United States

Background: Life adversities, such as neighborhood disadvantage and lower household incomes, are associated with well-established impairments on language development, which predict academic difficulties throughout school. These language delays are observable by age 2, but it remains unclear if adversities experienced in utero affect neurological underpinnings of language development before delays emerge. Of interest are 3 white matter tracts implicated in early language skills: the corpus callosum (CC), inferior fronto-occipital fasciculus (IFOF), and uncinate (Unc).

Methods: A longitudinal cohort of 160 term-born (&gt;36 weeks gestation) neonates were recruited from the eLABE study at Washington University, which oversampled St. Louis families exposed to poverty. Structural equation modeling was used to create 2 latent constructs of prenatal adversity. The first, “social disadvantage”, aggregates neighborhood disadvantage, family income, insurance status, maternal education, and diet. The second, “maternal psychosocial stress”, models maternal depression, stress, life adversities, and perceived discrimination. At birth, diffusion MRI data were collected, and parameters for white matter tract development were created using probabilistic tractography in FSL. In-person follow-up at age 2 evaluated child language skills. To assess the independent and interactive effects of prenatal adversities and neonatal white matter microstructure on language skills, stepwise linear regression models were conducted after adjustment for child sex, gestational age, and postmenstrual age at scan. 


Results: Prenatal social disadvantage (p=.00) and maternal psychosocial stress (p=.00) predicted significantly lower language scores by age 2. However, in a joint model, only the effects due to social disadvantage remained significant. Lower CC fractional anisotropy predicted significantly lower language scores (p=.02) independently of social disadvantage (p=.00). IFOF and Unc were not predictive of language ( p &gt; .05). To examine the relationship between CC maturation and social disadvantage, a moderation analysis was conducted after dichotomizing families’ income into above and below 200% the federal poverty line (FPL), as most federal assistance programs use this value as a threshold for benefit eligibility. The interaction term was not significant (p= .11), but upon plotting results by income group, the slope for infants above 200% FPL was somewhat stronger. 

Conclusion: This study suggests that prenatal adversity, particularly social disadvantage, and immature CC myelination are strong predictors of language delays by age 2. These data can be used as empirical evidence to advocate for increased funding of federal assistance programs that benefit pregnant people (ex., WIC) and downstream fetal brain development. By continuing to explore the relationship between prenatal adversities on fetal brain development and emerging language skills, future studies will continue to identify specific neurological markers of early language development to allow clinicians to intervene before delays emerge.

2023 AMA Research Challenge

The Effects of Prenatal Adversity and Neonatal White Matter Microstructure on Child Language Skills at Age 2

Background: Life adversities, such as neighborhood disadvantage and lower household incomes, are associated with well-established impairments on language development, which predict academic difficulties throughout school. These language delays are observable by age 2, but it remains unclear if adversities experienced in utero affect neurological underpinnings of language development before delays emerge. Of interest are 3 white matter tracts implicated in early language skills: the corpus callosum (CC), inferior fronto-occipital fasciculus (IFOF), and uncinate (Unc).

Methods: A longitudinal cohort of 160 term-born (>36 weeks gestation) neonates were recruited from the eLABE study at Washington University, which oversampled St. Louis families exposed to poverty. Structural equation modeling was used to create 2 latent constructs of prenatal adversity. The first, “social disadvantage”, aggregates neighborhood disadvantage, family income, insurance status, maternal education, and diet. The second, “maternal psychosocial stress”, models maternal depression, stress, life adversities, and perceived discrimination. At birth, diffusion MRI data were collected, and parameters for white matter tract development were created using probabilistic tractography in FSL. In-person follow-up at age 2 evaluated child language skills. To assess the independent and interactive effects of prenatal adversities and neonatal white matter microstructure on language skills, stepwise linear regression models were conducted after adjustment for child sex, gestational age, and postmenstrual age at scan. 


Results: Prenatal social disadvantage (p=.00) and maternal psychosocial stress (p=.00) predicted significantly lower language scores by age 2. However, in a joint model, only the effects due to social disadvantage remained significant. Lower CC fractional anisotropy predicted significantly lower language scores (p=.02) independently of social disadvantage (p=.00). IFOF and Unc were not predictive of language ( p > .05). To examine the relationship between CC maturation and social disadvantage, a moderation analysis was conducted after dichotomizing families’ income into above and below 200% the federal poverty line (FPL), as most federal assistance programs use this value as a threshold for benefit eligibility. The interaction term was not significant (p= .11), but upon plotting results by income group, the slope for infants above 200% FPL was somewhat stronger. 

Conclusion: This study suggests that prenatal adversity, particularly social disadvantage, and immature CC myelination are strong predictors of language delays by age 2. These data can be used as empirical evidence to advocate for increased funding of federal assistance programs that benefit pregnant people (ex., WIC) and downstream fetal brain development. By continuing to explore the relationship between prenatal adversities on fetal brain development and emerging language skills, future studies will continue to identify specific neurological markers of early language development to allow clinicians to intervene before delays emerge.

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Background
Breast cancer related lymphedema effects one in five breast cancer survivors. This debilitating complication is due to transection and obstruction of lymph flow during surgery. Although lymphedema has been met with new surgical and clinical treatments, little is known about the anatomy of the lymphatic system. Diagnostic dyes have become a vital tool in surgery and lymphatic mapping. Microsurgeons utilize florescent Indocyanine green (ICG) distally in extremities to identify afferent lymphatic pathways. In immediate lymphatic reconstruction (ILR) following mastectomies, ICG helps microsurgeons locate transected channels for anastomosis to a neighboring vein, restoring lymph flow. Isosulfane blue (ISB) is an easily visible dye favored by breast surgeons. In axillary reverse mapping, surgeons inject ISB into the proximal upper extremity, allowing them to locate and preserve lymphatic channels wherever possible. The benefit of utilizing both ICG and ISB during axillary dissection and ILR is reliable visualization of lymphatics intraoperatively. Using dual-dye technique, we aim to differentiate afferent lymphatic drainage from the distal and proximal upper extremity into the axilla.

Methods
To identify the distal and proximal lymphatic zones in breast cancer patients receiving ILR following axillary dissection, ICG and ISB were injected in the ipsilateral arm. ICG was injected intradermally at the first and third webspace and volar wrist, while ISB was injected at the same depth into the upper medial arm. Operative reports were reviewed to determine how often each dye was visualized during axillary dissection. Details of the anastomoses were also documented.

Results
Twenty-six breast cancer patients undergoing ILR following axillary lymph node dissection were reviewed. Twenty-one patients met the criteria of dual-dye technique. ICG was seen in 100% of axillary dissections. ISB was seen with ICG in 61.9% of procedures, indicating a shared lymphatic pathway. ISB was never seen alone. The average lumen size of all lymphatic channels was 1.12mm. An average of 2.46 channels were bypassed to an average of 1.65 veins per procedure. Venous lumen size ranged from 1 to 3 mm. 

Conclusion
Dual-dye technique allows for visualization of axillary lymphatic drainage by the breast and plastic surgeons intraoperatively. Utilizing dyes with different visual properties enabled us to determine if lymphatic flow originated from the distal or proximal upper extremity. This technique could provide useful anatomic data in correlating the development of lymphedema to regional lymphatic drainage within the arm, allowing potential anastomotic connections and clinical treatments. 


Differentiating Afferent Lymphatic Pathways Using Dual-Dye Technique During Immediate Lymphatic Reconstruction

Background: Clinical Practice Guidelines (CPGs) aim to offer guidance to physcians to improve patient outcomes. The Reporting Items for Practice Guidelines in Healthcare (RIGHT) Working Group created a set of rules for CPGs to aid guideline presentation and communication. CPGs in Plastic and Reconstructive surgery have not yet been evaluated by CPG metrics, such as RIGHT. This investigation aims to assess and recognize areas for improvement in currently available guidelines. 
Methods: Three reviewers extracted and reviewed all 5 guidelines listed on the American Society of Plastic Surgeons (ASPS) website in March 2023 and scored them according to the RIGHT checklist. RIGHT criteria in the form of 22 distinct statements were broken down into 35 items, and guidelines were assigned a “1” if they met the criteria and a “0” otherwise. Interrater agreeability through Fleiss’s kappa scores calculated for each guideline. 
Results: Among the 5 PRS guidelines checked against the RIGHT criteria, Fleiss’s kappa interrater agreeability ranged from 0.762 to 0.962, indicating strong agreement among independent raters. However, 4 (22.9%) RIGHT items were not met by any ASPS guidelines. There was a mean adherence of 21 RIGHT items. Guidelines were most lacking in categories concerning reporting of quality and review processes. 
Conclusion: Overall, many RIGHT framework recommendations were met fully by ASPS guidelines, but there is room for improvement in disclosure of the guideline development process. By evaluating fidelity to the RIGHT checklist, specific and actionable opportunities for improvement to guideline language and reporting can be implemented after identification.

Evaluation of Plastic Surgery Clinical Practice Guidelines Using the RIGHT Checklist

Background:
First-line treatment for major depressive disorder (MDD) include cognitive behavioral therapy (CBT) and/or antidepressant medications (ADM). However, these treatments can be highly effective in one patient but ineffective in another. Previous treatment selection biomarker studies using resting state fMRI implicate differential subcallosal connectivity to the left anterior insula, left ventromedial prefrontal, and left periaqueductal gray in CBT and medication remitters (Dunlop AJP 2017). Structural connectivity changes that might mediate these functional connectivity patterns are unknown. Therefore, we evaluated pretreatment White matter (WM) integrity in treatment naïve MDD patients as a function of differential 3-month clinical outcome to monotherapy with CBT or ADM. 
Methods
A retrospective analysis of diffusion-weighted imaging scans (DWI) was performed in 167 treatment naive MDD patients randomized to 12 weeks of CBT or ADM. Subjects were grouped into CBT or ADM remitters (HDRS17 score <7 at 10 and 12 weeks) and CBT or ADM failure (HDRS score change <30%). A Whole brain fractional anisotropy (FA) map was calculated for each subject using Fdt toolbox in FMRIB and Tract-Based Spatial Statistics (TBSS) generated for statistical comparison across outcome groups. A voxel-wise 2 x 2 ANOVA: treatment (CBT/ADM) by outcome (remitter/nonresponder) was performed using the AFNI 3dMVM toolbox. Lastly, regional WM changes were correlated with HDRS score changes with treatment. 
Results
A significant treatment by outcome interaction was identified affecting WM tracts adjacent to the left anterior insula, left supplementary motor area, and left hippocampus (p < 0.001). Post hoc analysis revealed ADM remitters and CBT nonresponders show higher FA values in the left insula and SMA compared to both ADM nonresponders and CBT remitters, similar to the location and differential pattern of functional connectivity. In contrast, ADM remitters and CBT nonresponders show lower FA in the left hippocampus compared to ADM nonresponders and CBT remitters. The left SMA and hippocampus showed significant correlation (R2=0.05 p<0.005) with HDRS score improvement in all groups. The VMPFC and SMA showed similar results within the ADM group. The CBT group showed significant correlation with the DLPFC (R2=0.17 p<0.005).
Conclusion
These findings identify differential WM integrity in WM tracts adjacent to the insula, SMA, and hippocampus in remitters and failures to CBT and ADM. These structural and functional connectivity patterns may define imaging biotypes that guide optimal first line MDD treatment selection. Finally, these findings implicate WM connectivity in differential predictive outcomes in MDD treatment success by treatment.

White matter markers for treatment outcomes in major depressive disorder

Background
Pack-year history is an invaluable clinical tool for measuring tobacco-associated disease risk and determining eligibility for lung cancer screening with low-dose computed tomography. Patient-reported measures of smoking history have demonstrated strong test-retest reliability across various survey methods, but the variation between research and clinical settings suggests that non-standardized smoking history interview questions in community practice may not always reveal the true extent of a patient’s tobacco exposure. To date, no study has compared patient responses to differently phrased questions assessing the same measure of smoking history. We hypothesize there is a significant discordance between patient-reported number of years smoked and calculated elapsed time between age at initiation and age at cessation (or present age if current smoker).

Methods
This was a two-month prospective survey-based study conducted at the Western Michigan University Homer Stryker M.D. School of Medicine's Internal Medicine resident clinic in Kalamazoo, Michigan, including patients with a documented smoking history in their electronic medical records. Through verbal interviews, we collected data on number of years smoked, packs per day, and age of smoking initiation/cessation. Primary outcome variables were total years smoked and calculated pack-years. Secondary outcome variables were gender, age, and age of smoking initiation.

Results
There were 124 respondents (36% male, 63% female, 1% non-binary) with an average age of 55 and average smoking history of 1.2 packs per day. Of them, 46% were current and 54% were former smokers. Using a paired sample one-tail t-test, we compared patient-reported years smoked (M=22.06, SD=12.44) to calculated years based on age of initiation/cessation (M=24.03, SD=13.53), which showed a significant mean difference of 1.97 years (95% CI 1.16- 2.78, t=4.05, p<0.001). This discordance translated to a 21.29% increase in pack-years (from 24.32 to 29.50 pack-years) and a mean difference of 5.21 pack-years (95% CI 1.04-9.38, t=2.07, p=0.02).

Conclusion
Our study underscores the importance of critically evaluating the ways in which we gather a patient’s smoking history. When compared to pack-years calculated using age of smoking initiation/cessation, our sample population tended to underestimate their exposure by over 5 pack-years—a clinically significant difference for someone at high risk who might not otherwise receive screening imaging. Often a pivotal moment in adolescence, participants recalled their age of smoking initiation with greater precision compared to their estimations of total exposure. These results call for urgent reevaluation of the tobacco history interview, its notation in electronic medical records, and the methodology of taking a substance abuse history in general.

Rethinking the Smoking History Interview: A Prospective Survey-based Study

Using deep learning to augment radiologist interpretation of brain MRIs for Alzheimer’s disease

Objective: Femoral endarterectomy is a common vascular procedure. Previous data have shown that it is associated with elevated risk of surgical site infection (SSI) that is estimated to be 15% or higher. Obesity is a known risk factor for SSI. Presence of an overhanging pannus may be associated with increased risk of wound infections, due to decreased local hygiene and increased frictional forces. The aim of the current study was to study the relationship between pannus size and SSI after femoral endarterectomy performed at a rural tertiary medical center. 
Methods: Retrospective chart review was used to evaluate femoral endarterectomy performed between January 1, 2010 and December 31, 2019. Patients were excluded if they did not have a CTA or CT abdomen/pelvis within 6 months of endarterectomy. Cases were identified using CPT code, and basic demographic data and preoperative risk factors were identified. Incidence of postoperative wound infection was recorded. Perioperative CT scans were evaluated using TeraRecon to measure the area of the subcutaneous tissue overlying the common femoral artery on the operative leg, hypothesized to be a surrogate for pannus size. 
Results: The total number of participants was 250, with a 17% incidence of SSI. There was a significant difference in pannus size in those who developed postoperative SSI (30.5 cm2 ± 17.2 cm2) compared to those who did not (24.5 cm2 ± 13.7 cm2) (p =0.022). Pannus area was on average 6cm2 larger in those who developed postoperative SSI. BMI, obesity, hypertension, and diabetes were associated with pannus area but were not strong predictors of SSI. BMI and pannus size were strongly correlated, although BMI was more variable as pannus size increased. A 5cm2 increase in pannus size was associated with an absolute relative risk of SSI of 1.10. In patients with pannus size ≤26cm2, 12% had an SSI; in patients with pannus >26cm2, 24% had an SSI; the relative risk of SSI for pannus >26cm2 was 1.99. 
Conclusions: This study highlights a novel method to measure pannus size, which is a stronger predictor than BMI alone for postoperative SSI after femoral endarterectomy. This can help guide preoperative risk identification and decision making, and assign more aggressive postoperative infection prevention measures to patients at risk of SSI.

Relation of pannus size to postoperative wound infection after femoral endarterectomy

Background
Physician burnout, characterized by emotional exhaustion and a diminished sense of personal accomplishment, affects nearly 25% to 60% of primary care physicians (PCPs). With the ever- increasing burden of non-clinical tasks that compete with direct patient care, burnout rates are only projected to increase. Machine learning (ML), a subset of artificial intelligence where computers learn and make decisions from data, has been previously applied to healthcare to optimize processes and enhance decision-making. We hypothesized that ML-based natural language processing (NLP) could streamline non-clinical tasks by automating patient assessment form (PAF) completion for outpatient PCPs.

Methods
We developed and internally validated a ML-enabled workflow that combined note extraction from the EMR, protected health information de-identification, and NLP and federated learning to automate PAF completion. PAFs were auto-populated with ICD-10 codes matched directly to patient clinic notes. We externally validated our workflow in a real-world setting by applying it to a primary care clinic serving patients who are Medicare Advantage beneficiaries, following their annual wellness visits. PCPs then reviewed and approved completed PAFs with one click, triggering the workflow to auto-generate screening orders for at-risk patients.

Results
Our ML-enabled workflow was trained on data from 6,000 synthetic notes and achieved a ten-fold cross-validation accuracy of 96%. We further externally validated our workflow in a real-world, suburban outpatient clinic. Over five months, PAFs were completed for 179 patients, requiring only six hours of provider review time with a 99.4% approval rate. Compared to the previous year, the ML workflow decreased manual work from 30 hours across three staff to six hours for one provider, yielding overhead savings of $1,680, reimbursement incentives of $8,365, and an additional $8,480 from increased patient engagement. The system also led to a 3.2x increase in preventative and diagnostic order submissions for at-risk patients who have historically failed to complete necessary screenings.

Conclusion
Our study demonstrates the application of AI and ML in improving healthcare providers' operational efficiency and fiscal accountability, as well as enhancing patient care management, particularly for at-risk individuals needing preventative and diagnostic screenings. While future studies could expand on this preliminary data to investigate impacts on metrics like CMS Star and risk adjustment factor (RAF), the current results underline the potential for time savings, reduced healthcare costs, and improved provider satisfaction and rates of burnout. Given these promising findings, further exploration and development of ML-based workflows in healthcare are warranted.

Utilizing a ML-Enabled EMR Provider Workflow to Improve Non-Clinical Tasks

Background
Racial minorities and socioeconomically disadvantaged populations are commonly insured through the government-funded Medicaid program. Medicaid has historically not covered the cost of care for these populations. Additionally, these populations often suffer from nonmedical social determinants of health, further increasing the cost of their care. The goal of this study was to determine the impact of Medicaid funding on the profit margins of academic medical centers (AMCs), both governments funded (GAMCs) and non-profit (NPAMCs).

Methods
We used institutional financial data from the National Academy for State Health Policy and Rice University’s Baker Institute of Public Policy, available between 2011 and 2019. The data set included 4,128 hospitals of which 452 were registered with the Association of American Medical Colleges and reported non-profit or government ownership. Aggregate panel data were analyzed by year and medical center. The primary outcome was net profit margin defined as the net income divided by net patient revenue. The main exposure of interest was Medicaid coverage, defined as the proportion of admissions at the hospital level with Medicaid as the primary insurer. Linear regression models examined the impact of Medicaid coverage on net profit margin when adjusted for facility size. Profit margin change was described using basis points – a financial unit of measure where a 1% change is equivalent to 100 basis points.

Results
We identified 378 AMCs under non-profit and 74 AMCs under government ownership. On average Medicaid insurance coverage represented 16% and 20% (p<0.001) of the payor mix among NPAMCs vs. GAMCs, respectively. Increasing proportion of Medicaid coverage was significantly associated with decreasing net profit margins, regardless of institution type. However, the magnitude of profit margin change was more substantial among government centers. For GAMCs, every 1% or 100 basis point increase in Medicaid proportion was associated with an average profit margin decrease of 0.19% or 19 basis points (p=0.002). For NPAMCs, every 1% or 100 basis point increase in Medicaid proportion was associated with an average profit margin decrease of 0.13% or 13 basis points (p=0.001).


Conclusion
Our findings highlight the negative impact of Medicaid funding on profit margins of academic medical centers. This leads to a vicious cycle in which the hospitals that treat high number of these vulnerable, Medicaid-insured patient cohorts become financially drained and unable to invest in capital expenditures and personnel resources. The resulting hospital-level resource depletion impacts access and quality of care for disadvantaged patient populations, and greatly augments health care disparities.

Medicaid Health Insurance Associated with Decreasing Profit Margins among Academic Medical Centers

Background: Tumor lysis syndrome (TLS) is an oncologic emergency that can occur spontaneously or after chemotherapy administration. Rasburicase, allopurinol, and intravenous fluids are the cornerstone treatments for hyperuricemia. Unfortunately, there is a lack of consistent and evidence-based pattern usage of rasburicase in clinical practice. Inappropriate use can range from 30 to 70%, which leads to institutional financial toxicity, in addition to the unnecessary side effects from rasburicase. Therefore, every attempt should be made to ensure that clinicians follow established TLS guidelines when prescribing rasburicase. 
Methods: Change in the Electronic Medical Record (EMR) system was implemented to add an order set for rasburicase in September 2021. Instead of the previous version of a single-click, ready-to-sign order, the newly incorporated order set had multiple selections that followed a guideline-based algorithm with the aim to ensure the appropriateness of rasburicase use. To investigate if the intervention was successful, all rasburicase orders were reviewed and compared for appropriateness by segregating them into 2 groups (A) before intervention (March-September 2021), and (b) after intervention (October 2021-April 2022). Statistical analysis was done using chi-square, and T-test for categorical and continuous variables respectively.
Results: The study included 67 patients from March 2021-April 2022 [n=31 in pre-intervention, and n=36 in the post-intervention group] (Table 1). Most of the patients had hematological malignancies both in the pre-intervention (n=22/31) and post-intervention group (n=28/36). We found that with the intervention, there was a significant improvement in the percentage of clinicians following the appropriate guidelines while prescribing rasburicase (67.74% versus 88.96%; p = 0.03). With the implementation of this new order set, we were able to reduce inappropriate orders by 21.22%. A review of inappropriate orders showed that isolated hyperuricemia of <12 mg/dL (without TLS) was the most common reason for prescribing rasburicase (n=4/10; 40% in pre-intervention and 3/4; 75% in the post-intervention group). We also noted that 25.81%, and 16.67% of the patients in the pre-, and post-intervention groups were not prescribed allopurinol, respectively (p<0.001). 
Conclusion: A newly implemented and multistep, algorithm-based order set helped us to reduce inappropriate rasburicase use, which significantly reduced unwanted side effects, and also financial toxicity.

Implementation Of A New Electronic Medical Record Algorithm To Streamline The Appropriate Use Of Rasburicase

Background:
Arab Americans are one of the largest ethnic groups in the United States. However, the mental health of Arab Americans and their opinions on mental health remain largely understudied despite high rates of mental illness and lower rates of treatment. Unique cultural conceptualizations of mental illness might generate stigma, which contributes to disparities in treatment. We assessed the attitudes and perspectives of Arab Americans about mental illness to address barriers to treatment.

Methods:
Responses were collected through an anonymous bilingual Qualtrics survey from both Arab and non-Arab participants aged 18-years and older. Participants were assessed on stigma towards mental illness and mental health treatment. conceptualizations of mental illness origins, preferred resources for treatment, and perceived barriers to accessing treatment. Comparisons were performed between Arabs and non-Arabs and among Arabs using different demographic parameters. Data analysis was conducted on SPSS using chi-squared analyses, ANCOVA, and T-tests. 

Results:
Compared to non-Arabs, Arabs have significantly higher average stigma towards mental illness (t(292) = -3.42, p < .001) and were more likely to rate psychiatric medications as addictive and unhelpful (t(292) = -2.93, p = .004; t(292) = -3.09, p = .013). Additionally, among Arabs, being Christian, male, and older increased stigma (t(194) = 2.10, p=.037; t(216) = 4.889, p < .001; t(216) = 2.16, p = .037). Regarding beliefs about mental illness, Arabs were less likely to believe in a biological explanation for mental illness compared to non-Arabs (χ² = 10.629, p = .001). Arabs were also less likely than non-Arabs to choose treatment from a therapist or primary care provider (χ² = 5.24, p = .022; χ² = 5.001; p = .025) and more likely to defer mental health treatment entirely (χ² = 6.410; p = .011). Among Arabs, females were more likely to prefer a therapist than males (χ² = 10.562, p = .001). Finally, Arabs were more likely than non-Arabs to endorse fear of being called “crazy” and provider cultural differences as barriers to seeking mental health treatment (χ² = 6.430, p = .011; χ² = 20.274, p < .001). 

Conclusion: 
Our results demonstrate an increased stigma against mental illness among Arab Americans and hesitancy to seek treatment due to social repercussions from the community and cultural discrepancies. 

Significance:
These are among the first findings describing mental illness stigma and barriers to mental health treatment access in the Arab American population and may inform future community interventions providing culturally competent care to Arab Americans.

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The Effects of Prenatal Adversity and Neonatal White Matter Microstructure on Child Language Skills at Age 2

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Differentiating Afferent Lymphatic Pathways Using Dual-Dye Technique During Immediate Lymphatic Reconstruction