1
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Gangavelli A, Liu Z, Wang J, Okoh A, Steinberg R, Patel K, Pandey A, Gupta DK, Dickert N, Patel SA, Morris AA. Racial differences in low natriuretic peptide levels: Implications for heart failure clinical trials. Am Heart J 2023; 265:1-10. [PMID: 37343812 PMCID: PMC10592492 DOI: 10.1016/j.ahj.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Some patients with heart failure (HF) have low natriuretic peptide (NP) levels. It is unclear whether specific populations are disproportionately excluded from participation in randomized clinical trials (RCT) with inclusion requirements for elevated NPs. We investigated factors associated with unexpectedly low NP levels in a cohort of patients hospitalized with HF, and the implications on racial diversity in a prototype HF RCT. METHODS We created a retrospective cohort of 31,704 patients (age 72 ± 16 years, 49% female, 52% Black) hospitalized with HF from 2010 to 2020 with B-type natriuretic peptide (BNP) measurements. Factors associated with unexpectedly low BNP levels (<50 pg/mL) were identified using multivariable logistic regression models. We simulated patient eligibility for a prototype HF trial using specific inclusion and exclusion criteria, and varying BNP cut-offs. RESULTS Unexpectedly low BNP levels were observed in 8.9% of the cohort. Factors associated with unexpectedly low BNP levels included HFpEF (aOR 3.76, 95% CI: 3.36, 4.20), obesity (aOR 1.96, 95% CI: 1.73, 2.21), self-identification as Black (aOR 1.53, 95% CI: 1.36, 1.71), and male gender (aOR 1.45, 95% CI: 1.31, 1.60). Applying limited clinical inclusion and exclusion criteria from PARAGLIDE-HF disproportionately excluded Black patients, with impairment in renal function having the greatest impact. Adding thresholds for BNP of ≥35, ≥50, ≥67, ≥100, and ≥150 pg/mL demonstrated the risk of exclusion was higher for Black compared to non-Black patients (RR = 2.03 [95% CI: 1.73, 2.39], 1.90 [95% CI: 1.68, 2.15], 1.63 [95% CI: 1.48, 1.81], 1.38 [95% CI: 1.28, 1.50], and 1.23 [95% CI: 1.15, 1.31], respectively). CONCLUSIONS Nearly 10% of patients hospitalized with HF have unexpectedly low BNP levels. Simulating inclusion into a prototype HFpEF RCT demonstrated that requiring increasingly elevated NP levels disproportionately excludes Black patients.
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Affiliation(s)
- Apoorva Gangavelli
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA.
| | - Zihao Liu
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA
| | - Jeffrey Wang
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Alexis Okoh
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Rebecca Steinberg
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Krishan Patel
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Deepak K Gupta
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Neal Dickert
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
| | - Shivani A Patel
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA
| | - Alanna A Morris
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA
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2
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Steinberg RS, Udeshi E, Dickert N, Quyyumi A, Chirinos JA, Morris AA. Novel Measures of Arterial Hemodynamics and Wave Reflections Associated With Clinical Outcomes in Patients With Heart Failure. J Am Heart Assoc 2023; 12:e027666. [PMID: 36927108 PMCID: PMC10111560 DOI: 10.1161/jaha.122.027666] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Background Arterial stiffness and earlier wave reflections can increase afterload and impair cardiovascular function. Most prior studies have been performed in patients with preserved left ventricular function. We describe novel measures of pulsatile arterial hemodynamics and their association with clinical outcomes in patients with heart failure with reduced ejection fraction. Methods and Results Participants with heart failure with reduced ejection fraction (n=137, median age 56 years, 49% women, 58% Black) and age-matched healthy controls (n=124) underwent measurements of large artery stiffness and pulsatile arterial hemodynamics. Carotid-femoral pulse wave velocity and augmentation index were assessed using radial applanation tonometry. Pressure-flow analyses derived reflected wave transit time, the systolic pressure-time integral imposed by proximal aortic characteristic impedance, and the pressure-time integral from wave reflection (wasted pressure effort). Cox proportional hazards models defined associations between hemodynamic measures and (1) all-cause death and (2) a combined end point of left ventricular assist device implant, heart transplant, and death, at 2 years adjusted for race, BNP (B-type natriuretic peptide), and the Meta-Analysis Global Group in Chronic Heart Failure Risk Score. Compared with controls, participants with heart failure with reduced ejection fraction exhibited similar carotid-femoral pulse wave velocity (6.8±1.6 versus 7.0±1.6 m/s, P=0.40) but higher augmentation index normalized to a heart rate of 75 bpm (13±2% versus 22±2%, P<0.001). Shorter reflected wave transit time (ie, earlier wave reflection arrival to the proximal aorta) was associated with an increased risk of death (adjusted hazard ratio [aHR] 1.67 [95% CI 1.03-1.63]) and the combined end point of death/left ventricular assist device/heart transplant (aHR, 1.61 [95% CI, 1.06-2.44]) at 2 years. Wasted pressure effort/proximal aortic characteristic impedance, representing the proportion of systolic load from wave reflection versus aortic root characteristic impedance, was univariately associated with death (hazard ratio (HR), 1.44 [95% CI, 1.05-1.97]) and with death/left ventricular assist device/heart transplant on univariate (HR, 1.42 [95% CI, 1.07-1.88]) and multivariable (aHR, 1.40 [95% CI, 1.02-1.93]) analysis. Conclusions Increased left ventricular systolic load from premature wave reflections is associated with adverse clinical outcomes in patients with heart failure with reduced ejection fraction.
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Affiliation(s)
| | - Eisha Udeshi
- Division of Cardiology Emory University Atlanta GA
| | - Neal Dickert
- Division of Cardiology Emory University Atlanta GA
| | | | - Julio A Chirinos
- Division of Cardiology University of Pennsylvania Philadelphia PA
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3
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Morain S, Kraft SA, Wilfond B, McGuire A, Dickert N, Garland A, Sugarman J. Toward Meeting the Obligation of Respect for Persons in Pragmatic Clinical Trials. Hastings Cent Rep 2022; 52:9-17. [PMID: 35763201 PMCID: PMC9704739 DOI: 10.1002/hast.1391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Research ethics oversight systems have traditionally emphasized the informed consent process as the primary means by which to demonstrate respect for prospective subjects. Yet how researchers can best fulfill the ethical obligations of respect for persons in pragmatic clinical trials (PCTs)-particularly those that may alter or waive informed consent-remains unknown. We propose eight dimensions of demonstrating respect in PCTs: (1) engaging patients and communities in research design and execution, (2) promoting transparency and open communication, (3) maximizing agency, (4) minimizing burdens and promoting accessibility, (5) protecting privacy and confidentiality, (6) valuing interpersonal interactions with clinicians and study team members, (7) providing compensation, and (8) maximizing social value. While what respect requires in the context of PCTs will vary based on the nature of the PCT in question, the breadth of these dimensions demonstrates that respect obligations extend beyond informed consent processes.
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Affiliation(s)
- Stephanie Morain
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Stephanie A. Kraft
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, WA
- University of Washington School of Medicine, Seattle, WA
| | - Benjamin Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, WA
- University of Washington School of Medicine, Seattle, WA
| | - Amy McGuire
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX
| | - Neal Dickert
- Emory University School of Medicine, Atlanta, GA
| | - Andrew Garland
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD
| | - Jeremy Sugarman
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD
- Johns Hopkins School of Medicine, Baltimore, MD
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4
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Ross-Driscoll K, Esper G, Kinlaw K, Lee YTH, Morris A, Murphy DJ, Pentz RD, Robichaux C, Vong G, Wack K, Dickert N. Evaluating Approaches to Improve Equity in Critical Care Resource Allocation in the COVID-19 Pandemic. Am J Respir Crit Care Med 2021; 204:1481-1484. [PMID: 34624203 PMCID: PMC8865705 DOI: 10.1164/rccm.202106-1462le] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Katherine Ross-Driscoll
- Emory University School of Medicine, 12239, Department of Surgery, Atlanta, Georgia, United States
| | - Gregory Esper
- Emory University School of Medicine, 12239, Department of Neurology, Atlanta, Georgia, United States.,Emory Healthcare, 14360, Office of Quality and Risk, Atlanta, Georgia, United States
| | - Kathy Kinlaw
- Emory University, 1371, Center for Ethics, Atlanta, Georgia, United States.,Emory University School of Medicine, 12239, Department of Pediatrics , Atlanta, Georgia, United States
| | - Yi-Ting Hana Lee
- Emory University School of Medicine, 12239, Health Services Research Center, Atlanta, Georgia, United States
| | - Alanna Morris
- Emory University School of Medicine, 12239, Department of Medicine, Atlanta, Georgia, United States
| | - David J Murphy
- Emory University School of Medicine, 12239, Department of Pulmonology, Allergy, and Critical Care, Atlanta, Georgia, United States
| | - Rebecca D Pentz
- Emory University, 1371, Winship Cancer Institute , Atlanta, Georgia, United States
| | - Chad Robichaux
- Emory University School of Medicine, 12239, Department of Biomedical Informatics, Atlanta, Georgia, United States.,Georgia Clinical and Translational Science Alliance, Atlanta, Georgia, United States
| | - Gerard Vong
- Emory University, 1371, Center for Ethics, Atlanta, Georgia, United States.,Emory University School of Medicine, 12239, Department of Medicine, Atlanta, Georgia, United States
| | - Kevin Wack
- Emory Healthcare, 14360, Clinical Ethics, Atlanta, Georgia, United States
| | - Neal Dickert
- Emory University School of Medicine, 12239, Division of Cardiology, Atlanta, Georgia, United States;
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5
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Thomson MC, Allen L, Halpern SD, Ko YA, Matlock D, Moore MA, Morris A, Rao B, Scherer LD, Speight C, Ubel PA, Dickert N. PREDICTORS OF LIKELIHOOD OF TAKING SACUBITRIL-VALSARTAN AND A HYPOTHETICAL MEDICATION FOR COVID-19. J Am Coll Cardiol 2021. [PMCID: PMC8091429 DOI: 10.1016/s0735-1097(21)01919-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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6
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Speight C, Allen L, Halpern S, Ko YA, Matlock D, Moore M, Morris A, Rao B, Scherer L, Thomson MC, Ubel P, Dickert N. THE EFFECT OF OUT-OF-POCKET COST DISCUSSIONS ON WILLINGNESS TO TAKE SACUBITRIL VALSARTAN FOR HEART FAILURE. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)02229-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Patel SA, Krasnow M, Long K, Shirey T, Dickert N, Morris AA. Excess 30-Day Heart Failure Readmissions and Mortality in Black Patients Increases With Neighborhood Deprivation. Circ Heart Fail 2020; 13:e007947. [PMID: 33161734 DOI: 10.1161/circheartfailure.120.007947] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [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] [Indexed: 12/19/2022]
Abstract
BACKGROUND Longstanding racial disparities in heart failure (HF) outcomes exist in the United States, in part, due to social determinants of health. We examined whether neighborhood environment modifies the disparity in 30-day HF readmissions and mortality between Black and White patients in the Southeastern United States. METHODS We created a geocoded retrospective cohort of patients hospitalized for acute HF within Emory Healthcare from 2010 to 2018. Quartiles of the Social Deprivation Index characterized neighborhood deprivation at the census tract level. We estimated the relative risk of 30-day readmission and 30-day mortality following an index hospitalization for acute HF. Excess readmissions and mortality were estimated as the absolute risk difference between Black and White patients within each Social Deprivation Index quartile, adjusted for geographic clustering, demographic, clinical, and hospital characteristics. RESULTS The cohort included 30 630 patients, mean age 66 years, 48% female, 53% Black. Compared with White patients, Black patients were more likely to reside in deprived census tracts and have higher comorbidity scores. From 2010 to 2018, 29.4% of Black and 23.0% of White patients experienced either a 30-day HF readmission or 30-day death (P<0.001). Excess in composite 30-day HF readmissions and mortality for Black patients ranged from 3.9% (95% CI, 1.5%-6.3%; P=0.0002) to 6.8% (95% CI, 4.1%-9.5%; P<0.0001) across Social Deprivation Index quartiles. Accounting for traditional risk factors did not eliminate the Black excess in combined 30-day HF readmissions or mortality in any of the neighborhood quartiles. CONCLUSIONS Excess 30-day HF readmissions and mortality are present among Black patients in every neighborhood strata and increase with progressive neighborhood socioeconomic deprivation.
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Affiliation(s)
- Shivani A Patel
- Emory Rollins School of Public Health, Atlanta, GA (S.A.P., K.L.)
| | - Maya Krasnow
- University of Chicago Pritzker School of Medicine, Chicago, IL (M.K.)
| | - Kaitlyn Long
- Emory Rollins School of Public Health, Atlanta, GA (S.A.P., K.L.)
| | - Theresa Shirey
- Department of Medicine, (T.S.), Emory University, Atlanta, GA
| | - Neal Dickert
- Division of Cardiology, (N.D., A.A.M.), Emory University, Atlanta, GA
| | - Alanna A Morris
- Division of Cardiology, (N.D., A.A.M.), Emory University, Atlanta, GA
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8
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Venechuk GE, Allen LA, Doermann Byrd K, Dickert N, Matlock DD. Conflicting Perspectives on the Value of Neprilysin Inhibition in Heart Failure Revealed During Development of a Decision Aid Focusing on Patient Costs for Sacubitril/Valsartan. Circ Cardiovasc Qual Outcomes 2020; 13:e006255. [PMID: 32814457 DOI: 10.1161/circoutcomes.119.006255] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite concerns about rising costs in health care, cost is rarely an issue discussed by patients and clinicians when making treatment decisions in a clinical setting. This study aimed to understand stakeholder perspectives on a patient decision aid (PtDA) meant to help patients with heart failure choose between a generic and relatively low-cost heart failure medication (ACE [angiotensin-converting enzyme] inhibitor or angiotensin II receptor blocker) and a newer, but more expensive, heart failure medication (angiotensin II receptor blocker neprilysin inhibitor). METHODS AND RESULTS Feedback on the PtDA was solicited from 26 stakeholders including patients, clinicians, and the manufacturer. Feedback was recorded and discussed among development team members until consensus regarding both the interpretation of the data and the appropriate changes to the PtDA was reached. Stakeholders found the PtDA sufficient in clarifying the different treatment options for heart failure. However, patients, physicians, and the manufacturer had different opinions on the importance of highlighting cost in a PtDA. Patients indicated issues of cost were crucial to the decision while physicians and manufacturers expressed that the cost issue was secondary and should be de-emphasized. CONCLUSIONS The stratified perspectives on the role of cost in medical decision-making expressed by our participants underscore the importance and challenge of having clear, frank discussions during clinic visits about treatment cost and perceived value.
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Affiliation(s)
- Grace E Venechuk
- Adult and Child Consortium for Outcomes Research and Delivery Science (G.E.V., L.A.A., D.D.M.), University of Colorado School of Medicine, Aurora.,Center for Demography of Health and Aging, University of Wisconsin-Madison (G.E.V.)
| | - Larry A Allen
- Adult and Child Consortium for Outcomes Research and Delivery Science (G.E.V., L.A.A., D.D.M.), University of Colorado School of Medicine, Aurora.,Division of Cardiology (L.A.A.), University of Colorado School of Medicine, Aurora
| | | | - Neal Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Emory Clinical Cardiovascular Research Institute, Atlanta, GA (N.D.).,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (N.D.).,Emory Center for Ethics, Atlanta, GA (N.D.)
| | - Daniel D Matlock
- Adult and Child Consortium for Outcomes Research and Delivery Science (G.E.V., L.A.A., D.D.M.), University of Colorado School of Medicine, Aurora.,Division of Geriatric Medicine (D.D.M.), University of Colorado School of Medicine, Aurora.,Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Denver (D.D.M.)
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9
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Ferket BS, Ailawadi G, Gelijns AC, Acker MA, Hohmann SF, Chang HL, Bouchard D, Meltzer DO, Michler RE, Moquete EG, Voisine P, Mullen JC, Lala A, Mack MJ, Gillinov AM, Thourani VH, Miller MA, Gammie JS, Parides MK, Bagiella E, Smith RL, Smith PK, Hung JW, Gupta LN, Rose EA, O’Gara PT, Moskowitz AJ, Taddei-Peters WC, Buxton D, Geller NL, Gordon D, Jeffries NO, Lee A, Moy CS, Gombos IK, Ralph J, Weisel RD, Gardner TJ, Ascheim DD, Moquete E, Chang H, Chase M, Foo J, Gupta L, Kirkwood K, Dobrev E, Levitan R, O’Sullivan K, Overbey J, Santos M, Williams D, Williams P, Ye X, Mack M, Adame T, Settele N, Adams J, Ryan W, Grayburn P, Chen FY, Nohria A, Cohn L, Shekar P, Aranki S, Couper G, Davidson M, Bolman RM, Lawrence R, Blackstone EH, Geither C, Berroteran L, Dolney D, Doud K, Fleming S, Palumbo R, Whitman C, Sankovic K, Sweeney DK, Pattakos G, Clarke PA, Argenziano M, Williams M, Goldsmith L, Smith CR, Naka Y, Stewart A, Schwartz A, Bell D, Van Patten D, Sreekanth S, Alexander JH, Milano CA, Glower DD, Mathew JP, Harrison JK, Welsh S, Berry MF, Parsa CJ, Tong BC, Williams JB, Ferguson TB, Kypson AP, Rodriguez E, Harris M, Akers B, O’Neal A, Puskas JD, Guyton R, Baer J, Baio K, Neill AA, Senechal M, Dagenais F, O’Connor K, Dussault G, Ballivian T, Keilani S, Speir AM, Magee P, Ad N, Keyte S, Dang M, Slaughter M, Headlee M, Moody H, Solankhi N, Birks E, Groh MA, Shell LE, Shepard SA, Trichon BH, Nanney T, Hampton LC, Mangusan R, D’Alessandro DA, DeRose JJ, Goldstein DJ, Bello R, Jakobleff W, Garcia M, Taub C, Spevak D, Swayze R, Sookraj N, Perrault LP, Basmadjian AJ, Bouchard D, Carrier M, Cartier R, Pellerin M, Tanguay JF, El-Hamamsy I, Denault A, Lacharité J, Robichaud S, Horvath KA, Corcoran PC, Siegenthaler MP, Murphy M, Iraola M, Greenberg A, Sai-Sudhakar C, Hasan A, McDavid A, Kinn B, Pagé P, Sirois C, Young CA, Beach D, Villanueva R, Woo YJ, Mayer ML, Bowdish M, Starnes VA, Shavalle D, Matthews R, Javadifar S, Romar L, Kron IL, Johnston K, Dent JM, Kern J, Keim J, Burks S, Gahring K, Bull DA, Desvigne-Nickens P, Dixon DO, Haigney M, Holubkov R, Jacobs A, Miller F, Murkin JM, Spertus J, Wechsler AS, Sellke F, McDonald CL, Byington R, Dickert N, Dixon DO, Ikonomidis JS, Williams DO, Yancy CW, Fang JC, Giannetti N, Richenbacher W, Rao V, Furie KL, Miller R, Pinney S, Roberts WC, Walsh MN, Hung J, Zeng X, Kilcullen N, Hung D, Keteyian S, Aldred H, Brawner C, Mathew J, Browndyke J, Toulgoat-Dubois Y. Cost-Effectiveness of Mitral Valve Repair Versus Replacement for Severe Ischemic Mitral Regurgitation. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.117.004466] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Bart S. Ferket
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville (G.A.)
| | - Annetine C. Gelijns
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Michael A. Acker
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia (M.A.A.)
| | | | - Helena L. Chang
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Denis Bouchard
- Montréal Heart Institute, University of Montréal, QC, Canada (D.B.)
| | | | - Robert E. Michler
- Department of Cardiovascular and Thoracic Surgery, Department of Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY (R.E.M.)
| | - Ellen G. Moquete
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Pierre Voisine
- Institut Universitaire de Cardiologie de Québec, Hôpital Laval, Canada (P.V.)
| | - John C. Mullen
- Division of Cardiac Surgery, University of Alberta, Edmonton, Canada (J.C.M.)
| | - Anuradha Lala
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Michael J. Mack
- Department of Cardiothoracic Surgery, Baylor Research Institute, Baylor Scott & White Health, Plano, TX (M.J.M., R.L.S.)
| | - A. Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, OH (A.M.G.)
| | - Vinod H. Thourani
- Clinical Research Unit, Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA and Department of Cardiac Surgery, Med-Star Heart & Vascular Institute, Washington, DC (V.H.T.)
| | - Marissa A. Miller
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (M.A.M.)
| | - James S. Gammie
- Division of Cardiac Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore (J.S.G.)
| | - Michael K. Parides
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Emilia Bagiella
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
| | - Robert L. Smith
- Department of Cardiothoracic Surgery, Baylor Research Institute, Baylor Scott & White Health, Plano, TX (M.J.M., R.L.S.)
| | - Peter K. Smith
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC (P.K.S.)
| | - Judy W. Hung
- Division of Cardiology, Massachusetts General Hospital, Boston (J.W.H.)
| | | | - Eric A. Rose
- Department of Cardiac Surgery, Mount Sinai Health System, New York, NY (E.A.R.)
| | - Patrick T. O’Gara
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (P.T.O.)
| | - Alan J. Moskowitz
- International Center for Health Outcomes and Innovation Research, the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY (B.S.F., A.C.G., H.L.C., E.G.M., A.L., M.K.P., E.B., A.J.M.)
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10
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Abstract
The shift away from paternalistic decision-making and toward patient-centered, shared decision-making has stemmed from the recognition that in order to practice medicine ethically, health care professionals must take seriously the values and preferences of their patients. At the same time, there is growing recognition that minor and seemingly irrelevant features of how choices are presented can substantially influence the decisions people make. Behavioral economists have identified striking ways in which trivial differences in the presentation of options can powerfully and predictably affect people's choices. Choice-affecting features of the decision environment that do not restrict the range of choices or significantly alter the incentives have come to be known as "nudges." Although some have criticized conscious efforts to influence choice, we believe that clinical nudges may often be morally justified. The most straightforward justification for nudge interventions is that they help people bypass their cognitive limitations-for example, the tendency to choose the first option presented even when that option is not the best for them-thereby allowing people to make choices that best align with their rational preferences or deeply held values. However, we argue that this justification is problematic. We argue that, if physicians wish to use nudges to shape their patients' choices, the justification for doing so must appeal to an ethical and professional standard, not to patients' preferences. We demonstrate how a standard with which clinicians and bioethicists already are quite familiar-the best-interest standard-offers a robust justification for the use of nudges.
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Shore S, Speight C, Kelkar A, Dickert N. Abstract 224: Why Do Patients Decline to Participate in Heart Failure Trials? Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Randomized controlled trials (RCTs) remain the gold standard in establishing clinical efficacy. However, low patient enrollment escalates costs of conducting trials and selective enrollment leads to under-representation of the real-world population. Limited data exists on why patients decline participation in RCTs and what factors may lead to increased participation rates.
Methods:
In-person and telephone interviews were conducted with 20 patients with congestive heart failure who declined participation in a RCT using a semi-structured interview guide. Questions assessed comprehension of the trial they were approached for, perceived risks and benefits, perception about the recruiter, rationale behind declining participation, and suggestions to improve participation. Qualitative descriptive analysis was conducted of transcribed responses.
Results:
Participants’ median age was 63 years (IQR 51.5-69), 50% were female, and 60% were African-American. Only 6 participants could accurately describe the intervention and understood design of the trial in which they were asked to participate. Majority of the participants (n=15) had a positive view of the recruiter who approached them. Most participants made the decision to not participate quickly while only 2 participants took extended time to deliberate. The most common reasons for not participating was due to concern for adverse events from the intervention being studied (n=15) and because participation was thought to be too burdensome (n=10). Other reasons for not participating included mistrust of research staff (n=3), concern for receiving inadequate treatment (n=3) and lack of involvement or consultation with the patient’s physician (n=3). The most common suggestion provided to increase participant recruitment was involving primary care physicians or cardiologists known to the patients. Overall, 5 decliners reported previously participating in research studies stating prior participation was less burdensome (n=2), they were previously approached by physicians known to them (n=2) or their health was better and participation seemed less risky (n=1).
Conclusion:
Slow participant enrollment in clinical trials threatens our ability to produce timely data necessary to guide clinical practice, while increasing cost of conducting them. The most common suggestion to improve participation made by patients who declined enrollment in a clinical trial was engaging physicians known to the patient in the process of recruitment while making participation less burdensome. Accordingly, educating potential participants regarding clinical trials, clarifying study risks and benefits with incorporation of design features that reduce burden such as frequency of invasive testing and follow-up visits can help increase participation rates.
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Smith G, Shore S, Mitchell A, Moore M, Morris A, Speight C, Dickert N. DISCUSSING OUT-OF-POCKET COSTS WITH PATIENTS: SHARED DECISION-MAKING FOR SACUBUTRIL-VALSARTAN IN CONGESTIVE HEART FAILURE. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)33167-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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13
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Parnia S, Spearpoint K, de Vos G, Fenwick P, Goldberg D, Yang J, Zhu J, Baker K, Killingback H, McLean P, Wood M, Zafari AM, Dickert N, Beisteiner R, Sterz F, Berger M, Warlow C, Bullock S, Lovett S, McPara RMS, Marti-Navarette S, Cushing P, Wills P, Harris K, Sutton J, Walmsley A, Deakin CD, Little P, Farber M, Greyson B, Schoenfeld ER. AWARE—AWAreness during REsuscitation—A prospective study. Resuscitation 2014; 85:1799-805. [DOI: 10.1016/j.resuscitation.2014.09.004] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 09/02/2014] [Accepted: 09/07/2014] [Indexed: 11/25/2022]
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14
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Silbergleit R, Biros MH, Harney D, Dickert N, Baren J. Implementation of the exception from informed consent regulations in a large multicenter emergency clinical trials network: the RAMPART experience. Acad Emerg Med 2012; 19:448-54. [PMID: 22506949 PMCID: PMC3335290 DOI: 10.1111/j.1553-2712.2012.01328.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Clinical trials investigating therapies for acutely and critically ill and injured patients in the earliest phases of treatment often can only be performed under regulations allowing for exception from informed consent (EFIC) for emergency research. Implementation of these regulations in multicenter clinical trials involves special challenges and opportunities. The Rapid Anticonvulsant Medication Prior to Arrival Trial (RAMPART), the first EFIC trial conducted by the Neurological Emergencies Treatment Trials (NETT) network, combined centralized resources and coordination with retention of local control and flexibility to facilitate compliance with the EFIC regulations. Specific methods used by the NETT included common tools for community consultation and public disclosure, sharing of experiences and knowledge, and reporting of aggregate results. Tracking of community consultation and public disclosure activities and feedback facilitates empirical research on EFIC methods in the network and supports quality improvements for future NETT trials. The NETT model used in RAMPART demonstrates how EFIC may be effectively performed in established clinical trial networks.
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Affiliation(s)
- Robert Silbergleit
- Department of Emergency Medicine, University of Michigan, Ann Arbor, USA.
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Abstract
An investigator planning a study in Africa of the prevalence of pulmonary hypertension in children with severe malaria anticipates that she and her team will encounter significant unmet health needs during the course of the study. She recognizes that study procedures, particularly echocardiography, may identify and diagnose conditions that are not treatable within the local health system due to resource constraints. Aware that some of these needs may be serious, as well as difficult and costly to treat, she asks the bioethics consultation service for assistance in determining the extent to which she as an investigator has a responsibility to provide clinical care for conditions that she finds while conducting the study. This article reviews the issue of investigators' responsibilities to meet participants' needs for ancillary care and argues that investigators can have a responsibility to provide care for a wide range of health needs, including at times care for conditions not connected to the research question or study procedures. That responsibility, however, is significantly limited by the depth of the investigator's relationship with participants and the resource demands of providing such care.
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Affiliation(s)
- Neal Dickert
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Dickert N, DeRiemer K, Duffy PE, Garcia-Garcia L, Mutabingwa TK, Sina BJ, Tindana P, Lie R. Ancillary-care responsibilities in observational research: two cases, two issues. Lancet 2007; 369:874-877. [PMID: 17350458 PMCID: PMC2945388 DOI: 10.1016/s0140-6736(07)60416-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- N Dickert
- Johns Hopkins University School of Medicine and Bloomberg School of Public Health, 600 North Wolfe Street, Baltimore, MD 21287, USA.
| | - K DeRiemer
- School of Medicine, University of California, Davis, CA 95616, USA
| | - P E Duffy
- Seattle Biomedical Research Institute, Seattle, WA 98109, USA
| | - L Garcia-Garcia
- Tuberculosis Unit, Instituto Nacional de Salud Pública, Cuernavaca, Morelos CP 62508, Mexico
| | - T K Mutabingwa
- London School of Hygiene and Tropical Medicine, London, UK; Muheza, Tanga, Tanzania
| | - B J Sina
- Division of International Training and Research, Fogarty International Center, National Institutes of Health, Bethesda, MD 20892, USA
| | - P Tindana
- Department of Clinical Bioethics, National Institutes of Health, Bethesda, MD 20892, USA
| | - R Lie
- Navrongo Health Research Centre, Ghana Health Service, Navrongo, Ghana
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18
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Abstract
Although the informed consent process is crucial to protecting human research subjects, there are cases when particular information within the consent form may present risks to those subjects. In this paper, we examine a case in which including the sponsor's name on the consent form may allow the form to serve as a surrogate for subjects' HIV status. There is no literature addressing the ethical acceptability of excluding particular information from consent forms, and there exists little regulatory guidance on this issue. We argue that excluding information from the consent form is, in fact, obligatory when that information is disclosed orally during the consent process but its presence on the form poses risks to the subjects the consent process is designed to protect. Further, we argue that the regulations ought to be amended to reflect this obligation.
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Affiliation(s)
- Neal Dickert
- Department of Health Policy and Management, Phoebe R. Berman Bioethics Institute, John Hopkins University Bloomberg School of Public Health, Hampton House 348, 624 N. Broadway, Baltimore, MD 21205, USA.
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Abstract
In response to the traditional emphasis on the rights, interests, and well-being of individual research subjects, there has been growing attention focused on the importance of involving communities in research development and approval. Community consultation is a particularly common method of involving communities. However, the fundamental ethical goals of community consultation have not been delineated, which makes it difficult for investigators, sponsors, and institutional review boards to design and evaluate consultation efforts. Community consultation must be tailored to the communities in which it is conducted, but the purposes of consultation-the ethical goals it is designed to achieve-should be universal. We propose 4 ethical goals that give investigators, sponsors, institutional review boards, and communities a framework for evaluating community consultation processes.
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Affiliation(s)
- Neal Dickert
- Phoebe R. Berman Bioethics Institute, Johns Hopkins University, Hampton House 351, 624 N Broadway, Baltimore, MD 21205, USA
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Grady C, Dickert N, Jawetz T, Gensler G, Emanuel E. An analysis of U.S. practices of paying research participants. Contemp Clin Trials 2005; 26:365-75. [PMID: 15911470 DOI: 10.1016/j.cct.2005.02.003] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2004] [Revised: 01/13/2005] [Accepted: 02/04/2005] [Indexed: 11/22/2022]
Abstract
BACKGROUND Despite controversy about paying research subjects, little is known about actual practices in the U.S., including what type of studies offer payment, to what type of subjects, and how amounts are determined. OBJECTIVE To document current U.S. practices regarding payment to research subjects. METHODS The protocols and consent forms of 467 studies offering payment to research subjects approved by 11 IRBs across the U.S. were reviewed to analyze how they describe and justify payment to subjects. RESULTS Money was offered in a wide variety of study types, from short term physiologic studies to large clinical trials of therapeutic interventions, to both patient (61%) and healthy (24.4%) subjects or both (14.6%). Dollar amounts varied widely and were infrequently explicitly described as based on time (19%) or procedures (12%). Unexplained variation in dollar amounts occurred in similar studies or in the same (multi-site) study at different sites, and for similar procedures across studies sometimes even within one site. Although the range was wide ($5-$2000), total amounts were usually modest (overall median $155), and almost always described in the consent form (94.4%) and usually as pro-rated (73%). CONCLUSIONS Both patient and healthy subjects are offered payment in a wide variety of types of research in the U.S. Variation in the dollar amounts offered is largely unexplained.
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Affiliation(s)
- Christine Grady
- Department of Clinical Bioethics, W.G. Magnuson Clinical Center, National Institutes of Health, Bethesda MD 20892-1156, United States.
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Abstract
BACKGROUND Few data are available on guidelines used by research organizations to make decisions about paying subjects. OBJECTIVE To analyze existing guidance regarding payment of research subjects and to identify common characteristics and areas for further research. DESIGN Descriptive content analysis of policies. MEASUREMENTS Written policies and rules of thumb about paying subjects from 32 U.S. research organizations. RESULTS Of 32 organizations, 37.5% had written guidelines about paying subjects; all but 1 reported having rules of thumb. Few (18.8%) were able to provide a confident estimate of the proportion of studies that pay subjects. Organizations reported that investigators and institutional review boards make payment decisions and that both healthy and ill subjects in some studies are paid for their time (87%), for inconvenience (84%), for travel (68%), as incentive (58%), or for incurring risk (32%). Most organizations require that payment be prorated (84%) and described in the consent document (94%). CONCLUSIONS Most organizations pay some research subjects, but few have written policies on payment. Because investigators and institutional review boards make payment decisions with little specific guidance, standards vary.
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Affiliation(s)
- Neal Dickert
- W.G. Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland 20892-1156, USA
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22
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Abstract
CONTEXT Understanding the consent process that organ procurement organizations (OPOs) use is crucial to improving the process and thereby reducing the number of individuals who die each year for want of an organ transplant. However, no data exist on OPOs' current consent practices. OBJECTIVE To assess whose wishes OPOs follow when procuring solid organs from deceased individuals and whether advance directives and computerized registries might improve the consent process for solid organ procurement. DESIGN, SETTING, AND PARTICIPANTS Telephone survey conducted from June to August 1999 of all 61 active OPOs. MAIN OUTCOME MEASURES Responses to the 49-question survey addressing consent practices in specific scenarios of deceased and next of kin wishes. RESULTS Widespread divergence exists in OPOs' consent practices for cadaveric solid organ procurement. Regarding overall consent practices, 19 (31%) OPOs reported that they follow the deceased's wishes, 19 (31%) follow the next of kin's wishes, 13 (21%) procure organs if neither party objects, 8 (13%) procure organs if either party consents or neither objects, and 2 (3%) do not follow any of these 4 overall practices. These differences appear to be traceable to implicit ethical disagreements about whose wishes should be followed. A total of 29 (48%) OPOs reported having an official policy to address whether they follow the family's or deceased's wishes. Regarding factors that influence OPOs' choice of consent practice, 29 (48%) respondents ranked impact on the deceased's family as the most important factor, 13 (21%) ranked state law as most important, and 7 (11%) ranked the priority of the deceased's wishes as most important. Durable power of attorney appeared to have substantial weight in OPOs' decisions; for example, in the scenario in which the deceased supported organ donation and the next of kin opposed it, 34 (56%) OPOs reported they were likely to procure organs based on the consent of the holder of the deceased's durable power of attorney, whereas only 7 (11%) reported they were likely to procure organs based on a document of gift (a living will, donor card, or driver's license). CONCLUSIONS Expanding the legal scope of living wills to cover individuals' organ donation preferences would likely have little impact on procurement rates. In contrast, expanding the legal scope of durable powers of attorney for health care may have a significant impact. A national discussion should take place addressing the underlying ethical issues that appear to account for much of the divergence among OPOs' consent practices for cadaveric solid organ procurement.
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Affiliation(s)
- D Wendler
- Department of Clinical Bioethics, Bldg 10, Room 1C118, National Institutes of Health, Bethesda, MD 20892, USA.
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23
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Affiliation(s)
- N Dickert
- National Institutes of Health, Bethesda, MD 20892, USA
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