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Adler L, Radomyslsky Z, Mizrahi Reuveni M, Schejter E, Yehoshua I, Segal Y, Kivity S, Naimi E, Saban M. Harnessing innovation to help meet the needs of elders: field testing an electronic tool to streamline geriatric assessments across healthcare settings. Fam Med Community Health 2024; 12:e002729. [PMID: 38762223 PMCID: PMC11103227 DOI: 10.1136/fmch-2024-002729] [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: 05/20/2024] Open
Abstract
BACKGROUND As populations age globally, effectively managing geriatric health poses challenges for primary care. Comprehensive geriatric assessments (CGAs) aim to address these challenges through multidisciplinary screening and coordinated care planning. However, most CGA tools and workflows have not been optimised for routine primary care delivery. OBJECTIVE This study aimed to evaluate the impact of a computerised CGA tool, called the Golden Age Visit, implemented in primary care in Israel. METHODS This study employed a quasiexperimental mixed-methods design to evaluate outcomes associated with the Golden Age electronic health assessment tool. Quantitative analysis used electronic medical records data from Maccabi Healthcare Services, the second largest health management organisation (HMO) in Israel. Patients aged 75 and older were included in analyses from January 2017 to December 2019 and January 2021 to December 2022. For patients, data were also collected on controls who did not participate in the Golden Age Visit programme during the same time period, to allow for comparison of outcomes. For physicians, qualitative data were collected via surveys and interviews with primary care physicians who used the Golden Age Visit SMARTEST e-assessment tool. RESULTS A total of 9022 community-dwelling adults aged 75 and older were included in the study: 1421 patients received a Golden Age Visit CGA (intervention group), and 7601 patients did not receive the assessment (control group). After CGAs, diagnosis rates increased significantly for neuropsychiatric conditions and falls. Referrals to physiotherapy, occupational therapy, dietetics and geriatric outpatient clinics also rose substantially. However, no differences were found in rates of hip fracture or relocation to long-term care between groups. Surveys among physicians (n=151) found high satisfaction with the programme. CONCLUSION Implementation of a large-scale primary care CGA programme was associated with improved diagnosis and management of geriatric conditions. Physicians were also satisfied, suggesting good uptake and feasibility within usual care. Further high-quality studies are still needed but these results provide real-world support for proactively addressing geriatric health needs through structured screening models.
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Affiliation(s)
- Limor Adler
- Maccabi Healthcare Services, Tel Aviv, Israel
| | - Zorian Radomyslsky
- Maccabi Healthcare Services, Tel Aviv, Israel
- Department of Health system management, Ariel University, Ariel, Israel
| | | | | | | | - Yakov Segal
- Maccabi Healthcare Services, Tel Aviv, Israel
| | - Sara Kivity
- Maccabi Healthcare Services, Tel Aviv, Israel
- Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Etti Naimi
- Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Mor Saban
- Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
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Shimazaki Y, Kishimoto K, Ishikawa J, Iwakiri R, Araki A, Imai S. Association between Cognitive Impairment Severity and Polypharmacy in Older Patients with Atrial Fibrillation: A Retrospective Study Using Inpatient Data from a Specialised Geriatric Hospital. Geriatrics (Basel) 2024; 9:15. [PMID: 38392102 PMCID: PMC10887641 DOI: 10.3390/geriatrics9010015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/19/2023] [Accepted: 01/17/2024] [Indexed: 02/24/2024] Open
Abstract
This study aimed to investigate the association between cognitive impairment and polypharmacy in patients with atrial fibrillation prone to cognitive decline, and to elucidate if the Dementia Assessment Sheet for Community-based Integrated Care System 21-Items (DASC-21) severity classification indicates drug adjustment. This retrospective cohort study used the DASC-21 and Diagnosis Procedure Combination data at a specialised geriatric hospital with patients hospitalised between April 2019 and March 2022. The association between cognitive severity evaluated using the DASC-21 and polypharmacy was investigated using a multivariate logistic regression model. Data of 1191 inpatients (44.3% aged ≥85 years, 49.0% male) were analysed. Compared with severe cognitive impairment, mild (odds ratio [OR]: 3.33, 95% confidence interval [CI]: 1.29-8.57) and moderate (OR: 2.46, 95% CI: 1.06-5.72) impairments were associated with concurrent use of ≥6 medications. Antithrombotics were related to polypharmacy. The ORs did not change with 6, 8, or 10 medications (2.11 [95% CI: 1.51-2.95, p < 0.001], 2.42 [95% CI: 1.79-3.27, p < 0.001], and 2.01 [95% CI: 1.46-2.77, p < 0.001], respectively). DASC-21 severity was associated with polypharmacy in patients with atrial fibrillation, with a trend toward decreased polypharmacy from moderate to severe. The DASC-21 may serve as an indicator for drug adjustment in clinical practice.
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Affiliation(s)
- Yoshitomo Shimazaki
- Division of Pharmacy, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan
- Depertment of Pharmacoepidemiology, Showa University Graduate School of Pharmacy, 1-8-5, Hatanodai, Shinagawaku, Tokyo 142-8555, Japan
| | - Keiko Kishimoto
- Department of Social Pharmacy, Showa University Graduate School of Pharmacy, 1-8-5, Hatanodai, Shinagawaku, Tokyo 142-8555, Japan
| | - Joji Ishikawa
- Division of Cardiology, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan
| | - Rika Iwakiri
- Division of Elderly Care, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan
| | - Atsushi Araki
- Frail Prevention Center, Training Center, Tokyo Metropolitan Institute for Geriatrics and Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan
| | - Shinobu Imai
- Depertment of Pharmacoepidemiology, Showa University Graduate School of Pharmacy, 1-8-5, Hatanodai, Shinagawaku, Tokyo 142-8555, Japan
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Donaghy E, Still F, Frost H, Lutte J, Shenkin SD, Jones HE, Mercer SW. GP-led adapted comprehensive geriatric assessment for frail older people: a multi-methods evaluation of the 'Living Well Assessment' quality improvement project in Scotland. BJGP Open 2023; 7:BJGPO.2022.0184. [PMID: 36564081 DOI: 10.3399/bjgpo.2022.0184] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Evidence to support comprehensive geriatric assessment (CGA) in primary care for frail older people is limited. AIM To evaluate a GP-led adapted CGA quality improvement project. DESIGN & SETTING Multi-methods evaluation in a large practice in Midlothian in Scotland. METHOD The intervention was conducted by 10 GPs in a practice of approximately 11 000 patients, initially in the patient's home, and then remotely (by telephone or video consultation) during the COVID-19 pandemic. Evaluation included a patient questionnaire, and qualitative interviews with GPs delivering the Living Well Assessment (LWA), analysed by thematic analysis. RESULTS A total of 165/220 (75%) patients responded to the survey, of which 86% reported a 'very good experience' of the LWA. The method of delivery did not significantly influence this although most (58%) stated a preference for face-to-face consultation. For the 31% who preferred remote LWA, most (23%) preferred telephone to video consultation (8%). Problems in remote consultations related to technical issues (video), poor vision (video), or deafness (telephone or video). GPs felt that home-based LWAs had real benefits but switching to remote during the pandemic had proven feasible. Concerns included potential increase in GP workload owing to the LWA and whether it was an efficient use of GPs' time. CONCLUSION GP-led adapted CGA was feasible in a large practice, even during the pandemic, and highly valued by frail patients. Questions regarding efficient use of GPs' time, effectiveness in terms of important patient outcomes and impact, and cost-effectiveness, requires further investigation in a larger study.
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Affiliation(s)
- Eddie Donaghy
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Franca Still
- Medical School, University of Edinburgh, Edinburgh, UK
| | - Helen Frost
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Julia Lutte
- Penicuik Medical Practice, Midlothian, Penicuik, UK
| | | | - Helen E Jones
- Department of Medicine of the Elderly, Western General Hospital, NHS Lothian, Edinburgh, UK
| | - Stewart W Mercer
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
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Underprescription of medications in older adults: causes, consequences and solutions-a narrative review. Eur Geriatr Med 2021; 12:453-462. [PMID: 33709336 DOI: 10.1007/s41999-021-00471-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 02/10/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE Under-prescription is defined as the omission of a medication that is indicated for the treatment of a condition or a disease, without any valid reason for not prescribing it. The aim of this review is to provide an updated overview of under-prescription, summarizing the available evidence concerning its prevalence, causes, consequences and potential interventions to reduce it. METHODS A PubMed search was performed, using the following keywords: under-prescription; under-treatment; prescribing omission; older adults; polypharmacy; cardiovascular drugs; osteoporosis; anticoagulant. The list of articles was evaluated by two authors who selected the most relevant of them. The reference lists of retrieved articles were screened for additional pertinent studies. RESULTS Although several pharmacological therapies are safe and effective in older patients, under-prescription remains widespread in the older population, with a prevalence ranging from 22 to 70%. Several drugs are underused, including cardiovascular, oral anticoagulant and anti-osteoporotic drugs. Many factors are associated with under-prescription, e.g. multi-morbidity, polypharmacy, dementia, frailty, risk of adverse drug events, absence of specific clinical trials in older patients and economic factors. Under-prescription is associated with negative consequences, such as higher risk of cardiovascular events, worsening disability, hospitalization and death. The implementation of explicit criteria for under-prescription, the use of the comprehensive geriatric assessment by geriatricians, and the involvement of a clinical pharmacist seem to be promising options to reduce under-prescription. CONCLUSION Under-prescription remains widespread in the older population. Further studies should be performed, to provide a better comprehension of this phenomenon and to confirm the efficacy of corrective interventions.
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Aggarwal P, Woolford SJ, Patel HP. Multi-Morbidity and Polypharmacy in Older People: Challenges and Opportunities for Clinical Practice. Geriatrics (Basel) 2020; 5:E85. [PMID: 33126470 PMCID: PMC7709573 DOI: 10.3390/geriatrics5040085] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 11/16/2022] Open
Abstract
Multi-morbidity and polypharmacy are common in older people and pose a challenge for health and social care systems, especially in the context of global population ageing. They are complex and interrelated concepts in the care of older people that require early detection and patient-centred shared decision making underpinned by multi-disciplinary team-led comprehensive geriatric assessment (CGA) across all health and social care settings. Personalised care plans need to remain responsive and adaptable to the needs and wishes of the patient, enabling the individual to maintain their independence. In this review, we aim to give an up-to-date account of the recognition and management of multi-morbidity and polypharmacy in the older person.
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Affiliation(s)
- Pritti Aggarwal
- Southampton City Clinical Commissioning Group, Southampton SO16 4GX, UK;
- Living Well Partnership, Southampton SO19 9GH, UK
- School of Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton SO17 1BJ, UK
| | - Stephen J. Woolford
- Medicine for Older People, University Hospital Southampton NHS FT, Southampton SO16 6YD, UK;
| | - Harnish P. Patel
- Medicine for Older People, University Hospital Southampton NHS FT, Southampton SO16 6YD, UK;
- Academic Geriatric Medicine, University of Southampton, Southampton SO16 6YD, UK
- NIHR Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS FT, Southampton SO16 6YD, UK
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Garrard JW, Cox NJ, Dodds RM, Roberts HC, Sayer AA. Comprehensive geriatric assessment in primary care: a systematic review. Aging Clin Exp Res 2020; 32:197-205. [PMID: 30968287 PMCID: PMC7033083 DOI: 10.1007/s40520-019-01183-w] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 03/23/2019] [Indexed: 11/29/2022]
Abstract
Background Comprehensive geriatric assessment (CGA) involves the multidimensional assessment and management of an older person. It is well described in hospital and home-based settings. A novel approach could be to perform CGA within primary healthcare, the initial community located healthcare setting for patients, improving accessibility to a co-located multidisciplinary team. Aim To appraise the evidence on CGA implemented within the primary care practice. Methods The review followed PRISMA recommendations. Eligible studies reported CGA on persons aged ≥ 65 in a primary care practice. Studies focusing on a single condition were excluded. Searches were run in five databases; reference lists and publications were screened. Two researchers independently screened for eligibility and assessed study quality. All study outcomes were reviewed. Results The authors screened 9003 titles, 145 abstracts and 97 full texts. Four studies were included. Limited study bias was observed. Studies were heterogeneous in design and reported outcomes. CGAs were led by a geriatrician (n = 3) or nurse practitioner (n = 1), with varied length and extent of follow-up (12–48 months). Post-intervention hospital admission rates showed mixed results, with improved adherence to medication modifications. No improvement in survival or functional outcomes was observed. Interventions were widely accepted and potentially cost-effective. Discussion The four studies demonstrated that CGA was acceptable and provided variable outcome benefit. Further research is needed to identify the most effective strategy for implementing CGA in primary care. Particular questions include identification of patients suitable for CGA within primary care CGA, a consensus list of outcome measures, and the role of different healthcare professionals in delivering CGA. Electronic supplementary material The online version of this article (10.1007/s40520-019-01183-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James W Garrard
- Radcliffe Department of Medicine, University of Oxford, Oxford, OX1 2JD, UK.
| | - Natalie J Cox
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Richard M Dodds
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- AGE Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - Helen C Roberts
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Wessex, University of Southampton, Southampton, UK
| | - Avan A Sayer
- Academic Geriatric Medicine, Faculty of Medicine, University of Southampton, Southampton, UK
- AGE Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
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Valassi JMR, Carvas Junior N, Matsura Shirassu M, de Paula KE, Atkinson ER, Koike MK. Factors Associated With Medication Adherence In Elderly Retired Outpatients In São Paulo, Brazil. Patient Prefer Adherence 2019; 13:1619-1628. [PMID: 31686788 PMCID: PMC6777441 DOI: 10.2147/ppa.s208026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 09/01/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To evaluate medication adherence and associated socioeconomic factors in elderly Brazilians. METHODOLOGY This observational study was conducted with 159 elderly retired in an outpatient clinic in the city of São Paulo. Treatment adherence was assessed with the questions from the Morisky Green Levine Medication Adherence Questionnaire, and medications were classified using the Anatomical Therapeutic Chemical system. Statistical tests and adjusted Poisson regression models were used to analyze variables. RESULTS The study population was mostly female (67.5%), had an average age of, and took an average of 6.5 medications per day. The most commonly used drugs were agents acting on the renin-angiotensin system (67.9%), statins (62.3%), antithrombotic agents (48.4%), and biguanides (37.1%) for the treatment of hypertension (76.7%), dyslipidemia (54.1%), and diabetes (47.8%). The rate of adherence was below 60% in the groups of participants that were analyzed except for the high household income category, which had a rate of 75.8%. CONCLUSION Medication adherence among the elderly was low in all categories except for the high household income category, a relevant finding that will help to understand medication adherence patterns in elderly Brazilians.
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Affiliation(s)
| | - Nelson Carvas Junior
- Health Sciences Department, Institute for Medical Assistance to State Public Servants, São Paulo, Brazil
| | - Mirian Matsura Shirassu
- Health Sciences Department, Institute for Medical Assistance to State Public Servants, São Paulo, Brazil
| | - Kaleo Eduardo de Paula
- Health Sciences Department, Institute for Medical Assistance to State Public Servants, São Paulo, Brazil
| | | | - Marcia Kiyomi Koike
- Health Sciences Department, Institute for Medical Assistance to State Public Servants, São Paulo, Brazil
- Emergency Medicine Department, Medical School, University of São Paulo, São Paulo, Brazil
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Overcash J. Comprehensive Geriatric Assessment: Interprofessional Team Recommendations for Older Adult Women With Breast Cancer. Clin J Oncol Nurs 2019; 22:304-315. [PMID: 29781467 DOI: 10.1188/18.cjon.304-315] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Geriatric oncology incorporates comprehensive geriatric assessment (CGA) and traditional oncology care. OBJECTIVES The aims are to identify limitations reflected by mean scores on the CGA instruments and describe the CGA recommendations documented in the medical record. METHODS CGA was administered and consisted of the Timed Up and Go Test, the Activities of Daily Living Scale, the Instrumental Activities of Daily Living Scale, grip strength, falls, pain, the Brief Fatigue Inventory, the Pittsburgh Sleep Quality Index, the Geriatric Depression Scale, the Mini-Cog, and the Mini Nutritional Assessment. CGA recommendations were obtained from the medical record. Descriptive statistics were used to analyze the data. FINDINGS Most recommendations were for general cancer treatment, followed by fall referral/education.
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Ouellet GM, Ouellet JA, Tinetti ME. Principle of rational prescribing and deprescribing in older adults with multiple chronic conditions. Ther Adv Drug Saf 2018; 9:639-652. [PMID: 30479739 PMCID: PMC6243421 DOI: 10.1177/2042098618791371] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 06/27/2018] [Indexed: 12/12/2022] Open
Abstract
Although the majority of older adults in the developed world live with multiple chronic conditions (MCCs), the task of selecting optimal treatment regimens is still fraught with difficulty. Older adults with MCCs may derive less benefit from prescribed medications than healthier patients as a result of the competing risk of several possible outcomes including, but not limited to, death before a benefit can be accrued. In addition, these patients may be at increased risk of medication-related harms in the form of adverse effects and significant burdens of treatment. At present, the balance of these benefits and harms is often uncertain, given that older adults with MCCs are often excluded from clinical trials. In this review, we propose a framework to consider patients' own priorities to achieve optimal treatment regimens. To begin, the practicing clinician needs information on the patient's goals, what the patient is willing and able to do to achieve these goals, an estimate of the patient's clinical trajectory, and what the patient is actually taking. We then describe how to integrate this information to understand what matters most to the patient in the context of an array of potential tradeoffs. Finally, we propose conducting serial therapeutic trials of prescribing and deprescribing, with success measured as progress towards the patient's own health outcome goals. The process described in this manuscript is truly an iterative process, which should be repeated regularly to account for changes in the patient's priorities and clinical status. With this process, we aim to achieve optimal prescribing, that is, treatment regimens that maximize benefits that matter to the patient and minimize burdens and potential harms.
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Affiliation(s)
- Gregory M. Ouellet
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, 367 Cedar Street, Harkness A, Room 308-A, New Haven, CT 06520-8093, USA
| | - Jennifer A. Ouellet
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Mary E. Tinetti
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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