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Ohikere K, Wong RJ. Hepatic Encephalopathy: Clinical Manifestations. Clin Liver Dis 2024; 28:253-263. [PMID: 38548437 DOI: 10.1016/j.cld.2024.01.005] [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: 04/02/2024]
Abstract
Hepatic encephalopathy (HE) can occur as a complication of chronic liver disease as well as acute liver failure. HE is associated with significantly increased morbidity and worse patient outcomes. The clinical manifestation of HE ranges from early less-severe presentations that may only be accurately detected on dedicated psychomotor diagnostic testing to overt alterations in cognition and mental status to the most severe form of coma. Greater awareness of the clinical manifestations of HE across the spectrum of symptom severity is critical for early identification and timely initiation of appropriate therapy to improve patient outcomes.
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Affiliation(s)
- Kabiru Ohikere
- Value Based Care Department, San Francisco Health Network / Zuckerberg San Francisco General Hospital and Trauma Center
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine; Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA, USA.
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Minimal Hepatic Encephalopathy and Mild Cognitive Impairment Worsen Quality of Life in Elderly Patients With Cirrhosis. Clin Gastroenterol Hepatol 2020; 18:3008-3016.e2. [PMID: 32205222 PMCID: PMC7502426 DOI: 10.1016/j.cgh.2020.03.033] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/03/2020] [Accepted: 03/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with cirrhosis are growing older. The overlap between minimal hepatic encephalopathy (MHE) and predementia mild cognitive impairment (MCI) could affect quality of life (QOL). We investigated the performance of elderly patients with cirrhosis on tests for MHE and MCI and their effects on QOL. METHODS We recruited outpatients with cirrhosis (n = 109) and without cirrhosis (controls, n = 100), 65 years or older, at 4 centers (derivation cohort). All study participants were assessed for psychometric hepatic encephalopathy score (PHES), EncephalApp score, and QOL. MCI was tested in patients with cirrhosis using the repeatable battery for assessment of neuropsychological status and assigned to the following groups: unimpaired, MCI only, MHE only, and MCI+MHE. We created adjusted norms to detect MHE using PHES and EncephalApp scores from the controls. Findings were validated using data from a separate cohort of 77 patients with cirrhosis (mean age, 69.49 ± 4.36 y; 72% men) at the same study sites. RESULTS Controls were older but were more educated, performed better cognitively, and had better QOL. Among patients with cirrhosis, age, education, model for end-stage liver disease score, EncephalApp score, and QOL were similar, but PHES and repeatable battery for assessment of neuropsychological status differed among sites. In the derivation cohort, the presence of MHE, with or without MCI, was associated with poor QOL, which was lowest in the MCI+MHE group. When we adjusted for age, sex, and education, 49% of patients with cirrhosis had MHE based on the EncephalApp and 8% had MHE based on the PHES. A similar pattern (49% MHE based on EncephalApp and 6% MHE based on PHES) was found in a validation cohort. CONCLUSIONS In a multicenter study of patients with cirrhosis (>65 y) and controls, the presence of MHE, regardless of MCI, was associated with poor cognition and QOL. We created adjusted norms that defined the high sensitivity of EncephalApp for the detection of MHE in older individuals and validated it in a separate cohort.
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Ridola L, Riggio O, Gioia S, Nardelli S. Minimal hepatic encephalopathy and sleep disorders in patients with cirrhosis: Which comes first? Saudi J Gastroenterol 2020; 26:111-112. [PMID: 32415046 PMCID: PMC7392295 DOI: 10.4103/sjg.sjg_169_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Lorenzo Ridola
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome, Italy,Address for correspondence: Dr. Lorenzo Ridola, Department of Translational and Precision Medicine,“Sapienza” University of Rome, vialedell' Università 37, Rome 00185, Italy. E-mail:
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, “Sapienza” University of Rome, Rome, Italy
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Formentin C, De Rui M, Zoncapè M, Ceccato S, Zarantonello L, Senzolo M, Burra P, Angeli P, Amodio P, Montagnese S. The psychomotor vigilance task: Role in the diagnosis of hepatic encephalopathy and relationship with driving ability. J Hepatol 2019; 70:648-657. [PMID: 30633946 DOI: 10.1016/j.jhep.2018.12.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/14/2018] [Accepted: 12/16/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND & AIMS Hepatic encephalopathy (HE) is a syndrome of decreased vigilance and has been associated with impaired driving ability. The aim of this study was to evaluate the psychomotor vigilance task (PVT), which is used to assess both vigilance and driving ability, in a group of patients with cirrhosis and varying degrees of HE. METHODS A total of 145 patients (120 males, 59 ± 10 years, model for end-stage liver disease [MELD] score 13 ± 5) underwent the PVT; a subgroup of 117 completed a driving questionnaire and a subgroup of 106 underwent the psychometric hepatic encephalopathy score (PHES) and an electroencephalogram (EEG), based on which, plus a clinical evaluation, they were classed as being unimpaired (n = 51), or as having minimal (n = 35), or mild overt HE (n = 20). All patients were followed up for an average of 13 ± 5 months in relation to the occurrence of accidents and/or traffic offences, HE-related hospitalisations and death. Sixty-six healthy volunteers evenly distributed by sex, age and education served as a reference cohort for the PVT. RESULTS Patients showed worse PVT performance compared with healthy volunteers, and PVT indices significantly correlated with MELD, ammonia levels, PHES and the EEG results. Significant associations were observed between neuropsychiatric performance/PVT indices and licence/driving status. PVT, PHES and EEG results all predicted HE-related hospitalisations and/or death over the follow-up period; none predicted accidents or traffic offences. However, individuals with the slowest reaction times and most lapses on the PVT were often not driving despite having a licence. When patients who had stopped driving for HE-related reasons (n = 6) were modelled as having an accident or fine over the subsequent 6 and 12 months, PVT was a predictor of accidents and traffic offences, even after correction for MELD and age. CONCLUSIONS The PVT is worthy of further study for the purposes of both HE and driving ability assessment. LAY SUMMARY Hepatic encephalopathy (HE) is a complication of advanced liver disease that can manifest as excessive sleepiness. Some patients with HE have been shown to have difficulty driving. Herein, we used a test called the Psychomotor Vigilance Task (PVT), which measures sleepiness and can also be used to assess driving competence. We showed that PVT performance is fairly stable in healthy individuals. We also showed that PVT performance parallels performance in tests which are commonly used in cirrhotic patients to measure HE. We suggest that this test is helpful in quantifying HE and identifying dangerous drivers among patients with cirrhosis.
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Affiliation(s)
| | - Michele De Rui
- Department of Medicine, University of Padova, Padova, Italy
| | - Mirko Zoncapè
- Department of Medicine, University of Padova, Padova, Italy
| | - Silvia Ceccato
- Department of Medicine, University of Padova, Padova, Italy
| | | | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Italy
| | - Patrizia Burra
- Department of Surgery, Oncology and Gastroenterology, University of Padova, Italy
| | - Paolo Angeli
- Department of Medicine, University of Padova, Padova, Italy
| | - Piero Amodio
- Department of Medicine, University of Padova, Padova, Italy
| | - Sara Montagnese
- Department of Medicine, University of Padova, Padova, Italy.
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Abstract
Hepatic encephalopathy (HE) has a major impact on health-related quality of life (HRQOL) in patients, which has clinical and psychosocial consequences. HRQOL in cirrhosis has been measured by generic and liver-specific instruments, with most studies indicating a negative impact of HE. HRQOL abnormalities span daily functioning, sleep–wake cycle changes, and the ability to work. Of these, sleep–wake cycle changes have a major effect on HRQOL, which remains challenging to treat. The personal effect of HRQOL is modulated by the presence of HE, the etiology of cirrhosis, and cognitive reserve. Patients with higher cognitive reserve are able to tolerate HE and its impact on HRQOL better than those with a poor cognitive reserve. The impact of HRQOL impairment is felt by patients (higher mortality and poor daily functioning), as well as by caregivers and families. Caregivers of patients with HE bear a major financial and psychological burden, which may affect their personal health and longevity.
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Abstract
In the intersection of alcohol ingestion with the law, medical ethics, and public safety, physicians are often unsure about how to proceed. Physicians' primary focus should be on patient education with an ethical and legal duty to warn the patient of the adverse effects of alcohol. Warning third parties of potential harm related to alcohol-related impairment may involve a breach of patient confidentiality; therefore it should only be undertaken after careful analysis suggests that the risk for significant harm exceeds the burden that results to the patient from warning others. The law remains vague in this area.
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Affiliation(s)
- Maya Balakrishnan
- Section of Gastroenterology, Department of Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA.
| | - Stephen Chris Pappas
- Section of Gastroenterology, Department of Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
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Abstract
Sleep dysfunction is an epidemic, the implications of which have a profound impact on a variety of gastrointestinal disease. Recent data suggests a relationship between sleep dysfunction and intestinal dysbiosis, a known proinflammatory driver. This article evaluates the interplay between sleep dysfunction and gastrointestinal health and disease, with a focus on the impact of circadian rhythm disruption on the commensal microbiota.
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Wake-up Call to Clinicians: The Impact of Sleep Dysfunction on Gastrointestinal Health and Disease. J Clin Gastroenterol 2018; 52:194-203. [PMID: 29189428 DOI: 10.1097/mcg.0000000000000963] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Sleep dysfunction is an epidemic affecting a large portion of the adult population. Recent studies have linked sleep dysfunction with an upregulation of proinflammatory cytokines (eg, tumor necrosis factor-α, interleukin-1 and interleukin-6), the implications of which can have a profound impact on a variety of gastrointestinal disease. In particular, sleep dysfunction seems to accelerate disease states characterized by inflammation (eg, gastroesophageal reflux disease, irritable bowel syndrome and functional dyspepsia, chronic liver disease, inflammatory bowel disease, and colorectal cancer). This article evaluates the complex interplay between sleep dysfunction and gastrointestinal health and disease.
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Johansson M, Månsson M, Lins LE, Scharschmidt B, Doverskog M, Bäckström T. GR3027 reversal of neurosteroid-induced, GABA-A receptor-mediated inhibition of human brain function: an allopregnanolone challenge study. Psychopharmacology (Berl) 2018; 235:1533-1543. [PMID: 29492615 PMCID: PMC5919995 DOI: 10.1007/s00213-018-4864-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 02/15/2018] [Indexed: 12/12/2022]
Abstract
RATIONALE GR3027 is a novel small molecule GABA-A receptor-modulating steroid antagonist, which in non-clinical studies has shown promise for treatment of human disorders due to allosteric over-activation of GABA-A receptors by neurosteroids, such as allopregnanolone. We here studied its safety, pharmacokinetics, and ability to inhibit allopregnanolone effects in humans. METHODS Safety and pharmacokinetics were studied in healthy adult males receiving ascending single or multiple oral GR3027 vs. placebo. GR3027-mediated reversal of allopregnanolone effect on maximal saccadic eye velocity (SEV), and self-rated somnolence was studied in a double-blind, placebo-controlled, three-part cross-over study in which 3 or 30 mg oral GR3027 preceded 0.05 mg/kg of i.v. allopregnanolone. RESULTS GR3027 was well tolerated, adverse events were generally mild and transient, and no dose-limiting toxicity or grade 3 adverse events were observed up to the highest single (200 mg) or multiple (100 mg every 12 h for 5 days) doses. The maximum concentration (Cmax) and systemic exposure (area under the plasma concentration-time curve from dose extrapolated to infinity [AUC0-∞] and/or AUC during the dosing interval [AUCτ]) varied linearly with dose; with dose-dependent accumulation ratios of 1.3-1.6. Allopregnanolone decreased SEV and induced somnolence in most, but not all subjects. By predefined analyses, 30 mg GR3027 significantly inhibited allopregnanolone-induced decrease in SEV (p = 0.03); 3 and 30 mg GR3027 non-significantly inhibited allopregnanolone-induced sedation. By post hoc analyses restricted to subjects with allopregnanolone-induced changes and the time period over which they occurred, GR3027 dose dependently inhibited allopregnanolone-induced decrease in SEV (p = 0.04 at 30 mg, non-significant at 3 mg) and allopregnanolone-induced sedation (p = 0.01/0.05 at 3/30 mg doses). CONCLUSION Oral GR3027 mitigates inhibition of brain function induced by allopregnanolone at doses which are clinically well tolerated and associated with linear pharmacokinetics.
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Affiliation(s)
- Maja Johansson
- Umecrine Cognition AB, Karolinska Institutet Science Park, Fogdevreten 2, SE-171 65, Solna, Sweden. .,Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE-901 87, Umeå, Sweden.
| | - Maria Månsson
- Umecrine Cognition AB, Karolinska Institutet Science Park, Fogdevreten 2, SE-171 65 Solna, Sweden
| | - Lars-Eric Lins
- Umecrine Cognition AB, Karolinska Institutet Science Park, Fogdevreten 2, SE-171 65 Solna, Sweden
| | - Bruce Scharschmidt
- Umecrine Cognition AB, Karolinska Institutet Science Park, Fogdevreten 2, SE-171 65 Solna, Sweden
| | - Magnus Doverskog
- Umecrine Cognition AB, Karolinska Institutet Science Park, Fogdevreten 2, SE-171 65 Solna, Sweden
| | - Torbjörn Bäckström
- Umecrine Cognition AB, Karolinska Institutet Science Park, Fogdevreten 2, SE-171 65 Solna, Sweden ,Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE-901 87 Umeå, Sweden
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Symptom Domain Groups of the Patient-Reported Outcomes Measurement Information System Tools Independently Predict Hospitalizations and Re-hospitalizations in Cirrhosis. Dig Dis Sci 2017; 62:1173-1179. [PMID: 28258378 DOI: 10.1007/s10620-017-4509-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 02/21/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patient-Reported Outcomes Measurement Information System (PROMIS) tools can identify health-related quality of life (HRQOL) domains that could differentially affect disease progression. Cirrhotics are highly prone to hospitalizations and re-hospitalizations, but the current clinical prognostic models may be insufficient, and thus studying the contribution of individual HRQOL domains could improve prognostication. AIM Analyze the impact of individual HRQOL PROMIS domains in predicting time to all non-elective hospitalizations and re-hospitalizations in cirrhosis. METHODS Outpatient cirrhotics were administered PROMIS computerized tools. The first non-elective hospitalization and subsequent re-hospitalizations after enrollment were recorded. Individual PROMIS domains significantly contributing toward these outcomes were generated using principal component analysis. Factor analysis revealed three major PROMIS domain groups: daily function (fatigue, physical function, social roles/activities and sleep issues), mood (anxiety, anger, and depression), and pain (pain behavior/impact) accounted for 77% of the variability. Cox proportional hazards regression modeling was used for these groups to evaluate time to first hospitalization and re-hospitalization. RESULTS A total of 286 patients [57 years, MELD 13, 67% men, 40% hepatic encephalopathy (HE)] were enrolled. Patients were followed at 6-month (mth) intervals for a median of 38 mths (IQR 22-47), during which 31% were hospitalized [median IQR mths 12.5 (3-27)] and 12% were re-hospitalized [10.5 mths (3-28)]. Time to first hospitalization was predicted by HE, HR 1.5 (CI 1.01-2.5, p = 0.04) and daily function PROMIS group HR 1.4 (CI 1.1-1.8, p = 0.01), independently. In contrast, the pain PROMIS group were predictive of the time to re-hospitalization HR 1.6 (CI 1.1-2.3, p = 0.03) as was HE, HR 2.1 (CI 1.1-4.3, p = 0.03). CONCLUSIONS Daily function and pain HRQOL domain groups using PROMIS tools independently predict hospitalizations and re-hospitalizations in cirrhotic patients.
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Khanijow V, Prakash P, Emsellem HA, Borum ML, Doman DB. Sleep Dysfunction and Gastrointestinal Diseases. Gastroenterol Hepatol (N Y) 2015; 11:817-825. [PMID: 27134599 PMCID: PMC4849511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Sleep deprivation and impaired sleep quality have been associated with poor health outcomes. Many patients experience sleep disturbances, which can increase the risk of medical conditions such as hypertension, obesity, stroke, and heart disease as well as increase overall mortality. Recent studies have suggested that there is a strong association between sleep disturbances and gastrointestinal diseases. Proinflammatory cytokines, such as tumor necrosis factor, interleukin-1, and interleukin-6, have been associated with sleep dysfunction. Alterations in these cytokines have been seen in certain gastrointestinal diseases, such as gastroesophageal reflux disease, inflammatory bowel disease, liver disorders, and colorectal cancer. It is important for gastroenterologists to be aware of the relationship between sleep disorders and gastrointestinal illnesses to ensure good care for patients. This article reviews the current research on the interplay between sleep disorders, immune function, and gastrointestinal diseases.
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Affiliation(s)
- Vikesh Khanijow
- Dr Khanijow and Dr Prakash are gastroenterology fellows in the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center and are affiliated with Medical Faculty Associates, both in Washington, DC. Dr Emsellem is a clinical professor of neurology at George Washington University Medical Center and is director of the Center for Sleep and Wake Disorders in Chevy Chase, Maryland. Dr Borum is a professor of medicine at George Washington University School of Medicine in Washington, DC and is director of the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center; she is also affiliated with Medical Faculty Associates. Dr Doman is a clinical professor of medicine at George Washington University School of Medicine
| | - Pia Prakash
- Dr Khanijow and Dr Prakash are gastroenterology fellows in the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center and are affiliated with Medical Faculty Associates, both in Washington, DC. Dr Emsellem is a clinical professor of neurology at George Washington University Medical Center and is director of the Center for Sleep and Wake Disorders in Chevy Chase, Maryland. Dr Borum is a professor of medicine at George Washington University School of Medicine in Washington, DC and is director of the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center; she is also affiliated with Medical Faculty Associates. Dr Doman is a clinical professor of medicine at George Washington University School of Medicine
| | - Helene A Emsellem
- Dr Khanijow and Dr Prakash are gastroenterology fellows in the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center and are affiliated with Medical Faculty Associates, both in Washington, DC. Dr Emsellem is a clinical professor of neurology at George Washington University Medical Center and is director of the Center for Sleep and Wake Disorders in Chevy Chase, Maryland. Dr Borum is a professor of medicine at George Washington University School of Medicine in Washington, DC and is director of the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center; she is also affiliated with Medical Faculty Associates. Dr Doman is a clinical professor of medicine at George Washington University School of Medicine
| | - Marie L Borum
- Dr Khanijow and Dr Prakash are gastroenterology fellows in the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center and are affiliated with Medical Faculty Associates, both in Washington, DC. Dr Emsellem is a clinical professor of neurology at George Washington University Medical Center and is director of the Center for Sleep and Wake Disorders in Chevy Chase, Maryland. Dr Borum is a professor of medicine at George Washington University School of Medicine in Washington, DC and is director of the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center; she is also affiliated with Medical Faculty Associates. Dr Doman is a clinical professor of medicine at George Washington University School of Medicine
| | - David B Doman
- Dr Khanijow and Dr Prakash are gastroenterology fellows in the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center and are affiliated with Medical Faculty Associates, both in Washington, DC. Dr Emsellem is a clinical professor of neurology at George Washington University Medical Center and is director of the Center for Sleep and Wake Disorders in Chevy Chase, Maryland. Dr Borum is a professor of medicine at George Washington University School of Medicine in Washington, DC and is director of the Division of Gastroenterology and Liver Diseases at George Washington University Medical Center; she is also affiliated with Medical Faculty Associates. Dr Doman is a clinical professor of medicine at George Washington University School of Medicine
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