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Barbash IJ, Davis BS, Saul M, Hwa R, Brant EB, Seymour CW, Kahn JM. Association Between Medicare's Sepsis Reporting Policy (SEP-1) and the Documentation of a Sepsis Diagnosis in the Clinical Record. Med Care 2024; 62:388-395. [PMID: 38620117 DOI: 10.1097/mlr.0000000000001997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
STUDY DESIGN Interrupted time series analysis of a retrospective, electronic health record cohort. OBJECTIVE To determine the association between the implementation of Medicare's sepsis reporting measure (SEP-1) and sepsis diagnosis rates as assessed in clinical documentation. BACKGROUND The role of health policy in the effort to improve sepsis diagnosis remains unclear. PATIENTS AND METHODS Adult patients hospitalized with suspected infection and organ dysfunction within 6 hours of presentation to the emergency department, admitted to one of 11 hospitals in a multi-hospital health system from January 2013 to December 2017. Clinician-diagnosed sepsis, as reflected by the inclusion of the terms "sepsis" or "septic" in the text of clinical notes in the first two calendar days following presentation. RESULTS Among 44,074 adult patients with sepsis admitted to 11 hospitals over 5 years, the proportion with sepsis documentation was 32.2% just before the implementation of SEP-1 in the third quarter of 2015 and increased to 37.3% by the fourth quarter of 2017. Of the 9 post-SEP-1 quarters, 8 had odds ratios for a sepsis diagnosis >1 (overall range: 0.98-1.26; P value for a joint test of statistical significance = 0.005). The effects were clinically modest, with a maximum effect of an absolute increase of 4.2% (95% CI: 0.9-7.8) at the end of the study period. The effect was greater in patients who did not require vasopressors compared with patients who required vasopressors ( P value for test of interaction = 0.02). CONCLUSIONS SEP-1 implementation was associated with modest increases in sepsis diagnosis rates, primarily among patients who did not require vasoactive medications.
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Affiliation(s)
- Ian J Barbash
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, School of Medicine, Pittsburgh, PA
- Department of Critical Care Medicine, CRISMA Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- UPMC, Pittsburgh PA
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Billie S Davis
- Department of Critical Care Medicine, CRISMA Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Melissa Saul
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rebecca Hwa
- Department of Computer Science, School of Computing and Information, University of Pittsburgh, Pittsburgh, PA
| | - Emily B Brant
- Department of Critical Care Medicine, CRISMA Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- UPMC, Pittsburgh PA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Christopher W Seymour
- Department of Critical Care Medicine, CRISMA Center, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- UPMC, Pittsburgh PA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jeremy M Kahn
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, School of Medicine, Pittsburgh, PA
- UPMC, Pittsburgh PA
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
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Adhikari NKJ, Hashmi M, Tirupakuzhi Vijayaraghavan BK, Haniffa R, Beane A, Webb SA, Angus DC, Gordon AC, Cook DJ, Guyatt GH, Berry LR, Lorenzi E, Mouncey PR, Au C, Pinto R, Ménard J, Sprague S, Masse MH, Huang DT, Heyland DK, Nichol AD, McArthur CJ, de Man A, Al-Beidh F, Annane D, Anstey M, Arabi YM, Battista MC, Berry S, Bhimani Z, Bonten MJM, Bradbury CA, Brant EB, Brunkhorst FM, Burrell A, Buxton M, Cecconi M, Cheng AC, Cohen D, Cove ME, Day AG, Derde LPG, Detry MA, Estcourt LJ, Fagbodun EO, Fitzgerald M, Goossens H, Green C, Higgins AM, Hills TE, Ichihara N, Jayakumar D, Kanji S, Khoso MN, Lawler PR, Lewis RJ, Litton E, Marshall JC, McAuley DF, McGlothlin A, McGuinness SP, McQuilten ZK, McVerry BJ, Murthy S, Parke RL, Parker JC, Reyes LF, Rowan KM, Saito H, Salahuddin N, Santos MS, Saunders CT, Seymour CW, Shankar-Hari M, Tolppa T, Trapani T, Turgeon AF, Turner AM, Udy AA, van de Veerdonk FL, Zarychanski R, Lamontagne F. Intravenous Vitamin C for Patients Hospitalized With COVID-19: Two Harmonized Randomized Clinical Trials. JAMA 2023; 330:1745-1759. [PMID: 37877585 PMCID: PMC10600726 DOI: 10.1001/jama.2023.21407] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023]
Abstract
Importance The efficacy of vitamin C for hospitalized patients with COVID-19 is uncertain. Objective To determine whether vitamin C improves outcomes for patients with COVID-19. Design, Setting, and Participants Two prospectively harmonized randomized clinical trials enrolled critically ill patients receiving organ support in intensive care units (90 sites) and patients who were not critically ill (40 sites) between July 23, 2020, and July 15, 2022, on 4 continents. Interventions Patients were randomized to receive vitamin C administered intravenously or control (placebo or no vitamin C) every 6 hours for 96 hours (maximum of 16 doses). Main Outcomes and Measures The primary outcome was a composite of organ support-free days defined as days alive and free of respiratory and cardiovascular organ support in the intensive care unit up to day 21 and survival to hospital discharge. Values ranged from -1 organ support-free days for patients experiencing in-hospital death to 22 organ support-free days for those who survived without needing organ support. The primary analysis used a bayesian cumulative logistic model. An odds ratio (OR) greater than 1 represented efficacy (improved survival, more organ support-free days, or both), an OR less than 1 represented harm, and an OR less than 1.2 represented futility. Results Enrollment was terminated after statistical triggers for harm and futility were met. The trials had primary outcome data for 1568 critically ill patients (1037 in the vitamin C group and 531 in the control group; median age, 60 years [IQR, 50-70 years]; 35.9% were female) and 1022 patients who were not critically ill (456 in the vitamin C group and 566 in the control group; median age, 62 years [IQR, 51-72 years]; 39.6% were female). Among critically ill patients, the median number of organ support-free days was 7 (IQR, -1 to 17 days) for the vitamin C group vs 10 (IQR, -1 to 17 days) for the control group (adjusted proportional OR, 0.88 [95% credible interval {CrI}, 0.73 to 1.06]) and the posterior probabilities were 8.6% (efficacy), 91.4% (harm), and 99.9% (futility). Among patients who were not critically ill, the median number of organ support-free days was 22 (IQR, 18 to 22 days) for the vitamin C group vs 22 (IQR, 21 to 22 days) for the control group (adjusted proportional OR, 0.80 [95% CrI, 0.60 to 1.01]) and the posterior probabilities were 2.9% (efficacy), 97.1% (harm), and greater than 99.9% (futility). Among critically ill patients, survival to hospital discharge was 61.9% (642/1037) for the vitamin C group vs 64.6% (343/531) for the control group (adjusted OR, 0.92 [95% CrI, 0.73 to 1.17]) and the posterior probability was 24.0% for efficacy. Among patients who were not critically ill, survival to hospital discharge was 85.1% (388/456) for the vitamin C group vs 86.6% (490/566) for the control group (adjusted OR, 0.86 [95% CrI, 0.61 to 1.17]) and the posterior probability was 17.8% for efficacy. Conclusions and Relevance In hospitalized patients with COVID-19, vitamin C had low probability of improving the primary composite outcome of organ support-free days and hospital survival. Trial Registration ClinicalTrials.gov Identifiers: NCT04401150 (LOVIT-COVID) and NCT02735707 (REMAP-CAP).
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Affiliation(s)
- Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Madiha Hashmi
- Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan
| | | | - Rashan Haniffa
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, Scotland
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Abi Beane
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, Scotland
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Steve A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- St John of God Health Care, Perth, Australia
| | - Derek C Angus
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Imperial College London, London, England
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, England
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Paul R Mouncey
- Intensive Care National Audit and Research Centre, London, England
| | - Carly Au
- Intensive Care National Audit and Research Centre, London, England
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Ménard
- Research Centre of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Sheila Sprague
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Marie-Hélène Masse
- Research Centre of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - David T Huang
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Alistair D Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Australia
- University College Dublin, Dublin, Ireland
- Alfred Health, Melbourne, Australia
| | - Colin J McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Angelique de Man
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Djillali Annane
- UVSQ University Paris Saclay, Institut-Hospitalo Universitaire Prometheus, Paris, France
- Médecine Intensive-Réanimation, Hôpital Raymond-Poincaré, Garches, France
| | - Matthew Anstey
- Sir Charles Gairdner Hospital, Nedlands, Australia
- University of Western Australia, Perth
| | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Marie-Claude Battista
- Research Centre of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Zahra Bhimani
- St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- European Clinical Research Alliance on Infectious Diseases, Utrecht, the Netherlands
| | | | - Emily B Brant
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Frank M Brunkhorst
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Aidan Burrell
- Alfred Health, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Meredith Buxton
- Global Coalition for Adaptive Research, Larkspur, California
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Allen C Cheng
- Monash Infectious Disease, Monash Health and School of Clinical Sciences, Monash University, Clayton, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dian Cohen
- Bishop's University, Sherbrooke, Quebec, Canada
- Massawippi Valley Foundation, Ayer's Cliff, Quebec, Canada
| | - Matthew E Cove
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew G Day
- Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | - Lennie P G Derde
- European Clinical Research Alliance on Infectious Diseases, Utrecht, the Netherlands
- Intensive Care Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Lise J Estcourt
- Department of Haematology, NHS Blood and Transplant, Bristol, England
- Radcliffe Department of Medicine, University of Oxford, Oxford, England
| | | | | | - Herman Goossens
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Nao Ichihara
- Department of Cardiovascular Surgery, School of Medicine, Jikei University, Tokyo, Japan
| | | | - Salmaan Kanji
- Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Patrick R Lawler
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Edward Litton
- Fiona Stanley Hospital, Department of Intensive Care Unit, University of Western Australia, Perth
| | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Daniel F McAuley
- Queen's University of Belfast, Belfast, Northern Ireland
- Centre for Infection and Immunity, Royal Victoria Hospital, Belfast, Northern Ireland
| | | | - Shay P McGuinness
- Medical Research Institute of New Zealand, Wellington
- Auckland City Hospital, Cardiothoracic and Vascular Intensive Care Unit, Auckland, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | | | - Bryan J McVerry
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Rachael L Parke
- Medical Research Institute of New Zealand, Wellington
- Auckland City Hospital, Cardiothoracic and Vascular Intensive Care Unit, Auckland, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane C Parker
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Australia
| | - Luis Felipe Reyes
- Department of Infectious Diseases, Universidad de La Sabana, Chia, Colombia
- Department of Critical Care Medicine, Clinica Universidad de La Sabana, Chia, Colombia
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, London, England
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St Marianna University Yokohama Seibu Hospital, Yokohama, Japan
| | - Nawal Salahuddin
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Marlene S Santos
- Department of Critical Care, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher W Seymour
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Manu Shankar-Hari
- Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, Scotland
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, Scotland
| | - Timo Tolppa
- National Intensive Care Surveillance, Colombo, Sri Lanka
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care, Université Laval, Quebec City, Quebec, Canada
- Population Health and Optimal Health Practices Research Unit, Departments of Traumatology, Emergency Medicine, and Critical Care Medicine, Université Laval Research Center, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Anne M Turner
- Medical Research Institute of New Zealand, Wellington
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia
| | | | - Ryan Zarychanski
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - François Lamontagne
- Research Centre of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Zhao H, Kennedy JN, Wang S, Brant EB, Bernard GR, DeMerle K, Chang CCH, Angus DC, Seymour CW. Revising Host Phenotypes of Sepsis Using Microbiology. Front Med (Lausanne) 2021; 8:775511. [PMID: 34805235 PMCID: PMC8602092 DOI: 10.3389/fmed.2021.775511] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 10/18/2021] [Indexed: 01/27/2023] Open
Abstract
Background: There is wide heterogeneity in sepsis in causative pathogens, host response, organ dysfunction, and outcomes. Clinical and biologic phenotypes of sepsis are proposed, but the role of pathogen data on sepsis classification is unknown. Methods: We conducted a secondary analysis of the Recombinant Human Activated Protein C (rhAPC) Worldwide Evaluation in Severe Sepsis (PROWESS) Study. We used latent class analysis (LCA) to identify sepsis phenotypes using, (i) only clinical variables ("host model") and, (ii) combining clinical with microbiology variables (e.g., site of infection, culture-derived pathogen type, and anti-microbial resistance characteristics, "host-pathogen model"). We describe clinical characteristics, serum biomarkers, and outcomes of host and host-pathogen models. We tested the treatment effects of rhAPC by phenotype using Kaplan-Meier curves. Results: Among 1,690 subjects with severe sepsis, latent class modeling derived a 4-class host model and a 4-class host-pathogen model. In the host model, alpha type (N = 327, 19%) was younger and had less shock; beta type (N=518, 31%) was older with more comorbidities; gamma type (N = 532, 32%) had more pulmonary dysfunction; delta type (N = 313, 19%) had more liver, renal and hematologic dysfunction and shock. After the addition of microbiologic variables, 772 (46%) patients changed phenotype membership, and the median probability of phenotype membership increased from 0.95 to 0.97 (P < 0.01). When microbiology data were added, the contribution of individual variables to phenotypes showed greater change for beta and gamma types. In beta type, the proportion of abdominal infections (from 20 to 40%) increased, while gamma type patients had an increased rate of lung infections (from 50 to 78%) with worsening pulmonary function. Markers of coagulation such as d-dimer and plasminogen activator inhibitor (PAI)-1 were greater in the beta type and lower in the gamma type. The 28 day mortality was significantly different for individual phenotypes in host and host-pathogen models (both P < 0.01). The treatment effect of rhAPC obviously changed in gamma type when microbiology data were added (P-values of log rank test changed from 0.047 to 0.780). Conclusions: Sepsis host phenotype assignment was significantly modified when microbiology data were added to clinical variables, increasing cluster cohesiveness and homogeneity.
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Affiliation(s)
- Huiying Zhao
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, United States,*Correspondence: Huiying Zhao
| | - Jason N. Kennedy
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, United States
| | - Shu Wang
- Department of Biostatistics, University of Florida, Gainesville, FL, United States
| | - Emily B. Brant
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, United States
| | - Gordon R. Bernard
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kimberley DeMerle
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, United States
| | - Chung-Chou H. Chang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, United States
| | - Derek C. Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, United States
| | - Christopher W. Seymour
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States,Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, United States,Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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