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Shweikeh F, Hong G, Rogers K, Mouchli M, Hoscheit M, Lembo A. Colonoscopy Utilization in Elderly Patients with Dementia: Characteristics, Complications, and Charges in a National Matched-Cohort Analysis. Dig Dis Sci 2024; 69:1613-1625. [PMID: 38528210 PMCID: PMC11098859 DOI: 10.1007/s10620-024-08363-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 02/19/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND It is projected that the elderly population will continue to increase. Many will develop chronic conditions such as dementia. AIMS Our aims are to describe the utilization of colonoscopy among patients with dementia and compare outcomes in those with and without dementia. METHODS This population-based analysis utilized the National Inpatient Sample (NIS) during 2019. Patients with dementia over the age of 60 years receiving colonoscopy were identified utilizing ICD-10 codes. Logistic regression was used for propensity score matching between the comparison groups. A Greedy one-to-one matching algorithm was utilized along with standardized mean differences to assess balance. Mcnemar test, signed rank sum, and paired t-test were used to compare the outcomes. RESULTS Initially, 50,692 patients without dementia were compared with 4323 patients with dementia. Patients with dementia were more likely to be female, older, less likely White, had lower income, and more likely to be on Medicare. In the matched comparison (4176 in each group), complication analysis showed that patients with dementia did not have higher colonoscopy-related complications. They did have higher rates of other complications including renal/AKI (p = 0.0042), pulmonary/pneumonia (p = 0.003), cerebrovascular accidents (p = 0.0063), and sepsis (< 0.0001). Patients with dementia were also less likely to have routine discharges (< 0.0001), had longer hospital stays (< 0.0001), and higher hospital costs (< 0.0001). CONCLUSIONS Elderly patients with dementia have similar colonoscopy-related complications as patients without dementia. However, they do have higher complications in general. The decision whether to perform colonoscopy in this patient population is multifactorial. A careful assessment of a dementia patient's history can help with this decision.
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Affiliation(s)
- Faris Shweikeh
- Department of Internal Medicine, Cleveland Clinic Akron General, 1 Akron General Ave., Akron, OH, 44307, USA.
| | - Gordon Hong
- Department of Internal Medicine, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Kathleen Rogers
- Geriatrics Service, Cleveland Clinic Akron General, Akron, OH, USA
| | - Mohamad Mouchli
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Matthew Hoscheit
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Anthony Lembo
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Frederiksen KS, Lanctôt KL, Weidner W, Hahn-Pedersen JH, Mattke S. A Literature Review on the Burden of Alzheimer's Disease on Care Partners. J Alzheimers Dis 2023; 96:947-966. [PMID: 37980660 DOI: 10.3233/jad-230487] [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: 11/21/2023]
Abstract
BACKGROUND Many individuals with Alzheimer's disease (AD) are dependent on nonprofessional care partners. Providing informal care can result in emotional, physical, and financial burdens; however, there is a need for a better understanding of the impact of AD on care partners to support the clinical and economic assessment of potential new treatments. OBJECTIVE We conducted a literature review to evaluate the burden experienced by care partners of individuals with AD. METHODS Electronic screening and supplementary searches identified studies published from 2011 to 2022 describing the association between AD and the quality of life (QoL) and physical health of care partners, and the economic or financial burden of AD. RESULTS Following electronic screening, 62, 25, and 39 studies were included on care partner burden, cost, and healthcare resource use in AD, respectively. Supplementary searches identified an additional 32 studies, resulting in 149 unique studies. These studies showed that care partners of individuals with AD report moderate to severe burden. Higher burden and lower QoL were observed in those caring for individuals with more severe AD. Care partners of individuals with AD experience higher burden, lower QoL, and higher levels of stress, depression, and anxiety than those without caring responsibilities. Informal care costs increased with AD severity and accounted for the greatest proportion of overall societal cost. CONCLUSIONS Care partners of individuals with AD experience emotional and economic burden, which increases with AD severity. These impacts should be quantified comprehensively in future studies and captured in economic evaluations of AD interventions.
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Affiliation(s)
- Kristian Steen Frederiksen
- Danish Dementia Research Centre, Department of Neurology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Krista L Lanctôt
- Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | | | | | - Soeren Mattke
- Center for Economic and Social Research, University of Southern California, Los Angeles, CA, US
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Anastasio AT, Guisse NF, Farley KX, Rhee JM. Hospital Burdens of Patients With Cerebral Palsy Undergoing Posterior Spinal Fusion for Scoliosis. Global Spine J 2022; 12:883-889. [PMID: 33203253 PMCID: PMC9344497 DOI: 10.1177/2192568220968542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES Many patients undergoing posterior spinal fusion (PSF) for scoliosis have concurrent cerebral palsy (CP), which is associated with many medical comorbidities and inherent operative risk. We aimed to quantify the contribution of CP to increased cost, length of stay (LOS), and complication rates in patients with scoliosis undergoing PSF. METHODS Using the National Inpatient Sample database, we collected data regarding patient demographics, hospital characteristics, comorbidities, in-hospital complications, and mortality. Primary outcomes included complications, hospital LOS, and total hospital costs. Multivariate regression models assessed the contribution of CP to in-hospital complications, discharge status, and mortality. Linear regression identified the contribution of a diagnosis of CP on hospital LOS and inflation-adjusted cost. RESULTS Cerebral palsy was an independent predictor of several complications. The most striking differences were seen for mortality (odds ratio [OR]: 3.40, P < .001), a postoperative requirement for total parenteral nutrition (OR: 3.16, P < .001), urinary tract infection (OR: 2.75, P < .001), surgical site infection (OR: 2.67, P < .001), and pneumonia (2.21, P < .001). Patients with CP ultimately cost an additional $13 482 (P < .001) with a 2.07-day greater LOS (P < .001) than patients without CP. CONCLUSION Most complications were seen in higher rates in the CP cohort, with higher cost and LOS in patients with CP versus those with idiopathic scoliosis (IS). Our findings represent important areas of emphasis during preoperative consultations with patients with CP and their families. Extra care in patient selection and multifaceted treatment protocols should continue to be implemented with further investigation on how to mitigate common complications.
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Affiliation(s)
| | - Ndeye F. Guisse
- Emory University, Atlanta, GA, USA
- Ndeye F. Guisse, 7 Executive Park Drive NE,
Apt 1314, Atlanta, GA 30329, USA.
| | | | - John M. Rhee
- Emory University, Atlanta, GA, USA
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
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Chao YT, Kuo FH, Lee YS, Huang YH, Weng SC, Chou YY, Lin CS, Lin SY. Characteristics and Outcome Determinants of Hospitalized Older Patients with Cognitive Dysfunction. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19010584. [PMID: 35010842 PMCID: PMC8744733 DOI: 10.3390/ijerph19010584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/01/2022] [Accepted: 01/01/2022] [Indexed: 12/10/2022]
Abstract
Cognitive dysfunction commonly occurs among older patients during admission and is associated with adverse prognosis. This study evaluated clinical characteristics and outcome determinants in hospitalized older patients with cognitive disorders. The main outcomes were length of stay, readmission within 30 days, Barthel index (BI) score at discharge, BI score change (discharge BI score minus BI score), and proportion of positive BI score change to indicate change of activities of daily living (ADL) change during hospitalization. A total of 642 inpatients with a mean age of 79.47 years (76–103 years) were categorized into three groups according to the medical history of dementia, and Mini-Mental State Examination (MMSE) scores at admission. Among them, 74 had dementia diagnosis (DD), 310 had cognitive impairment (CI), and 258 had normal MMSE scores. Patients with DD and CI generally had a higher risk of many geriatric syndromes, such as multimorbidities, polypharmacy, delirium, incontinence, visual and auditory impairment, fall history, physical frailty. They had less BI score, BI score change, and proportion of positive BI score change ADL at discharge. (DD 70.0%, CI 79.0%), suggesting less ADL change during hospitalization compared with those with normal MMSE scores (92.9%; p < 0.001). Using multiple regression analysis, we found that among patients with DD and CI, age (p = 0.008) and walking speed (p = 0.023) were predictors of discharge BI score. In addition, age (p = 0.047) and education level were associated with dichotomized BI score change (positive vs. non-positive) during hospitalization. Furthermore, the number and severity of comorbidities predicted LOS (p < 0.001) and readmission (p = 0.001) in patients with cognitive disorders. It is suggested that appropriate strategies are required to improve clinical outcomes in these patients.
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Affiliation(s)
- Yi-Ting Chao
- Center for Geriatrics & Gerontology, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-T.C.); (F.-H.K.); (Y.-S.L.); (Y.-H.H.); (S.-C.W.); (Y.-Y.C.); (C.-S.L.)
- Division of Neurology, Taichung Veterans General Hospital, Taichung 407219, Taiwan
| | - Fu-Hsuan Kuo
- Center for Geriatrics & Gerontology, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-T.C.); (F.-H.K.); (Y.-S.L.); (Y.-H.H.); (S.-C.W.); (Y.-Y.C.); (C.-S.L.)
- Division of Neurology, Taichung Veterans General Hospital, Taichung 407219, Taiwan
| | - Yu-Shan Lee
- Center for Geriatrics & Gerontology, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-T.C.); (F.-H.K.); (Y.-S.L.); (Y.-H.H.); (S.-C.W.); (Y.-Y.C.); (C.-S.L.)
- Division of Neurology, Taichung Veterans General Hospital, Taichung 407219, Taiwan
| | - Yu-Hui Huang
- Center for Geriatrics & Gerontology, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-T.C.); (F.-H.K.); (Y.-S.L.); (Y.-H.H.); (S.-C.W.); (Y.-Y.C.); (C.-S.L.)
- Department of Nursing, Taichung Veterans General Hospital, Taichung 407219, Taiwan
| | - Shuo-Chun Weng
- Center for Geriatrics & Gerontology, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-T.C.); (F.-H.K.); (Y.-S.L.); (Y.-H.H.); (S.-C.W.); (Y.-Y.C.); (C.-S.L.)
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112201, Taiwan
| | - Yin-Yi Chou
- Center for Geriatrics & Gerontology, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-T.C.); (F.-H.K.); (Y.-S.L.); (Y.-H.H.); (S.-C.W.); (Y.-Y.C.); (C.-S.L.)
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan
| | - Chu-Sheng Lin
- Center for Geriatrics & Gerontology, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-T.C.); (F.-H.K.); (Y.-S.L.); (Y.-H.H.); (S.-C.W.); (Y.-Y.C.); (C.-S.L.)
- Department of Family Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan
| | - Shih-Yi Lin
- Center for Geriatrics & Gerontology, Taichung Veterans General Hospital, Taichung 407219, Taiwan; (Y.-T.C.); (F.-H.K.); (Y.-S.L.); (Y.-H.H.); (S.-C.W.); (Y.-Y.C.); (C.-S.L.)
- Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112201, Taiwan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 407219, Taiwan
- Correspondence:
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Hollenbeck BK, Dunn RL, Sukul D, Modi PK, Nallamothu BK, Sen A, Bynum JP. Aortic valve replacement among patients with Alzheimer's disease and related dementias. J Am Geriatr Soc 2021; 69:3468-3475. [PMID: 34498253 DOI: 10.1111/jgs.17432] [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] [Received: 05/05/2021] [Revised: 07/16/2021] [Accepted: 07/31/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) has made palliation from aortic stenosis more broadly available to populations previously thought to be too high risk for surgery, such as those with Alzheimer's disease and related dementias (ADRD); however, its safety and effectiveness in this context are uncertain. METHODS We performed a retrospective cohort study of national Medicare beneficiaries, aged 66 and older with Parts A and B, between 2010 and 2016. Patients undergoing AVR were identified, and follow-up was available through 2017. Multivariable regression was used to measure the independent association between having a diagnosis of ADRD at the time of AVR, stratified by TAVR and surgery, and outcomes (mortality and Medicare institutional days at 1 year after AVR). RESULTS The average rate of increase in AVR per year was 17.5 cases per 100,000 ADRD and 8.4 per 100,000 non-ADRD beneficiaries, largely driven by more rapid adoption of TAVR. Adjusted mortality following AVR declined significantly between those treated in 2010 and 2016, from 13.5% (95% CI 10.2%-17.7%) to 6.3% (95% CI 5.2%-7.6%) and from 13.7% (95% CI 12.7%-14.7%) to 6.3% (95% CI 5.8%-6.9%) in those with and without ADRD, respectively. The sharpest decline was noted for patients undergoing TAVR between 2011 and 2016, with adjusted mortality declining from 19.9% (95% CI 11.2%-32.8%) to 5.2% (95% CI 4.1%-6.5%) and from 12.2% (95% CI 9.3%-15.8%) to 5.0% (95% CI 4.4%-5.6%) in patients with and without ADRD, respectively. Similar declines were evident for Medicare institutional days in the year after AVR in both patient groups. CONCLUSIONS Rates of AVR in those with ADRD increased during the past decade largely driven by the diffusion of TAVR. The use of TAVR in this vulnerable population did not come at the expense of increasing Medicare institutional days or mortality at 1-year.
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Affiliation(s)
- Brent K Hollenbeck
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Rodney L Dunn
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Devraj Sukul
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Parth K Modi
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Brahmajee K Nallamothu
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Ananda Sen
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Julie P Bynum
- Departments of Urology, Medicine, and Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
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Rasu RS, Zalmai R, Karpes Matusevich AR, Hunt SL, Phadnis MA, Rianon N. Shorter length of hospital stay for hip fracture in those with dementia and without a known diagnosis of osteoporosis in the USA. BMC Geriatr 2020; 20:523. [PMID: 33272213 PMCID: PMC7713172 DOI: 10.1186/s12877-020-01924-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/22/2020] [Indexed: 12/20/2022] Open
Abstract
Background About 50% of all hospitalized fragility fracture cases in older Americans are hip fractures. Approximately 3/4 of fracture-related costs in the USA are attributable to hip fractures, and these are mostly covered by Medicare. Hip fracture patients with dementia, including Alzheimer’s disease, have worse health outcomes including longer hospital length of stay (LOS) and charges. LOS and hospital charges for dementia patients are usually higher than for those without dementia. Research describing LOS and acute care charges for hip fractures has mostly focused on these outcomes in trauma patients without a known pre-admission diagnosis of osteoporosis (OP). Lack of documented diagnosis put patients at risk of not having an appropriate treatment plan for OP. Whether having a diagnosis of OP would have an effect on hospital outcomes in dementia patients has not been explored. We aim to investigate whether having a diagnosis of OP, dementia, or both has an effect on LOS and hospital charges. In addition, we also report prevalence of common comorbidities in the study population and their effects on hospital outcomes. Methods We conducted a cross-sectional analysis of claims data (2012–2013) for 2175 Medicare beneficiaries (≥65 years) in the USA. Results Compared to those without OP or dementia, patients with demenia only had a shorter LOS (by 5%; P = .04). Median LOS was 6 days (interquartile range [IQR]: 5–7), and the median hospital charges were $45,100 (IQR: 31,500 − 65,600). In general, White patients had a shorter LOS (by 7%), and those with CHF and ischemic heart disease (IHD) had longer LOS (by 7 and 4%, respectively). Hospital charges were 6% lower for women, and 16% lower for White patients. Conclusion This is the first study evaluating LOS in dementia in the context of hip fracture which also disagrees with previous reporting about longer LOS in dementia patients. Patients with CHF and IHD remains at high risk for longer LOS regardless of their diagnosis of dementia or OP.
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Affiliation(s)
- Rafia S Rasu
- Department of Pharmacotherapy,, University of North Texas Health Science Center, College of Pharmacy, Fort Worth, TX, USA.,Department of Health Behavior and Health Systems, University of North Texas Health Science Center, School of Public Health, Fort Worth, TX, USA
| | - Rana Zalmai
- Department of Pharmacotherapy,, University of North Texas Health Science Center, College of Pharmacy, Fort Worth, TX, USA
| | - Aliza R Karpes Matusevich
- Department of Pharmacotherapy,, University of North Texas Health Science Center, College of Pharmacy, Fort Worth, TX, USA
| | - Suzanne L Hunt
- Department of Biostatistics and Data Science, University of Kansas Medical Center, School of Medicine, Kansas City, Kansas, USA
| | - Milind A Phadnis
- Department of Biostatistics and Data Science, University of Kansas Medical Center, School of Medicine, Kansas City, Kansas, USA
| | - Nahid Rianon
- Department of Family and Community Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, 6341 Fannin Street, #JJL 324C, Houston, TX, 77030, USA. .,Division of Geriatric and Palliative Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, TX, Houston, USA.
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Anderson TS, Marcantonio ER, McCarthy EP, Herzig SJ. National Trends in Potentially Preventable Hospitalizations of Older Adults with Dementia. J Am Geriatr Soc 2020; 68:2240-2248. [PMID: 32700399 DOI: 10.1111/jgs.16636] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/09/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND/OBJECTIVES Dementia is associated with higher healthcare expenditures, in large part due to increased hospitalization rates relative to patients without dementia. Data on contemporary trends in the incidence and outcomes of potentially preventable hospitalizations of patients with dementia are lacking. DESIGN Retrospective cohort study using the National Inpatient Sample from 2012 to 2016. SETTING U.S. acute care hospitals. PARTICIPANTS A total of 1,843,632 unique hospitalizations of older adults (aged ≥65 years) with diagnosed dementia. MEASUREMENTS Annual trends in the incidence of hospitalizations for all causes and for potentially preventable conditions including acute ambulatory care sensitive conditions (ACSCs), chronic ACSCs, and injuries. In-hospital outcomes including mortality, discharge disposition, and hospital costs. RESULTS The survey weighted sample represented an estimated 9.27 million hospitalizations for patients with diagnosed dementia (mean [standard deviation] age = 82.6 [6.7] years; 61.4% female). In total, 3.72 million hospitalizations were for potentially preventable conditions (40.1%), 2.07 million for acute ACSCs, .76 million for chronic ACSCs, and .89 million for injuries. Between 2012 and 2016, the incidence of all-cause hospitalizations declined from 1.87 million to 1.85 million per year (P = .04) while the incidence of potentially preventable hospitalizations increased from .75 million to .87 million per year (P < .001), driven by an increased number of hospitalizations of community-dwelling older adults. Among patients with dementia hospitalized for potentially preventable conditions, inpatient mortality declined from 6.4% to 6.1% (P < .001), inflation-adjusted median costs increased from $7,319 to $7,543 (P < .001), and total annual costs increased from $7.4 to $9.3 billion. Although 86.0% of hospitalized patients were admitted from the community, only 32.7% were discharged to the community. CONCLUSION The number of potentially preventable hospitalizations of older adults with dementia is increasing, driven by hospitalizations of community-dwelling older adults. Improved strategies for early detection and goal-directed treatment of potentially preventable conditions in patients with dementia are urgently needed. J Am Geriatr Soc 68:2240-2248, 2020.
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Affiliation(s)
- Timothy S Anderson
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Edward R Marcantonio
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Ellen P McCarthy
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Division of Gerontology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Shoshana J Herzig
- Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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