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Seed PT, Brien SB, Oakley LL, Robinson V, Sharif J, Thompson H, Joseph J, Oteng-Ntim E. Serial prophylactic exchange blood transfusion in pregnant women with sickle cell disease (TAPS-2): statistical and qualitative analysis plan for a randomised controlled feasibility trial. Trials 2023; 24:225. [PMID: 36964626 PMCID: PMC10037353 DOI: 10.1186/s13063-023-07235-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/10/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND There are significant knowledge gaps regarding the effectiveness of serial prophylactic exchange blood transfusion (SPEBT) for pregnant women with sickle cell disease (SCD). The protocol for the randomised feasibility trial assessing SPEBT versus usual care in women with SCD (TAPS2 trial) has previously been published. This publication outlines the statistical and qualitative analysis plan for the study. METHODS AND DESIGN TAPS2 is a randomised two-arm phase 2 feasibility trial with a nested qualitative study and health economic evaluation. Up to 50 pregnant women with SCD and a singleton pregnancy will be recruited and individually randomised to either SPEBT approximately every 6-10 weeks until delivery (intervention arm) or to usual care (control arm). Information will be collected on a range of feasibility and clinical outcomes. RESULTS Due to the impact of COVID-19 on study recruitment, the initial study period of 24 months was extended to 48 months. Other protocol updates designed to mitigate the impact of COVID-19-related disruption included allowing for remote consent and conducting all qualitative interviews by telephone. The primary outcome for the trial is the overall recruitment rate. The number of women screened, eligible, consented, randomised and withdrawn will be summarised as a CONSORT flow diagram. Differences in clinical outcomes will additionally be presented as an initial assessment of efficacy and to inform sample size calculations for a future definitive trial. Qualitative interviews with trial participants and clinicians will be analysed using reflexive thematic analysis; data from interviews with participants who declined to participate in the trial will be extracted and incorporated into summary tables to report key findings. The health economic analysis plan is not covered by this update. CONCLUSION The publication of this analysis plan is designed to aid transparency and to reduce the potential for reporting bias. TRIAL REGISTRATION NIH registry ( www. CLINICALTRIALS gov ), registration number NCT03975894 (registered 05/06/19); ISRCTN ( www.isrctn.com ), registration number ISRCTN52684446 (retrospectively registered 02/08/19).
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Affiliation(s)
- Paul T Seed
- Division of Women's Health, King's College London, 10th floor North Wing, St Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK
| | - Sarah B Brien
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, SO16 6YD, UK
| | - Laura L Oakley
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
- Centre for Fertility and Health, Norwegian Institute of Public Health, Skøyen, P.O. box 222, N-0213, Oslo, Norway.
| | - Vicky Robinson
- Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Joseph Sharif
- Manchester University NHS Foundation Trust, Oxford Road, Manchester, M13 9WL, UK
| | - Hilary Thompson
- Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Jeannine Joseph
- Patient author, c/o Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Eugene Oteng-Ntim
- Division of Women's Health, King's College London, 10th floor North Wing, St Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH, UK
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
- Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
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do Kleyton Palmeira Ó, da Silva Freire AK, de Nóbrega DN, Dos Santos Souza R, Farias ICC, de Mendonça Belmont TF, da Silva AS, da Silva Arcanjo G, da Silva Araujo A, Dos Anjos ACM, de Araujo ARL, Bezerra MAC, de Moura PMMF, do Socorro Mendonça Cavalcanti M, Vasconcelos LRS. Polymorphisms and gene expression of metalloproteinases and their inhibitors associated with cerebral ischemic stroke in young patients with sickle cell anemia. Mol Biol Rep 2023; 50:3341-3353. [PMID: 36720795 DOI: 10.1007/s11033-023-08262-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 01/09/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND Sickle cell anemia (SCA) is a genetic disease with great clinical heterogeneity and few viable strategies for treatment; hydroxyurea (HU) is the only widely used drug. Thus, the study of single nucleotide polymorphisms (SNPs) and the gene expression of MMPs 1, 2, 9, 7 and TIMPs 1 and 2, which are involved in the regulation of extracellular matrix, inflammation, and neuropathies, may provide further insights into the pathophysiology of the disease and elucidate biomarkers and molecules as potential therapeutic targets for patients with SCA. METHODS AND RESULTS We evaluated 251 young individuals with SCA from northeastern Brazil. The groups were divided according to vaso-occlusive crisis (VOC) and cerebrovascular disease (CVD), compared to control individuals. SNP detection and gene expression assays were performed by real-time PCR, TaqMan system®. Both the expression levels of MMP1 gene, and the SNP MMP1-1607 1G/2G were associated with the risk of cerebral ischemic stroke (IS), and the expression of MMP1 was also associated with a higher frequency of VOC/year. Expression levels of MMP7, TIMP1, and TIMP2 were increased in patients conditioned to IS. The SNP 372T>C (rs4898) TIMP1 T alleles were more frequent in patients with > 5 VOC events/year. The SNP rs17576 of MMP9 showed differences in gene expression levels; it was increased in the genotypes AG, and AG+GG. CONCLUSION The findings of this study, the SNPs, and expression provide initial support for understanding the role of MMPs-TIMPs in the pathophysiology of SCA in young patients.
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Affiliation(s)
- Ó do Kleyton Palmeira
- Instituto Aggeu Magalhães Research Center - IAM-FIOCRUZ-PE, Av. Professor Moraes Rego, S/N, Recife, PE, 50.740-465, Brazil
| | - Ana Karla da Silva Freire
- Institute of Biological Sciences and Faculty of Medical Sciences, University of Pernambuco, Recife, PE, Brazil
| | - Débora Nascimento de Nóbrega
- Instituto Aggeu Magalhães Research Center - IAM-FIOCRUZ-PE, Av. Professor Moraes Rego, S/N, Recife, PE, 50.740-465, Brazil
| | - Roberta Dos Santos Souza
- Instituto Aggeu Magalhães Research Center - IAM-FIOCRUZ-PE, Av. Professor Moraes Rego, S/N, Recife, PE, 50.740-465, Brazil
| | | | | | - Andreia Soares da Silva
- Institute of Biological Sciences and Faculty of Medical Sciences, University of Pernambuco, Recife, PE, Brazil
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Light J, Boucher M, Baskin-Miller J, Winstead M. Managing the Cerebrovascular Complications of Sickle Cell Disease: Current Perspectives. J Blood Med 2023; 14:279-293. [PMID: 37082003 PMCID: PMC10112470 DOI: 10.2147/jbm.s383472] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 03/31/2023] [Indexed: 04/22/2023] Open
Abstract
The importance of protecting brain function for people with sickle cell disease (SCD) cannot be overstated. SCD is associated with multiple cerebrovascular complications that threaten neurocognitive function and life. Without screening and preventive management, 11% of children at 24% of adults with SCD have ischemic or hemorrhagic strokes. Stroke screening in children with SCD is well-established using transcranial Doppler ultrasound (TCD). TCD velocities above 200 cm/s significantly increase the risk of stroke, which can be prevented using chronic red blood cell (RBC) transfusion. RBC transfusion is also the cornerstone of acute stroke management and secondary stroke prevention. Chronic transfusion requires long-term management of complications like iron overload. Hydroxyurea can replace chronic transfusions for primary stroke prevention in a select group of patients or in populations where chronic transfusions are not feasible. Silent cerebral infarction (SCI) is even more common than stroke, affecting 39% of children and more than 50% of adults with SCD; management of SCI is individualized and includes careful neurocognitive evaluation. Hematopoietic stem cell transplant prevents cerebrovascular complications, despite the short- and long-term risks. Newer disease-modifying agents like voxelotor and crizanlizumab, as well as gene therapy, may treat cerebrovascular complications, but these approaches are investigational.
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Affiliation(s)
- Jennifer Light
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria Boucher
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jacquelyn Baskin-Miller
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mike Winstead
- Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Correspondence: Mike Winstead, Division of Pediatric Hematology-Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, Chapel Hill, NC, USA, Tel +1 919-966-1178, Fax +1 919-966-7629, Email
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Liu Y, Hesse LE, Geiger MK, Zinn KR, McMahon TJ, Chen C, Spence DM. A 3D-printed transfusion platform reveals beneficial effects of normoglycemic erythrocyte storage solutions and a novel rejuvenating solution. LAB ON A CHIP 2022; 22:1310-1320. [PMID: 35258064 PMCID: PMC9235508 DOI: 10.1039/d2lc00030j] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
A set of 3D-printed analytical devices were developed to investigate erythrocytes (ERYs) processed in conventional and modified storage solutions used in transfusion medicine. During storage, prior to transfusion into a patient recipient, ERYs undergo many chemical and physical changes that are not completely understood. However, these changes are thought to contribute to an increase in post-transfusion complications, and even an increase in mortality rates. Here, a reusable fluidic device (fabricated with additive manufacturing technologies) enabled the evaluation of ERYs prior to, and after, introduction into a stream of flowing fresh ERYs, thus representing components of an in vivo ERY transfusion on an in vitro platform. Specifically, ERYs stored in conventional and glucose-modified solutions were assayed by chemiluminescence for their ability to release flow-induced ATP. The ERY's deformability was also determined throughout the storage duration using a novel membrane transport approach housed in a 3D-printed scaffold. Results show that hyperglycemic conditions permanently alter ERY deformability, which may explain the reduced ATP release, as this phenomenon is related to cell deformability. Importantly, the reduced deformability and ATP release were reversible in an in vitro model of transfusion; specifically, when stored cells were introduced into a flowing stream of healthy cells, the ERY-derived release of ATP and cell deformability both returned to states similar to that of non-stored cells. However, after 1-2 weeks of storage, the deleterious effects of the storage were permanent. These results suggest that currently approved hyperglycemic storage solutions are having adverse effects on stored ERYs used in transfusion medicine and that normoglycemic storage may reduce the storage lesion, especially for cells stored for longer than 14 days.
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Affiliation(s)
- Yueli Liu
- Departments of Chemistry, Michigan State University, East Lansing, MI, 48824, USA
| | - Laura E Hesse
- Departments of Chemistry, Michigan State University, East Lansing, MI, 48824, USA
| | - Morgan K Geiger
- Biomedical Engineering, Michigan State University, East Lansing, MI, 48824, USA.
- Institute for Quantitative Health Sciences and Engineering, Michigan State University, East Lansing, MI, 48824, USA
| | - Kurt R Zinn
- Biomedical Engineering, Michigan State University, East Lansing, MI, 48824, USA.
- Institute for Quantitative Health Sciences and Engineering, Michigan State University, East Lansing, MI, 48824, USA
| | - Timothy J McMahon
- Department of Medicine, Duke University, Durham, North Carolina, 27710, USA
| | - Chengpeng Chen
- Department of Chemistry and Biochemistry, University of Maryland Baltimore County, Baltimore, MD, 21250, USA
| | - Dana M Spence
- Biomedical Engineering, Michigan State University, East Lansing, MI, 48824, USA.
- Institute for Quantitative Health Sciences and Engineering, Michigan State University, East Lansing, MI, 48824, USA
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Sporns PB, Fullerton HJ, Lee S, Kim H, Lo WD, Mackay MT, Wildgruber M. Childhood stroke. Nat Rev Dis Primers 2022; 8:12. [PMID: 35210461 DOI: 10.1038/s41572-022-00337-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 01/09/2023]
Abstract
Stroke is an important cause of neurological morbidity in children; most survivors have permanent neurological deficits that affect the remainder of their life. Stroke in childhood, the focus of this Primer, is distinguished from perinatal stroke, defined as stroke before 29 days of age, because of its unique pathogenesis reflecting the maternal-fetal unit. Although approximately 15% of strokes in adults are haemorrhagic, half of incident strokes in children are haemorrhagic and half are ischaemic. The causes of childhood stroke are distinct from those in adults. Urgent brain imaging is essential to confirm the stroke diagnosis and guide decisions about hyperacute therapies. Secondary stroke prevention strongly depends on the underlying aetiology. While the past decade has seen substantial advances in paediatric stroke research, the quality of evidence for interventions, such as the rapid reperfusion therapies that have revolutionized arterial ischaemic stroke care in adults, remains low. Substantial time delays in diagnosis and treatment continue to challenge best possible care. Effective primary stroke prevention strategies in children with sickle cell disease represent a major success, yet barriers to implementation persist. The multidisciplinary members of the International Pediatric Stroke Organization are coordinating global efforts to tackle these challenges and improve the outcomes in children with cerebrovascular disease.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic of Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Heather J Fullerton
- Departments of Neurology and Pediatrics, Benioff Children's Hospital, University of California at San Francisco, San Francisco, CA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Helen Kim
- Departments of Anesthesia and Perioperative Care, and Epidemiology and Biostatistics, Center for Cerebrovascular Research, University of California at San Francisco, San Francisco, CA, USA
| | - Warren D Lo
- Departments of Pediatrics and Neurology, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Mark T Mackay
- Department of Neurology, Royal Children's Hospital, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Moritz Wildgruber
- Department of Radiology, University Hospital Munich, LMU Munich, Munich, Germany.
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Clarke K, Benameur K, Wiley Z, Shin YM, Moussa M, El Rassi F, McLemore M. Catastrophic Neurological Complications in 2 Patients With Sickle Cell Disease and COVID-19. J Investig Med High Impact Case Rep 2022; 10:23247096221111778. [PMID: 35850596 PMCID: PMC9301110 DOI: 10.1177/23247096221111778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/11/2022] [Accepted: 06/18/2022] [Indexed: 11/25/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus (SARS-CoV-2) infection is commonly associated with neurological complications. Patients with sickle cell disease are at increased risk of developing neurologic complications throughout their lifetimes and often have underlying cardiopulmonary comorbidities that may predispose them to poor outcomes during serious infections. In this case series, we describe 2 patients with sickle cell disease who developed devastating neurologic complications following SARS-CoV-2 infection, which ultimately led to brain edema and death. We highlight the unusual manifestations of coronavirus disease 2019 in patients with sickle cell disease and address the risk of these patients to develop catastrophic neurologic injury due to COVID-19, if not recognized promptly.
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Affiliation(s)
- Karen Clarke
- Department of Medicine, Emory University
School of Medicine, Atlanta, GA, USA
| | - Karima Benameur
- Department of Neurology, Emory University
School of Medicine, Atlanta, GA, USA
| | - Zanthia Wiley
- Department of Medicine, Emory University
School of Medicine, Atlanta, GA, USA
| | - Yoo Mee Shin
- Department of Medicine, Emory University
School of Medicine, Atlanta, GA, USA
| | - Mohamad Moussa
- Department of Medicine, Emory University
School of Medicine, Atlanta, GA, USA
| | - Fuad El Rassi
- Department of Hematology and Medical
Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Morgan McLemore
- Department of Hematology and Medical
Oncology, Emory University School of Medicine, Atlanta, GA, USA
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Kanne CK, Nebor D, Pochron M, Oksenberg D, Sheehan VA. Rheological Impact of GBT1118 Cessation in a Sickle Mouse Model. Front Physiol 2021; 12:742784. [PMID: 34630162 PMCID: PMC8497897 DOI: 10.3389/fphys.2021.742784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
In sickle cell disease (SCD), higher whole blood viscosity is a risk factor for vaso-occlusive crisis, avascular necrosis, and proliferative retinopathy. Blood viscosity is strongly impacted by hemoglobin (Hb) levels and red blood cell (RBC) deformability. Voxelotor is a hemoglobin S (HbS) polymerization inhibitor with anti-sickling properties that increases the Hb affinity for oxygen, thereby reducing HbS polymerization. In clinical trials, voxelotor increased Hb by an average of 1g/dl, creating concern that this rise in Hb could increase viscosity, particularly when the drug was cleared. To investigate this potential rebound hyperviscosity effect, we treated SCD mice with GBT1118, a voxelotor analog, and stopped the treatment to determine the effect on blood viscosity and RBC deformability under a range of oxygen concentrations. GBT1118 treatment increased Hb, improved RBC deformability by increasing the elongation index under normoxic (EImax) and hypoxic conditions (EImin), and decreased the point of sickling (PoS) without increasing blood viscosity. The anti-sickling effects and improvement of RBC deformability balanced the effect of increased Hb such that there was no increase in blood viscosity. Forty-eight hours after ceasing GBT1118, Hb declined from the rise induced by treatment, viscosity did not increase, and EImin remained elevated compared to control animals. Hb and PoS were not different from control animals, suggesting a return to native oxygen affinity and clearance of the drug. RBC deformability did not return to baseline, suggesting some residual rheological improvement. These data suggest that concerns regarding viscosity rise above pre-treatment levels upon sudden cessation of voxelotor are not warranted.
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Affiliation(s)
- Celeste K. Kanne
- Aflac Cancer & Blood Disorders Center Children’s Healthcare of Atlanta, School of Medicine, Emory University, Atlanta, GA, United States
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
| | - Danitza Nebor
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
| | - Mira Pochron
- Global Blood Therapeutics, South, San Francisco, CA, United States
| | - Donna Oksenberg
- Global Blood Therapeutics, South, San Francisco, CA, United States
| | - Vivien A. Sheehan
- Aflac Cancer & Blood Disorders Center Children’s Healthcare of Atlanta, School of Medicine, Emory University, Atlanta, GA, United States
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, TX, United States
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Abstract
Sickle cell disease (SCD) is an inherited disorder that occurs due to point mutation in the beta-globin chain resulting in the production of hemoglobin S that tends to become rigid and sickle-shaped under low oxygen concentration. These sickle-shaped red blood cells (RBCs) obstruct the blood vessels leading to reduced blood flow to the organs, causing ischemia and tissue fibrosis. These sickle RBCs being abnormal in shape are frequently sequestered by the spleen, creating a state of chronic anemia in the body. This chronic anemia leads to a high cardiac output state causing cardiac remodeling. To tackle chronic anemia, patients are frequently treated with blood transfusions that makes them more prone to the risk of iron overload (from newly transfused RBCs and iron release from the RBCs that just got sequestered as well as from volume overload) and volume overload causing left ventricular (LV) dilation. The above-mentioned mechanism of cardiac hypertrophy, along with LV dilation together, makes SCD-related cardiomyopathy unique cardiomyopathy with features of restrictive cardiomyopathy with LV dilation. It is interesting to note here that even though there is a presence of LV dilatation, Systolic dysfunction is very uncommon in SCD-related cardiomyopathy.
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Affiliation(s)
- Harsimran Kaur
- Internal Medicine, California Institute of Behavioural Neurosciences and Psychology, Fairfield, USA
| | - Fahad Aurif
- General Surgery, California Institute of Behavioural Neurosciences and Psychology, Fairfield, USA
| | - Mahdi Kittaneh
- General and Laparoscopic Surgery, California Institute of Behavioural Neurosciences and Psychology, Fairfield, USA
| | - Jeoffrey Patrick G Chio
- Family Medicine, California Institute of Behavioural Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioural Neurosciences and Psychology, Fairfield, USA
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