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Vecchio N, Belardi D, Benzadón M, Seoane L, Daquarti G, Scazzuso F. Impact of a hybrid decision support system to improve the adherence to implantable cardioverter defibrillator therapy guidelines for primary prevention of sudden cardiac death. Int J Med Inform 2018; 114:76-80. [PMID: 29673607 DOI: 10.1016/j.ijmedinf.2018.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/24/2018] [Accepted: 03/26/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Despite the well-documented benefit of implantable cardioverter defibrillator (ICD) in patients with severe left ventricular dysfunction, there is a large number of patients who had not been offered this therapy. The aim of this study is to evaluate the utility of a hybrid decision support system (hCDSS) to improve the adherence to indicate ICD therapy in our institution. METHODS We conducted a retrospective, observational and single-center study. An hCDSS focused on patients with severe deterioration of the left ventricular function was implemented, creating a mandatory field containing the value of left ejection fraction and three options to choose: >35%, ≤ 35% or unknown. When the option ≤ 35% is checked, an email is automatically sent to the electrophysiology section where the staff can contact the treating physician to discuss the indication of ICD therapy. We measured the number of ICDs implanted before the alert (month 1-21), immediate post and late post alert (month 22-27 and 28-48 months respectively) RESULTS: The rate of ICD implantation increased from 1.76% per month in the pre-intervention period to 4.48% after the intervention (p < 0.001). This increase in the rate of ICD implantation remained stable between the immediate and late post-intervention period (4.6 vs. 4.4; p = .8) CONCLUSION: The implementation of a hybrid decision support system was associated with improved adherence to clinical guidelines for prevention of sudden cardiac death, as evidenced by a rapid and sustained increase in the number of ICD implants in patients with severe left ventricular dysfunction.
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Affiliation(s)
- Nicolás Vecchio
- Electrophysiology Fellowship, Instituto Cardiovascular de Buenos Aires, Argentina.
| | - Diego Belardi
- Staff, Electrophysiology Service, Kaiser Permanente Colorado, United States
| | - Mariano Benzadón
- Chief, Intensive Care Unit, Director of Quality, Safety and Patient Experience Instituto Cardiovascular de Buenos Aires, Argentina
| | - Leonardo Seoane
- Staff, Intensive Care Unit, Instituto Cardiovascular de Buenos Aires, Argentina
| | - Gustavo Daquarti
- Nuclear Medicine Fellowship, Instituto Cardiovascular de Buenos Aires, Argentina
| | - Fernando Scazzuso
- Chief, Electrophysiology Service, Instituto Cardiovascular de Buenos Aires, Argentina
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Rivera S, Ricapito MDLP, Tomas L, Parodi J, Bardera Molina G, Banega R, Bueti P, Orosco A, Reinoso M, Caro M, Belardi D, Albina G, Giniger A, Scazzuso F. Results of Cryoenergy and Radiofrequency-Based Catheter Ablation for Treating Ventricular Arrhythmias Arising From the Papillary Muscles of the Left Ventricle, Guided by Intracardiac Echocardiography and Image Integration. Circ Arrhythm Electrophysiol 2016; 9:e003874. [PMID: 27069089 DOI: 10.1161/circep.115.003874] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 02/25/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Catheter radiofrequency ablation of ventricular arrhythmias (VAs) arising from the left ventricle's papillary muscles has been associated with inconsistent results. The use of cryoenergy versus radiofrequency has not been compared yet. This study compares outcomes and complications of catheter ablation of VA from the papillary muscles of the left ventricle with either cryoenergy or radiofrequency. METHODS AND RESULTS Twenty-one patients (40±12 years old; 47% males; median ejection fraction 59±7.3%) with drug refractory premature ventricular contractions or ventricular tachycardia underwent catheter cryoablation or radiofrequency ablation. VAs were localized using 3-dimensional mapping, multidetector computed tomography, and intracardiac echocardiography, with arrhythmia foci being mapped at either the anterolateral papillary muscle or posteromedial papillary muscles of the left ventricle. Focal ablation was performed using an 8-mm cryoablation catheter or a 4-mm open-irrigated radiofrequency catheter, via transmitral approach. Acute success rate was 100% for cryoenergy (n=12) and 78% for radiofrequency (n=9; P=0.08). Catheter stability was achieved in all patients (100%) treated with cryoenergy, and only in 2 (25%) patients treated with radiofrequency (P=0.001). Incidence of multiple VA morphologies was observed in 7 patients treated with radiofrequency (77.7%), whereas none was observed in those treated with cryoenergy (P=0.001). VA recurrence at 6 months follow-up was 0% for cryoablation and 44% for radiofrequency (P=0.03). CONCLUSIONS Cryoablation was associated with higher success rates and lower recurrence rates than radiofrequency catheter ablation, better catheter stability, and lesser incidence of polymorphic arrhythmias.
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Affiliation(s)
- Santiago Rivera
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina.
| | - Maria de la Paz Ricapito
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Leandro Tomas
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Josefina Parodi
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Guillermo Bardera Molina
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Rodrigo Banega
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Pablo Bueti
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Agustin Orosco
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Marcelo Reinoso
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Milagros Caro
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Diego Belardi
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Gaston Albina
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Alberto Giniger
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Fernando Scazzuso
- From the Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
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Rivera S, de la Paz Ricapito M, Espinoza J, Belardi D, Albina G, Giniger A, Roux JF, Ayala-Paredes F, Scazzuso F. Cryoablation for Ventricular Arrhythmias Arising From the Papillary Muscles of the Left Ventricle Guided by Intracardiac Echocardiography and Image Integration. JACC Clin Electrophysiol 2015; 1:509-516. [PMID: 29759404 DOI: 10.1016/j.jacep.2015.07.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 07/27/2015] [Accepted: 07/31/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This case series reports outcomes and complications of catheter cryoablation at the papillary muscles (PM) of the left ventricle (LV). BACKGROUND Catheter radiofrequency ablation is an effective treatment for ventricular arrhythmias (VAs) arising from the PM of the LV. The use of cryoablation at PMs has not been described. METHODS Ten patients (70% men; median age: 38 years [range: 34 to 45 years]) with drug-refractory premature ventricular contractions or ventricular tachycardia underwent catheter cryoablation. VAs were localized using 3-dimensional (3D) mapping, multidetector computed tomography, and intracardiac echocardiography, with arrhythmia foci being mapped at either the anterolateral PM or posteromedial papillary muscle (PMPM) of the LV. Focal ablation, up to 240 s with freeze-thaw-freeze cycles was performed using an 8-mm cryoablation catheter via a transmitral approach. RESULTS Termination of ventricular arrhythmia was observed in all 10 patients during ablation. Median follow-up was 6 months after ablation. The PMPM had higher prevalence of clinical arrhythmias (100% PMPM VAs vs. 10% anterolateral PM VAs). The PM base was the most frequent site of origin of the arrhythmias (60% of patients). Pace-mapping showed ≥11/12 match in all treated PM at the site of effective lesion. All VAs arising from the base of the PM showed Purkinje potentials. There were no post-procedure complications. VA recurred in 1 patient. CONCLUSIONS Cryoablation for arrhythmias arising from the PMs of the LV can be performed, and is a safe and effective alternative energy source for ablation.
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Affiliation(s)
- Santiago Rivera
- Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina.
| | - Maria de la Paz Ricapito
- Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Juan Espinoza
- Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Diego Belardi
- Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Gaston Albina
- Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Alberto Giniger
- Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Jean-François Roux
- Centre Hospitalaire Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada
| | - Felix Ayala-Paredes
- Centre Hospitalaire Universitaire de Sherbrooke (CHUS), Sherbrooke, Quebec, Canada
| | - Fernando Scazzuso
- Cardiovascular Institute of Buenos Aires (ICBA), Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
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Worley S, Patel M, Belardi D, Bernabei M, Gohn D. Snare assisted left ventricular lead placement: results, safety and feasibility in 25 patients. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht309.p3188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Yokokawa M, Latchamsetty R, Ghanbari H, Belardi D, Makkar A, Roberts B, Saint-Phard W, Sinno M, Carrigan T, Kennedy R, Suwanagool A, Good E, Crawford T, Jongnarangsin K, Pelosi F, Bogun F, Oral H, Morady F, Chugh A. Characteristics of atrial tachycardia due to small vs large reentrant circuits after ablation of persistent atrial fibrillation. Heart Rhythm 2013; 10:469-76. [DOI: 10.1016/j.hrthm.2012.12.018] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Indexed: 11/24/2022]
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Takimoto E, Nagayama T, Vahebi S, Tocchetti CG, Ketner E, Belardi D, Champion H, Mendelsohn M, Kass DA. Molecular modulators of cardiac stress targeted by PDE5 inhibition. BMC Pharmacol 2007. [DOI: 10.1186/1471-2210-7-s1-s6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Takimoto E, Belardi D, Tocchetti CG, Vahebi S, Cormaci G, Ketner EA, Moens AL, Champion HC, Kass DA. Compartmentalization of cardiac beta-adrenergic inotropy modulation by phosphodiesterase type 5. Circulation 2007; 115:2159-67. [PMID: 17420342 DOI: 10.1161/circulationaha.106.643536] [Citation(s) in RCA: 130] [Impact Index Per Article: 7.6] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent cell-based studies have found that cGMP synthesis and hydrolysis by phosphodiesterase (PDE) appear compartmentalized, with nitric oxide synthase-derived and/or PDE type 5 (PDE-5)-hydrolyzable cGMP undetected at the sarcolemmal membrane in contrast to cGMP stimulated by natriuretic peptide. In the present study, we determine the functional significance of such compartments with a comparison of beta-adrenergic modulation by PDE-5 inhibition to that of natriuretic peptide stimulation in both cardiomyocytes and intact hearts. The potential role of differential cGMP and protein kinase G stimulation by these 2 modulators was also studied. METHODS AND RESULTS Intact C57/BL6 mouse hearts were studied with pressure-volume analysis, and adult isolated myocytes were studied with fluorescence microscopy. PDE-5 inhibition with 0.1 to 1 micromol/L sildenafil (SIL) suppressed isoproterenol (ISO)-stimulated contractility, whereas 10 micromol/L atrial natriuretic peptide (ANP) had no effect. ISO suppression by SIL was prevented in cells pretreated with a protein kinase G inhibitor. Surprisingly, myocardial cGMP changed little with SIL+ISO yet rose nearly 5-fold with ANP, whereas protein kinase G activation (vasodilator-stimulated protein phosphorylation; ELISA assay) displayed the opposite: increased with SIL+ISO but unaltered by ANP+ISO. PDE-5 and ANP compartments were functionally separated, as inhibition of nitric oxide synthase by N(w)-nitro-L-arginine methyl ester eliminated antiadrenergic effects of SIL, yet this was not restorable by co-stimulation with ANP. CONCLUSIONS Regulation of cardiac beta-adrenergic response by cGMP is specifically linked to a nitric oxide-synthesis/PDE-5-hydrolyzed pool signaling via protein kinase G. Natriuretic peptide stimulation achieves greater detectable increases in cGMP but not protein kinase G activity and does not modulate beta-adrenergic response. Such disparities likely contribute to differential cardiac regulation by drugs that modulate cGMP synthesis and hydrolysis.
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MESH Headings
- 3',5'-Cyclic-GMP Phosphodiesterases/antagonists & inhibitors
- 3',5'-Cyclic-GMP Phosphodiesterases/physiology
- Animals
- Atrial Natriuretic Factor/pharmacology
- Cell Compartmentation/physiology
- Cell Membrane/enzymology
- Cells, Cultured/drug effects
- Cells, Cultured/physiology
- Cyclic GMP/physiology
- Cyclic GMP-Dependent Protein Kinases/antagonists & inhibitors
- Cyclic GMP-Dependent Protein Kinases/physiology
- Cyclic Nucleotide Phosphodiesterases, Type 5
- Cytosol/enzymology
- Enzyme Activation/drug effects
- Guanylate Cyclase/metabolism
- Isoproterenol/pharmacology
- Male
- Mice
- Mice, Inbred C57BL
- Myocardial Contraction/drug effects
- Myocardial Contraction/physiology
- Myocytes, Cardiac/drug effects
- Myocytes, Cardiac/physiology
- NG-Nitroarginine Methyl Ester/pharmacology
- Nitric Oxide/physiology
- Phosphodiesterase Inhibitors/pharmacology
- Piperazines/pharmacology
- Protein Kinase Inhibitors/pharmacology
- Purines/pharmacology
- Receptors, Adrenergic, beta/drug effects
- Receptors, Adrenergic, beta/physiology
- Second Messenger Systems/physiology
- Sildenafil Citrate
- Sulfones/pharmacology
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Affiliation(s)
- Eiki Takimoto
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD 21205, USA
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Takimoto E, Champion H, Belardi D, Li M, Kass DA. Role of PDE5a in cardiac stress response. BMC Pharmacol 2005. [DOI: 10.1186/1471-2210-5-s1-s26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Takimoto E, Champion HC, Li M, Belardi D, Ren S, Rodriguez ER, Bedja D, Gabrielson KL, Wang Y, Kass DA. Chronic inhibition of cyclic GMP phosphodiesterase 5A prevents and reverses cardiac hypertrophy. Nat Med 2005; 11:214-22. [PMID: 15665834 DOI: 10.1038/nm1175] [Citation(s) in RCA: 693] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2004] [Accepted: 12/07/2004] [Indexed: 11/09/2022]
Abstract
Sustained cardiac pressure overload induces hypertrophy and pathological remodeling, frequently leading to heart failure. Genetically engineered hyperstimulation of guanosine 3',5'-cyclic monophosphate (cGMP) synthesis counters this response. Here, we show that blocking the intrinsic catabolism of cGMP with an oral phosphodiesterase-5A (PDE5A) inhibitor (sildenafil) suppresses chamber and myocyte hypertrophy, and improves in vivo heart function in mice exposed to chronic pressure overload induced by transverse aortic constriction. Sildenafil also reverses pre-established hypertrophy induced by pressure load while restoring chamber function to normal. cGMP catabolism by PDE5A increases in pressure-loaded hearts, leading to activation of cGMP-dependent protein kinase with inhibition of PDE5A. PDE5A inhibition deactivates multiple hypertrophy signaling pathways triggered by pressure load (the calcineurin/NFAT, phosphoinositide-3 kinase (PI3K)/Akt, and ERK1/2 signaling pathways). But it does not suppress hypertrophy induced by overexpression of calcineurin in vitro or Akt in vivo, suggesting upstream targeting of these pathways. PDE5A inhibition may provide a new treatment strategy for cardiac hypertrophy and remodeling.
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Affiliation(s)
- Eiki Takimoto
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Ross 835, 720 Rutland Avenue, Baltimore, Maryland 21205, USA
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Takimoto E, Champion HC, Belardi D, Moslehi J, Mongillo M, Mergia E, Montrose DC, Isoda T, Aufiero K, Zaccolo M, Dostmann WR, Smith CJ, Kass DA. cGMP catabolism by phosphodiesterase 5A regulates cardiac adrenergic stimulation by NOS3-dependent mechanism. Circ Res 2004; 96:100-9. [PMID: 15576651 DOI: 10.1161/01.res.0000152262.22968.72] [Citation(s) in RCA: 168] [Impact Index Per Article: 8.4] [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] [Indexed: 11/16/2022]
Abstract
Beta-adrenergic agonists stimulate cardiac contractility and simultaneously blunt this response by coactivating NO synthase (NOS3) to enhance cGMP synthesis and activate protein kinase G (PKG-1). cGMP is also catabolically regulated by phosphodiesterase 5A (PDE5A). PDE5A inhibition by sildenafil (Viagra) increases cGMP and is used widely to treat erectile dysfunction; however, its role in the heart and its interaction with beta-adrenergic and NOS3/cGMP stimulation is largely unknown. In nontransgenic (control) murine in vivo hearts and isolated myocytes, PDE5A inhibition (sildenafil) minimally altered rest function. However, when the hearts or isolated myocytes were stimulated with isoproterenol, PDE5A inhibition was associated with a suppression of contractility that was coupled to elevated cGMP and increased PKG-1 activity. In contrast, NOS3-null hearts or controls with NOS inhibited by N(G)-nitro-L-arginine methyl ester, or soluble guanylate cyclase (sGC) inhibited by 1H-[1,2,4]oxadiazolo[4,3-a]quinoxaline-1-one, showed no effect of PDE5A inhibition on beta-stimulated contractility or PKG-1 activation. This lack of response was not attributable to altered PDE5A gene or protein expression or in vitro PDE5A activity, but rather to an absence of sGC-generated cGMP specifically targeted to PDE5A catabolism and to a loss of PDE5A localization to z-bands. Re-expression of active NOS3 in NOS3-null hearts by adenoviral gene transfer restored PDE5A z-band localization and the antiadrenergic efficacy of PDE5A inhibition. These data support a novel regulatory role of PDE5A in hearts under adrenergic stimulation and highlight specific coupling of PDE5A catabolic regulation with NOS3-derived cGMP attributable to protein subcellular localization and targeted synthetic/catabolic coupling.
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Affiliation(s)
- Eiki Takimoto
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Md, USA
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