
Similar to the low pH thresholds, base Yes 3.6b 3.7 13.2b 8.6a
excess thresholds were examined as well.
No 0.5 1.4 3.4 4.0
A base excess of e12 mmol/L was
associated with a statistically significant Mode of delivery
increase in MAS (aOR, 4.2; 95% CI, Cesarean 1.0b 1.7a 5.8b 4.6a
2.1e8.4), neonatal sepsis (aOR, 4.7; 95% Vaginal 0.3 1.3 2.8 3.9
CI, 1.9e12.1), RDS (aOR, 2.2; 95% CI,
Shoulder dystocia
1.1e4.4), and NICU admission (aOR,
2.9; 95% CI, 2.0e4.4). Similar trends Yes 0.5 1.5 3.6 4.2
were also seen with a base excess of No 0.3 0.6 3.4 2.8
e10 mmol/L (Table 5). Operative delivery
Finally, to better capture and evaluate
Yes 0.5 1.8a 4.3b 5.4
the effects of a mixed or metabolic
acidosis in neonates with an Apgar score No 0.4 1.3 3.3 3.8
of
7 at 5-minutes, a combined variable Gestational
that encompassed both pH and base diabetes mellitus
excess was created. When we examined Yes 1.1 1.3 4.8 3.4
them together, we found that neonates No 0.8 1.7 4.0 4.5
with both a pH 7.0 and base excess
e12 mmol/L continued to demon- Chronic hypertension
strate an increased risk of NICU admis- Yes 0.5 1.4 4.5 4.9
sion and RDS, with aORs of 9.6 and 6.0, No 0.8 1.7 4.0 4.5
respectively. This risk persisted in neo-
Preeclampsia
nates with a pH 7.1 and base excess
e10 mmol/L as well, with aORs of 4.5 Yes 1.6a 2.8a 6.3b 7.8b
and 1.1 (Table 6). No 0.7 1.7 3.9 4.42a
a
P < .05; b P < .001.
Comment Sabol & Caughey. Neonatal acidemia with 5-minute Apgar
7. Am J Obstet Gynecol 2016.
The Apgar score was proposed in 1952 as
a means of rapidly evaluating the clinical
status of a newborn infant and currently there is still a residual risk of neonatal outcomes and thus should not be used
remains an accepted method for acidemia. Similar to other studies, our for that purpose.”9 It is not meant to be
newborn infant assessment immediately study found that neonatal acidemia is used in lieu of a cord blood gas for the
after delivery.9 In many institutions, it is associated with adverse neonatal out- assessment of neonatal acid-base status,
not common practice to obtain a cord comes. However, our study uniquely but rather in conjunction with umbilical
blood gas, as a means of additional demonstrates that neonates with acid- cord blood gas for an overall impression
assessment, in deliveries with an Apgar emia at the time of delivery, despite a of neonatal status. Furthermore, there
score of
7, despite literature to suggest normal Apgar score, have worse out- are limited studies on the acid-base sta-
poor correlation between Apgar scores at comes compared with their nonacidemic tus of neonates with normal Apgar
1 and 5 minutes and resultant neonatal counterparts. scores, which is likely because of varia-
acid-base status.10,11 Neonatal acidemia The American College of Obstetrics & tions in umbilical cord blood sampling
occurs in 1e2% of deliveries; it generally Gynecology endorses the Apgar score as practices.
has been believed that acidemia in clin- a tool to identify the need for immediate By taking advantage of a clinical
ically vigorous neonates is insignificant.7 neonatal resuscitation but cautions setting that attempted to obtain univer-
Albeit rare, our study demonstrates that, that it is not predictive of “individual sal cord blood gases, our study begins to
in the setting of normal Apgar scores, neonatal mortality or neurologic fill this gap in knowledge by assessing a

486.e3 American Journal of Obstetrics & Gynecology OCTOBER 2016

ajog.org OBSTETRICS Original Research

are born with acidemia will not require

TABLE 3
additional intervention or develop sub-
Neonatal outcomes with a 5-minute Apgar score >7
sequent morbidity. With that being said,
Meconium Respiratory Neonatal Malin et al,1 in a recent systemic review
Cord blood gas aspiration distress intensive care and meta-analysis of umbilical cord pH
component syndrome, % syndrome, % Sepsis, % unit admission, % and perinatal and long-term outcomes,
pH concluded that “increased initial sur-
7.1 1.7a 4.7b 0.4 11.4b veillance of neonates born with a low
arterial cord pH, regardless of their
>7.1 0.7a 1.0b 0.2 4.3b
clinical condition, is warranted as the
7.0 1.9 a
7.6 b
0 28.9b odds of complications have been shown
>7.0 0.7a 1.1b 0.2 4.4b to be higher in this group.” Based on the
Base excess, mmol/L findings of our study, we agree with this
conclusion and find merit in universal
>e10 0.6b 1.1a 0.2b 4.4b
umbilical cord blood sampling as a
e10 1.7b 2.0a 1.0b 8.0b method of identifying neonates who are
>e12 0.7 b
1.1 a
0.2 b
4.5b at risk.
e12 2.6b 2.9a 1.4b 9.7b Although the current study demon-
strated specific neonatal complications
a
P < .05; b P < .001.
Sabol & Caughey. Neonatal acidemia with 5-minute Apgar
7. Am J Obstet Gynecol 2016. that are associated with abnormal
umbilical artery cord blood gases, addi-
tional benefits to universal cord blood
gas collection may exist from a quality
large cohort of neonates with normal the NICU. These risks were further standpoint. First, when cord blood gases
Apgar scores and comparing the inci- increased with the severity of acidemia. are obtained only in the setting of a low
dence of acidemia with subsequent We acknowledge that the incidence of Apgar score, they are often being done in
neonatal outcomes. Our study demon- neonatal acidemia in the setting of an emergent setting. Obtaining cord
strated that, even in neonates born with a normal Apgar scores and reassuring blood gases in this setting is extremely
reassuring clinical status, acidemia can clinical status is an overall rare occur- important; therefore, having a routine
still occur and that neonates with acid- rence; our study accounts for just approach to collection is likely to
emia are at a significantly higher risk of 0.5e3.4% of deliveries. We also improve the probability of a successful
having RDS, MAS, and admission to acknowledge that most neonates who and interpretable cord blood gas sample.
Second, the information from the cord
blood gas, normal or abnormal, can be
useful in interpreting the fetal heart rate
TABLE 4 monitoring strip for quality improve-
Multivariable regressiona results for neonatal outcomes in neonates ment purposes. Given our relatively poor
with a 5-minute Apgar score of >7 and pH £7.0 and pH £7.1 compared ability to interpret and use fetal heart rate
pH >7.0 and pH >7.1 monitoring, especially its correlation
with identifying neonatal acidemia,
Adjusted 95% Confidence
opportunities to improve its predictive
Outcomes odds ratio interval P value
ability should be embraced.12-15
pH 7.0 When discussing the benefits of uni-
Meconium aspiration syndrome 1.47 0.20e10.72 .699 versal cord blood gas collection, we
Respiratory distress syndrome 6.47 2.93e14.28 <.001c would be remiss to not address the
Neonatal intensive care unit admission 10.84 6.76e17.38 <.001c
medico-legal implications and associ-
ated costs. The actual cost of cord blood
pH 7.1 gas collection is relatively inexpensive,
Meconium aspiration syndrome 2.43 1.30e4.53 .005b approximately $3.50e$5.00 per sample;
Respiratory distress syndrome 4.60 3.10e6.84 <.001c however, there is wide variation in the
Sepsis 1.67 0.60e4.65 .328
cost charged by the hospital.7 In our
current medico-legal environment, there
Neonatal intensive care unit admission 3.68 2.81e4.82 <.001c is understandable concern surrounding
a
Regression adjusted for parity, maternal age, maternal race/ethnicity, insurance type, chronic hypertension, gestational universal cord blood gas analysis and
diabetes mellitus, and preeclampsia; b P < .05; c P < .001.
Sabol & Caughey. Neonatal acidemia with 5-minute Apgar
7. Am J Obstet Gynecol 2016. implications of unexpected neonatal
acidemia. One must remember,

OCTOBER 2016 American Journal of Obstetrics & Gynecology 486.e4

Original Research OBSTETRICS ajog.org

TABLE 5
Multivariable regressiona results for neonatal outcomes in neonates with a 5-minute Apgar score of >7 and
base excess of £e12 mmol/L and £e10 mmol/L compared with those with a base excess of
>e12 mmol/L and >e10 mmol/L
Outcomes Adjusted odds ratio 95% Confidence interval P value
Base excess e12 mmol/L
Meconium aspiration syndrome 4.21 2.12e8.38 <.001c
Respiratory distress syndrome 2.21 1.08e4.53 .03b
Sepsis 4.72 1.85e12.05 .001b
Neonatal intensive care unit admission 2.92 1.96e4.35 <.001c
Base excess e10 mmol/L
Meconium aspiration syndrome 2.67 1.57e4.53 <.001c
Respiratory distress syndrome 1.40 0.811e2.43 .225
Sepsis 3.13 1.56e6.25 .001b
Neonatal intensive care unit admission 2.33 1.77e3.07 <.001c
a
Regression adjusted for parity, maternal age, maternal race/ethnicity, insurance type, chronic hypertension, gestational diabetes mellitus, and preeclampsia; b P < .05; c P < .001.
Sabol & Caughey. Neonatal acidemia with 5-minute Apgar
7. Am J Obstet Gynecol 2016.

however, that the vast majority of neo- majority of neonates who have cerebral this study, we were unable to control for
nates who are born with acidemia will palsy are not acidemic at birth.7,16 all possible confounding variables and
not go on to experience any long-term This study is not without limitations. were limited to information previously
neurologic deficits and that the Because of the retrospective nature of obtained. Thus, there may be persistent

TABLE 6
Combined impact of low pH and elevated base excess on neonatal outcomes in neonates with a 5-minute
Apgar score >7
No acidemia Acidemia
pH >7.0 & base pH >7.1 & base pH 7.0 & base pH 7.1 & base
Outcomes excess >e12 mmol/L excess >e10 mmol/L excess e12 mmol/L excess e10 mmol/L
Meconium aspiration 99.3 99.3 0.7 0.7
syndrome, %
Adjusted odds ratio — — 2.5 (0.3e18.6) 2.1 (0.9e5.2)
(95% confidence interval)
Respiratory distress 98.9 98.9 1.1a 1.1a
syndrome, %
Adjusted odds ratio — — 6.0 (2.1e16.9)a 3.4 (1.9e6.2)a
(95% confidence interval)
Sepsis, % 99.8 99.8 0.2 0.2b
Adjusted odds ratio — — — 2.3 (0.7e7.4)
(95% confidence interval)
Neonatal intensive care unit 95.5 95.6 4.5a 4.4a
admission, %
Adjusted odds ratio — — 9.6 (5.2e17.8)a 4.6 (3.3e6.5)a
(95% confidence interval)
Regression adjusted for parity, maternal age, maternal race/ethnicity, insurance type, chronic hypertension, gestational diabetes mellitus, and preeclampsia.
a
P < .001; b P < .05.
Sabol & Caughey. Neonatal acidemia with 5-minute Apgar
7. Am J Obstet Gynecol 2016.

486.e5 American Journal of Obstetrics & Gynecology OCTOBER 2016

ajog.org
confounding in our multivariable
results. We were also unable to assess
long-term neonatal outcomes that
included developmental delay, neuro-
logic morbidity, and cerebral palsy.
Additionally, although cord blood gases
were attempted to be collected univer-
sally, they were missing in 13% of
deliveries that met the inclusion criteria.
It is possible that such cord blood gases
would be more likely to be absent in
certain high-risk settings such as
placental abruption with decreased cord
blood available for collection. If these
missing cord blood gases were more
common among high-risk patients, this
would have biased our results slightly
towards underestimates of the frequency
of acidemia in these neonates with
normal Apgar scores. Alternatively, if
they were more likely to be missing
because the urgency to obtain them was
lower, then our results would mildly
overestimate the rate of abnormal cord
blood gases.
Furthermore, given the limitations of
a retrospective study, we were unable to
evaluate how the knowledge of acidemia
in a clinically vigorous neonate may have
changed or influenced clinical manage-
ment and practice patterns within the
institution. We were unable to assess
whether knowledge of acidemia at the
time of delivery biased the treatment that
the neonate received. We were also un-
able to assess whether the knowledge of
fetal acidemia at the time of delivery had
any impact on management or short- or
long-term outcomes. Further investiga-
tion into how the knowledge of umbili-
cal cord pH at the time of delivery
OBSTETRICS
influences management and outcomes is
needed.
Despite these limitations, the results
of this study demonstrate the frequency
and potential risks of neonatal acidemia,
even in the setting of a normal 5-minute
Apgar score. It is our belief, based on the
data presented, that broad or universal
umbilical cord blood gas collection at the
time of delivery would be a clinically
beneficial practice to better stratify
neonatal risk levels and, at minimum,
demands further investigation. n acidemia. Am J Obstet Gynecol 2003;188:
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Author and article information
From the Department of Obstetrics and Gynecology,
Oregon Health and Science University, Portland, OR.
Received April 5, 2016; revised May 22, 2016;
accepted May 24, 2016.
The authors report no conflict of interest.
Presented as a poster at the 35th Society of Maternal-
Fetal Medicine Annual Meeting, San Diego, CA, February
2-8, 2015.
Corresponding author: Bethany Sabol, MD. sabol@
ohsu.edu
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