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Steiner JM, West KM, Bayley E, Pechan J, Albright C, Buber J, Engelberg RA. Experience With Advance Care Planning Discussions Among Pregnant Women With Congenital Heart Disease. J Pain Symptom Manage 2021; 62:587-592. [PMID: 33561491 DOI: 10.1016/j.jpainsymman.2021.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 11/21/2022]
Abstract
CONTEXT Women with adult congenital heart disease (ACHD) have an increased risk of adverse events during pregnancy. Advance care planning may therefore be an appropriate component of prenatal care. OBJECTIVE The aim of this study was to describe the perspectives of women with ACHD surrounding advance care planning during pregnancy. METHODS We conducted a thematic analysis of 25 semi-structured interviews with women with ACHD who had been pregnant. Purposive sampling was used to gain diversity in ACHD lesion complexity, race, age at pregnancy, and marital status. RESULTS Mean age at pregnancy was 29 years (range 15-41 years), and ACHD was classified as simple (24%), moderate (44%), or complex (32%). We identified three primary themes: 1) the role of advance care planning in being prepared and providing security for family; 2) reasons for avoiding advance care planning, including its lower priority among more pressing concerns and the impact it might have on their current psychological state; and 3) varied openness to advance care planning discussions during pregnancy. CONCLUSION Advance care planning is not a routine part of prenatal care in ACHD, and its role in this population requires further assessment.
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Affiliation(s)
- Jill M Steiner
- Division of Cardiology, University of Washington, Seattle, Washington, USA.
| | - Kathleen M West
- Department of Bioethics & Humanities, University of Washington, Seattle, Washington, USA
| | - Elizabeth Bayley
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Jaimie Pechan
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Catherine Albright
- Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington, USA
| | - Jonathan Buber
- Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Ruth A Engelberg
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA
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2
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Todd SH, Sonntag EA, Buchanan ML, Jones BW, Dellon EP, Donaldson SH, Goralski JL. Development of an Advance Care Planning Protocol in a Cystic Fibrosis Outpatient Clinic. J Palliat Med 2021; 24:1383-1386. [PMID: 34191614 DOI: 10.1089/jpm.2021.0186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Advance care planning (ACP) is recommended for all patients with cystic fibrosis (CF), yet clear implementation guidelines do not exist. Methods: The University of North Carolina Adult CF Care Team developed a process to implement semistructured multidisciplinary outpatient ACP meetings as routine care for patients with CF. Premeeting and post-meeting surveys were used to elicit patients' attitudes toward ACP. Results: Twenty-seven adults with CF completed a face-to-face ACP meeting, and 13 completed both surveys. Following the multidisciplinary ACP meeting, overall scores for understanding of ACP topics improved by 4.5 points (p = 0.003). Conclusion: We successfully implemented sustainable ACP meetings for adults with CF and found increased comfort with ACP and documentation of wishes after ACP meetings. It is important for CF care providers to meet the needs of this patient population by ensuring that ACP is in place before crisis situations.
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Affiliation(s)
- Sarah H Todd
- Departments of Medicine and Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elizabeth A Sonntag
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Marianne L Buchanan
- UNC Hospitals Department of Social Work, and The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brooke W Jones
- UNC Hospitals Department of Social Work, and The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elisabeth P Dellon
- Division of Pediatric Pulmonology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Scott H Donaldson
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer L Goralski
- Division of Pulmonary and Critical Care Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Division of Pediatric Pulmonology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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3
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Dauber-Decker KL, Basile M, King D, Polo J, Calise K, Khan S, Solomon J, Dunne D, Hajizadeh N. Developing a Decision Aid to Facilitate Informed Decision Making About Invasive Mechanical Ventilation and Lung Transplantation Among Adults With Cystic Fibrosis: Usability Testing. JMIR Hum Factors 2021; 8:e21270. [PMID: 33851921 PMCID: PMC8082389 DOI: 10.2196/21270] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/08/2020] [Accepted: 12/23/2020] [Indexed: 11/27/2022] Open
Abstract
Background Cystic fibrosis (CF) is a life-limiting genetic disease that causes chronic lung infections. We developed an internet-based decision aid (DA) to help patients with CF make better informed decisions regarding treatments and advance care planning. We built the DA around two major treatment decisions: whether to have a lung transplant and whether to agree to invasive mechanical ventilation (intubation). Objective This study aims to conduct usability testing of the InformedChoices CF DA among key stakeholder groups. Methods We performed a patient needs assessment using think-aloud usability testing with patients with CF, their surrogates, and CF clinicians. Think-aloud participants provided feedback while navigating the DA, and after viewing, they answered surveys. Transcripts from the think-aloud sessions and survey results were categorized into common, generalizable themes and optimizations for improving content, comprehension, and navigation. We assessed the ease of use of the DA (System Usability Scale) and also assessed the participants’ perceptions regarding the overall tone, with an emphasis on emotional reactions to the DA content, level of detail, and usefulness of the information for making decisions about either intubation or lung transplantation, including how well they understood the information and were able to apply it to their own decision-making process. We also assessed the DA’s ease of navigation, esthetics, and whether participants were able to complete a series of usability tasks (eg, locating specific information in the DA or using the interactive survival estimates calculator) to ensure that the website was easy to navigate during the clinic-based advance care planning discussions. Results A total of 12 participants from 3 sites were enrolled from March 9 to August 30, 2018, for the usability testing: 5 CF clinicians (mean age 48.2, SD 12.0 years), 5 adults with CF, and 2 family and surrogate caregivers of people with CF (mean age of CF adults and family and surrogate caregivers 38.8, SD 10.8 years). Among the 12 participants, the average System Usability Scale score for the DA was 88.33 (excellent). Think-aloud analysis identified 3 themes: functionality, visibility and navigation, and content and usefulness. Areas for improvement included reducing repetition, enhancing comprehension, and changing the flow. Several changes to improve the content and usefulness of the DA were recommended, including adding information about alternatives to childbearing, such as adoption and surrogacy. On the basis of survey responses, we found that the navigation of the site was easy for clinicians, patients, and surrogates who participated in usability testing. Conclusions Usability testing revealed areas of potential improvement. Testing also yielded positive feedback, suggesting the DA’s future success. Integrating changes before implementation should improve the DA’s comprehension, navigation, and usefulness and lead to greater adoption.
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Affiliation(s)
- Katherine L Dauber-Decker
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Center for Health Innovations and Outcomes Research, Manhasset, NY, United States
| | - Melissa Basile
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Center for Health Innovations and Outcomes Research, Manhasset, NY, United States
| | - D'Arcy King
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Center for Health Innovations and Outcomes Research, Manhasset, NY, United States
| | - Jennifer Polo
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Center for Health Innovations and Outcomes Research, Manhasset, NY, United States
| | - Karina Calise
- School of Health Professions and Human Services, Hofstra University, Hempstead, NY, United States
| | - Sundas Khan
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Center for Health Innovations and Outcomes Research, Manhasset, NY, United States
| | - Jeffrey Solomon
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Center for Health Innovations and Outcomes Research, Manhasset, NY, United States
| | - Daniel Dunne
- iDEAL Institute, Loyola Marymount University, Los Angeles, CA, United States
| | - Negin Hajizadeh
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Feinstein Institutes for Medical Research, Center for Health Innovations and Outcomes Research, Manhasset, NY, United States
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4
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Abstract
To avoid discomfort, health care professionals may hesitate to pursue conversations about end of life with patients. Certain tools have the potential to facilitate smoother conversations in this matter. The objective was to explore the experiences of patients in palliative care in using statement cards to talk about their wishes and priorities. Forty-six cards with statements of wishes and priorities were developed and tested for feasibility with 40 participants, who chose the 10 most important cards and shared their thoughts about the statements and conversation. Data from individual interviews and field notes were analyzed using content analysis. One category describes practical aspects of using the cards including the relevance of the content and the process of sorting the cards. The second category describes the significance of using the cards including becoming aware of what is important, sharing wishes and priorities, and reflecting on whether wishes and priorities change closer to death. The cards helped raise awareness and verbalize wishes and priorities. All statements were considered relevant. The conversations focused not only on death and dying, but also on challenges in the participants' current life situation. For the most ill and frail participants, the number of cards needs to be reduced.
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5
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Steiner JM, Dhami A, Brown CE, Stout KK, Curtis JR, Engelberg RA, Kirkpatrick JN. Barriers and Facilitators of Palliative Care and Advance Care Planning in Adults With Congenital Heart Disease. Am J Cardiol 2020; 135:128-134. [PMID: 32866444 DOI: 10.1016/j.amjcard.2020.08.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/14/2020] [Accepted: 08/18/2020] [Indexed: 02/07/2023]
Abstract
Palliative care has potential to improve quality of life and goal-concordant care for patients with adult congenital heart disease (ACHD). However, it is rarely employed prior to critical illness because the best methods for implementation are not well-defined. We qualitatively evaluated ACHD patients' understanding of and opinions regarding palliative care and advance care planning (ACP) to better define the needs of this population. We conducted a thematic analysis of 25 semistructured interviews with patients with ACHD in which we assessed participants' perspectives on the need for, and barriers and facilitators to, the use of palliative care and ACP. In a group of participants with ACHD (mean age 38, 48% male) classified as simple (24%), moderate (32%), or complex (44%), we identified 4 major themes: (1) using knowledge to combat future uncertainties; (2) unfamiliarity with and limited exposure to palliative care and ACP; (3) facilitators and barriers to engaging in palliative care and ACP; and (4) importance of timing and presentation of ACP discussions. In conclusion, participants expressed a desire for knowledge about ACHD progression and treatment. They supported routine incorporation of palliative care and ACP and identified related facilitators and barriers to doing so. Importantly, timing and format of these discussions must be individualized using shared decision-making between clinicians, patients, and their families.
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6
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Miller M. Living and dying with cystic fibrosis. BMJ Support Palliat Care 2020; 11:86-88. [PMID: 32917651 DOI: 10.1136/bmjspcare-2020-002631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/18/2020] [Indexed: 11/04/2022]
Affiliation(s)
- Mary Miller
- Palliative Care, Oxford University Hospitals NHS Foundation Trust, Oxford, UK .,Honorary Senior Clinical Lecturer, Nuffield Department of Medicine, Oxford University, Oxford, UK
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7
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Lange AV, Rueschhoff A, Terauchi S, Cohen L, Reisch J, Jain R, Finklea JD. End-of-Life Care in Cystic Fibrosis: Comparing Provider Practices Based on Lung Transplant Candidacy. J Palliat Med 2020; 23:1606-1612. [PMID: 32380886 DOI: 10.1089/jpm.2019.0304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The optimal timing to introduce palliative care (PC) and end-of-life (EOL) conversations into the lives of people with cystic fibrosis (CF) has not been established. Objective: Compare EOL care practices for people with CF who died without a lung transplant (LT), are living without an LT, and those who received an LT. Design: Retrospective chart review. Setting/Subjects: People with CF who received care from 2012 to 2017 at the University of Texas Southwestern Medical Center. Measurements: Primary outcomes were (1) EOL discussion with a pulmonologist, (2) time of EOL discussion before death or LT, (3) evaluation by PC, and (4) documentation of advanced directive or medical power of attorney. Results: Twenty-three patients died without LT, 40 patients received an LT, and 222 were living without an LT. Among LT recipients, 10% had EOL conversations compared with 74% of deceased patients and 5% of living patients without LT (p = 0.001). Among deceased patients, 39% had EOL conversations more than six months before death, while 5% of transplanted patients had EOL conversation more than six months before LT (p < 0.001). Deceased patients were more likely to have seen PC (57%) than either patients who received LT (2%) or those living without LT (3%, p = 0.0001). Conclusions: Patients who died without LT were more likely to have seen PC and had an EOL conversation than patients who received LT or who are living without LT. Further research should explore the optimal timing to discuss EOL care and the best timing to involve PC.
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Affiliation(s)
- Allison V Lange
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Ali Rueschhoff
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Stephanie Terauchi
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA.,Divisions of Palliative Care Medicine and University of Texas Southwestern, Dallas, Texas, USA
| | - Leah Cohen
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA.,Divisions of Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Joan Reisch
- Department of Population and Data Science, University of Texas Southwestern, Dallas, Texas, USA
| | - Raksha Jain
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA.,Divisions of Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - James D Finklea
- Department of Internal Medicine, University of Texas Southwestern, Dallas, Texas, USA.,Divisions of Pulmonary and Critical Care Medicine, University of Texas Southwestern, Dallas, Texas, USA
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8
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Chin M, McIntosh ID, Somayaji R. Overlooking the landscape of palliative care in cystic fibrosis. J Cyst Fibros 2020; 19:336-338. [PMID: 32305179 DOI: 10.1016/j.jcf.2020.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Affiliation(s)
- M Chin
- Division of Respirology, Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON.
| | - I D McIntosh
- Director, Healthcare; Cystic Fibrosis Canada, Toronto, ON.
| | - R Somayaji
- Departments of Medicine; Microbiology, Immunology and Infectious Disease; Community Health Sciences, University of Calgary, Calgary, AB.
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9
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Abstract
BACKGROUND Advance care planning and palliative care are gaining recognition as critical care components for adults with CHD, yet these often do not occur. Study objectives were to evaluate ACHD providers' 1) comfort managing patients' physical symptoms and psychosocial needs and 2) perspectives on the decision/timing of advance care planning initiation and palliative care referral. METHODS Cross-sectional study of ACHD providers. Six hypothetical patients were described in case format, followed by questions regarding provider comfort managing symptoms, initiating advance care planning, and palliative care referral. RESULTS Fifty providers (72% physicians) completed surveys. Participants reported low levels of personal palliative care knowledge, without variation by gender, years in practice, or prior palliative care training. Providers appeared more comfortable managing physical symptoms and discussing prognosis than addressing psychosocial needs. Providers recognised advance directives as important, although the percentage who would initiate advance care planning ranged from 18 to 67% and referral to palliative care from 14 to 32%. Barriers and facilitators to discussing advance care planning with patients were identified. Over 20% indicated that advance care planning and end-of-life discussions are best initiated with the development of at least one life-threatening complication/hospitalisation. CONCLUSIONS Providers noted high value in advance directives yet were themselves less likely to initiate advance care planning or refer to palliative care. This raises the critical questions of when, how, and by whom discussion of these important matters should be initiated and how best to support ACHD providers in these endeavours.
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10
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Advanced Stage Lung Disease. Respir Med 2020. [DOI: 10.1007/978-3-030-42382-7_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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11
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Friedman D, Linnemann RW, Altstein LL, Georgiopoulos AM, Islam S, Bach KT, St John A, Fracchia MS, Neuringer I, Lapey A, Sicilian L, Moskowitz SM, Yonker LM. Effects of a primary palliative care intervention on quality of life and mental health in cystic fibrosis. Pediatr Pulmonol 2019; 54:984-992. [PMID: 30854795 DOI: 10.1002/ppul.24311] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 01/16/2019] [Accepted: 02/06/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite the significant impact of chronic symptoms on quality of life with cystic fibrosis (CF), the role of palliative care in management of this disease is not well defined. The coping, goal assessment, and relief from evolving CF symptoms (CF-CARES) model is a primary palliative care intervention designed to provide chronic symptom management at all stages of the disease. The goal of this pilot study was to estimate the effectiveness of the CF-CARES intervention on improving chronic symptoms and quality of life for people living with CF. METHODS A structured assessment was used to guide referral to supportive services intended to address burdensome symptoms. Follow-up assessments were performed approximately 3 and 6 months later. Longitudinal regression analyses of changes in symptoms and quality of life were performed for all participants regardless of utilization of supportive services. Subgroup analyses were performed for subjects participating in mental health and alternative health services. RESULTS Forty-one subjects completed assessment and referral processes. The mean number of CF-associated symptoms decreased over time, as did respiratory symptom-related distress and depressive symptoms. Subjects utilizing alternative health services reported less psychological distress at follow-up. Among subjects with severe disease, mental health, and quality of life improved, especially for those using mental health services. CONCLUSIONS The CF-CARES model resulted in significant mental health and quality-of-life benefits, suggesting the value of integrating symptom management interventions into routine CF care. Moreover, mental health services can play a key role in CF-specific primary palliative care, especially for those with advanced disease.
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Affiliation(s)
- Deborah Friedman
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Rachel W Linnemann
- Department. of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lily L Altstein
- Department of Biostatistics, Massachusetts General Hospital, Boston, Massachusetts
| | - Anna M Georgiopoulos
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Suhayla Islam
- Department. of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Kieu-Tram Bach
- Department. of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Anita St John
- Department. of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - M Shannon Fracchia
- Department. of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Isabel Neuringer
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Allen Lapey
- Department. of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Leonard Sicilian
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Samuel M Moskowitz
- Department. of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Lael M Yonker
- Department. of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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