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Ahmed MA, Okour M, Brundage R, Kartha RV. Orphan drug development: the increasing role of clinical pharmacology. J Pharmacokinet Pharmacodyn 2019; 46:395-409. [PMID: 31338634 DOI: 10.1007/s10928-019-09646-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 07/04/2019] [Indexed: 12/11/2022]
Abstract
Over the last few decades there has been a paradigm shift in orphan drug research and development. The development of the regulatory framework, establishment of rare disease global networks that support drug developments, and advances in technology, has resulted in tremendous growth in orphan drug development. Nevertheless, several challenges during orphan drug development such as economic constraints; insufficient clinical information; fewer patients and thus inadequate power; etc. still exist. While the standard regulatory requirements for drug approval stays the same, applications of scientific judgment and regulatory flexibility is significantly important to help meeting some of the immense unmet medical need in rare diseases. Clinical pharmacology presents a vital role in accelerating orphan drug development and overcoming some of these challenges. This review highlights the critical contributions of clinical pharmacology in orphan drug development; for example, dose finding, optimizing clinical trial design, indication expansion, and population extrapolation. Examples of such applications are reviewed in this article.
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Affiliation(s)
- Mariam A Ahmed
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Twin Cities, MN, USA.
- , 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA.
| | - Malek Okour
- Clinical Pharmacology Modeling and Simulation (CPMS), GlaxoSmithKline, Upper Providence, PA, USA
| | - Richard Brundage
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Twin Cities, MN, USA
- Center for Orphan Drug Research, University of Minnesota, Twin Cities, MN, USA
| | - Reena V Kartha
- Department of Experimental and Clinical Pharmacology, University of Minnesota, Twin Cities, MN, USA
- Center for Orphan Drug Research, University of Minnesota, Twin Cities, MN, USA
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Demographics, treatment trends, and survival rate in incident pulmonary artery hypertension in Korea: A nationwide study based on the health insurance review and assessment service database. PLoS One 2018; 13:e0209148. [PMID: 30566510 PMCID: PMC6300275 DOI: 10.1371/journal.pone.0209148] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 12/02/2018] [Indexed: 11/19/2022] Open
Abstract
Epidemiologic data regarding pulmonary arterial hypertension (PAH) have relied on registries from Western countries. We assessed the current status of PAH in the Korean population. The Health Insurance Review and Assessment Service (HIRA) claim database, which comprises nationwide medical insurance data of Koreans from 2008–2016, was assessed to determine the current status of PAH. Overall, 1,307 patients were newly diagnosed with PAH from 2008–2016 (0.0005%, annual incidence: 4.84 patients/1 million people/year). The mean age at diagnosis was 44±13 years (range 18–65) and patients were mostly women (n = 906, 69.3%). Cases of idiopathic PAH (51.6%) accounted for the largest proportion, followed by acquired PAH (APAH) associated with congenital heart disease (25.8%) and APAH with connective tissue disease (17.2%). Overall, 807 (61.7%) patients received a single PAH-specific treatment based on their last prescription, of which bosentan (50.6%) was the most frequently used. Only 240 (18.4%) patients received combination therapy, with the bosentan-beraprost combination (32.9%) being the most common. During the mean follow-up of 1.9 years, the 1-, 2-, 3-, and 5-year estimated survival rates were 85%, 62%, 54%, and 46%, respectively. The prevalence and incidence of PAH in the Korean population is currently comparable with that in previous registries. The 5-year survival rate was slightly higher in the Korean population than previously reported.
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Neuman Y, Koslow M, Matveychuk A, Bar-Sef A, Guber A, Shitrit D. Increased hypoxemia in patients with COPD and pulmonary hypertension undergoing bronchoscopy with biopsy. Int J Chron Obstruct Pulmon Dis 2015; 10:2627-32. [PMID: 26674252 PMCID: PMC4676507 DOI: 10.2147/copd.s88946] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Patients with pulmonary hypertension (PH) are considered to be at risk for complications associated with flexible bronchoscopy (FB), but data concerning the degree of PH are often lacking. We investigated whether COPD patients with PH who undergo bronchoscopy are at greater risk for complications. METHODS This prospective study included 207 consecutive COPD patients undergoing FB. All underwent an echo-Doppler to evaluate pulmonary artery pressure on the day of the bronchoscopy procedure. Pulmonologists were blinded to the echocardiogram results. RESULTS A total of 167 patients (80.7%) had normal pulmonary pressure. The remaining 40 patients (19.3%) had PH: 27 (13.0%) mild, eight (3.9%) moderate, and five (2.4%) severe. Noninvasive hemodynamic parameters between groups before and after FB were similar. Two patients with normal pulmonary pressure developed supraventricular tachycardia. None developed hemodynamically significant dysrhythmia. Bleeding episodes between groups in bronchoalveolar lavage (BAL) and transbronchial biopsy (TBB) did not differ. PH patients who underwent BAL and TBB had decreased O2 saturation during the procedure compared with the non-PH group (23.5% vs 6.9%, P=0.033). No deaths were attributable to FB. CONCLUSION PH is common among COPD patients undergoing FB. PH patients undergoing BAL and TBB are at higher risk of decreased O2 saturation than those without PH. Further studies should assess the risk among COPD patients with moderate-to-severe PH.
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Affiliation(s)
- Yoram Neuman
- Division of Cardiology, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Matthew Koslow
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alona Matveychuk
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avigdor Bar-Sef
- Division of Cardiology, Meir Medical Center, Kfar Saba, Israel
| | - Alexander Guber
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Shitrit
- Pulmonary Department, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Bayar N, Çay HF, Erkal Z, Sezer İ, Arslan Ş, Çağırcı G, Çay S, Yüksel İÖ, Köklü E. The importance of fragmented QRS in the early detection of cardiac involvement in patients with systemic sclerosis. Anatol J Cardiol 2014; 15:209-12. [PMID: 25333976 PMCID: PMC5337056 DOI: 10.5152/akd.2014.5191] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective: Systemic sclerosis (SSc) is an autoimmune connective tissue disorder characterized by fibrosis. The prognosis of the disease is bad when clinically symptomatic cardiac dysfunction is occurred, therefore early detection of cardiac dysfunction is important in patients with SSc. The aim of this study was to investigate the frequency of fQRS in superficial electrocardiography in cardiacally asymptomatic patients with SSc and its relation to the systolic pulmonary artery pressure (sPAP). Methods: This study included 31 cardiacally asymptomatic patients with SSc (23 females, 40.4±9.2 years) and 41 healthy volunteers as the control (31 females, 38.2±11.8 years). The ECGs with 12 derivations and transthoracic echocardiographies of the patients were evaluated. The presence of fQRS in the superficial ECG, and its relation to systolic pulmonary artery pressure (sPAP) were investigated. Results: The mean sPAP value in the SSc group was observed to be higher than that of the control group (26 mm Hg and 20 mm Hg, respectively, p<0.001). The presence of fQRS in the SSc group was more frequent than the control group (55% and 10%, respectively, p<0.001). In SSc patients presence of fQRS become relevant with ≥24 mm Hg sPAP by 88% sensitivity and 79% specificity. Conclusion: In our study, the presence of fQRS in SSc patients, were more frequent than in the normal population. Since pulmonary hypertension is the primary cause of mortality in patients with SSc, the correlation of fQRS with sPAP should also be considered.
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Affiliation(s)
- Nermin Bayar
- Clinic of Cardiology, Antalya Training and Research Hospital; Antalya-Turkey.
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Sandoval J, Torbicki A, Souza R, Ramírez A, Kurzyna M, Jardim C, Jerjes-Sánchez Díaz C, Teal SA, Hwang LJ, Pulido T. Safety and efficacy of sitaxsentan 50 and 100 mg in patients with pulmonary arterial hypertension. Pulm Pharmacol Ther 2011; 25:33-9. [PMID: 22079088 DOI: 10.1016/j.pupt.2011.10.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 10/06/2011] [Accepted: 10/16/2011] [Indexed: 10/15/2022]
Abstract
OBJECTIVE To assess safety and efficacy of sitaxsentan 50 and 100 mg in patients with pulmonary arterial hypertension (PAH). BACKGROUND Sitaxsentan is a highly selective endothelin-A receptor antagonist that was recently withdrawn by the manufacturer because of a pattern of idiosyncratic liver injury. METHODS Before sitaxsentan withdrawal, this 18-week double-blind, placebo-controlled study randomized patients with PAH to receive placebo or sitaxsentan 50 or 100 mg once daily. The primary efficacy endpoint was change from baseline in 6-min walk distance (6MWD) at week 18. Changes in World Health Organization (WHO) functional class and time to clinical worsening (TTCW) were secondary endpoints. The primary efficacy analysis was powered for sitaxsentan 100 mg versus placebo. RESULTS Of 98 randomized patients, 61% were WHO functional class II at baseline. Improvement from baseline to week 18 in 6MWD occurred with sitaxsentan 100 but not 50 mg; a strong placebo effect was observed. At week 18, WHO functional class was improved or maintained in more patients receiving sitaxsentan 100 mg than placebo (P = 0.038); 0% versus 12% of patients deteriorated, respectively. TTCW was not significantly different for 100-mg sitaxsentan patients than placebo (P = 0.090). Adverse events (AEs) occurring more frequently with sitaxsentan (50 or 100 mg) included headache, peripheral edema, dizziness, nausea, extremity pain, and fatigue; most AEs were of mild or moderate severity. CONCLUSION Sitaxsentan 100 mg improved functional class but not 6MWD in PAH patients who were mostly WHO functional class II at baseline. No patient receiving sitaxsentan 100 mg experienced clinical worsening; sitaxsentan was well tolerated.
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Serra W, Chetta A, Santilli D, Mozzani F, Dall'Aglio PP, Olivieri D, Cattabiani MA, Ardissino D, Gherli T. Echocardiography may help detect pulmonary vasculopathy in the early stages of pulmonary artery hypertension associated with systemic sclerosis. Cardiovasc Ultrasound 2010; 8:25. [PMID: 20598164 PMCID: PMC2908574 DOI: 10.1186/1476-7120-8-25] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 07/05/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) in patients with systemic sclerosis is associated with a poor prognosis, but this can be improved by early disease detection. Abnormal pulmonary and cardiac function can be detected early by means of echocardiography, whereas right heart catheterization is usually performed later. OBJECTIVES The purpose of this prospective study was to detect early the presence of pulmonary artery vasculopathy in patients with verified systemic sclerosis without significant pulmonary fibrosis, normal lung volumes and a mildly reduced lung diffusion capacity of carbon monoxide (DLCO). METHODS Nineteen consecutive female NYHA class I-II patients with scleroderma and a PAPs of < 35 mm/Hg measured by echocardiography, were enrolled between September 2007 and September 2009. They had a mean age of 51 +/- 13 years, body mass index of 25 +/- 5 kg/m2). They all underwent complete Doppler echocardiography, CPET, a pulmonary ventilation test (carbon monoxide lung diffusion, DLCO), HRCT. To investigate PAH by means of complete resting Doppler echocardiography estimates of systolic pulmonary artery pressure (PAPs) derived from tr icuspid regurgitation, mean PAP derived from pulmonary regurgitation, pulmonary vessel resistance (PVR) derived from the acceleration time of the pulmonary outflow tract (ACTpo), and right ventricular function derived from tricuspid annular plane systolic excursion (TAPSE). Right heart catheterisation was conducted only, if pulmonary hypertension was suggested by echocardiography and an abnormal ventilator test.The data are given as mean values +/- SD, unless otherwise stated. The correlations between the variables were analysed using Pearson's r coefficient, and the predictive value of the variables was calculated using linear regression analysis. A p value of > 0.05 was considered significant. RESULTS Right heart catheterization detected PAH in 15/19 patients; mean PAP was 30.5 mm/Hg and RVP 3.6 UW. Coronary angiography of the patients aged more than 55 years showed some evidence of significant coronary artery disease. Echocardiography showed high systolic PAP values (46 +/- 8 mmHg), whereas right ventricular function was normal (TAPSE 23 +/- 3 mm), and in line with the NYHA class. ACTpo was reduced in the patients with a systolic PAP of < 46 mm/Hg (p > 0.001) and positively correlated with DLCO (p > 0.001) and the hemodynamic data.There was a good correlation between ACTpo and PVR (hemodynamic data) (r = -0615; p > 0.01). CONCLUSIONS Although they need to be confirmed by studies of larger series of patients, our findings suggest that, in comparison with hemodynamic data, non-invasive echocardiographic measurements are an excellent means of identifying early-stage PAH.
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Affiliation(s)
- Walter Serra
- Cardiopulmonary Dept., Cardiology Unit, University Hospital, Parma, Italy
| | - Alfredo Chetta
- Cardiopulmonary Dept., Pneumology Unit, University Hospital, Parma, Italy
| | - Daniele Santilli
- Immunology Dept., Rheumatology Unit, University Hospital, Parma, Italy
| | - Flavio Mozzani
- Immunology Dept., Rheumatology Unit, University Hospital, Parma, Italy
| | | | - Dario Olivieri
- Cardiopulmonary Dept., Pneumology Unit, University Hospital, Parma, Italy
| | | | - Diego Ardissino
- Cardiopulmonary Dept., Cardiology Unit, University Hospital, Parma, Italy
| | - Tiziano Gherli
- Cardiopulmonary Dept., Cardiology Unit, University Hospital, Parma, Italy
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Lai HC, Lai HC, Wang KY, Lee WL, Ting CT, Liu TJ. Severe pulmonary hypertension complicates postoperative outcome of non-cardiac surgery. Br J Anaesth 2007; 99:184-90. [PMID: 17576968 DOI: 10.1093/bja/aem126] [Citation(s) in RCA: 146] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Whether and how pulmonary hypertension (PH) impacts perioperative outcome in non-cardiac surgery is incompletely understood. METHODS From November 1999, all patients undergoing non-cardiac, non-local anaesthetic surgery and ever examined by echocardiography within 30 days before surgery were screened. Those having echocardiographic pulmonary artery systolic pressure >70 mm Hg were enrolled provided they were not already intubated. Case-matched peers with normal pulmonary pressures served as controls. Perioperative outcomes were compared between the two groups, and predictors of adverse perioperative outcomes were investigated by multivariate logistic regression analysis. RESULTS From November 1999 to August 2004, a total of 62 patients (male 38, mean age 67 yr) with PH were found. Compared with the case-matched controls, patients with PH experienced equivalently smooth operative courses, but significantly more frequent postoperative heart failure (9.7 vs 0%, P = 0.028), delayed tracheal extubation (21 vs 3%, P = 0.004), and in-hospital deaths (9.7 vs 0%, P = 0.028). Multivariate regression analysis identified emergency surgery [odds ratio (OR), 44.738; P = 0.028], coronary artery disease (CAD; OR, 9.933; P = 0.042), and systolic pulmonary artery pressure (OR, 1.101; P = 0.026) as independent predictors of postoperative mortality and surgery-specific cardiac risk level (OR, 6.791; P = 0.033) and CAD (OR 6.546, P = 0.017) as predictors of morbidity. CONCLUSION PH is an important predictor of adverse cardiopulmonary outcome in non-cardiac surgery as reflected by markedly increased postoperative complications, especially in patients with coexistent high-risk clinical and surgical characteristics.
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Affiliation(s)
- H-C Lai
- Department of Anaesthesiology, Taichung Veterans General Hospital, Taichung, Taiwan
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Mahmud M, Champion HC. Right ventricular failure complicating heart failure: pathophysiology, significance, and management strategies. Curr Cardiol Rep 2007; 9:200-8. [PMID: 17470333 DOI: 10.1007/bf02938351] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Right heart failure most commonly results from the complication of left heart failure (systolic or nonsystolic dysfunction) or pulmonary hypertension. Over the past decade, greater attention has been paid to the role of right ventricular failure in the morbidity and mortality associated with cardiomyopathy and pulmonary hypertension. The right ventricle is distinct from the left ventricle not only in its spatial localization, but also in its response to increased afterload and signaling mechanisms. This article discusses the role of right ventricular failure in the setting of heart failure as well as the clinical diagnosis and management of right ventricular failure.
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Affiliation(s)
- Mobusher Mahmud
- Division of Cardiology, Department of Medicine, Johns Hopkins University, 720 Rutland Avenue, Ross 850, Baltimore, MD 21205, USA
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Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening disease characterised by a progressive pulmonary vasculopathy with ensuing right heart failure if left untreated. In the 1980s, prior to the current treatment era, idiopathic PAH carried a very poor prognosis, with a median survival of 2.8 years from the time of diagnosis. Since then, continuous intravenous epoprostenol has been used for the treatment of severe PAH with tremendous success, improving haemodynamics, quality of life, exercise capacity, functional class and even survival. In addition, in the past 5 years there have been several new advances in the treatment of PAH; however, there is still no cure. A better understanding of how the currently available agents work together is essential to optimise the long-term care of patients with PAH. Ultimately, additional agents that target the underlying pulmonary vasculopathy and endothelial abnormalities are necessary to cure this fatal disease. This comprehensive review of the currently available and emerging novel therapies provides insight into future management of PAH patients.
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Affiliation(s)
- Erika B Rosenzweig
- Columbia University, College of Physicians and Surgeons, New York, NY 10032, USA.
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Abstract
Idiopathic pulmonary arterial hypertension is a progressive and potentially fatal disease with a limited number of therapeutic options. Two key lesions underlie the pathophysiology of this disease. The principal lesion is found in large- and intermediate-sized blood vessels and is characterized by medial and adventitial hypertrophy/hyperplasia, with distal extension of smooth-muscle layers into normally nonmuscularized vessels. The second lesion, found prominently in severe forms of pulmonary hypertension, originates in small precapillary vessel segments, commonly at blood vessel bifurcations. This "plexiform lesion" is a lumen-obliterative lesion comprised, at least in part, of cells that share endothelial cell attributes, but that have lost the "law of the monolayer." Indeed, the endothelial contribution to the (mal-)adaptive response in pulmonary hypertension is becoming increasingly apparent, with evidence that endothelium plays an important role in promoting the vasoconstriction and hyperproliferation of medial and adventitial cell layers in large- and intermediate-vessel sizes, and lumen obliteration in the plexiform lesion. Recent evidence indicates endothelial cells along the pulmonary artery and precapillary segments are phenotypically distinct and may fulfill different roles in these site-specific lesions. Thus, the present review summarizes our current understanding of pulmonary endothelial cell heterogeneity and discusses the potential role(s) of endothelial cell heterogeneity in the pathogenesis of pulmonary hypertension.
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Affiliation(s)
- Troy Stevens
- Department of Pharmacology, Center for Lung Biology, University of South Alabama College of Medicine, Mobile, AL 36688, USA.
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Abstract
Pulmonary arterial hypertension is a disease of the small pulmonary arteries characterized by vascular narrowing and increased pulmonary vascular resistance, which eventually leads to right ventricular failure. Vasoconstriction, vascular proliferation, remodeling of the pulmonary vessels, and thrombosis are all contributing factors to the increased vascular resistance seen in this disease. Pulmonary arterial hypertension develops as a sporadic disease (idiopathic), as an inherited disorder (familial), or in association with certain conditions (collagen vascular diseases, portal hypertension, human immunodeficiency virus infection, congenital systemic-to-pulmonary shunts, ingestion of drugs or dietary products, or persistent fetal circulation). The pathogenesis of pulmonary arterial hypertension is a complicated, multifactorial process. It seems doubtful that any one factor alone is sufficient to activate the necessary pathways leading to the development of this disease. Rather, clinically apparent pulmonary arterial hypertension most likely develops after a second insult occurs in an individual who is already susceptible owing to genetic factors, environmental exposures, or acquired disorders. Currently, there is no cure for pulmonary arterial hypertension but several novel therapeutic options are now available that can improve symptoms and increase survival.
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Affiliation(s)
- Azad Raiesdana
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Affiliation(s)
- Harrison W Farber
- Evans Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
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