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Wynn A, Sileo KM, Schmarje Crockett K, Naigino R, Ediau M, Wanyenze RK, Kiwanuka N, Martin NK, Kiene SM. Prevalence of alcohol use by gender and HIV status in rural Uganda. PLoS One 2024; 19:e0303885. [PMID: 39012870 PMCID: PMC11251619 DOI: 10.1371/journal.pone.0303885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/03/2024] [Indexed: 07/18/2024] Open
Abstract
BACKGROUND Alcohol use is a major contributor to mortality and morbidity worldwide. Uganda has a high level of alcohol use per capita. Compared to men, women are less likely to consume alcohol globally; however, women who drink have increased risks for co-occurring conditions, including depression, intimate partner violence, and HIV. This study assessed the prevalence of alcohol use and correlates of harmful alcohol use by gender and HIV status in rural Uganda. METHODS We used cross-sectional data from a study among women and men aged 15-59 residing in rural, central Uganda and accepting home-based HIV testing (Nov 2017 to Dec 2020). We estimated the prevalence of levels of alcohol use (categorized as no alcohol use (score 0), low (score 1-3 for men; 1-2 for women), medium (score 4-5 for men; 3-5 for women), high (score 6-7), and very-high (score 8-12) use with the AUDIT-C), stratified by gender and HIV status. We assessed correlates of harmful alcohol use using multivariable logistic regression models for women and men. RESULTS Among 18,460 participants, 67% (95% CI: 66-67%) reported no alcohol use, 16% (95% CI: 16-17%) reported low, 5% (95% CI: 4.8-5%) reported medium, 5% (95% CI: 4-5%) reported high, and 3% (95% CI: 2.8-3) reported very high alcohol use. Compared to women, men were more likely to report alcohol use (Chi-squared p-value<0.0001). People diagnosed with HIV (both newly diagnosed and previously aware of their status prior to home-based HIV testing) were more likely to report low, medium, high, and very high alcohol use compared to those who were HIV negative (Chi-squared p-value<0.0001). Among women, those who were newly diagnosed were more likely report alcohol use, compared to those who were HIV negative. In multivariable models, being newly diagnosed with HIV (compared to HIV negative) increased the odds of harmful alcohol use among women, but not men. CONCLUSION While alcohol use was higher among men and people living with HIV, being newly diagnosed with HIV had a stronger relationship with harmful alcohol use among women than men. More research is needed to understand how alcohol use may increase the risks of HIV acquisition among women and to identify gender-responsive services to address harmful alcohol use and increase access to HIV testing and linkage to care for women who use harmful levels of alcohol.
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Affiliation(s)
- Adriane Wynn
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, La Jolla, California, United States of America
| | - Katelyn M. Sileo
- Department of Public Health, The University of Texas at San Antonio, San Antonio, Texas, United States of America
| | - Katherine Schmarje Crockett
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, California, United States of America
- The Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, United States of America
| | - Rose Naigino
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, California, United States of America
- The Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, United States of America
| | - Michael Ediau
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, California, United States of America
- The Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, California, United States of America
| | - Rhoda K. Wanyenze
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Noah Kiwanuka
- Epidemiology and Biostatistics Department, at Makerere University School of Public Health, Kampala, Uganda
| | - Natasha K. Martin
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, La Jolla, California, United States of America
| | - Susan M. Kiene
- Division of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, California, United States of America
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
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Owino L, Johnson-Peretz J, Lee J, Getahun M, Coppock-Pector D, Maeri I, Onyango A, Cohen CR, Bukusi EA, Kabami J, Ayieko J, Petersen M, Kamya MR, Charlebois E, Havlir D, Camlin CS. Exploring HIV risk perception mechanisms among youth in a test-and-treat trial in Kenya and Uganda. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002922. [PMID: 38696376 PMCID: PMC11065277 DOI: 10.1371/journal.pgph.0002922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/24/2024] [Indexed: 05/04/2024]
Abstract
Understanding risk perception and risk-taking among youth can inform targeted prevention efforts. Using a health beliefs model-informed framework, we analysed 8 semi-structured, gender-specific focus group discussions with 93 youth 15-24 years old (48% male, 52% female), drawn from the SEARCH trial in rural Kenya and Uganda in 2017-2018, coinciding with the widespread introduction of PrEP. Highly connected social networks and widespread uptake of antiretrovirals shaped youth HIV risk perception. Amid conflicting information about HIV prevention methods, youth felt exposed to multiple HIV risk factors like the high prevalence of HIV, belief that people with HIV(PWH) purposefully infect others, dislike of condoms, and doubts about PrEP efficacy. Young women also reported minimal sexual autonomy in the context of economic disadvantages, the ubiquity of intergenerational and transactional sex, and peer pressure from other women to have many boyfriends. Young men likewise reported vulnerability to intergenerational sex, but also adopted a sexual conquest mentality. Comprehensive sexuality education and economic empowerment, through credible and trusted sources, may moderate risk-taking. Messaging should leverage youth's social networks to spread fact-based, gender- and age-appropriate information. PrEP should be offered alongside other reproductive health services to address both pregnancy concerns and reduce HIV risk.
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Affiliation(s)
- Lawrence Owino
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Jason Johnson-Peretz
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Joi Lee
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Monica Getahun
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Dana Coppock-Pector
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Irene Maeri
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | | | - Craig R. Cohen
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
| | | | - Jane Kabami
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
| | - James Ayieko
- Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Maya Petersen
- Divisions of Biostatistics and Epidemiology, School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Moses R. Kamya
- Infectious Diseases Research Collaboration (IDRC), Kampala, Uganda
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Edwin Charlebois
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, United States of America
| | - Diane Havlir
- HIV, Infectious Disease and Global Medicine, University of California, San Francisco, San Francisco, California, United States of America
| | - Carol S. Camlin
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California, San Francisco, San Francisco, California, United States of America
- Center for AIDS Prevention Studies, University of California, San Francisco, San Francisco, California, United States of America
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Smith MJ, Phillips RV, Luque-Fernandez MA, Maringe C. Application of targeted maximum likelihood estimation in public health and epidemiological studies: a systematic review. Ann Epidemiol 2023; 86:34-48.e28. [PMID: 37343734 DOI: 10.1016/j.annepidem.2023.06.004] [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: 03/03/2023] [Revised: 05/24/2023] [Accepted: 06/06/2023] [Indexed: 06/23/2023]
Abstract
PURPOSE The targeted maximum likelihood estimation (TMLE) statistical data analysis framework integrates machine learning, statistical theory, and statistical inference to provide a least biased, efficient, and robust strategy for estimation and inference of a variety of statistical and causal parameters. We describe and evaluate the epidemiological applications that have benefited from recent methodological developments. METHODS We conducted a systematic literature review in PubMed for articles that applied any form of TMLE in observational studies. We summarized the epidemiological discipline, geographical location, expertize of the authors, and TMLE methods over time. We used the Roadmap of Targeted Learning and Causal Inference to extract key methodological aspects of the publications. We showcase the contributions to the literature of these TMLE results. RESULTS Of the 89 publications included, 33% originated from the University of California at Berkeley, where the framework was first developed by Professor Mark van der Laan. By 2022, 59% of the publications originated from outside the United States and explored up to seven different epidemiological disciplines in 2021-2022. Double-robustness, bias reduction, and model misspecification were the main motivations that drew researchers toward the TMLE framework. Through time, a wide variety of methodological, tutorial, and software-specific articles were cited, owing to the constant growth of methodological developments around TMLE. CONCLUSIONS There is a clear dissemination trend of the TMLE framework to various epidemiological disciplines and to increasing numbers of geographical areas. The availability of R packages, publication of tutorial papers, and involvement of methodological experts in applied publications have contributed to an exponential increase in the number of studies that understood the benefits and adoption of TMLE.
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Affiliation(s)
- Matthew J Smith
- Inequalities in Cancer Outcomes Network, London School of Hygiene and Tropical Medicine, London, UK.
| | - Rachael V Phillips
- Division of Biostatistics, School of Public Health, University of California at Berkeley, Berkeley, CA
| | - Miguel Angel Luque-Fernandez
- Inequalities in Cancer Outcomes Network, London School of Hygiene and Tropical Medicine, London, UK; Department of Statistics and Operations Research, University of Granada, Granada, Spain
| | - Camille Maringe
- Inequalities in Cancer Outcomes Network, London School of Hygiene and Tropical Medicine, London, UK
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Muinde R, Owuor K, Mutiso J, Mwangi J, Wekesa P. Optimizing HIV case identification: investigating client characteristics predictive of HIV positivity from provider-initiated testing (PITC) in central Kenya. BMC Health Serv Res 2023; 23:1005. [PMID: 37726795 PMCID: PMC10508048 DOI: 10.1186/s12913-023-09876-9] [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: 11/17/2022] [Accepted: 08/04/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Routine program data indicates positivity rates under 2% from HIV testing services (HTS) at sites supported by Centre for Health Solutions-Kenya in Central Kenya. Achieving the UNAIDS 95:95:95 goals requires continuous identification of people living with HIV in an environment of diminishing resources. We assessed non-clinical and clinical characteristics of persons who tested HIV-positive aimed at improving the process of HTS through Provider-Initiated HIV Testing & Counseling (PITC). METHODS We conducted a retrospective analysis of routine PITC program data collected between October 2018 and September 2019 from six health facilities located in three counties in central Kenya. Stratification was based on county and facility volume. A multivariable logistic regression model, clustered adjusted for facility using robust standard errors, was used to determine predictors of a positive HIV result. RESULTS The total sample was 80,693 with an overall positivity rate of 1.2%. Most, (65.5%), were female and 6.1% were < 15 years. Most clients, 55,464 (68.7%), had previously tested for HIV. Client characteristics associated with a higher odds of positivity on multivariable analysis included: being female (adjusted odds ratio [aOR] 1.27, 95% confidence interval [CI] (1.03-1.57); adults 15 years and above compared to children < 15 years, divorced and married polygamous compared to married monogamous [aOR 3.98, 95% CI (2.12-7.29) and aOR 2.41 95% CI (1.48-3.94) respectively]; clients testing for the first time compared to repeat testers in less than 12 months [aOR 1.39, 95% CI (1.27-1.51)]. Similarly, repeat testers in more than 12 months compared to repeat testers in less than 12 months [aOR 1.90, 95% CI (1.55-2.32)]; presumptive TB clients compared to those without signs of TB [aOR 16.25, 95% CI (10.63-24.84)]. Clients tested at inpatient departments (IPD) were more likely to get a positive HIV result compared to those tested at outpatient departments (OPD), and other departments. CONCLUSIONS The study findings highlight client characteristics such as age, marital status, HIV test entry point, first-time test, repeat test after 12 months, and TB status as factors that could influence PITC results and could be used to develop a screening tool to target eligible clients for HTS in low HIV prevalence settings.
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Affiliation(s)
| | | | | | - Jonathan Mwangi
- Division of Global HIV & TB, Center for Global Health, US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Paul Wekesa
- Centre for Health Solutions, Nairobi, Kenya.
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Sharkey T, Wall KM, Parker R, Tichacek A, Pappas-DeLuca KA, Kilembe W, Inambao M, Malama K, Hoagland A, Peeling R, Allen S. A cluster randomized trial to reduce HIV risk from outside partnerships in Zambian HIV-Negative couples using a novel behavioral intervention, "Strengthening Our Vows": Study protocol and baseline data. Contemp Clin Trials Commun 2021; 24:100850. [PMID: 34622087 PMCID: PMC8481973 DOI: 10.1016/j.conctc.2021.100850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 08/02/2021] [Accepted: 09/08/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Heterosexual couples contribute to most new HIV infections in areas of generalized HIV epidemics in sub-Saharan Africa. After Couples' Voluntary HIV Counseling and Testing (CVCT), heterosexual concordant HIV negative couples (CNC) in cohabiting unions contribute to approximately 47% of residual new infections in couples. These infections are attributed to concurrent sexual partners, a key driver of the HIV epidemic in Zambia. METHODS/DESIGN Ten Zambian government clinics in two of the largest cities were randomized in matched pairs to a Strengthening Our Vows (SOV) intervention or a Good Health Package (GHP) comparison arm. SOV addressed preventing HIV infection from concurrent partners and protecting spouses after exposures outside the relationship. GHP focused on handwashing; water chlorination; household deworming; and screening for hypertension, diabetes and schistosomiasis. CNC were referred from CVCT services in government clinics. Follow-up includes post-intervention questionnaires and outcome assessments through 60 months. Longitudinal outcomes of interest include self-report and laboratory markers of condomless sex with outside partners and reported sexual agreements. We present baseline characteristics and factors associated with study arm and reported risk using descriptive statistics. RESULTS The mean age of men was 32 and 26 for women. On average, couples cohabited for 6 years and had 2 children. Baseline analyses demonstrated some failures of randomization by study arm which will be considered in future primary analyses of longitudinal data. An HIV/STI risk factor composite was not different in the two study arms. Almost one-quarter of couples had an HIV risk factor at baseline. DISCUSSION In preparation for future biomedical and behavioral interventions in sub-Saharan Africa, it is critical to understand and decrease HIV risk within CNC.
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Affiliation(s)
- Tyronza Sharkey
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
- London School of Hygiene and Tropical Medicine, UK
| | - Kristin M. Wall
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
- Department of Epidemiology, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Rachel Parker
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Amanda Tichacek
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Katina A. Pappas-DeLuca
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - William Kilembe
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Mubiana Inambao
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Kalonde Malama
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | - Alexandra Hoagland
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
| | | | - Susan Allen
- Rwanda Zambia HIV Research Group, Department of Pathology & Laboratory Medicine, School of Medicine and Hubert Department of Global Health, Rollins School of Public Health, Laney Graduate School, Emory University, Atlanta, GA, 30322, USA
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Ismail SD, Pankrac J, Ndashimye E, Prodger JL, Abrahams MR, Mann JFS, Redd AD, Arts EJ. Addressing an HIV cure in LMIC. Retrovirology 2021; 18:21. [PMID: 34344423 PMCID: PMC8330180 DOI: 10.1186/s12977-021-00565-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/19/2021] [Indexed: 12/15/2022] Open
Abstract
HIV-1 persists in infected individuals despite years of antiretroviral therapy (ART), due to the formation of a stable and long-lived latent viral reservoir. Early ART can reduce the latent reservoir and is associated with post-treatment control in people living with HIV (PLWH). However, even in post-treatment controllers, ART cessation after a period of time inevitably results in rebound of plasma viraemia, thus lifelong treatment for viral suppression is indicated. Due to the difficulties of sustained life-long treatment in the millions of PLWH worldwide, a cure is undeniably necessary. This requires an in-depth understanding of reservoir formation and dynamics. Differences exist in treatment guidelines and accessibility to treatment as well as social stigma between low- and-middle income countries (LMICs) and high-income countries. In addition, demographic differences exist in PLWH from different geographical regions such as infecting viral subtype and host genetics, which can contribute to differences in the viral reservoir between different populations. Here, we review topics relevant to HIV-1 cure research in LMICs, with a focus on sub-Saharan Africa, the region of the world bearing the greatest burden of HIV-1. We present a summary of ART in LMICs, highlighting challenges that may be experienced in implementing a HIV-1 cure therapeutic. Furthermore, we discuss current research on the HIV-1 latent reservoir in different populations, highlighting research in LMIC and gaps in the research that may facilitate a global cure. Finally, we discuss current experimental cure strategies in the context of their potential application in LMICs.
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Affiliation(s)
- Sherazaan D Ismail
- Division of Medical Virology, Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, 7925, South Africa
| | - Joshua Pankrac
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A5C1, Canada
| | - Emmanuel Ndashimye
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A5C1, Canada
- Center for AIDS Research Uganda Laboratories, Joint Clinical Research Centre, Kampala, Uganda
| | - Jessica L Prodger
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A5C1, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Melissa-Rose Abrahams
- Division of Medical Virology, Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, 7925, South Africa
| | - Jamie F S Mann
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A5C1, Canada
- Bristol Veterinary School, University of Bristol, Langford House, Langford, Bristol, BS40 5DU, UK
| | - Andrew D Redd
- Division of Medical Virology, Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, 7925, South Africa
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Laboratory of Immunoregulation, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Bethesda, MD, USA
| | - Eric J Arts
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A5C1, Canada.
- Division of Infectious Diseases, Department of Medicine, Case Western Reserve University, Cleveland, OH, 44106, USA.
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