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Gaynor JW, Moldenhauer JS, Zullo EE, Burnham NB, Gerdes M, Bernbaum JC, D’Agostino JA, Linn RL, Klepczynski B, Randazzo I, Gionet G, Choi GH, Karaj A, Russell WW, Zackai EH, Johnson MP, Gebb JS, Soni S, DeBari SE, Szwast AL, Ahrens-Nicklas RC, Drivas TG, Jacobwitz M, Licht DJ, Vossough A, Nicolson SC, Spray TL, Rychik J, Putt ME. Progesterone for Neurodevelopment in Fetuses With Congenital Heart Defects: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2412291. [PMID: 38805228 PMCID: PMC11134212 DOI: 10.1001/jamanetworkopen.2024.12291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/08/2024] [Indexed: 05/29/2024] Open
Abstract
Importance Neurodevelopmental outcomes for children with congenital heart defects (CHD) have improved minimally over the past 20 years. Objectives To assess the feasibility and tolerability of maternal progesterone therapy as well as the magnitude of the effect on neurodevelopment for fetuses with CHD. Design, Setting, and Participants This double-blinded individually randomized parallel-group clinical trial of vaginal natural progesterone therapy vs placebo in participants carrying fetuses with CHD was conducted between July 2014 and November 2021 at a quaternary care children's hospital. Participants included maternal-fetal dyads where the fetus had CHD identified before 28 weeks' gestational age and was likely to need surgery with cardiopulmonary bypass in the neonatal period. Exclusion criteria included a major genetic or extracardiac anomaly other than 22q11 deletion syndrome and known contraindication to progesterone. Statistical analysis was performed June 2022 to April 2024. Intervention Participants were 1:1 block-randomized to vaginal progesterone or placebo by diagnosis: hypoplastic left heart syndrome (HLHS), transposition of the great arteries (TGA), and other CHD diagnoses. Treatment was administered twice daily between 28 and up to 39 weeks' gestational age. Main Outcomes and Measures The primary outcome was the motor score of the Bayley Scales of Infant and Toddler Development-III; secondary outcomes included language and cognitive scales. Exploratory prespecified subgroups included cardiac diagnosis, fetal sex, genetic profile, and maternal fetal environment. Results The 102 enrolled fetuses primarily had HLHS (n = 52 [50.9%]) and TGA (n = 38 [37.3%]), were more frequently male (n = 67 [65.7%]), and without genetic anomalies (n = 61 [59.8%]). The mean motor score differed by 2.5 units (90% CI, -1.9 to 6.9 units; P = .34) for progesterone compared with placebo, a value not statistically different from 0. Exploratory subgroup analyses suggested treatment heterogeneity for the motor score for cardiac diagnosis (P for interaction = .03) and fetal sex (P for interaction = .04), but not genetic profile (P for interaction = .16) or maternal-fetal environment (P for interaction = .70). Conclusions and Relevance In this randomized clinical trial of maternal progesterone therapy, the overall effect was not statistically different from 0. Subgroup analyses suggest heterogeneity of the response to progesterone among CHD diagnosis and fetal sex. Trial Registration ClinicalTrials.gov Identifier: NCT02133573.
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Affiliation(s)
- J. William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Julie S. Moldenhauer
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Erin E. Zullo
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nancy B. Burnham
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marsha Gerdes
- Department of Psychology, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Judy C. Bernbaum
- Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jo Ann D’Agostino
- Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rebecca L. Linn
- Division of Anatomic Pathology, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brenna Klepczynski
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Isabel Randazzo
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Gabrielle Gionet
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Grace H. Choi
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Antoneta Karaj
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - William W. Russell
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Elaine H. Zackai
- Division of Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mark P. Johnson
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Juliana S. Gebb
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Shelly Soni
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Suzanne E. DeBari
- Center for Fetal Diagnosis and Treatment, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anita L. Szwast
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca C. Ahrens-Nicklas
- Division of Genetics, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Theodore G. Drivas
- Division of Translational Medicine and Human Genetics, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marin Jacobwitz
- Division of Neurology, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Daniel J. Licht
- Division of Neurology, Department of Pediatrics, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Arastoo Vossough
- Division of Radiology, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Susan C. Nicolson
- Division of Cardiac Anesthesia, Department of Anesthesia and Critical Medicine, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Thomas L. Spray
- Division of Cardiothoracic Surgery, Department of Surgery, Children’s Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jack Rychik
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary E. Putt
- Department of Biostatistics, Epidemiology, and Informatics, the Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Arnaert A, Ahmed A, Debe Z, Charbonneau S, Paul S. Telehealth nursing interventions for phenotypes of older adults with COPD: an exploratory study. Front Digit Health 2023; 5:1144075. [PMID: 37808916 PMCID: PMC10558261 DOI: 10.3389/fdgth.2023.1144075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 08/01/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Inconclusive results exist around the effectiveness of telemonitoring for patients with COPD, and studies recommended conducting subgroup analyses to identify patient phenotypes that could benefit from these services. This exploratory study investigated what type of COPD patients were receiving which type of telenursing interventions more frequently using the telemonitoring platform. Methods A sample of 36 older adults with COPD were receiving telenursing services for 12 months and were asked to answer five COPD-symptom related questions and submit their vital signs daily. Results Findings revealed two phenotypes of older adults for whom the frequency of telenursing calls and related interventions differed. Although no statistically significant differences were observed in participants' GOLD grades and hospitalizations, cluster one participants used their COPD action plan significantly more frequently, and were in frequent contact with the telenurse. Discussion It is paramount that further research is needed on the development of patient phenotypes who may benefit from telemonitoring.
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Affiliation(s)
- A. Arnaert
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
| | - A.M.I. Ahmed
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
| | - Z. Debe
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
| | - S. Charbonneau
- Montreal West Island Integrated University Health and Social Service Centre, Montreal, QC, Canada
| | - S. Paul
- Ingram School of Nursing, McGill University, Montreal, QC, Canada
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DeNucci G, Wilkinson T, Sverdloff C, Babadopulos T, Woodcock A, Shute J, Renato Guazelli P, Gerbase LF, Mourão PAS, Singh D, van Haren FMP, Page C. Inhaled nebulised unfractionated heparin (UFH) for the treatment of hospitalised patients with COVID-19: A randomised controlled pilot study. Pulm Pharmacol Ther 2023; 80:102212. [PMID: 36990381 PMCID: PMC10064078 DOI: 10.1016/j.pupt.2023.102212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/07/2023] [Accepted: 03/19/2023] [Indexed: 03/29/2023]
Abstract
There is a strong scientific rationale to use nebulised unfractionated heparin (UFH) in treating patients with COVID-19. This pilot study investigated whether nebulised UFH was safe and had any impact on mortality, length of hospitalisation and clinical progression, in the treatment of hospitalised patients with COVID-19. This parallel group, open label, randomised trial included adult patients with confirmed SARS-CoV-2 infection admitted to two hospitals in Brazil. One hundred patients were planned to be randomised to either "standard of care" (SOC) or SOC plus nebulized UFH. The trial was stopped after randomisation of 75 patients due to falling COVID-19 hospitalisation rates. Significance tests were 1-sided test (10% significance level). The key analysis populations were intention to treat (ITT) and modified ITT (mITT) which excluded (from both arms) subjects admitted to ITU or who died within 24 h of randomisation. In the ITT population (n = 75), mortality was numerically lower for nebulised UFH (6 out of 38 patients; 15.8%) versus SOC (10 out of 37 patients; 27.0%), but not statistically significant; odds ratio (OR) 0.51, p = 0.24. However, in the mITT population, nebulised UFH reduced mortality (OR 0.2, p = 0.035). Length of hospital stay was similar between groups, but at day 29, there was a greater improvement in ordinal score following treatment with UFH in the ITT and mITT populations (p = 0.076 and p = 0.012 respectively), while mechanical ventilation rates were lower with UFH in the mITT population (OR 0.31; p = 0.08). Nebulised UFH did not cause any significant adverse events. In conclusion, nebulised UFH added to SOC in hospitalised patients with COVID-19 was well tolerated and showed clinical benefit, particularly in patients who received at least 6 doses of heparin. This trial was funded by The J.R. Moulton Charity Trust and registered under REBEC RBR-8r9hy8f (UTN code: U1111-1263-3136).
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Affiliation(s)
- Gilberto DeNucci
- Department of Pharmacology, University of Sao Paulo, Brazil; Department of Pharmacology, University of Campinas, Brazil
| | - Tom Wilkinson
- Department of Respiratory Medicine, University of Southampton, UK
| | | | | | - Ashley Woodcock
- Manchester Academic Health Sciences Centre, Medicines Evaluation Unit, University of Manchester, UK
| | - Jan Shute
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, UK
| | | | | | - Paulo A S Mourão
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Brazil
| | - Dave Singh
- Manchester Academic Health Sciences Centre, Medicines Evaluation Unit, University of Manchester, UK
| | - Frank M P van Haren
- Australian National University, College of Health and Medicine, Canberra, Australia; Intensive Care Unit, St George Hospital, Sydney, Australia
| | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, King's College London, UK
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Cruz F, Danchenko N, Fahrbach K, Freitag A, Tarpey J, Whalen J. Efficacy of abobotulinumtoxinA versus onabotulinumtoxinA for the treatment of refractory neurogenic detrusor overactivity: a systematic review and indirect treatment comparison. J Med Econ 2023; 26:200-207. [PMID: 36647624 DOI: 10.1080/13696998.2023.2165366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
AIMS To compare the efficacy and safety of abobotulinumtoxinA (aboBoNT-A) and onabotulinumtoxinA (onaBoNT-A) for the treatment of refractory neurogenic detrusor overactivity (NDO), using an indirect treatment comparison (ITC). MATERIALS AND METHODS A systematic literature review was used to identify randomized controlled trials (RCTs) that evaluated botulinum toxin type A for the treatment of refractory NDO. Treatments were compared using a Bucher ITC approach. Efficacy outcomes were reduction in number of weekly urinary incontinence (UI) episodes at 6, 12, and 24 weeks of follow-up. The safety outcome was the proportion of patients with treatment-emergent urinary tract infections (TE-UTIs) during follow-up. Subgroup/sensitivity analyses were performed to investigate the impact of heterogeneity. RESULTS Fifteen studies of botulinum toxin type A were identified. Among these, onaBoNT-A 200 U was the only botulinum toxin type A considered an appropriate comparator for aboBoNT-A 600 U and 800 U. As such, six RCTs that evaluated onaBoNT-A or aboBoNT-A were included in the ITC. In base-case analyses, there were no statistically significant differences between aboBoNT-A and onaBoNT-A in terms of UI episodes or TE-UTIs. Numerically, the trend favored aboBoNT-A (either dose) for all endpoints and time points. At 12 and 24 weeks, the difference in reduction of UI episodes per week was considered clinically relevant when comparing aboBoNT-A 800 U with onaBoNT-A 200 U, but not when comparing the lower dose of aboBoNT-A (600 U) with onaBoNT-A 200 U. Results from subgroup/sensitivity analyses were consistent with the base case. LIMITATIONS Heterogeneity across studies was observed; however, strong consistency of trends across analyses suggests the impact of heterogeneity is low. CONCLUSIONS There may be potential advantages of aboBoNT-A over onaBoNT-A, in terms of UI reduction, in patients with refractory NDO. More confirmatory studies are needed owing to the sparsity of current evidence.
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Affiliation(s)
- Francisco Cruz
- Hospital de São João, Porto, Portugal
- i3S Institute of Health Research and Innovation, University of Porto, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
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Liu JB, Tam V, Zenati MS, Schwartz D, Ali A, Low CA, Smith LJ, Zeh HJ, Zureikat AH, Hogg ME. Association of robotic approach with patient-reported outcomes after pancreatectomy: a prospective cohort study. HPB (Oxford) 2022; 24:1659-1667. [PMID: 35568654 DOI: 10.1016/j.hpb.2022.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/22/2022] [Accepted: 04/20/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Robotic-assisted pancreatectomy continues to proliferate despite limited evidence supporting its benefits from the patient's perspective. We compared patient-reported outcomes (PROs) between patients undergoing robotic and open pancreatectomies. METHODS PROs, measured with the FACT-Hep, FACT-G, and HCS, were assessed in the immediate postoperative (i.e., preoperative to discharge) and recovery (i.e., discharge to three months postoperative) periods. Linear mixed models estimated the association of operative approach on PROs. Minimally important differences (MIDs) were also considered. RESULTS Among 139 patients, 105 (75.5%) underwent robotic pancreatectomies. Compared to those who underwent open operations, those who underwent robotic operations experienced worse FACT-Hep scores that were both statistically and clinically significant (mean difference [MD] 8.6 points, 95% CI 1.0-16.3). Declines in FACT-G (MD 4.3, 95% CI -1.0 to 9.6) and HCS (MD 4.3, 95% CI 0.8-7.9) scores appeared to contribute equally in both operative approaches to the decline in total FACT-Hep score. Patients who underwent robotic versus open operations both statistically and clinically significantly improved due to improvements in HCS (MD 6.1, 95% CI 2.3-9.9) but not in FACT-G (MD 1.2, 95% CI - 5.1-7.4). CONCLUSION The robotic approach to pancreas surgery might offer, from the patient's perspective, greater improvement in symptoms over the open approach by three months postoperatively.
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Affiliation(s)
- Jason B Liu
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vernissia Tam
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; Department of Surgery, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Mazen S Zenati
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Danielle Schwartz
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Areej Ali
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Carissa A Low
- Departments of Medicine and Psychology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Lillian J Smith
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Herbert J Zeh
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Amer H Zureikat
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
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Magirr D. Non-proportional hazards in immuno-oncology: Is an old perspective needed? Pharm Stat 2020; 20:512-527. [PMID: 33350587 DOI: 10.1002/pst.2091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/24/2020] [Accepted: 12/08/2020] [Indexed: 11/11/2022]
Abstract
A fundamental concept in two-arm non-parametric survival analysis is the comparison of observed versus expected numbers of events on one of the treatment arms (the choice of which arm is arbitrary), where the expectation is taken assuming that the true survival curves in the two arms are identical. This concept is at the heart of the counting-process theory that provides a rigorous basis for methods such as the log-rank test. It is natural, therefore, to maintain this perspective when extending the log-rank test to deal with non-proportional hazards, for example, by considering a weighted sum of the "observed - expected" terms, where larger weights are given to time periods where the hazard ratio is expected to favor the experimental treatment. In doing so, however, one may stumble across some rather subtle issues, related to difficulties in the interpretation of hazard ratios, that may lead to strange conclusions. An alternative approach is to view non-parametric survival comparisons as permutation tests. With this perspective, one can easily improve on the efficiency of the log-rank test, while thoroughly controlling the false positive rate. In particular, for the field of immuno-oncology, where researchers often anticipate a delayed treatment effect, sample sizes could be substantially reduced without loss of power.
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Affiliation(s)
- Dominic Magirr
- Advanced Methodology and Data Science, Novartis Pharma AG, Basel, Switzerland
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Ou FS, Le-Rademacher JG, Ballman KV, Adjei AA, Mandrekar SJ. Guidelines for Statistical Reporting in Medical Journals. J Thorac Oncol 2020; 15:1722-1726. [PMID: 32858236 DOI: 10.1016/j.jtho.2020.08.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 01/14/2023]
Abstract
Statistical methods are essential in medical research. They are used for data analysis and drawing appropriate conclusions. Clarity and accuracy of statistical reporting in medical journals can enhance readers' understanding of the research conducted and the results obtained. In this manuscript, we provide guidelines for statistical reporting in medical journals for authors to consider, with a focus on the Journal of Thoracic Oncology.
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Affiliation(s)
- Fang-Shu Ou
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota.
| | | | - Karla V Ballman
- Department of Health Care Policy and Research, Weill Cornell Medical College, Ithaca, New York
| | - Alex A Adjei
- Department of Oncology, Mayo Clinic, Rochester, Minnesota
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