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Samuels-Kalow ME, Mayes K, Cash RE, Schiavoni KH, Vogeli C, Thorndike AN, Camargo CA. Missed Screening for Adverse Social Determinants of Health and Emergency Department Utilization. Ann Emerg Med 2024; 83:416-418. [PMID: 38142374 PMCID: PMC10960706 DOI: 10.1016/j.annemergmed.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/01/2023] [Accepted: 11/06/2023] [Indexed: 12/25/2023]
Affiliation(s)
- Margaret E Samuels-Kalow
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Katherine Mayes
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Katherine H Schiavoni
- Population Health Management, Mass General Brigham, Somerville, MA; Departments of Medicine and Pediatrics, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | | | - Anne N Thorndike
- Harvard Medical School, Boston, MA; Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
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Mayes KD, Cash RE, Schiavoni KH, Vogeli C, Thorndike AN, Camargo CA, Samuels-Kalow M. Social Risk, Social Need, and Use of the Emergency Department. JAMA Netw Open 2024; 7:e2352365. [PMID: 38241050 PMCID: PMC10799261 DOI: 10.1001/jamanetworkopen.2023.52365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/29/2023] [Indexed: 01/22/2024] Open
Abstract
This cohort study examines the association of social risk and social need with emergency department use by patients within a Medicaid accountable care organization who were screened for adverse social determinants of health in primary care.
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Affiliation(s)
| | - Rebecca E. Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
| | | | - Christine Vogeli
- Mongan Institute Health Policy Center, Mass General Research Institute, Boston, Massachusetts
| | | | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
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Schiavoni KH, Flom M, Blumenthal KJ, Orav EJ, Hefferon M, Maher E, Boudreau AA, Giuliano CP, Chambers B, Mandell MH, Vienneau M, Mendu ML, Vogeli C. Cost, Utilization, and Patient and Family Experience With ACO-Based Pediatric Care Management. Pediatrics 2023; 152:e2022058268. [PMID: 38013488 DOI: 10.1542/peds.2022-058268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Children and Youth with Special Health Care Needs have high healthcare utilization, fragmented care, and unmet health needs. Accountable Care Organizations (ACOs) increasingly use pediatric care management to improve quality and reduce unnecessary utilization. We evaluated effects of pediatric care management on total medical expense (TME) and utilization; perceived quality of care coordination, unmet needs, and patient and family experience; and differential impact by payor, risk score, care manager discipline, and behavioral health diagnosis. METHODS Mixed-methods analysis including claims using quasi-stepped-wedge design pre and postenrollment to estimate difference-in-differences, participant survey, and semistructured interviews. Participants included 1321 patients with medical, behavioral, or social needs, high utilization, in Medicaid or commercial ACOs, and enrolled in multidisciplinary, primary care-embedded care management. RESULTS TME significantly declined 1 to 6 months postenrollment and continued through 19 to 24 months (-$645.48 per member per month, P < .001). Emergency department and inpatient utilization significantly decreased 7 to 12 months post-enrollment and persisted through 19 to 24 months (-29% emergency department, P = .012; -82% inpatient, P < .001). Of respondents, 87.2% of survey respondents were somewhat or very satisfied with care coordination, 56.1% received education coordination when needed, and 81.5% had no unmet health needs. Emergency department or inpatient utilization decreases were consistent across payors and care manager disciplines, occurred sooner with behavioral health diagnoses, and were significant among children with above-median risk scores. Satisfaction and experience were equivalent across groups, with more unmet needs and frustration with above-median risk scores. CONCLUSIONS Pediatric care management in multipayor ACOs may effectively reduce TME and utilization and clinically provide high-quality care coordination, including education and family stress, with high participant satisfaction.
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Affiliation(s)
- Katherine H Schiavoni
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- Departments of Medicine and Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Megan Flom
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
| | - Karen J Blumenthal
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - E John Orav
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Margaret Hefferon
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
| | - Erin Maher
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
| | - Alexy Arauz Boudreau
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts
| | - Christopher P Giuliano
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- Affiliated Pediatric Practices, Dedham, Massachusetts
- Mass General Brigham Community Physicians Organization, Somerville, Massachusetts
| | - Barbara Chambers
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- Mass General Brigham Community Physicians Organization, Somerville, Massachusetts
| | - Mark H Mandell
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- Pediatric Associates of Greater Salem, Salem, Massachusetts
| | - Maryann Vienneau
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
| | - Mallika L Mendu
- Harvard Medical School, Boston, Massachusetts
- Department of Medicine, Renal Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Christine Vogeli
- Mass General Brigham, Population Health Management, Somerville, Massachusetts
- The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
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Schiavoni KH, Helscel K, Vogeli C, Thorndike AN, Cash RE, Camargo CA, Samuels-Kalow ME. Prevalence of social risk factors and social needs in a Medicaid Accountable Care Organization (ACO). BMC Health Serv Res 2022; 22:1375. [PMID: 36403024 PMCID: PMC9675191 DOI: 10.1186/s12913-022-08721-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/23/2022] [Indexed: 11/20/2022] Open
Abstract
Background Health-related social needs (HRSN) are associated with higher chronic disease prevalence and healthcare utilization. Health systems increasingly screen for HRSN during routine care. In this study, we compare the differential prevalence of social risk factors and social needs in a Medicaid Accountable Care Organization (ACO) and identify the patient and practice characteristics associated with reporting social needs in a different domain from social risks. Methods Cross-sectional study of patient responses to HRSN screening February 2019-February 2020. HRSN screening occurred as part of routine primary care and assessed social risk factors in eight domains and social needs by requesting resources in these domains. Participants included adult and pediatric patients from 114 primary care practices. We measured patient-reported social risk factors and social needs from the HRSN screening, and performed multivariable regression to evaluate patient and practice characteristics associated with reporting social needs and concordance to social risks. Covariates included patient age, sex, race, ethnicity, language, and practice proportion of patients with Medicaid and/or Limited English Proficiency (LEP). Results Twenty-seven thousand four hundred thirteen individuals completed 30,703 screenings, including 15,205 (55.5%) caregivers of pediatric patients. Among completed screenings, 13,692 (44.6%) were positive for ≥ 1 social risk factor and 2,944 (9.6%) for ≥ 3 risks; 5,861 (19.1%) were positive for social needs and 4,848 (35.4%) for both. Notably, 1,013 (6.0%) were negative for social risks but positive for social needs. Patients who did not identify as non-Hispanic White or were in higher proportion LEP or Medicaid practices were more likely to report social needs, with or without social risks. Patients who were non-Hispanic Black, Hispanic, preferred non-English languages or were in higher LEP or Medicaid practices were more likely to report social needs without accompanying social risks. Conclusions Half of Medicaid ACO patients screened for HRSN reported social risk factors or social needs, with incomplete overlap between groups. Screening for both social risks and social needs can identify more individuals with HRSN and increase opportunities to mitigate negative health outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08721-9.
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Schiavoni KH, Lawrence J, Xue J, Kotelchuck M, Boudreau AA. Pediatric Practice Transformation and Long-Acting Reversible Contraception (LARC) Use in Adolescents. Acad Pediatr 2022; 22:296-304. [PMID: 34758402 DOI: 10.1016/j.acap.2021.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/27/2021] [Accepted: 10/31/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Long acting reversible contraceptives (LARCs) are recommended as highly effective for adolescents. Although the uptake of LARCs has increased, overall use remains low due to barriers for both providers and patients. We evaluate whether pediatric medical home transformation, including implant placement in pediatrics, may increase LARC use or decrease adolescent pregnancy rates. METHODS Retrospective interrupted time-series analysis of adolescents ages 11 to 19 years at 2 pediatric practices in academically affiliated community health centers during 2005-2015. The intervention practice underwent medical home transformation including team-based care with family planning and health coaching, youth-friendly policies, and contraceptive implant placement. The control practice continued usual care. Differential changes in population event rates were evaluated using a segmented longitudinal regression model. RESULTS The study population included 4946 adolescent females at the intervention practice and 1992 at the control practice. Following practice transformation, LARC use increased significantly more at the intervention practice compared to the control (1.73 versus 0.28 events per 1000 patients quarterly P = 0.004). Pregnancy rate declined at both practices without temporal correlation to the LARC intervention. During the medical home transformation period, the intervention practice showed a greater decline in pregnancy rate, though this difference did not reach statistical significance (2.01 versus 0.81 events per 1000 patients quarterly P = 0.090). CONCLUSIONS Adolescents had higher LARC use where implant placement was offered within the pediatric practice as part of medical home transformation. Although LARC did not impact pregnancy rate, the process of practice transformation may have accelerated its decline through heightened adolescent health focus.
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Affiliation(s)
- Katherine H Schiavoni
- Massachusetts General Hospital, Department of Pediatrics (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass; Mass General Brigham, Population Health Management (KH Schiavoni), Somerville, Mass; Harvard Medical School (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass.
| | - Jourdyn Lawrence
- Harvard T. H. Chan School of Public Heath, Department of Social and Behavioral Sciences (J Lawrence), Boston, Mass
| | - Jiayin Xue
- Massachusetts General Hospital, Department of Pediatrics (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass; Harvard Medical School (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass
| | - Milton Kotelchuck
- Massachusetts General Hospital, Department of Pediatrics (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass; Harvard Medical School (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass
| | - Alexy Arauz Boudreau
- Massachusetts General Hospital, Department of Pediatrics (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass; Harvard Medical School (KH Schiavoni, J Xue, M Kotelchuck, and AA Boudreau), Boston, Mass
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Schiavoni KH, Helscel K, Vogeli C, Thorndike AN, Camargo CA, Samuels‐Kalow ME. Prevalence of Social Risk and Social Need in a Medicaid Accountable Care Organization. Health Serv Res 2021. [DOI: 10.1111/1475-6773.13835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Katherine H. Schiavoni
- Mass General Brigham Somerville Massachusetts USA
- Massachusetts General Hospital Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
| | | | - Christine Vogeli
- Mass General Brigham Somerville Massachusetts USA
- Massachusetts General Hospital Boston Massachusetts USA
| | - Anne N. Thorndike
- Massachusetts General Hospital Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
| | - Carlos A. Camargo
- Massachusetts General Hospital Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
| | - Margaret E. Samuels‐Kalow
- Massachusetts General Hospital Boston Massachusetts USA
- Harvard Medical School Boston Massachusetts USA
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Bakshi S, Schiavoni KH, Carlson LC, Chang TE, Flaster AO, Forester BP, Kronenberg FR, Pu CT, Rowe JS, Terry DF, Wasfy JH, Bartels SJ, Sequist TD, Meyer GS, Mendu ML. The essential role of population health during and beyond COVID-19. Am J Manag Care 2021; 27:123-128. [PMID: 33720669 DOI: 10.37765/ajmc.2021.88511] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed how health care systems deliver services and revealed the tenuousness of care delivery based on face-to-face office visits and fee-for-service reimbursement models. Robust population health management, fostered by value-based contract participation, integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises. In this article, we describe how mature population health programs in a learning health system have been rapidly leveraged to address the challenges of the pandemic. Population-level data and care management have facilitated identification of demographic-based disparities and community outreach. Telemedicine and integrated behavioral health have ensured critical primary care and specialty access, and mobile health and postacute interventions have shifted site of care and optimized hospital utilization. Beyond the pandemic, population health can lead as a cornerstone of a resilient health system, better prepared to improve public health and mitigate risk in a value-based paradigm.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mallika L Mendu
- Department of Quality and Safety, Brigham and Women's Hospital, One Brigham Circle, Boston, MA 02115.
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Chien AT, Schiavoni KH, Sprecher E, Landon BE, McNeil BJ, Chernew ME, Schuster MA. How Accountable Care Organizations Responded to Pediatric Incentives in the Alternative Quality Contract. Acad Pediatr 2016; 16:200-7. [PMID: 26523636 DOI: 10.1016/j.acap.2015.10.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/15/2015] [Accepted: 10/24/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE From 2009 to 2010, 12 accountable care organizations (ACOs) entered into the alternative quality contract (AQC), BlueCross BlueShield of Massachusetts's global payment arrangement. The AQC included 6 outpatient pediatric quality measures among 64 total measures tied to pay-for-performance bonuses and incorporated pediatric populations in their global budgets. We characterized the pediatric infrastructure of these adult-oriented ACOs and obtained leaders' perspectives on their ACOs' response to pediatric incentives. METHODS We used Massachusetts Health Quality Partners and American Hospital Association Survey data to characterize ACOs' pediatric infrastructure as extremely limited, basic, and substantial on the basis of the extent of pediatric primary care, outpatient specialist, and inpatient services. After ACOs had 16 to 43 months of experience with the AQC, we interviewed 22 leaders to gain insight into how organizations made changes to improve pediatric care quality, tried to reduce pediatric spending, and addressed care for children with special health care needs. RESULTS ACOs' pediatric infrastructure ranged from extremely limited (eg, no general pediatricians in their primary care workforce) to substantial (eg, 42% of workforce was general pediatricians). Most leaders reported intensifying their pediatric quality improvement efforts and witnessing changes in quality metrics; most also investigated pediatric spending patterns but struggled to change patients' utilization patterns. All reported that the AQC did little to incentivize care for children with special health care needs and that future incentive programs should include this population. CONCLUSIONS Although ACOs involved in the AQC were adult-oriented, most augmented their pediatric quality improvement and spending reduction efforts when faced with pediatric incentives.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Katherine H Schiavoni
- Harvard Medical School, Boston, Mass; Department of Medicine and Pediatrics, Massachusetts General Hospital, Boston, Mass
| | - Eli Sprecher
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass
| | - Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Mass; Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Barbara J McNeil
- Department of Health Care Policy, Harvard Medical School, Boston, Mass; Department of Radiology, Brigham and Women's Hospital, Boston, Mass
| | - Michael E Chernew
- Department of Health Care Policy, Harvard Medical School, Boston, Mass
| | - Mark A Schuster
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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Freeman TL, Hong Y, Schiavoni KH, Indika Bandara DM, Pletneva EV. Changes in the heme ligation during folding of a Geobacter sulfurreducens sensor GSU0935. Dalton Trans 2012; 41:8022-30. [DOI: 10.1039/c2dt30166k] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Dinkova-Kostova AT, Talalay P, Sharkey J, Zhang Y, Holtzclaw WD, Wang XJ, David E, Schiavoni KH, Finlayson S, Mierke DF, Honda T. An exceptionally potent inducer of cytoprotective enzymes: elucidation of the structural features that determine inducer potency and reactivity with Keap1. J Biol Chem 2010; 285:33747-55. [PMID: 20801881 PMCID: PMC2962473 DOI: 10.1074/jbc.m110.163485] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2010] [Revised: 08/20/2010] [Indexed: 12/15/2022] Open
Abstract
The Keap1/Nrf2/ARE pathway controls a network of cytoprotective genes that defend against the damaging effects of oxidative and electrophilic stress, and inflammation. Induction of this pathway is a highly effective strategy in combating the risk of cancer and chronic degenerative diseases, including atherosclerosis and neurodegeneration. An acetylenic tricyclic bis(cyano enone) bearing two highly electrophilic Michael acceptors is an extremely potent inducer in cells and in vivo. We demonstrate spectroscopically that both cyano enone functions of the tricyclic molecule react with cysteine residues of Keap1 and activate transcription of cytoprotective genes. Novel monocyclic cyano enones, representing fragments of rings A and C of the tricyclic compound, reveal that the contribution to inducer potency of the ring C Michael acceptor is much greater than that of ring A, and that potency is further enhanced by spatial proximity of an acetylenic function. Critically, the simultaneous presence of two cyano enone functions in rings A and C within a rigid three-ring system results in exceptionally high inducer potency. Detailed understanding of the structural elements that contribute to the reactivity with the protein sensor Keap1 and to high potency of induction is essential for the development of specific and selective lead compounds as clinically relevant chemoprotective agents.
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Affiliation(s)
- Albena T. Dinkova-Kostova
- From the Biomedical Research Institute, University of Dundee, Dundee DD1 9SY, Scotland, United Kingdom
- the Lewis B. and Dorothy Cullman Chemoprotection Center and the Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, and
| | - Paul Talalay
- the Lewis B. and Dorothy Cullman Chemoprotection Center and the Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, and
| | - John Sharkey
- From the Biomedical Research Institute, University of Dundee, Dundee DD1 9SY, Scotland, United Kingdom
| | - Ying Zhang
- From the Biomedical Research Institute, University of Dundee, Dundee DD1 9SY, Scotland, United Kingdom
| | - W. David Holtzclaw
- the Lewis B. and Dorothy Cullman Chemoprotection Center and the Department of Pharmacology and Molecular Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, and
| | - Xiu Jun Wang
- From the Biomedical Research Institute, University of Dundee, Dundee DD1 9SY, Scotland, United Kingdom
| | - Emilie David
- the Department of Chemistry, Dartmouth College, Hanover, New Hampshire 03755
| | | | - Stewart Finlayson
- From the Biomedical Research Institute, University of Dundee, Dundee DD1 9SY, Scotland, United Kingdom
| | - Dale F. Mierke
- the Department of Chemistry, Dartmouth College, Hanover, New Hampshire 03755
| | - Tadashi Honda
- the Department of Chemistry, Dartmouth College, Hanover, New Hampshire 03755
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