1
|
Yellin S, Wiener S, Kankaria R, Vorawandthanachai T, Hsu D, Haberer K, Bortnick AE, Diana WS. Characteristics and outcomes of socioeconomically disadvantaged pregnant individuals with adult congenital heart disease presenting to a Cardio-Obstetrics Program. Am J Obstet Gynecol MFM 2023; 5:101146. [PMID: 37659603 PMCID: PMC11157696 DOI: 10.1016/j.ajogmf.2023.101146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/20/2023] [Accepted: 08/26/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Outcomes of individuals with adult congenital heart disease who are socioeconomically disadvantaged and cared for in cardio-obstetrical programs, are lacking. OBJECTIVE This study aimed to describe the clinical characteristics, maternal pregnancy outcomes, and contraceptive uptake in individuals with adult congenital heart disease in an urban cardio-obstetrical program. STUDY DESIGN Retrospective data were collected for individuals with adult congenital heart disease seen in the Maternal Fetal Medicine-Cardiology Joint Program at Montefiore Health System between 2015 and 2021 and compared using modified World Health Organization class I, II vs the modified World Health Organization class ≥II/III. RESULTS Over 90% of individuals with adult congenital heart disease were pregnant at the time of referral. Modified World Health Organization class I, II (n=77, 62.4% Black or Hispanic/Latina) had a total of 94 pregnancies and modified World Health Organization class ≥II/III (n=49, 49.0% Black or Hispanic/Latina) had a total of 56 pregnancies. Over 25% of individuals in each group had a body mass index ≥30 (P=.78), and very low summary socioeconomic scores. Modified World Health Organization class ≥II/III were more likely to be anticoagulated in the first trimester than modified World Health Organization class I, II (10.7% vs 0.0%, P=.002) and throughout pregnancy (14.3% vs 3.2% P=.02). Modified World Health Organization class ≥II/III were more likely to require arterial monitoring during delivery than modified World Health Organization class I, II (14.3% vs 0.0%, P=.001) or delivery under general anesthesia (8.9% vs 1.1%, P=.03) but had a comparable frequency of cesarean delivery (35.8% vs 41.3%, P=.68). There were no in-hospital maternal deaths. There was no difference in the type of contraception recommended by modified World Health Organization class, however, modified World Health Organization class ≥II/III were more likely to receive long-acting types or permanent sterilization (35.6% vs 54.6%, P=.045). CONCLUSION In a socioeconomically disadvantaged cohort with adult congenital heart disease from a historically marginalized community, those with modified World Health Organization class ≥II/III had more complex antepartum and intrapartum needs but similar maternal and obstetrical outcomes as modified World Health Organization class I, II. The multidisciplinary approach offered by a cardio-obstetrics program may contribute to successful outcomes in this high-risk cohort, and these data are hypothesis-generating.
Collapse
Affiliation(s)
- Shira Yellin
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana)
| | - Sara Wiener
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana)
| | - Rohan Kankaria
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana)
| | - Thammatat Vorawandthanachai
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana)
| | - Daphne Hsu
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana); Division of Pediatric Cardiology and Adult Congenital Heart Program, Department of Pediatrics, Children's Hospital at Montefiore Medical Center, Bronx, NY (Dr. Hsu and Dr. Haberer)
| | - Kim Haberer
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana); Division of Pediatric Cardiology and Adult Congenital Heart Program, Department of Pediatrics, Children's Hospital at Montefiore Medical Center, Bronx, NY (Dr. Hsu and Dr. Haberer)
| | - Anna E Bortnick
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana); Division of Cardiology, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (Dr. Bortnick and Dr. Diana); Maternal Fetal Medicine-Cardiology Joint Program, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (Dr. Bortnick and Dr. Diana); Department of Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (Dr. Bortnick and Dr. Diana)
| | - Wolfe S Diana
- Albert Einstein College of Medicine, Bronx, NY (Dr. Yellin, Dr. Wiener, Dr. Kankaria, Dr. Vorawandthanachai, Dr. Hsu, Dr. Haberer, Dr. Bortnick, and Dr. Diana); Division of Cardiology, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (Dr. Bortnick and Dr. Diana); Maternal Fetal Medicine-Cardiology Joint Program, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (Dr. Bortnick and Dr. Diana); Department of Women's Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY (Dr. Bortnick and Dr. Diana).
| |
Collapse
|
2
|
Chazouilleres O, Beuers U, Bergquist A, Karlsen TH, Levy C, Samyn M, Schramm C, Trauner M. EASL Clinical Practice Guidelines on sclerosing cholangitis. J Hepatol 2022; 77:761-806. [PMID: 35738507 DOI: 10.1016/j.jhep.2022.05.011] [Citation(s) in RCA: 83] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 05/16/2022] [Indexed: 02/07/2023]
Abstract
Management of primary or secondary sclerosing cholangitis is challenging. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics including diagnostic methods, prognostic assessment, early detection of complications, optimal care pathways and therapeutic (pharmacological, endoscopic or surgical) options both in adults and children.
Collapse
|
3
|
Christelle K, Norhayati MN, Jaafar SH. Interventions to prevent or treat heavy menstrual bleeding or pain associated with intrauterine-device use. Cochrane Database Syst Rev 2022; 8:CD006034. [PMID: 36017945 PMCID: PMC9413853 DOI: 10.1002/14651858.cd006034.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Heavy menstrual bleeding and pain are common reasons women discontinue intrauterine device (IUD) use. Copper IUD (Cu IUD) users tend to experience increased menstrual bleeding, whereas levonorgestrel IUD (LNG IUD) users tend to have irregular menstruation. Medical therapies used to reduce heavy menstrual bleeding or pain associated with Cu and LNG IUD use include non-steroidal anti-inflammatory drugs (NSAIDs), anti-fibrinolytics and paracetamol. We analysed treatment and prevention interventions separately because the expected outcomes for treatment and prevention interventions differ. We did not combine different drug classes in the analysis as they have different mechanisms of action. This is an update of a review originally on NSAIDs. The review scope has been widened to include all interventions for treatment or prevention of heavy menstrual bleeding or pain associated with IUD use. OBJECTIVES To evaluate all randomized controlled trials (RCTs) that have assessed strategies for treatment and prevention of heavy menstrual bleeding or pain associated with IUD use, for example, pharmacotherapy and alternative therapies. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL to January 2021. SELECTION CRITERIA We included RCTs in any language that tested strategies for treatment or prevention of heavy menstrual bleeding or pain associated with IUD (Cu IUD, LNG IUD or other IUD) use. The comparison could be no intervention, placebo or another active intervention. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, and extracted data. Primary outcomes were volume of menstrual blood loss, duration of menstruation and painful menstruation. We used a random-effects model in all meta-analyses. Review authors assessed the certainty of evidence using GRADE. MAIN RESULTS This review includes 21 trials involving 3689 participants from middle- and high-income countries. Women were 18 to 45 years old and either already using an IUD or had just had one placed for contraception. The included trials examined NSAIDs and other interventions. Eleven were treatment trials, of these seven were on users of the Cu IUD, one on LNG IUD and three on an unknown type. Ten were prevention trials, six focused on Cu IUD users, and four on LNG IUD users. Sixteen trials had high risk of detection bias due to subjective assessment of pain and bleeding. Treatment of heavy menstrual bleeding Cu IUD Vitamin B1 resulted in fewer pads used per day (mean difference (MD) -7.00, 95% confidence interval (CI) -8.50 to -5.50) and fewer bleeding days (MD -2.00, 95% CI -2.38 to -1.62; 1 trial; 110 women; low-certainty evidence) compared to placebo. The evidence is very uncertain about the effect of naproxen on the volume of menstruation compared to placebo (odds ratio (OR) 0.09, 95% CI 0.00 to 1.78; 1 trial, 40 women; very low-certainty evidence). Treatment with mefenamic acid resulted in less volume of blood loss compared to tranexamic acid (MD -64.26, 95% CI -105.65 to -22.87; 1 trial, 94 women; low-certainty evidence). However, there was no difference in duration of bleeding with treatment of mefenamic acid or tranexamic acid (MD 0.08 days, 95% CI -0.27 to 0.42, 2 trials, 152 women; low-certainty evidence). LNG IUD The use of ulipristal acetate in LNG IUD may not reduce the number of bleeding days in 90 days in comparison to placebo (MD -9.30 days, 95% CI -26.76 to 8.16; 1 trial, 24 women; low-certainty evidence). Unknown IUD type Mefenamic acid may not reduce volume of bleeding compared to Vitex agnus measured by pictorial blood assessment chart (MD -2.40, 95% CI -13.77 to 8.97; 1 trial; 84 women; low-certainty evidence). Treatment of pain Cu IUD Treatment with tranexamic acid and sodium diclofenac may result in little or no difference in the occurrence of pain (OR 1.00, 95% CI 0.06 to 17.25; 1 trial, 38 women; very low-certainty evidence). Unknown IUD type Naproxen may reduce pain (MD 4.10, 95% CI 0.91 to 7.29; 1 trial, 33 women; low-certainty evidence). Prevention of heavy menstrual bleeding Cu IUD We found very low-certainty evidence that tolfenamic acid may prevent heavy bleeding compared to placebo (OR 0.54, 95% CI 0.34 to 0.85; 1 trial, 310 women). There was no difference between ibuprofen and placebo in blood volume reduction (MD -14.11, 95% CI -36.04 to 7.82) and duration of bleeding (MD -0.2 days, 95% CI -1.40 to 1.0; 1 trial, 28 women, low-certainty evidence). Aspirin may not prevent heavy bleeding in comparison to paracetamol (MD -0.30, 95% CI -26.16 to 25.56; 1 trial, 20 women; very low-certainty evidence). LNG IUD Ulipristal acetate may increase the percentage of bleeding days compared to placebo (MD 9.50, 95% CI 1.48 to 17.52; 1 trial, 118 women; low-certainty evidence). There were insufficient data for analysis in a single trial comparing mifepristone and vitamin B. There were insufficient data for analysis in the single trial comparing tranexamic acid and mefenamic acid and in another trial comparing naproxen with estradiol. Prevention of pain Cu IUD There was low-certainty evidence that tolfenamic acid may not be effective to prevent painful menstruation compared to placebo (OR 0.71, 95% CI 0.44 to 1.14; 1 trial, 310 women). Ibuprofen may not reduce menstrual cramps compared to placebo (OR 1.00, 95% CI 0.11 to 8.95; 1 trial, 20 women, low-certainty evidence). AUTHORS' CONCLUSIONS Findings from this review should be interpreted with caution due to low- and very low-certainty evidence. Included trials were limited; the majority of the evidence was derived from single trials with few participants. Further research requires larger trials and improved trial reporting. The use of vitamin B1 and mefenamic acid to treat heavy menstruation and tolfenamic acid to prevent heavy menstruation associated with Cu IUD should be investigated. More trials are needed to generate evidence for the treatment and prevention of heavy and painful menstruation associated with LNG IUD.
Collapse
Affiliation(s)
- Karen Christelle
- Department of Family Medicine, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Mohd N Norhayati
- Department of Family Medicine, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Sharifah Halimah Jaafar
- Department of Obstetrics and Gynaecology, Regency Specialist Hospital, Johor Bahru, Malaysia
| |
Collapse
|
4
|
Singh P, Covassin N, Marlatt K, Gadde KM, Heymsfield SB. Obesity, Body Composition, and Sex Hormones: Implications for Cardiovascular Risk. Compr Physiol 2021; 12:2949-2993. [PMID: 34964120 PMCID: PMC10068688 DOI: 10.1002/cphy.c210014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Cardiovascular disease (CVD) continues to be the leading cause of death in adults, highlighting the need to develop novel strategies to mitigate cardiovascular risk. The advancing obesity epidemic is now threatening the gains in CVD risk reduction brought about by contemporary pharmaceutical and surgical interventions. There are sex differences in the development and outcomes of CVD; premenopausal women have significantly lower CVD risk than men of the same age, but women lose this advantage as they transition to menopause, an observation suggesting potential role of sex hormones in determining CVD risk. Clear differences in obesity and regional fat distribution among men and women also exist. While men have relatively high fat in the abdominal area, women tend to distribute a larger proportion of their fat in the lower body. Considering that regional body fat distribution is an important CVD risk factor, differences in how men and women store their body fat may partly contribute to sex-based alterations in CVD risk as well. This article presents findings related to the role of obesity and sex hormones in determining CVD risk. Evidence for the role of sex hormones in determining body composition in men and women is also presented. Lastly, the clinical potential for using sex hormones to alter body composition and reduce CVD risk is outlined. © 2022 American Physiological Society. Compr Physiol 12:1-45, 2022.
Collapse
Affiliation(s)
- Prachi Singh
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
| | | | - Kara Marlatt
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
| | - Kishore M Gadde
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
| | - Steven B Heymsfield
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
| |
Collapse
|
5
|
Lindley KJ, Bairey Merz CN, Davis MB, Madden T, Park K, Bello NA. Contraception and Reproductive Planning for Women With Cardiovascular Disease: JACC Focus Seminar 5/5. J Am Coll Cardiol 2021; 77:1823-1834. [PMID: 33832608 PMCID: PMC8041063 DOI: 10.1016/j.jacc.2021.02.025] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 12/30/2022]
Abstract
The majority of reproductive-age women with cardiovascular disease are sexually active. Early and accurate counseling by the cardiovascular team regarding disease-specific contraceptive safety and effectiveness is imperative to preventing unplanned pregnancies in this high-risk group of patients. This document, the final of a 5-part series, provides evidence-based recommendations regarding contraceptive options for women with, or at high risk for, cardiovascular disease as well as recommendations regarding pregnancy termination for women at excessive cardiovascular mortality risk due to pregnancy.
Collapse
Affiliation(s)
- Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Tessa Madden
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ki Park
- Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Natalie A Bello
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| |
Collapse
|
6
|
Lindley KJ, Bairey Merz CN, Asgar AW, Bello NA, Chandra S, Davis MB, Gomberg-Maitland M, Gulati M, Hollier LM, Krieger EV, Park K, Silversides C, Wolfe NK, Pepine CJ. Management of Women With Congenital or Inherited Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 2/5. J Am Coll Cardiol 2021; 77:1778-1798. [PMID: 33832605 DOI: 10.1016/j.jacc.2021.02.026] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/19/2021] [Accepted: 02/12/2021] [Indexed: 01/15/2023]
Abstract
Maternal morbidity and mortality continue to rise in the United States, with cardiovascular disease as the leading cause of maternal deaths. Congenital heart disease is now the most common cardiovascular condition encountered during pregnancy, and its prevalence will continue to grow. In tandem with these trends, maternal cardiovascular health is becoming increasingly complex. The identification of women at highest risk for cardiovascular complications is essential, and a team-based approach is recommended to optimize maternal and fetal outcomes. This document, the second of a 5-part series, will provide practical guidance from pre-conception through postpartum for cardiovascular conditions that are predominantly congenital or heritable in nature, including aortopathies, congenital heart disease, pulmonary hypertension, and valvular heart disease.
Collapse
Affiliation(s)
- Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Anita W Asgar
- Division of Cardiology, Institut de Cardiologie de Montreal, Universite de Montreal, Montreal, Quebec, Canada
| | - Natalie A Bello
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sonal Chandra
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Melinda B Davis
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Mardi Gomberg-Maitland
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Martha Gulati
- Department of Medicine (Cardiology), University of Arizona-Phoenix, Phoenix, Arizona, USA
| | - Lisa M Hollier
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | - Eric V Krieger
- Seattle Adult Congenital Heart Service, University of Washington School of Medicine, Seattle, Washington, USA
| | - Ki Park
- Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Candice Silversides
- Division of Cardiology, University of Toronto Pregnancy and Heart Disease Program, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Natasha K Wolfe
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Carl J Pepine
- Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | | |
Collapse
|
7
|
Abstract
The pregnant cardiac patient has become a national focus in the United States during the 21st century. Maternal mortality in the United States is on the rise, cardiac disease in pregnancy has been identified as the number one indirect cause and has driven the increase in maternal death rate greatly. This may be explained by the increasing number of women with congenital heart disease reaching reproductive age and a higher prevalence of chronic medical diseases. A triad solution includes cardiovascular screening, patient education and a multidisciplinary team. The Cardio Obstetric team is described here.
Collapse
|
8
|
Abstract
PURPOSE OF REVIEW The aim of this study was to describe risks of systemic lupus erythematosus (SLE) in pregnancy and the importance of preconception counselling, medication optimization and close surveillance. RECENT FINDINGS Advances in care for pregnant patients with SLE have led to improved obstetric outcomes, but maternal and foetal risks continue to be elevated. Conception during periods of disease quiescence and continuation of most medications decrease adverse pregnancy outcomes. Hydroxychloroquine (HCQ) appears protective against flares in pregnancy, neonatal congenital heart block and preterm birth. SUMMARY SLE in pregnancy confers increased maternal and foetal risks, including disease flares, preeclampsia, preterm birth, foetal growth restriction, neonatal lupus erythematosus (NLE) and congenital heart block. Disease control on an effective medication regimen mitigates many of these risks, but pregnancy in women with SLE remains a high-risk condition requiring multidisciplinary care and an individualized approach to each patient.
Collapse
|
9
|
Wolfe DS, Hameed AB, Taub CC, Zaidi AN, Bortnick AE. Addressing maternal mortality: the pregnant cardiac patient. Am J Obstet Gynecol 2019; 220:167.e1-167.e8. [PMID: 30278179 DOI: 10.1016/j.ajog.2018.09.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/07/2018] [Accepted: 09/24/2018] [Indexed: 11/30/2022]
Abstract
Cardiac disease in pregnancy is the number one indirect cause of maternal mortality in the United States. We propose a triad solution that includes universal screening for cardiovascular disease in pregnancy and postpartum women, patient education, and institution of a multidisciplinary cardiac team. Additionally, we emphasize essential elements to maximize care for the pregnant cardiac patient based on our experience at our institution in Bronx, NY.
Collapse
Affiliation(s)
- Diana S Wolfe
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY.
| | | | - Cynthia C Taub
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Ali N Zaidi
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Anna E Bortnick
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| |
Collapse
|