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Kim YM, Jang SI, Cho JH, Koh DH, Kwon CI, Lee TH, Jeong S, Lee DK. Litholytic agents as an alternative treatment modality in patients with biliary dyspepsia. Medicine (Baltimore) 2020; 99:e21698. [PMID: 32846787 PMCID: PMC7447440 DOI: 10.1097/md.0000000000021698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 01/19/2023] Open
Abstract
Biliary dyspepsia presents as biliary colic in the absence of explanatory structural abnormalities. Causes include gallbladder dyskinesia, sphincter of Oddi dysfunction, biliary tract sensitivity, microscopic sludges, and duodenal hypersensitivity. However, no consensus treatment guideline exists for biliary dyspepsia. We investigated the effects of medical treatments on biliary dyspepsia.We retrospectively reviewed the electronic medical records of 414 patients who had biliary pain and underwent cholescintigraphy from 2008 to 2018. We enrolled patients who received litholytic agents and underwent follow-up scans after medical treatment. We divided the patients into the GD group (biliary dyspepsia with reduced gallbladder ejection fraction [GBEF]) and the NGD group (biliary dyspepsia with normal GBEF). We compared pre- and post-treatment GBEF and symptoms.Among 57 patients enrolled, 40 (70.2%) patients had significant GBEF improvement post-treatment, ranging from 34.4 ± 22.6% to 53.8 ± 26.8% (P < .001). In GD group (n = 35), 28 patients had GBEF improvement after medical treatment, and value of GBEF significantly improved from 19.5 ± 11.0 to 47.9 ± 27.3% (P < .001). In NGD group (n = 22), 12 patients had GBEF improvement after medical treatment, but value of GBEF did not have significant change. Most patients (97.1% in GD group and 81.8% in NGD group) had improved symptoms after medical treatment. No severe complication was reported during treatment period.Litholytic agents improved biliary colic in patients with biliary dyspepsia. Therefore, these agents present an alternative treatment modality for biliary dyspepsia with or without gallbladder dyskinesia. Notably, biliary colic in patients with gallbladder dyskinesia resolved after normalization of the GBEF. Further prospective and large-scale mechanistic studies are warranted.
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Affiliation(s)
- Young Min Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
| | - Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
- Department of Internal Medicine, Gachon University College of Medicine, Gil Medical Center, Incheon
| | - Dong Hee Koh
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine
| | - Chang-Il Kwon
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam
| | - Tae Hoon Lee
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan
| | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Incheon, South Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
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Duloxetine for the Treatment of Patients with Suspected Sphincter of Oddi Dysfunction: A Pilot Study. Dig Dis Sci 2016; 61:2704-9. [PMID: 27165434 DOI: 10.1007/s10620-016-4187-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/27/2016] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To examine the tolerability and efficacy of duloxetine in patients with suspected sphincter of Oddi dysfunction (SOD). METHODS An open-label, single-center, 12-week trial of duloxetine 60 mg once daily was conducted in 20 patients with suspected SOD. All patients were evaluated by expert pancreato-biliary specialists. The primary outcome measure was a Patient Global Impression of Change (PGIC) scale. Secondary measures included the pain burden, assessed by the Recurrent Abdominal Pain Intensity and Disability scale, the Short-Form Health Survey, and the Hospital Anxiety and Depression Scale. A positive clinical response was defined as a PGIC score of much or very much improved at 3 months and was estimated using a two-sided 90 % confidence interval. The primary outcome was analyzed using a one-sample binomial test at a significance level of 0.10. RESULTS Of the 20 screened patients, 18 were enrolled; 14 completed at least one post-baseline evaluation; and 10 patients completed the third month endpoint visit. Patients missing the third month visit were considered non-responders for the primary outcome. Response rates were 90 % for study completers (n = 10; 90 % CI 74-100; p = 0.02) and 64 % for patients who completed at least one post-baseline evaluation (n = 14; 90 % CI 43-85; p = 0.42). Seven patients did not complete the study due to adverse events (mostly fatigue and nausea). CONCLUSIONS Duloxetine showed an indication of efficacy in the treatment of pain in patients with suspected SOD, but adverse events limited its use. These preliminary, open-label results justify definitive placebo-controlled trials.
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Romagnuolo J, Cotton PB, Durkalski V, Pauls Q, Brawman-Mintzer O, Drossman DA, Mauldin P, Orrell K, Williams AW, Fogel EL, Tarnasky PR, Aliperti G, Freeman ML, Kozarek RA, Jamidar PA, Wilcox CM, Serrano J, Elta GH. Can patient and pain characteristics predict manometric sphincter of Oddi dysfunction in patients with clinically suspected sphincter of Oddi dysfunction? Gastrointest Endosc 2014; 79:765-72. [PMID: 24472759 PMCID: PMC4409681 DOI: 10.1016/j.gie.2013.11.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 11/25/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Biliopancreatic-type postcholecystectomy pain, without significant abnormalities on imaging and laboratory test results, has been categorized as "suspected" sphincter of Oddi dysfunction (SOD) type III. Clinical predictors of "manometric" SOD are important to avoid unnecessary ERCP, but are unknown. OBJECTIVE To assess which clinical factors are associated with abnormal sphincter of Oddi manometry (SOM). DESIGN Prospective, cross-sectional. SETTING Tertiary. PATIENTS A total of 214 patients with suspected SOD type III underwent ERCP and pancreatic SOM (pSOM; 85% dual SOM), at 7 U.S. centers (from August 2008 to March 2012) as part of a randomized trial. INTERVENTIONS Pain and gallbladder descriptors, psychosocial/functional disorder questionnaires. MAIN OUTCOME MEASUREMENTS Abnormal SOM findings. Univariate and multivariate analyses assessed associations between clinical characteristics and outcome. RESULTS The cohort was 92% female with a mean age of 38 years. Baseline pancreatic enzymes were increased in 5%; 9% had minor liver enzyme abnormalities. Pain was in the right upper quadrant (RUQ) in 90% (48% also epigastric); 51% reported daily abdominal discomfort. Fifty-six took narcotics an average of 33 days (of the past 90 days). Less than 10% experienced depression or anxiety. Functional disorders were common. At ERCP, 64% had abnormal pSOM findings (34% both sphincters, 21% biliary normal), 36% had normal pSOM findings, and 75% had at least abnormal 1 sphincter. Demographic factors, gallbladder pathology, increased pancreatobiliary enzymes, functional disorders, and pain patterns did not predict abnormal SOM findings. Anxiety, depression, and poorer coping were more common in patients with normal SOM findings (not significant on multivariate analysis). LIMITATIONS Generalizability. CONCLUSIONS Patient and pain factors and psychological comorbidity do not predict SOM results at ERCP in suspected type III SOD. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00688662.).
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Affiliation(s)
- Joseph Romagnuolo
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Peter B. Cotton
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Valerie Durkalski
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Qi Pauls
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | - Patrick Mauldin
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kyle Orrell
- Digestive Health Associates of Texas, Dallas, Texas, USA
| | - April W Williams
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | | | | | | | | | | | - Jose Serrano
- National Institute of Diabetes and Digestive and Kidney Diseases, Division of Digestive Diseases and Nutrition, National Institutes of Health, Bethesda, Maryland, USA
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Cheon YK. How to interpret a functional or motility test - sphincter of oddi manometry. J Neurogastroenterol Motil 2012; 18:211-7. [PMID: 22523732 PMCID: PMC3325308 DOI: 10.5056/jnm.2012.18.2.211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 02/24/2012] [Accepted: 03/04/2012] [Indexed: 12/23/2022] Open
Abstract
To date, endoscopic manometry is the best method for evaluating the function of the sphincter. Sphincter of Oddi manometry (SOM) remains the gold standard to correctly diagnose the sphincter of Oddi dysfunction (SOD) and stratify therapy. Several dynamic abnormalities relating to the intensity, frequency, and propagation of sphincter contractions have been described. However, their clinical use generally has been abandoned in favor of basal sphincter pressure alone, because this measurement is stable over time, and has stronger interobserver reliablility, reproducibility on repeating testing, and is associated with the responsiveness to therapy. A significant elevated risk of pancreatitis was attributed to the technique. The risk of pancreatitits associated with manometric evaluation of the pancreatic sphincter is markedly reduced when manometry is performed with continous aspiration from the pancreatic duct via one of the 3 catheter lumens. This section reviews indications, conscious sedative drugs, techniques, and the appropriate interpretations of SOM.
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Affiliation(s)
- Young Koog Cheon
- Digestive Disease Center, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
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Gong JQ, Ren JD, Tian FZ, Jiang R, Tang LJ, Pang Y. Management of patients with sphincter of Oddi dysfunction based on a new classification. World J Gastroenterol 2011; 17:385-90. [PMID: 21253400 PMCID: PMC3022301 DOI: 10.3748/wjg.v17.i3.385] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 09/26/2010] [Accepted: 10/03/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To propose a new classification system for sphincter of Oddi dysfunction (SOD) based on clinical data of patients.
METHODS: The clinical data of 305 SOD patients documented over the past decade at our center were analyzed retrospectively, and typical cases were reported.
RESULTS: The new classification with two more types (double-duct, biliary-pancreatic reflux) were set up on the basis of the Milwaukee criteria. There were 229 cases of biliary-type SOD, including 192 (83.8%) cases cured endoscopically, and 29 (12.7%) cured by open abdominal surgery, and the remaining 8 (3.5%) cases observed with unstable outcomes. Eight (50%) patients with pancreatic-type SOD were cured by endoscopic treatment, and the remaining 8 patients were cured after open abdominal surgery. There were 19 cases of double-duct-type SOD, which consisted of 7 (36.8%) patients who were cured endoscopically and 12 (63.2%) who were cured surgically. A total of 41 cases were diagnosed as biliary-pancreatic–reflux-type SOD. Twenty (48.8%) of them were treated endoscopically, 16 (39.0%) were treated by open abdominal surgery, and 5 (12.2%) were under observation.
CONCLUSION: The newly proposed SOD classification system introduced in this study better explains the clinical symptoms of SOD from the anatomical perspective and can guide clinical treatment of this disease.
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Cotton PB, Durkalski V, Orrell KB, Brawman-Mintzer O, Drossman DA, Wilcox CM, Mauldin PD, Elta GH, Tarnasky PR, Fogel EL, Jagganath SB, Kozarek RA, Freeman ML, Romagnuolo J, Robuck PR. Challenges in planning and initiating a randomized clinical study of sphincter of Oddi dysfunction. Gastrointest Endosc 2010; 72:986-91. [PMID: 21034899 PMCID: PMC4409682 DOI: 10.1016/j.gie.2010.08.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Accepted: 08/18/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sphincter of Oddi dysfunction (SOD) is a controversial topic, especially in patients with no objective findings on laboratory or imaging studies (SOD type III). The value of ERCP manometry with sphincterotomy is unproven and carries significant risks. OBJECTIVE To describe the process of planning and initiating a randomized sham-controlled study to establish whether patients with SOD respond to sphincter ablation, and whether the outcomes are predicted by the pain patterns, presence or absence of other functional GI or psychosocial problems, or the results of manometry. DESIGN Planning a trial to establish which patients with "suspected SOD" (if any) respond to endoscopic sphincter ablation. SETTING Meetings and correspondence by a planning group of gastroenterologists and clinical research specialists hosted at the Medical University of South Carolina. PATIENTS Clarifying subject characteristics and inclusion and exclusion criteria. INTERVENTIONS Defining the questionnaires, therapies, randomizations, and numbers of subjects required by outcome measures. Defining the metrics of success and failure. RESULTS The planning resulted in funding for the proposed study as a cooperative agreement with the National Institute of Diabetes and Digestive and Kidney Diseases. LIMITATIONS Lack of data required several consensus decisions in designing the protocol. CONCLUSION The planning process was challenging, and some changes were needed after initiation.
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Durkalski V, Stewart W, MacDougall P, Mauldin P, Romagnuolo J, Brawman-Minzter O, Cotton P. Measuring episodic abdominal pain and disability in suspected sphincter of Oddi dysfunction. World J Gastroenterol 2010; 16:4416-21. [PMID: 20845508 PMCID: PMC2941064 DOI: 10.3748/wjg.v16.i35.4416] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the reliability of an instrument that measures disability arising from episodic abdominal pain in patients with suspected sphincter of Oddi dysfunction (SOD). METHODS Although several treatments have been utilized to reduce pain and associated disability, measurement tools have not been developed to reliably track outcomes. Two pilot studies were conducted to assess test-retest reliability of a newly developed instrument, the recurrent abdominal pain intensity and disability (RAPID) instrument. The RAPID score is a 90-d summation of days where productivity for various daily activities is reduced as a result of abdominal pain episodes, and is modeled after the migraine disability assessment instrument used to measure headache-related disability. RAPID was administered by telephone on 2 consecutive occasions in 2 consenting populations with suspected SOD: a pre-sphincterotomy population (Pilot I, n = 55) and a post-sphincterotomy population (Pilot II, n = 70). RESULTS The average RAPID scores for Pilots I and II were: 82 d (median: 81.5 d, SD: 64 d) and 48 d (median: 0 d, SD: 91 d), respectively. The concordance between the 2 assessments for both populations was very good: 0.81 for the pre-sphincterotomy population and 0.95 for the post-sphincterotomy population. CONCLUSION The described pilot studies suggest that RAPID is a reliable instrument for measuring disability resulting from abdominal pain in suspected SOD patients.
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Maydeo AP. Idiopathic recurrent pancreatitis: too many questions, too few answers. Gastrointest Endosc 2008; 67:1035-6. [PMID: 18513546 DOI: 10.1016/j.gie.2007.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Accepted: 11/16/2007] [Indexed: 12/10/2022]
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Abstract
Sphincter of Oddi dysfunction (SOD) is a term used to describe a group of heterogenous pain syndromes caused by abnormalities in sphincter contractility. Biliary and pancreatic SOD are each sub-classified as type I, II or III, according to the Milwaukee classification. SOD appears to carry an increased risk of acute pancreatitis as well as rates of post ERCP pancreatitis of over 30%. Various mechanisms have been postulated but the exact role of SOD in the pathophysiology of acute pancreatitis is unknown. There is also an association between SOD and chronic pancreatitis but it is still unclear if this is a cause or effect relationship. Management of SOD is aimed at sphincter ablation, usually by endoscopic sphincterotomy (ES). Patients with type I SOD will benefit from ES in 55%-95% of cases. Sphincter of Oddi manometry is not necessary before ES in type I SOD. For patients with types II and III the benefit of ES is lower. These patients should be more thoroughly evaluated before performing ES. Some researchers have found that manometry and ablation of both the biliary and pancreatic sphincters is required to adequately assess and treat SOD. In pancreatic SOD up to 88% of patients will benefit from sphincterotomy. Therefore, there have been calls from some quarters for the current classification system to be scrapped in favour of an overall system encompassing both biliary and pancreatic types. Future work should be aimed at understanding the mechanisms underlying the relationship between SOD and pancreatitis and identifying patient factors that will help predict benefit from endoscopic therapy.
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Affiliation(s)
- M T McLoughlin
- Department of Gastroenterology, Belfast City Hospital, Northern Ireland
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Abstract
Sphincter of Oddi dysfunction (SOD) is a term used to describe a group of heterogenous pain syndromes caused by abnormalities in sphincter contractility. Biliary and pancreatic SOD are each sub-classified as typeI, II or III, according to the Milwaukee classification. SOD appears to carry an increased risk of acute pancreatitis as well as rates of post ERCP pancreatitis of over 30%. Various mechanisms have been postulated but the exact role of SOD in the pathophysiology of acute pancreatitis is unknown. There is also an association between SOD and chronic pancreatitis but it is still unclear if this is a cause or effect relationship. Management of SOD is aimed at sphincter ablation, usually by endoscopic sphincterotomy (ES). Patients with typeISOD will benefit from ES in 55%-95% of cases. Sphincter of Oddi manometry is not necessary before ES in typeISOD. For patients with types II and III the benefit of ES is lower. These patients should be more thoroughly evaluated before performing ES. Some researchers have found that manometry and ablation of both the biliary and pancreatic sphincters is required to adequately assess and treat SOD. In pancreatic SOD up to 88% of patients will benefit from sphincterotomy. Therefore, there have been calls from some quarters for the current classification system to be scrapped in favour of an overall system encompassing both biliary and pancreatic types. Future work should be aimed at understanding the mechanisms underlying the relationship between SOD and pancreatitis and identifying patient factors that will help predict benefit from endoscopic therapy.
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Abstract
BACKGROUND Data on sphincter of Oddi dysfunction (SOD) in children are scant. Most children diagnosed with SOD are treated by biliary sphincterotomy with suboptimal results. The efficacy and safety of pancreatic and dual sphincterotomy in children with SOD has not been previously reported. OBJECTIVE To evaluate the efficacy and safety of pancreatic and dual sphincterotomy in children with SOD. MATERIALS AND METHODS Prospective evaluation of all children who underwent endoscopic retrograde cholangiopancreatogram (ERCP) with sphincter of Oddi manometry for evaluation of suspected SOD over a 3-year period. Children diagnosed with SOD underwent pancreatic or dual sphincterotomy with prophylactic pancreatic stenting. RESULTS SOD was diagnosed by sphincter of Oddi manometry in 6 of 11 children who underwent ERCP for suspected SOD. Of the 6 children (mean age, 11 years; range, 5-16; 4 girls) with SOD, 3 presented with recurrent pancreatitis and 3 with postcholecystectomy pain. Pancreatic sphincter hypertension was noted in all 6 patients; concomitant biliary sphincter hypertension was noted in 3 patients with postcholecystectomy pain. Patients with recurrent pancreatitis underwent pancreatic sphincterotomy and those with postcholecystectomy pain underwent dual sphincterotomy. Prophylactic pancreatic stents were placed in all patients. One girl experienced mild post-ERCP pancreatitis. At a mean follow-up of 583 days (range, 325-1445), 4 patients were asymptomatic, 1 experienced partial symptom relief and 1 had recurrent symptoms. CONCLUSIONS As in adults, pancreatic and dual sphincterotomy, in expert hands, is effective and safe in a subgroup of children with SOD. Prospective, randomized trials with larger number of patients are required to validate the efficacy of endotherapy in children with SOD.
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Affiliation(s)
- Shyam Varadarajulu
- Division of Gastroenterology-Hepatology, University of Alabama at Birmingham School of Medicine, Birmingham, AL 35294-0007, USA.
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Abstract
Recurrent biliary-type abdominal pain is a perplexing clinical dilemma that occurs in patients with an acalculous gallbladder in situ or in patients who have undergone a previous cholecystectomy. The pathogenesis of functional biliary-type pain is often unclear; therefore, evaluation and management remain controversial. In patients with an acalculous gallbladder in situ, critical importance has been given to delayed gallbladder emptying using cholescintigraphy (CCK-CS) to determine if gallbladder dysfunction is present. However, several issues remain unresolved, including methodology, definition of delayed emptying, and the absence of high-quality studies to determine if CCK-CS can predict who will do well with cholecystectomy. In patients with previous cholecystectomy, the main area of controversy is the evaluation of patients with sphincter of Oddi Type III, including the role of endoscopic retrograde cholangiopancreatography with SO manometry and sphincterotomy in these patients. Suggested algorithms for management of both clinical scenarios are provided.
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Affiliation(s)
- Arnold Wald
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.
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