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McIntosh SE, Freer L, Grissom CK, Rodway GW, Giesbrecht GG, McDevitt M, Imray CH, Johnson EL, Pandey P, Dow J, Hackett PH. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2024 Update. Wilderness Environ Med 2024; 35:183-197. [PMID: 38577729 DOI: 10.1177/10806032231222359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for the prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the guidelines published in 2019.
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Affiliation(s)
- Scott E McIntosh
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | - Luanne Freer
- Everest ER, Himalayan Rescue Association, Kathmandu, Nepal
| | - Colin K Grissom
- Department of Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - George W Rodway
- Department of Family Medicine - Sports Medicine, School of Medicine, University of Nevada, Reno, NV
| | - Gordon G Giesbrecht
- Faculty of Kinesiology and Recreation Management, Departments of Anesthesia and Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Marion McDevitt
- Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT
| | - Christopher H Imray
- Warwick Medical School, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Eric L Johnson
- Community Faculty, Family Medicine, University Nevada-Reno, Reno, NV
| | | | - Jennifer Dow
- Denali National Park and Preserve, Denali Park, AK
| | - Peter H Hackett
- Altitude Research Center, University of Colorado Anschutz Medical Campus, Aurora, CO
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Regli IB, Oberhammer R, Zafren K, Brugger H, Strapazzon G. Frostbite treatment: a systematic review with meta-analyses. Scand J Trauma Resusc Emerg Med 2023; 31:96. [PMID: 38072923 PMCID: PMC10712146 DOI: 10.1186/s13049-023-01160-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/25/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Our objective was to perform a systematic review of the outcomes of various frostbite treatments to determine which treatments are effective. We also planned to perform meta-analyses of the outcomes of individual treatments for which suitable data were available. MAIN BODY We performed a systematic review and meta-analyses in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched PubMed, Cochrane Trials, and EMBase to identify primary references from January 1, 1900, to June 18, 2022. After eliminating duplicates, we screened abstracts to identify eligible studies containing information on treatment and outcomes of Grade 2 to 4 frostbite. We performed meta-analyses of groups of articles that provided sufficient data. We registered our review in the prospective registry of systematic reviews PROSPERO (Nr. 293,693). We identified 4,835 potentially relevant studies. We excluded 4,610 studies after abstract screening. We evaluated the full text of the remaining 225 studies, excluding 154. Ultimately, we included 71 articles with 978 cases of frostbite originating from 1 randomized controlled trial, 20 cohort studies and 51 case reports. We found wide variations in classifications of treatments and outcomes. The two meta-analyses we performed both found that patients treated with thrombolytics within 24 h had better outcomes than patients treated with other modalities. The one randomized controlled trial found that the prostacyclin analog iloprost was beneficial in severe frostbite if administered within 48 h. CONCLUSIONS Iloprost and thrombolysis may be beneficial for treating frostbite. The effectiveness of other commonly used treatments has not been validated. More prospective data from clinical trials or an international registry may help to inform optimal treatment.
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Affiliation(s)
- Ivo B Regli
- Institute of Mountain Emergency Medicine, EURAC Research, Viale Druso 1, 39100, Bolzano, BZ, Italy.
- Dr. Regli's Alpine Medical Services and Research, Unterägeri, ZG, Switzerland.
- Department of Internal and Emergency Medicine, Bürgerspital, Solothurn, SO, Switzerland.
| | - Rosmarie Oberhammer
- Department of Anesthesia and Intensive Care, Hospital of Brunico, Brunico, BZ, Italy
| | - Ken Zafren
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK, USA
- Department of Emergency Medicine, Stanford University Medical Center, Palo Alto, CA, USA
| | - Hermann Brugger
- Institute of Mountain Emergency Medicine, EURAC Research, Viale Druso 1, 39100, Bolzano, BZ, Italy
- Department of Anesthesia and Intensive Care, Medical University Innsbruck, Innsbruck, Tyrol, Austria
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, EURAC Research, Viale Druso 1, 39100, Bolzano, BZ, Italy
- Department of Anesthesia and Intensive Care, Medical University Innsbruck, Innsbruck, Tyrol, Austria
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Wang XH, Li M, Cheng Y, Wang GJ, Lin GL, Liu WN. Comprehensive treatment of deep frostbite of multiple fingers after trauma: A case report. World J Clin Cases 2023; 11:8219-8227. [PMID: 38130784 PMCID: PMC10731172 DOI: 10.12998/wjcc.v11.i34.8219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/27/2023] [Accepted: 11/29/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Frostbite is becoming increasingly common in urban environments, and severe cases can lead to tissue loss. The treatment goal is to preserve tissue and function; the sooner appropriate treatment is administered, the more tissue can be saved. However, not every patient with deep frostbite seeks medical care promptly. CASE SUMMARY We report the case of a 73-year-old male patient who was lost in the wilderness for 2 d due to trauma and confusion. He experienced deep frostbite on multiple fingers. Treatment should not be discontinued for patients with deep frostbite who present after the optimum treatment timing. Bullae that no longer form (bloody) blisters within 24 h of aspiration should be removed. Mucopolysaccharide polysulfate cream has clinical value in frostbite treatment. The patient was transferred to Chinese Academy of Medical Sciences and Peking Union Medical College Hospital 12 h after being rescued. The patient had contraindications for thrombolysis, the most effective treatment, due to intracranial hemorrhage and presenting past the optimum treatment timing. We devised a comprehensive treatment plan, which involved delayed use vasodilators and high-pressure oxygen therapy at day 49 post-injury. We experimented with mucopolysaccharide polysulfate cream to treat the frostbite. The aim of the treatment was to safeguard as much tissue as possible. In the end, the fingers that suffered from frostbite were able to be partially preserved. CONCLUSION The case indicated that patients with severe frostbite who missed the optimal treatment time and had contraindications for thrombolysis could still partially preserve the affected limbs through comprehensive treatment.
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Affiliation(s)
- Xi-Hua Wang
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Min Li
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yue Cheng
- Department of Nursing, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Guang-Jian Wang
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Guo-Le Lin
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Wei-Nan Liu
- Department of General Surgery, Peking Union Medical College Hospital and Chinese Academy of Medical Sciences, Beijing 100730, China
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Lowe J, Warner M. Can iloprost be used for treatment of cold weather injury at the point of wounding in a forward operating environment? A literature review. Int J Circumpolar Health 2023; 82:2210340. [PMID: 37154780 PMCID: PMC10167884 DOI: 10.1080/22423982.2023.2210340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
INTRODUCTION Cold Weather Injury (CWI) represents a spectrum of pathology, the two main divisions being Freezing Cold Injury (FCI) and Non-Freezing Cold Injury (NFCI). Both are disabling conditions associated with microvascular and nerve injury often treated hours after initial insult when presenting to a healthcarestablishment. Given that iloprost is used for the treatment of FCI, could it be used in a forward operating environment to mitigate treatment delay? Is there a role for its use in the forward treatment of NFCI? This review sought to evaluate the strength of evidence for the potential use of iloprost in a forward operating environment. METHODS Literature searches were undertaken using the following question for both FCI and NFCI: in [patients with FCI/NFCI] does [the use of iloprost] compared to [standard care] reduce the incidence of [long-term complications]. Medline, CINAHL and EMBASE databases were searched using the above question and relevant alternative terminology. Abstracts were reviewed before full articles were requested. RESULTS The FCI search yielded 17 articles that were found to refer to the use of iloprost and FCI. Of the 17, one referred to pre-hospital treatment of frostbite at K2 base camp; however, this was utilising tPA. No articles referred to pre-hospital use in either FCI or NFCI. DISCUSSION Although evidence exists to support the use of iloprost in the treatment of FCI, its use to date has been in hospital. A common theme is delayed treatment due to the challenges of evacuating casualties from a remote location. There may be a role for iloprost in the treatment of FCI; however, further study is required to better understand the risk of its use.
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Affiliation(s)
- Jonathon Lowe
- British Antarctic Survey Medical Unit, Emergency Department, Derriford Hospital, Plymouth, UK
| | - Matthew Warner
- British Antarctic Survey Medical Unit, Emergency Department, Derriford Hospital, Plymouth, UK
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Gauthier J, Morris-Janzen D, Poole A. Iloprost for the treatment of frostbite: a scoping review. Int J Circumpolar Health 2023; 82:2189552. [PMID: 36966492 PMCID: PMC10044161 DOI: 10.1080/22423982.2023.2189552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023] Open
Abstract
We performed a scoping review to identify the extent of the literature describing the use of iloprost in the treatment of frostbite. Iloprost is a stable synthetic analog of prostaglandin I2. As a potent inhibitor of platelet aggregation and vasodilator, it has been used to address the post-rewarming reperfusion injury in frostbite. The search using iloprost and frostbite as key words and MeSH terms yielded 200 articles. We included in our review the literature examining iloprost for the treatment of frostbite in humans in the form of primary research, conference proceedings and abstracts. Twenty studies published from 1994 to 2022 were selected for analysis. The majority were retrospective case series consisting of a homogeneous population of mountain sport enthusiasts. A total of 254 patients and over 1000 frostbitten digits were included among the 20 studies. The larger case series demonstrated a decrease in amputation rates relative to untreated patients. Primary gaps in the literature include a paucity of randomised trials and relatively limited study populations to date. While the case evidence is promising, a multi-centre collaboration would be crucial to adequately power prospective randomised studies to definitively determine if iloprost has a role in the treatment of frostbite.
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Affiliation(s)
- Josianne Gauthier
- Whitehorse General Hospital, Yukon Hospital Corporation, Whitehorse, Yukon, Canada
| | - Dunavan Morris-Janzen
- Northern Medical Program, University of British Columbia, Prince George, British Columbia, Canada
| | - Alexander Poole
- Whitehorse General Hospital, Yukon Hospital Corporation, Whitehorse, Yukon, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Klammer L, Ollier M, Gauthier J, Allen LR, Davidson M, Ahmed Y, Smith-Turchyn J, Hansen-Jaumard D, Hebert S, Logsetty S, Morris-Jantzen D, Peet R, Poole AJ, Champion C. Exploring the Development of a Canadian Frostbite Care Network and the Future of Frostbite Care in Canada Using a Qualitative Approach. Wilderness Environ Med 2023; 34:427-434. [PMID: 37479605 DOI: 10.1016/j.wem.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/08/2023] [Accepted: 06/08/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION The Canadian Frostbite Collaborative project is exploring frostbite patient care needs and current practices in Canada to inform the development of a Canadian frostbite care network (CFCN) as a national quality improvement initiative. METHODS Using a quantitative and qualitative approach, this study aimed to define the landscape of current frostbite practices, challenges, and interest in future work. RESULTS Current frostbite care practices were initially assessed through semistructured phone interviews of Canadian healthcare providers. Canadian healthcare providers managing frostbite in a range of health disciplines and contexts then participated in focus group sessions discussing the potential roles and opportunities as well as potential challenges in developing a CFCN. Roles and opportunities for a network in advancing frostbite care included facilitating research, educating stakeholders, facilitating collaboration, standardizing care, and advocating for frostbite care. Challenges identified in frostbite care and network development included managing resources, navigating the Canadian healthcare system, overcoming low numbers, and communicating with policymakers and frontline providers. CONCLUSIONS Formalizing a CFCN may provide important opportunities and support in overcoming critical barriers to providing high-quality frostbite care across Canada.
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Affiliation(s)
- Lauren Klammer
- College of Medicine University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Mary Ollier
- University of Toronto, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Josianne Gauthier
- Whitehorse General Hospital, Yukon Hospital Corporation, Yukon, Canada
| | - Lisa R Allen
- Muskoka Algonquin Healthcare, Huntsville and Bracebridge, Ontario, Canada.
| | - Malcolm Davidson
- University of Toronto, Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Yousuf Ahmed
- Department of Emergency Medicine, Saint John Regional Hospital, Saint John, New Brunswick, Canada; Department of Family Medicine, Dalhousie University, Saint John, New Brunswick, Canada
| | | | - Delphine Hansen-Jaumard
- Department of Emergency Medicine, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada; Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | | | - Sarvesh Logsetty
- Departments of Surgery and Psychiatry, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Rachel Peet
- Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Alex J Poole
- Whitehorse General Hospital, Yukon Hospital Corporation, Yukon, Canada; University of Calgary, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Caitlin Champion
- Northern Ontario School of Medicine University, Sudbury, Ontario, Canada; West Parry Sound Health Center, Parry Sound, Ontario, Canada
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Hyperbaric Oxygen Therapy with Iloprost Improves Digit Salvage in Severe Frostbite Compared to Iloprost Alone. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57111284. [PMID: 34833502 PMCID: PMC8620371 DOI: 10.3390/medicina57111284] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 11/06/2021] [Accepted: 11/08/2021] [Indexed: 12/13/2022]
Abstract
Background and Objectives: Frostbite is a freezing injury that can lead to amputation. Current treatments include tissue rewarming followed by thrombolytic or vasodilators. Hyperbaric oxygen (HBO) therapy might decrease the rate of amputation by increasing cellular oxygen availability to the damaged tissues. The SOS-Frostbite study was implemented in a cross-border program among the hyperbaric centers of Geneva, Lyon, and the Mont-Blanc hospitals. The objective was to assess the efficacy of HBO + iloprost among patients with severe frostbite. Materials and Methods: We conducted a multicenter prospective single-arm study from 2013 to 2019. All patients received early HBO in addition to standard care with iloprost. Outcomes were compared to a historical cohort in which all patients received iloprost alone between 2000 and 2012. Inclusion criteria were stage 3 or 4 frostbite and initiation of medical care <72 h from frostbite injury. Outcomes were the number of preserved segments and the rate of amputated segments. Results: Thirty patients from the historical cohort were eligible and satisfied the inclusion criteria, and 28 patients were prospectively included. The number of preserved segments per patient was significantly higher in the prospective cohort (mean 13 ± SD, 10) compared to the historical group (6 ± 5, p = 0.006); the odds ratio was significantly higher by 45-fold (95%CI: 6-335, p < 0.001) in the prospective cohort compared to the historical cohort after adjustment for age and delay between signs of freezing and treatment start. Conclusions: This study demonstrates that the combination of HBO and iloprost was associated with higher benefit in patients with severe frostbite. The number of preserved segments was two-fold higher in the prospective cohort compared to the historical group (mean of 13 preserved segments vs. 6), and the reduction of amputation was greater in patients treated by HBO + iloprost compared with the iloprost only.
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McIntosh SE, Freer L, Grissom CK, Auerbach PS, Rodway GW, Cochran A, Giesbrecht GG, McDevitt M, Imray CH, Johnson EL, Pandey P, Dow J, Hackett PH. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2019 Update. Wilderness Environ Med 2019; 30:S19-S32. [PMID: 31326282 DOI: 10.1016/j.wem.2019.05.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/14/2019] [Accepted: 05/17/2019] [Indexed: 12/13/2022]
Abstract
The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the guidelines published in 2014.
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Affiliation(s)
- Scott E McIntosh
- Division of Emergency Medicine, University of Utah, Salt Lake City, UT.
| | - Luanne Freer
- Everest Base Camp Medical Clinic, Nepal; Yellowstone National Park, WY
| | - Colin K Grissom
- Division of Critical Care Medicine, Intermountain Medical Center, Salt Lake City, UT
| | - Paul S Auerbach
- Department of Emergency Medicine, Stanford University, School of Medicine, Palo Alto, CA
| | - George W Rodway
- College of Nursing and School of Medicine, UC Davis, Davis, CA
| | - Amalia Cochran
- Department of Surgery, The Ohio State University, Columbus, OH
| | - Gordon G Giesbrecht
- Faculty of Kinesiology and Recreation Management, Departments of Anesthesia and Emergency Medicine, University of Manitoba, Winnipeg, Canada
| | - Marion McDevitt
- Emergency Medicine, Peace Health Ketchikan Medical Center, Ketchikan, AK
| | - Christopher H Imray
- Warwick Medical School, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Eric L Johnson
- Wound & Hyperbaric Medicine, Bozeman Health, Bozeman, MT
| | | | | | - Peter H Hackett
- Division of Emergency Medicine, Altitude Research Center, University of Colorado Denver School of Medicine, Denver, CO; Institute for Altitude Medicine, Telluride, CO
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Khan SL, Parikh R, Mooncai T, Sandhu S, Jawa R, Farber HW. Barriers to frostbite treatment at an academic medical center. Am J Emerg Med 2019; 37:1601.e3-1601.e5. [PMID: 31088748 DOI: 10.1016/j.ajem.2019.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 05/05/2019] [Indexed: 02/08/2023] Open
Abstract
The treatment of frostbite injuries has undergone a radical change over the past decade with a shift from supportive therapy and observation towards early and aggressive medical intervention with thrombolytics and vasodilators. Institutions that have implemented evidence-based protocols have significantly decreased their amputation rates (Bruen et al., 2007; Lindford et al., 2017a; Twomey et al., 2005). We present the case of a middle-aged male treated for frostbite of multiple fingers on both hands. Because there was no treatment protocol at our institution, there were multiple delays in the patient's care including imaging and initiation of intravenous (IV) prostanoids. This case illustrates the deleterious effects of delays in treatment and strongly suggests that all facilities located in areas of cold exposure should have protocols in place for such an occurrence.
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Affiliation(s)
- Sarah L Khan
- Boston Medical Center, Department of Internal Medicine, United States of America.
| | - Raj Parikh
- Boston Medical Center, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, United States of America
| | - Theodore Mooncai
- Boston Medical Center, Department of Emergency Medicine, United States of America
| | - Sukhmeet Sandhu
- Boston Medical Center, Department of Internal Medicine, United States of America
| | - Raagini Jawa
- Boston Medical Center, Department of Internal Medicine, United States of America
| | - Harrison W Farber
- Tufts Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, United States of America
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