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Pirich C, Graf S, Behesthi M. Diagnostic and Prognostic Impact of Nuclear Cardiology in the Management of Acute Coronary Syndromes and Acute Myocardial Infarction. ACTA ACUST UNITED AC 2004. [DOI: 10.1111/j.1617-0830.2004.00026.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mahmarian JJ, Dwivedi G, Lahiri T. Role of nuclear cardiac imaging in myocardial infarction: postinfarction risk stratification. J Nucl Cardiol 2004; 11:186-209. [PMID: 15052250 DOI: 10.1016/j.nuclcard.2003.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Karkos CD, Baguneid MS, Triposkiadis F, Athanasiou E, Spirou P. Routine Measurement of Radioisotope Left Ventricular Ejection Fraction Prior to Vascular Surgery: Is it Worthwhile? Eur J Vasc Endovasc Surg 2004; 27:227-38. [PMID: 14760589 DOI: 10.1016/j.ejvs.2003.12.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine whether estimation of left ventricular (LV) ejection fraction (EF) by means of multiple gated acquisition (MUGA) scanning could reliably stratify cardiac risk prior to elective major vascular surgery. METHODS A review of the English-language literature. RESULTS AND CONCLUSIONS Twenty-two studies enrolling a total of 3096 patients were identified from 1984 to date. Selection bias, blinding of the results, different cut-off limits, and several retrospective studies were some of the problems preventing a comprehensive analysis. The resting LVEF was not found to be a consistent predictor of perioperative ischaemic cardiac events. In the perioperative phase, poor LV function was, mainly, predictive of congestive heart failure, and, in the long-term, of cardiac outcome. The presence of myocardial wall motion abnormalities was also associated with both a higher chance of postoperative cardiac complications and a worse long-term cardiac outcome. Although measurements of LV function seem to play a key role in defining a patient's long-term prognosis, the value of routinely measuring LVEF preoperatively is limited and, therefore, MUGA scanning cannot be recommended as a general screening test. Despite this, it has been widely used for cardiac risk assessment in vascular surgery, and only recently its popularity has started declining. Other tests, such as stress-echocardiography and myocardial perfusion imaging, used selectively in moderate-risk patients can refine prediction of cardiac risk. In the future, gated stress myocardial perfusion scintigraphy, perhaps combined with ANP/BNP plasma level determination, may become a first choice test in preoperative cardiac risk assessment.
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Affiliation(s)
- C D Karkos
- Department of Cardiovasculr and Thoracic Surgery, University of Thessalia Medical School, Larissa, Grece.
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Abstract
In recent years, the characteristics of patients who suffer acute myocardial infarction without complications during hospitalization have changed. In addition, the range of non-invasive studies available for evaluating left ventricular systolic function, residual myocardial ischemia, and myocardial viability in these patients has improved. Left ventricular systolic function and residual ischemia should be evaluated in all patients before release. The non-invasive technique used (exercise test, echocardiography, nuclear cardiology, magnetic resonance imaging) depends on availability, experience, and results at each institution. Coronary arteriography should be performed in patients with significant ischemia or severe left ventricular systolic dysfunction in non-invasive studies. In these cases coronary angiography must be performed to determine if coronary arteries are suitable for revascularization before performing a test of myocardial viability.
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Affiliation(s)
- Jaume Candell Riera
- Servei de Cardiologia. Hospital General Universitari Vall d'Hebron. Barcelona. España.
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Ruiz-Salmerón RJ, de Araujo Martins-Romeo D, López A, Sanmartín M, del Campo V, Mantilla R, Castellanos R, Ocaranza R, Saa T, Guitián R, Goicolea J. [Value of gated-SPECT in defining the post-revascularization prognosis of patients with ischemic cardiomyopathy]. Rev Esp Cardiol 2003; 56:281-8. [PMID: 12622958 DOI: 10.1016/s0300-8932(03)76864-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION AND OBJECTIVES Gated-SPECT simultaneously evaluates perfusion and ventricular function and could provide important prognostic information in ischemic cardiomyopathy. Our aim was to study the value of gated-SPECT performed before revascularization in a cardioischemic population to predict the outcome of revascularization. METHODS One hundred and ten patients who had undergone percutaneous (n = 100) or surgical revascularization were included. Patients underwent sestamibi gated-SPECT before revascularization. After revascularization, they were followed-up for at least 12 months (mean 23.7 months, maximum 44 months). We recorded deaths and a combined clinical event of death, non-fatal infarction, and hospital re-admission for cardiac reasons. We analyzed the prognostic value of clinical, angiographic, and gated-SPECT variables. RESULTS During follow-up, there were 14 deaths (6.4%/ year) and 36 cases of combined events (16.5%/year). Multivariate analysis showed that depressed gated-SPECT ejection fraction (threshold 0.30) was the only variable independently related to death (OR = 4.8; 95%CI, 1.6-14.6) and combined event (OR = 2.5; 95%CI, 1.2-4.8). Survival analysis showed that patients with ejection fraction < or = 0.30% had a significantly shorter period of time free of death (33 months [28-38] versus 42 months [40-44]; p = 0.002) and combined events (28 months [23-32] versus 36 months [33-39]; p = 0.007). CONCLUSIONS Gated-SPECT, due to the information it provides about left ventricular function, predicts the prognosis of patients after coronary revascularization.
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Affiliation(s)
- Rafael J Ruiz-Salmerón
- Unidades de Cardiología Intervencionista. Instituto Gallego de Medicina Técnica. Hospital Meixoeiro. Vigo (Pontevedra). España.
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Bigi R, Desideri A, Rambaldi R, Cortigiani L, Sponzilli C, Fiorentini C. Angiographic and prognostic correlates of cardiac output by cardiopulmonary exercise testing in patients with anterior myocardial infarction. Chest 2001; 120:825-33. [PMID: 11555516 DOI: 10.1378/chest.120.3.825] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To assess the diagnostic and prognostic value of cardiac output assessed by cardiopulmonary exercise testing in patients with anterior acute myocardial infarction (AMI) and left ventricular dysfunction. PATIENTS AND SETTING Forty-six patients with AMI (7 female patients; mean +/- SD age, 55 +/- 8 years; ejection fraction, 39 +/- 7%) underwent cardiopulmonary exercise testing and coronary angiography following hospital discharge. MEASUREMENT AND RESULTS Cardiac output was estimated from oxygen uptake (VO(2)) during exercise according to a method based on the linear regression between arteriovenous oxygen content difference and percent maximum VO(2). Angiograms were scored using Gensini and Duke "jeopardy" scores. Cardiac output at anaerobic threshold (COAT) < or = 7.3 L/min was the best cutoff value for identifying multivessel coronary artery disease (relative risk, 3.1). Angiographic scores were significantly higher in patients with COAT < 7.3 L/min as compared to those with COAT > 7.3 L/min (82 +/- 8 vs 53 +/- 7 and 6 +/- 2 vs 4 +/- 3, respectively; p < 0.05) and were inversely and significantly correlated to COAT. Conversely, no correlation was found with ECG changes. COAT, VO(2) at anaerobic threshold, and peak VO(2) were univariate prognostic indicators. However, using Cox's model, COAT was the only multivariate predictor of outcome (odds ratio, 0.28; 95% confidence interval [CI], 0.09 to 0.9). Moreover, COAT < 7.3 L/min was associated to an increased risk of further cardiac events (odds ratio, 5; 95% CI, 1.4 to 17) and provided a significant discrimination of survival for the combined end point of cardiac death, reinfarction, and clinically driven revascularization. CONCLUSIONS COAT is a safe and feasible tool providing additional diagnostic and prognostic information in patients with AMI.
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Affiliation(s)
- R Bigi
- Cardiovascular Research Foundation, S. Giacomo Hospital, Castelfranco Veneto, Italy.
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Shaw LJ, Peterson ED, Kesler K, Hasselblad V, Califf RM. A metaanalysis of predischarge risk stratification after acute myocardial infarction with stress electrocardiographic, myocardial perfusion, and ventricular function imaging. Am J Cardiol 1996; 78:1327-37. [PMID: 8970402 DOI: 10.1016/s0002-9149(96)00653-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We assessed the relation of abnormal predischarge non-invasive test results to outcomes in postmyocardial infarction patients. We included series published from 1980 to 1995 containing only myocardial infarction patients, enrolling most patients after 1980, testing within 6 weeks of infarction, having follow-up rates > 80%, and having 2 x 2 frequency outcome rates for test results, that were the latest of multiple reports. Sensitivity, specificity, and predictive values were calculated for test results for 1-year outcomes (cardiac death, cardiac death or reinfarction). Univariable and summary odds were calculated for test results. Reports (n = 54) included a total of 19,874 patients and were primarily retrospective (76%) and small series (35% of reports included < 5 deaths). One-year mortality ranged from 2.5% for pharmacologic stress echocardiography to 9.3% for exercise radionuclide angiography. Positive predictive values for most noninvasive risk markers were < 0.10 for cardiac death and < 0.20 for death or reinfarction. Electrocardiographic, symptomatic, and scintigraphic risk markers of ischemia (ST-segment depression, angina, a reversible defect) were less sensitive (< or = 44%) for identifying morbid and fatal outcomes than markers of left ventricular dysfunction or heart failure (exercise duration, impaired systolic blood pressure response, and peak left ventricular ejection fraction). The positive predictive value of predischarge noninvasive testing is low. Markers of left ventricular dysfunction appear to be better predictors than markers of ischemia. Limitations of the literature-small samples and widely varying event rates-impede our ability to discern the accuracy of pre-discharge noninvasive testing. More rigorous, controlled trials are required to elucidate the relative value of these tests for risk stratification.
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Affiliation(s)
- L J Shaw
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina 27705-4667, USA
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Olona M, Candell-Riera J, Permanyer-Miralda G, Castell J, Barrabés JA, Domingo E, Rosselló J, Vaqué J, Soler-Soler J. Strategies for prognostic assessment of uncomplicated first myocardial infarction: 5-year follow-up study. J Am Coll Cardiol 1995; 25:815-22. [PMID: 7884082 DOI: 10.1016/0735-1097(94)00503-i] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Our aim was to use noninvasive studies early after infarction to assess medium-term prognosis in patients with a first uncomplicated myocardial infarction. BACKGROUND Although the use of early postinfarction assessment to gauge short-term prognosis in myocardial infarction is well established, there have been few comprehensive evaluations of noninvasive methods for assessing medium- and long-term prognosis. METHODS We prospectively studied 115 consecutive patients < 65 years old with a first acute uncomplicated myocardial infarction to evaluate the prognostic role of predischarge cardiac studies. These included submaximal exercise testing, thallium-201 scintigraphy, radionuclide exercise ventriculography, two-dimensional echocardiography, ambulatory electrocardiographic (Holter) monitoring and cardiac catheterization. All patients without complications were followed up > or = 5 years. RESULTS During the follow-up period, 78 patients (68%) developed complications, which were severe in 37 (32%). Exercise thallium-201 scintigraphy yielded the highest percentage (77%) for correctly classified patients. It also had the highest predictive value for complications (97%) and severe complications (92%) when it was used in association with exercise testing and radionuclide ventriculography. The addition of cardiac catheterization did not improve on the predictive power of noninvasive studies. Four decision trees (exercise testing + echocardiography, exercise testing + radionuclide ventriculography, thallium-201 + echocardiography, thallium-201 + radionuclide ventriculography) allowed stratification of all patients in a high, intermediate or low risk category. The combination of thallium-201 scintigraphy and radionuclide ventriculography yielded the best results (90% predictive value for complications if the outcome of both tests was positive), but there were no significant differences with the other models. CONCLUSIONS Any combination of a test detecting residual ischemia or functional capacity, or both (exercise testing or thallium-201 scintigraphy), and a test assessing ventricular function (echocardiography or radionuclide ventriculography) results in useful prognostic information in patients with an uncomplicated first acute myocardial infarction.
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Affiliation(s)
- M Olona
- Servei de Cardiologia, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
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Reperfusion in acute myocardial infarction. International Society and Federation of Cardiology and World Health Organization Task Force on Myocardial Reperfusion. Circulation 1994; 90:2091-102. [PMID: 7923697 DOI: 10.1161/01.cir.90.4.2091] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Affiliation(s)
- A Marmor
- Division of Cardiology, Safed Hospital, Israel
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Bonow RO. Prognostic assessment in coronary artery disease: role of radionuclide angiography. J Nucl Cardiol 1994; 1:280-91. [PMID: 9420711 DOI: 10.1007/bf02940342] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Left ventricular function is one of the most important determinants, if not the most important determinant, of outcome in patients with coronary artery disease. The ability of radionuclide angiography to assess resting and exercise ejection fraction accurately and reproducibly has been shown to be a critical determinant of survival in large-scale studies of survivors of myocardial infarction, as well as patients with chronic stable angina. In addition, several centers have demonstrated that the exercise ejection fraction is an extremely valuable (and perhaps the most valuable) noninvasive parameter in predicting survival among patients with coronary artery disease. The prognostic insights gained from the exercise ejection fraction add incremental predictive information to the coronary anatomic information obtained from coronary arteriography, especially in patients with multivessel disease and those with left ventricular dysfunction at rest.
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Affiliation(s)
- R O Bonow
- Division of Cardiology, Northwestern University Medical School, Chicago, Ill 60611, USA
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Affiliation(s)
- B L Zaret
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn. 06510
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Affiliation(s)
- A Sniderman
- Cardiology Division, Royal Victoria Hospital, McGill University, Quebec, Canada
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Candell-Riera J, Permanyer-Miralda G, Castell J, Rius-Daví A, Domingo E, Alvarez-Auñón E, Olona M, Rosselló J, Ortega D, Domènech-Torné FM. Uncomplicated first myocardial infarction: strategy for comprehensive prognostic studies. J Am Coll Cardiol 1991; 18:1207-19. [PMID: 1918697 DOI: 10.1016/0735-1097(91)90537-j] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To evaluate the prognostic role of combined cardiac studies (submaximal exercise test, thallium-201 scintigraphy, radionuclide exercise ventriculography, two-dimensional echocardiography, Holter monitoring and cardiac catheterization) in patients with a first acute myocardial infarction without complications during hospital admission, 115 consecutive patients aged less than 65 years were prospectively evaluated. The studies were carried out before hospital discharge and the patients were then clinically followed up for 12 months. During the follow-up period, 69 patients (60%) developed complications, which were severe in 23 (20%). Half of all complications and 70% of severe complications developed during the 1st follow-up month. Logistic regression analysis disclosed that the combination of studies with the highest predictive power for complications (probability of complications 99%) and severe complications (probability of severe complications 95%) was the association of exercise test + thallium-201 + echocardiogram. Four decision models (exercise test + echocardiography, exercise test + radionuclide ventriculography, thallium-201 scintigraphy + echocardiography, thallium-201 scintigraphy + radionuclide ventriculography) allowed the stratification of all patients in a particular risk category (high, intermediate or low). The best decision model was the association of thallium-201 scintigraphy + radionuclide ventriculography (probability of complications if both tests were positive 84%; probability of absence of severe complications if both tests were negative 88%), but there were no significant differences with the other models. Any association of a test detecting residual ischemia or functional capacity, or both (exercise test or thallium-201) and a test assessing ventricular function (echocardiography or radionuclide ventriculography) results in significant prognostic information in patients with an uncomplicated first acute myocardial infarction. Additional cardiac catheterization does not improve the predictive power of noninvasive studies, which should ideally be performed before hospital discharge because most complications develop during the 1st follow-up month.
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Affiliation(s)
- J Candell-Riera
- Servei de Cardiologia, Hospital General Vall d'Hebron, Barcelona, Spain
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DePuey EG, Rozanski A. Pharmacological and other nonexercise alternatives to exercise testing to evaluate myocardial perfusion and left ventricular function with radionuclides. Semin Nucl Med 1991; 21:92-101. [PMID: 1862354 DOI: 10.1016/s0001-2998(05)80047-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Pharmacological vasodilatation with either dipyridamole or adenosine is a safe and accurate alternative to exercise testing to diagnose coronary artery disease with thallium 201 myocardial perfusion imaging. The technique also provides important prognostic information with regard to future cardiac events in patients undergoing diagnostic testing, in those evaluated preoperatively, and in those with recent myocardial infarctions. Multigated equilibrium and first-pass radionuclide ventriculography also are well suited to evaluate the effects of interventional procedures. Success has been achieved using this methodology in a variety of interventions including conventional exercise testing, pharmacological stress testing, atrial pacing, assessment of myocardial viability with nitroglycerin, mental stress testing, and ambulatory monitoring of left ventricular ejection fraction.
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Affiliation(s)
- E G DePuey
- Department of Radiology, St. Luke's-Roosevelt Hospital Center, New York, NY 10025
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Lee KL, Pryor DB, Pieper KS, Harrell FE, Califf RM, Mark DB, Hlatky MA, Coleman RE, Cobb FR, Jones RH. Prognostic value of radionuclide angiography in medically treated patients with coronary artery disease. A comparison with clinical and catheterization variables. Circulation 1990; 82:1705-17. [PMID: 2225372 DOI: 10.1161/01.cir.82.5.1705] [Citation(s) in RCA: 126] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
To evaluate the usefulness of multiple measures from rest and exercise radionuclide angiography (RNA) in predicting cardiovascular death and cardiovascular events (death or nonfatal myocardial infarction) and to assess the prognostic usefulness of the RNA relative to clinical and catheterization data, we studied 571 stable patients with symptomatic coronary artery disease who had upright rest/exercise first-pass RNA within 3 months of catheterization and were medically treated. With a median follow-up of 5.4 years, 90 patients have died from cardiovascular causes, and 147 patients have either died or suffered a nonfatal myocardial infarction. Using the Cox regression model and a preselected group of RNA variables, the most important RNA predictor of mortality was exercise ejection fraction (chi 2 = 81, p less than 0.00001). Neither rest ejection fraction nor the change in ejection fraction from rest to exercise contributed additional predictive information. Two other RNA study variables, the change in heart rate from rest to exercise and rest end-diastolic volume index, did contribute additional prognostic information to the exercise ejection fraction (chi 2 = 23, p less than 0.0001). Compared with noninvasive clinical data (history, physical examination, electrocardiogram, and chest radiograph), RNA variables were considerably more predictive of mortality (chi 2 = 71 [clinical variables] versus chi 2 = 104 [RNA]). Remarkably, the strength of the relation of RNA variables with mortality was equivalent to that of the set of catheterization variables previously demonstrated in our large angiographic population to be prognostically important (chi 2 = 104 [RNA] versus chi 2 = 102 [catheterization variables]). The RNA contained 84% of the information provided by clinical and catheterization descriptors combined. Furthermore, the RNA contributed significant additional prognostic information to the clinical and catheterization data (chi 2 = 13.6, p = 0.0035). For cardiovascular events, the relative prognostic usefulness of the RNA was similar, although relations with this outcome were generally weaker. Descriptors from the rest/exercise RNA exhibit a powerful relation with long-term outcomes and can be useful in defining risk, even when clinical and catheterization data are available.
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Affiliation(s)
- K L Lee
- Department of Community and Family Medicine, Duke University Medical Center, Durham, NC 27710
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