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Cook J, de Virgilio C, Purdy A, Poola VP, Tolles J, Smith B, Simms E, Calhoun KE, Jarman B, Salcedo ES, Frey E, Wu E, Agopian V, Cryer C, Fleischman R, Dickinson KJ, Roy M, Han A, Amersi F. Association of Residency Applicants' Hobbies and Subsequent Technical Proficiency Ratings as General Surgery Chief Residents: A Multi-Institutional Study. J Surg Educ 2024; 81:339-343. [PMID: 38302298 DOI: 10.1016/j.jsurg.2023.11.021] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/25/2023] [Accepted: 11/26/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE To determine whether participation in certain hobbies (e.g., participation in sports, playing musical instruments, or other hobbies requiring fine motor skills), preresidency, are associated with higher technical skills ratings at the time of residency graduation. DESIGN Faculty members from 14 general surgery residency programs scored individual graduates from 2017 to 2020 on their technical skills using a 5-point Likert scale. Hobbies for these residents were collected from their Electronic Residency Application Service (ERAS) data. A single reviewer classified each ERAS hobby into predefined categories including musical instruments, sports requiring hand-eye coordination, team sports, and activities necessitating hand-eye coordination. Spearman correlation coefficients were calculated for the relationship between each category of hobby-as well as the total number of hobbies in each category-and the outcome of surgical faculty ratings of residents' technical surgical skills during their last year of residency. A proportional odds model including the above predictive variables was also fit to the data. SETTING Fourteen general surgery residency programs. PARTICIPANTS General surgery residency graduates from 14 different programs from 2017 to 2020. RESULTS There were 296 residents across 14 institutions. The average ranking of residents' technical skills was 3.24 (SD 1.1). A total of 40% of residents played sports involving hand-eye coordination, 31% played team sports, 28% participated in nonsport hobbies that require eye-hand coordination, and 20% played musical instruments. Correlation coefficients were not statistically significant for any of the categories. In the proportional odds model, none of the variables were associated with statistically significant increased odds of a higher technical skills rating. CONCLUSIONS There was no correlation between general surgery chief residents' technical skills as rated by faculty, and self-reported pre-residency hobbies on the ERAS application. These findings suggest such hobbies prior to residency are unlikely to predict future technical skills prowess.
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Affiliation(s)
- James Cook
- Department of Surgery, Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Christian de Virgilio
- Department of Surgery, Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Amanda Purdy
- Department of Surgery, Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - V Prasad Poola
- Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois
| | - Juliana Tolles
- Department of Surgery, Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Brian Smith
- Department of Surgery, Irvine Medical Center, University of California, Orange, California
| | - Eric Simms
- Department of Surgery, Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Kristine E Calhoun
- Department of Surgery, University of Washington Medical Center, Seattle, Washington
| | - Benjamin Jarman
- Department of Surgery, Gunderson Medical Foundation, La Crosse, Wisconsin
| | - Edgardo S Salcedo
- Department of Surgery, School of Medicine, University of California, Sacramento, California
| | - Edgar Frey
- Department of Surgery, Brookwood Baptist Medical Center, Birmingham, Alabama
| | - Esther Wu
- Department of Surgery, Loma Linda University, Loma Linda, California
| | - Vatche Agopian
- Department of Surgery, University of California, Los Angeles, California
| | - Chad Cryer
- Department of Surgery, University of Hawaii at Manoa, Honolulu, Hawaii
| | - Ross Fleischman
- Department of Surgery, Harbor-University of California, Los Angeles Medical Center, Torrance, California
| | - Karen J Dickinson
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mayank Roy
- Department of Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Amy Han
- Department of Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Farin Amersi
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.
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Serrano E, Voldal EC, Machado-Aranda D, DeUgarte DA, Kao L, Drake T, Winchell R, Cuschieri J, Krishnadasan A, Talan DA, Siparsky N, Ayoung-Chee P, Self WH, McGonagill P, Mandell KA, Liang MK, Dodwad SJ, Thompson CM, Padilla RM, Fleischman R, Price TP, Jones A, Bernardi K, Garcia L, Evans HL, Sanchez SE, Odom S, Comstock BA, Heagerty PJ, Lawrence SO, Monsell SE, Fannon EE, Kessler LG, Flum DR, Davidson GH. Trial Participation and Outcomes Among English-Speaking and Spanish-Speaking Patients With Appendicitis Randomized to Antibiotics: A Secondary Analysis of the CODA Randomized Clinical Trial. JAMA Surg 2023; 158:901-908. [PMID: 37379001 PMCID: PMC10308294 DOI: 10.1001/jamasurg.2023.2277] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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] [Received: 12/20/2022] [Accepted: 03/28/2023] [Indexed: 06/29/2023]
Abstract
Importance Spanish-speaking participants are underrepresented in clinical trials, limiting study generalizability and contributing to ongoing health inequity. The Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial intentionally included Spanish-speaking participants. Objective To describe trial participation and compare clinical and patient-reported outcomes among Spanish-speaking and English-speaking participants with acute appendicitis randomized to antibiotics. Design, Setting, and Participants This study is a secondary analysis of the CODA trial, a pragmatic randomized trial comparing antibiotic therapy with appendectomy in adult patients with imaging-confirmed appendicitis enrolled at 25 centers across the US from May 1, 2016, to February 28, 2020. The trial was conducted in English and Spanish. All 776 participants randomized to antibiotics are included in this analysis. The data were analyzed from November 15, 2021, through August 24, 2022. Intervention Randomization to a 10-day course of antibiotics or appendectomy. Main Outcomes and Measures Trial participation, European Quality of Life-5 Dimensions (EQ-5D) questionnaire scores (higher scores indicating a better health status), rate of appendectomy, treatment satisfaction, decisional regret, and days of work missed. Outcomes are also reported for a subset of participants that were recruited from the 5 sites with a large proportion of Spanish-speaking participants. Results Among eligible patients 476 of 1050 Spanish speakers (45%) and 1076 of 3982 of English speakers (27%) consented, comprising the 1552 participants who underwent 1:1 randomization (mean age, 38.0 years; 976 male [63%]). Of the 776 participants randomized to antibiotics, 238 were Spanish speaking (31%). Among Spanish speakers randomized to antibiotics, the rate of appendectomy was 22% (95% CI, 17%-28%) at 30 days and 45% (95% CI, 38%-52%) at 1 year, while in English speakers, these rates were 20% (95% CI, 16%-23%) at 30 days and 42% (95% CI 38%-47%) at 1 year. Mean EQ-5D scores were 0.93 (95% CI, 0.92-0.95) among Spanish speakers and 0.92 (95% CI, 0.91-0.93) among English speakers. Symptom resolution at 30 days was reported by 68% (95% CI, 61%-74%) of Spanish speakers and 69% (95% CI, 64%-73%) of English speakers. Spanish speakers missed 6.69 (95% CI, 5.51-7.87) days of work on average, while English speakers missed 3.76 (95% CI, 3.20-4.32) days. Presentation to the emergency department or urgent care, hospitalization, treatment dissatisfaction, and decisional regret were low for both groups. Conclusions and Relevance A high proportion of Spanish speakers participated in the CODA trial. Clinical and most patient-reported outcomes were similar for English- and Spanish-speaking participants treated with antibiotics. Spanish speakers reported more days of missed work. Trial Registration ClinicalTrials.gov Identifier: NCT02800785.
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Affiliation(s)
- Elina Serrano
- University of Washington, Seattle
- Fred Hutch Cancer Center, Seattle, Washington
| | - Emily C. Voldal
- University of Washington, Seattle
- Fred Hutch Cancer Center, Seattle, Washington
| | | | | | - Lillian Kao
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
| | | | | | - Joseph Cuschieri
- Harborview Medical Center, UW Medicine, Seattle, Washington
- University of California, San Francisco, San Francisco
| | | | - David A. Talan
- Olive View–UCLA Medical Center, Los Angeles, California
- Ronald Reagan UCLA Medical Center, Los Angeles, California
| | | | - Patricia Ayoung-Chee
- Bellevue Hospital Center, NYU School of Medicine, New York, New York
- Tisch Hospital, NYU Langone Medical Center, New York, New York
- Morehouse School of Medicine, Atlanta GA
| | - Wesley H. Self
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | - Mike K. Liang
- Lyndon B. Johnson General Hospital, University of Texas, Houston
- University of Houston, HCA Healthcare, Kingwood, Kingwood, Texas
| | - Shan-Jahan Dodwad
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
| | - Callie M. Thompson
- Vanderbilt University Medical Center, Nashville, Tennessee
- University of Utah, Salt Lake City
| | | | | | | | - Alan Jones
- The University of Mississippi Medical Center, Jackson
| | - Karla Bernardi
- Lyndon B. Johnson General Hospital, University of Texas, Houston
| | - Luis Garcia
- University of Iowa Hospitals and Clinics, Iowa City
| | - Heather L. Evans
- Harborview Medical Center, UW Medicine, Seattle, Washington
- The Medical University of South Carolina, Charleston
| | | | - Stephen Odom
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
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DeUgarte DA, Fleischman R, Mccollough M, Ault G, Rolfe K, de Virgilio C. Assessment of an Opioid Stewardship Program on Perioperative Opioid Prescribing in a Safety-Net Health System. JAMA Surg 2023; 158:318-319. [PMID: 36515920 PMCID: PMC9856683 DOI: 10.1001/jamasurg.2022.4499] [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] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This quality improvement study involves comparison of opioid prescription data before and after implementation of an opioid stewardship program in a safety-net medical system.
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Affiliation(s)
- Daniel A DeUgarte
- Harbor Medical Center, University of California, Los Angeles (UCLA), Torrance
| | - Ross Fleischman
- Harbor Medical Center, University of California, Los Angeles (UCLA), Torrance
| | | | - Glenn Ault
- Los Angeles County-University of South California (LAC-USC) Medical Center, Los Angeles
| | - Kevin Rolfe
- Harbor Medical Center, University of California, Los Angeles (UCLA), Torrance.,Rancho Los Amigos Medical Center, Downey, California
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Abouzeid M, Alam HB, Arif H, Ballman K, Bennion R, Bernardi K, Burris D, Carter D, Chee P, Chen F, Chung B, Clark S, Cooper R, Cuschieri J, Deeney K, Dhanani N, Diflo T, Drake FT, Fairfield C, Farjah F, Ferrigno L, Fischkoff K, Fleischman R, Foster C, Gerry T, Gibbons M, Guiden M, Haas N, Hayes LA, Hayward A, Hennessey L, Hernandez M, Horvath KF, Howell EC, Hsu C, Johnson J, Johnsson B, Kim D, Kim D, Ko TC, Lavallee DC, Lew D, Mack J, MacKenzie D, Maggi J, Marquez S, Martinez R, McGrane K, Melis M, Miller K, Mireles D, Moran GJ, Morgan D, Morris A, Moser KM, Mount L, O'Connor K, Odom SR, Olavarria O, Olbrich N, Osborn S, Owens O, Park P, Parr Z, Parsons CS, Pathmarajah K, Patki D, Patton JH, Peacock RK, Pierce K, Pullar K, Putnam B, Rushing A, Sabbatini A, Saltzman D, Salzberg M, Schaetzel S, Schmidt PJ, Shah P, Shapiro NI, Sinha P, Skeete D, Skopin E, Sohn V, Spence LH, Steinberg S, Tichter A, Tschirhart J, Tudor B, Uribe L, VanDusen H, Wallick J, Weiss M, Wells S, Wiebusch A, Williams EJ, Winchell RJ, Wisler J, Wolfe B, Wolff E, Yealy DM, Yu J, Zhang IY, Voldal EC, Davidson GH, Liao JM, Thompson CM, Self WH, Kao LS, Cherry-Bukowiec J, Raghavendran K, Kaji AH, DeUgarte DA, Gonzalez E, Mandell KA, Ohe K, Siparsky N, Price TP, Evans DC, Victory J, Chiang W, Jones A, Kutcher ME, Ciomperlik H, Liang MK, Evans HL, Faine BA, Neufeld M, Sanchez SE, Krishnadasan A, Comstock BA, Heagerty PJ, Lawrence SO, Monsell SE, Fannon EEC, Kessler LG, Talan DA, Flum DR. Association of Patient Belief About Success of Antibiotics for Appendicitis and Outcomes: A Secondary Analysis of the CODA Randomized Clinical Trial. JAMA Surg 2022; 157:1080-1087. [PMID: 36197656 PMCID: PMC9535504 DOI: 10.1001/jamasurg.2022.4765] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Importance A patient's belief in the likely success of a treatment may influence outcomes, but this has been understudied in surgical trials. Objective To examine the association between patients' baseline beliefs about the likelihood of treatment success with outcomes of antibiotics for appendicitis in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial. Design, Setting, and Participants This was a secondary analysis of the CODA randomized clinical trial. Participants from 25 US medical centers were enrolled between May 3, 2016, and February 5, 2020. Included in the analysis were participants with appendicitis who were randomly assigned to receive antibiotics in the CODA trial. After informed consent but before randomization, participants who were assigned to receive antibiotics responded to a baseline survey including a question about how successful they believed antibiotics could be in treating their appendicitis. Interventions Participants were categorized based on baseline survey responses into 1 of 3 belief groups: unsuccessful/unsure, intermediate, and completely successful. Main Outcomes and Measures Three outcomes were assigned at 30 days: (1) appendectomy, (2) high decisional regret or dissatisfaction with treatment, and (3) persistent signs and symptoms (abdominal pain, tenderness, fever, or chills). Outcomes were compared across groups using adjusted risk differences (aRDs), with propensity score adjustment for sociodemographic and clinical factors. Results Of the 776 study participants who were assigned antibiotic treatment in CODA, a total of 425 (mean [SD] age, 38.5 [13.6] years; 277 male [65%]) completed the baseline belief survey before knowing their treatment assignment. Baseline beliefs were as follows: 22% of participants (92 of 415) had an unsuccessful/unsure response, 51% (212 of 415) had an intermediate response, and 27% (111 of 415) had a completely successful response. Compared with the unsuccessful/unsure group, those who believed antibiotics could be completely successful had a 13-percentage point lower risk of appendectomy (aRD, -13.49; 95% CI, -24.57 to -2.40). The aRD between those with intermediate vs unsuccessful/unsure beliefs was -5.68 (95% CI, -16.57 to 5.20). Compared with the unsuccessful/unsure group, those with intermediate beliefs had a lower risk of persistent signs and symptoms (aRD, -15.72; 95% CI, -29.71 to -1.72), with directionally similar results for the completely successful group (aRD, -15.14; 95% CI, -30.56 to 0.28). Conclusions and Relevance Positive patient beliefs about the likely success of antibiotics for appendicitis were associated with a lower risk of appendectomy and with resolution of signs and symptoms by 30 days. Pathways relating beliefs to outcomes and the potential modifiability of beliefs to improve outcomes merit further investigation. Trial Registration ClinicalTrials.gov Identifier: NCT02800785.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Cindy Hsu
- Writing Group for the CODA Collaborative
| | | | | | - Dennis Kim
- Writing Group for the CODA Collaborative
| | - Daniel Kim
- Writing Group for the CODA Collaborative
| | - Tien C. Ko
- Writing Group for the CODA Collaborative
| | | | - Debbie Lew
- Writing Group for the CODA Collaborative
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Olga Owens
- Writing Group for the CODA Collaborative
| | | | - Zoe Parr
- Writing Group for the CODA Collaborative
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Vance Sohn
- Writing Group for the CODA Collaborative
| | | | | | | | | | | | | | | | | | | | - Sean Wells
- Writing Group for the CODA Collaborative
| | | | | | | | - Jon Wisler
- Writing Group for the CODA Collaborative
| | | | | | | | | | - Irene Y. Zhang
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Emily C. Voldal
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Giana H. Davidson
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Joshua M. Liao
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Callie M. Thompson
- Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Surgery, University of Utah, Salt Lake City
| | - Wesley H. Self
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lillian S. Kao
- McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
| | | | | | - Amy H. Kaji
- Harbor–UCLA Medical Center, West Carson, California
| | | | - Eva Gonzalez
- Harbor–UCLA Medical Center, West Carson, California
| | | | - Kristen Ohe
- The Swedish Medical Center, Seattle, Washington
| | | | | | - David C. Evans
- The Ohio State University Wexner Medical Center, Columbus
| | - Jesse Victory
- Bellevue Hospital Center, NYU School of Medicine, New York, New York
| | - William Chiang
- Tisch Hospital, NYU Langone Medical Center, New York, New York
| | - Alan Jones
- The University of Mississippi Medical Center, Jackson
| | | | | | - Mike K. Liang
- Lyndon B. Johnson General Hospital, University of Texas, Houston
- HCA Healthcare, University of Houston, Kingwood, Kingwood, Texas
| | - Heather L. Evans
- Harborview Medical Center, UW Medicine, Seattle, Washington
- The Medical University of South Carolina, Charleston
| | | | | | | | | | - Bryan A. Comstock
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Patrick J. Heagerty
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Sarah O. Lawrence
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Sarah E. Monsell
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Erin E. C. Fannon
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - Larry G. Kessler
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
| | - David A. Talan
- Olive View–UCLA Medical Center, Los Angeles, California
- Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - David R. Flum
- Department of Surgery, Surgical Outcomes Research Center, University of Washington, Seattle
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Yadav K, Meeker D, Mistry R, Doctor J, Fleming-Dutra K, Fleischman R, Gaona S, Stahmer A, May L. 1633. A Multifaceted Intervention to Improve Prescribing for Acute Respiratory Infection in Adults and Children in Emergency Department and Urgent Care Settings (MITIGATE Trial). Open Forum Infect Dis 2018. [PMCID: PMC6252972 DOI: 10.1093/ofid/ofy209.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Antibiotics are prescribed in approximately half of emergency department (ED) and urgent care center (UCC) visits for antibiotic inappropriate or presumed viral acute respiratory infection (ARI). Unnecessary antibiotic use increases adverse events, antibiotic resistance, and healthcare costs. Antibiotic stewardship in the ED and UCC requires specific implementation tailored to these unique settings. Objective. To evaluate the comparative effectiveness of patient and provider education adapted for the acute care setting (adapted intervention) to an intervention with behavioral nudges and individual peer comparisons (enhanced intervention), on reducing inappropriate antibiotic use for ARI in EDs and UCCs. Methods Pragmatic, cluster randomized clinical trial conducted in 3 academic health systems (1 pediatric-only, 2 serving adults and children) that included 5 adult and pediatric EDs and 4 UCCs. Sites were block randomized by health system, and providers at each site assigned to receive the adapted or enhanced intervention. Implementation science strategies were employed to tailor interventions at each site. The main outcome was the proportion of antibiotic inappropriate ARI diagnosis visits that received an antibiotic. We estimated a hierarchical mixed effects logistic regression model for visits that occurred between November and February for 2016–2017 (baseline) and 2017–2018 (intervention), controlling for organization and provider fixed effects. Results Across all sites, there were 45,160 ARI visits among 534 providers, with overall antibiotic prescribing at 2.6%; the pediatric-only system had a lower baseline rate (1.6%) compared with the other 2 systems (5.0% and 7.1%), P < 0.001). Despite the unusually low rate, we found a significant reduction in inappropriate prescribing after adjusting for health-system and provider-level effects from 2.6% to 1.4 % (odds ratio 0.52; 0.38–0.72). Reductions in prescribing between the 2 interventions were in the expected direction, but not significantly different (P < 0.062). Conclusion Implementation of antimicrobial stewardship for ARI is feasible and effective in the ED and UCC settings. The enhanced behavioral nudging methods were not more effective in high-performance settings. Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | | | | | - Jason Doctor
- University of Southern California, Los Angeles, California
| | | | | | - Samuel Gaona
- University of California-Davis, Sacramento, California
| | - Aubyn Stahmer
- University of California-Davis, Sacramento, California
| | - Larissa May
- University of California-Davis, Sacramento, California
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Carpenter J, Lumanauw D, Arndt J, Fleischman R, Kazzi Z, Tanen D. 385 Ethanol Metabolism in a Group of Experienced Users. Ann Emerg Med 2018. [DOI: 10.1016/j.annemergmed.2018.08.390] [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] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Douglass A, Yip K, Tanen D, Fleischman R, Lumanauw D, Jordan J. 174 Resident Clinical Experience in the Emergency Department: Patient Encounters by Post Graduate Year. Ann Emerg Med 2017. [DOI: 10.1016/j.annemergmed.2017.07.201] [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] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shrestha R, Nee J, Durbin E, Zia M, Ramlal R, Monohan G, Herzig R, Fleischman R, Hildebrandt G, Saeed H. Chemotherapy and radiation improve survival in early stage classical Hodgkin lymphoma: A statewide cancer registry analysis. Hematol Oncol 2017. [DOI: 10.1002/hon.2439_55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- R. Shrestha
- Internal Medicine-Division of Hematology and BMT; University of Kentucky; Lexington KY USA
| | - J. Nee
- Markey Cancer Control Program; Kentucky Cancer Registry; Lexington KY USA
| | - E.B. Durbin
- Markey Cancer Control Program; Kentucky Cancer Registry; Lexington KY USA
| | - M. Zia
- Internal Medicine-Division of Hematology and BMT; University of Kentucky; Lexington KY USA
| | - R. Ramlal
- Internal Medicine-Division of Hematology and BMT; University of Kentucky; Lexington KY USA
| | - G. Monohan
- Internal Medicine-Division of Hematology and BMT; University of Kentucky; Lexington KY USA
| | - R.H. Herzig
- Internal Medicine-Division of Hematology and BMT; University of Kentucky; Lexington KY USA
| | - R. Fleischman
- Internal Medicine-Division of Hematology and BMT; University of Kentucky; Lexington KY USA
| | - G. Hildebrandt
- Internal Medicine-Division of Hematology and BMT; University of Kentucky; Lexington KY USA
| | - H. Saeed
- Internal Medicine-Division of Hematology and BMT; University of Kentucky; Lexington KY USA
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Newgard CD, Staudenmayer K, Hsia RY, Mann NC, Bulger EM, Holmes JF, Fleischman R, Gorman K, Haukoos J, McConnell KJ. The cost of overtriage: more than one-third of low-risk injured patients were taken to major trauma centers. Health Aff (Millwood) 2014; 32:1591-9. [PMID: 24019364 DOI: 10.1377/hlthaff.2012.1142] [Citation(s) in RCA: 134] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Regionalized trauma care has been widely implemented in the United States, with field triage by emergency medical services (EMS) playing an important role in identifying seriously injured patients for transport to major trauma centers. In this study we estimated hospital-level differences in the adjusted cost of acute care for injured patients transported by 94 EMS agencies to 122 hospitals in 7 regions, overall and by injury severity. Among 301,214 patients, the average adjusted per episode cost of care was $5,590 higher in a level 1 trauma center than in a nontrauma hospital. We found hospital-level differences in cost among patients with minor, moderate, and serious injuries. Of the 248,342 low-risk patients-those who did not meet field triage guidelines for transport to trauma centers-85,155 (34.3 percent) were still transported to major trauma centers, accounting for up to 40 percent of acute injury costs. Adhering to field triage guidelines that minimize the overtriage of low-risk injured patients to major trauma centers could save up to $136.7 million annually in the seven regions we studied.
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Newgard CD, Hsia RY, Mann CN, Schmidt T, Sahni R, Bulger EM, Wang EN, Holmes JF, Fleischman R, Zive D, Staudenmayer K, Haukoos JS, Kuppermann N. The trade-offs in field trauma triage: A multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies. J Trauma Acute Care Surg 2013. [DOI: 10.1097/01586154-201305000-00017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Newgard CD, Hsia RY, Mann NC, Schmidt T, Sahni R, Bulger EM, Wang NE, Holmes JF, Fleischman R, Zive D, Staudenmayer K, Haukoos JS, Kuppermann N. The trade-offs in field trauma triage: a multiregion assessment of accuracy metrics and volume shifts associated with different triage strategies. J Trauma Acute Care Surg 2013; 74:1298-306; discussion 1306. [PMID: 23609282 PMCID: PMC3726266 DOI: 10.1097/ta.0b013e31828b7848] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND National benchmarks for trauma triage sensitivity (≥95%) and specificity (≥50%) have not been rigorously evaluated across broad populations of injured patients. We evaluated the impact of different field triage schemes for identifying seriously injured patients across a range of sensitivity values. Impact metrics included specificity and number of undertriaged and overtriaged patients compared with current triage practices. METHODS This was a retrospective cohort study of injured children and adults transported by 48 emergency medical service (EMS) agencies to 105 hospitals in 6 regions of the Western United States from 2006 through 2008. Hospital outcomes were probabilistically linked to EMS records through trauma registries, state discharge databases, and state emergency department databases. The primary outcome was an Injury Severity Score (ISS) of 16 or greater. We evaluated 40 field predictor variables, including 31 current field triage criteria, using classification and regression tree analysis and cross-validation to generate estimates for sensitivity and specificity. RESULTS A total of 89,261 injured patients were evaluated and transported by EMS providers during the 3-year period, of whom 5,711 (6.4%) had ISS of 16 or greater. As the 95% sensitivity target for triage was approached (from the current value of 87.5%), decision tree complexity increased, specificity decreased (from 62.8% to 18.7%), and the number of triage-positive patients without serious injury doubled (67,927 vs. 31,104). Analyses restricted to children and older adults were similar. The most consistent modification to the current triage algorithm to increase sensitivity without a major decrease in specificity was altering the Glasgow Coma Scale (GCS) score cutoff point from 13 or less to 14 or less (sensitivity increase to 90.4%). CONCLUSION Reaching the field triage sensitivity benchmark of 95% would require a large decrease in specificity (increase in overtriage). A 90% sensitivity target seems more realistic and may be obtainable by modest changes to the current triage algorithm.
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Affiliation(s)
- Craig D. Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California San Francisco, San Francisco General Hospital, San Francisco, California
| | - N. Clay Mann
- Intermountain Injury Control Research Center, University of Utah, Salt Lake City, Utah
| | - Terri Schmidt
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
- Clackamas County American Medical Response, Clackamas, Oregon
| | - Ritu Sahni
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
- Lake Oswego Fire Department, Lake Oswego, Oregon
| | - Eileen M. Bulger
- Department of Surgery, University of Washington, Seattle, Washington
| | - N. Ewen Wang
- Department of Emergency Medicine, Stanford University, Palo Alto, California
| | - James F. Holmes
- Department of Emergency Medicine, University of California at Davis, Sacramento, California
| | - Ross Fleischman
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | - Dana Zive
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Jason S. Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado, Department of Epidemiology, Colorado School of Public Health, University of Colorado School of Medicine, Aurora, Colorado
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California at Davis, Sacramento, California
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Hansen M, Fleischman R, Meckler G, Newgard CD. The association between hospital type and mortality among critically ill children in US EDs. Resuscitation 2012; 84:488-91. [PMID: 22902464 DOI: 10.1016/j.resuscitation.2012.07.032] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2012] [Revised: 07/12/2012] [Accepted: 07/23/2012] [Indexed: 11/25/2022]
Abstract
STUDY AIM Little is known about the setting of care for critically ill children and whether differences in outcomes are related to the presenting hospital type. This study describes the characteristics of hospitals to which critically ill children present and explores the associations between hospital factors and mortality. METHODS This is a retrospective cohort study using data from the 2007 Healthcare Cost and Utilization Project National Emergency Department Sample, representative of all US ED visits. Subjects include children aged 0-18 with ICD9 codes for cardiac arrest, respiratory arrest and/or respiratory failure. Predictor variables include: age, sex, presence of chronic illness, self-pay, public insurance, trauma diagnosis, major trauma center, urban hospital, ED volume and teaching hospital. Multivariate logistic regression estimates predictors of mortality. Analyses integrate clusters, strata, and weights from the probability sample. RESULTS There were an estimated 29 million pediatric ED visits in 2007 including 42,036 (0.1%) visits for cardiac or respiratory failure. Teaching hospitals (OR 0.57, 95% CI 0.50-0.66), trauma centers (OR 0.76, 95% CI 0.67-0.86), and urban hospitals (OR 0.78, 95% CI 0.63-0.97) were associated with lower mortality odds. Presence of a chronic illness (OR 14.5, 95% CI 10.5-20.1), diagnosis of an injury (OR 1.2, 95% CI 1.1-1.4) and self-pay status (OR 3.6, 95% CI 2.9-4.4) were associated with increased mortality odds. CONCLUSIONS The majority of children with cardiac and respiratory arrest present to urban teaching hospitals and trauma centers. After accounting for important confounders, mortality is lower at teaching hospitals and/or major trauma centers.
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Affiliation(s)
- Matthew Hansen
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA.
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Newgard CD, Zive D, Holmes JF, Bulger EM, Staudenmayer K, Liao M, Rea T, Hsia RY, Wang NE, Fleischman R, Jui J, Mann NC, Haukoos JS, Sporer KA, Gubler KD, Hedges JR. A multisite assessment of the American College of Surgeons Committee on Trauma field triage decision scheme for identifying seriously injured children and adults. J Am Coll Surg 2012; 213:709-21. [PMID: 22107917 DOI: 10.1016/j.jamcollsurg.2011.09.012] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [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] [Received: 04/25/2011] [Revised: 09/06/2011] [Accepted: 09/06/2011] [Indexed: 12/19/2022]
Abstract
BACKGROUND The American College of Surgeons Committee on Trauma (ACSCOT) has developed and updated field trauma triage protocols for decades, yet the ability to identify major trauma patients remains unclear. We estimate the diagnostic value of the Field Triage Decision Scheme for identifying major trauma patients (Injury Severity Score [ISS] ≥ 16) in a large and diverse multisite cohort. STUDY DESIGN This was a retrospective cohort study of injured children and adults transported by 94 emergency medical services (EMS) agencies to 122 hospitals in 7 regions of the Western US from 2006 through 2008. Patients who met any of the field trauma triage criteria (per EMS personnel) were considered triage positive. Hospital outcomes measures were probabilistically linked to EMS records through trauma registries, state discharge data, and emergency department data. The primary outcome defining a "major trauma patient" was ISS ≥ 16. RESULTS There were 122,345 injured patients evaluated and transported by EMS over the 3-year period, 34.5% of whom met at least 1 triage criterion and 5.8% had ISS ≥ 16. The overall sensitivity and specificity of the criteria for identifying major trauma patients were 85.8% (95% CI 85.0% to 86.6%) and 68.7% (95% CI 68.4% to 68.9%), respectively. Triage sensitivity and specificity, respectively, differed by age: 84.1% and 66.4% (0 to 17 years); 89.5% and 64.3% (18 to 54 years); and 79.9% and 75.4% (≥55 years). Evaluating the diagnostic value of triage by hospital destination (transport to Level I/II trauma centers) did not substantially improve these findings. CONCLUSIONS The sensitivity of the Field Triage Decision Scheme for identifying major trauma patients is lower and specificity higher than previously described, particularly among elders.
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Affiliation(s)
- Craig D Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA.
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Eagle H, Magnuson HJ, Fleischman R. RELATION OF THE SIZE OF THE INOCULUM AND THE AGE OF THE INFECTION TO THE CURATIVE DOSE OF PENICILLIN IN EXPERIMENTAL SYPHILIS, WITH PARTICULAR REFERENCE TO THE FEASIBILITY OF ITS PROPHYLACTIC USE. ACTA ACUST UNITED AC 2010; 85:423-40. [PMID: 19871627 PMCID: PMC2135616 DOI: 10.1084/jem.85.4.423] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
1. A relatively small amount of penicillin sufficed to abort syphilitic infection in rabbits when administered during the incubation period of the disease. 2. The abortive dose, given as a single intramuscular injection in oil and beeswax, varied with the age of the infection. (a) With a fixed intratesticular inoculum, the amount of penicillin necessary to prevent infection in half the animals remained at a constant level for 4 days. By the end of the 2nd week more than seven times this dosage was needed; and by the 6th week, after the chancre had appeared, more than thirty times the amount was needed to obtain the same result. The progressive increase in the abortive dose of penicillin with the passage of time probably reflects the interim multiplication of organisms. (b) Qualitatively similar results were obtained in rabbits inoculated intracutaneously. 3. The abortive dose varied also with the size of the inoculum. In animals inoculated intracutaneously with 20, 2,000, and 200,000 spirochetes, and treated 4 days later, it required 200, 500, and 3,500 units per kg., respectively, to protect half the animals, and the corresponding PD90 dosages were 500, 2,000, and 16,000 units per kg. 4. The present observations, indicating the ease of aborting experimental rabbit syphilis during the incubation period by a single injection of penicillin, are perhaps applicable to the prevention of the disease in man. 5. Asymptomatic infections were rare in animals receiving inadequate doses of penicillin during the incubation period. Sixty-four of sixty-five such animals developed darkfield-positive lesions at the inoculated site. In animals treated 6 weeks after inoculation, however, after the development of lesions, inadequate treatment was usually manifested by an asymptomatic redissemination of organisms demonstrable only by lymph node transfer. The difference in the two groups probably reflects the beginning development of immunity in the rabbits treated 6 weeks after inoculation. 6. As suggested by Rake and Dunham (11), the treatment of animals during the incubation period permits a rapid assay of antisyphilitic agents, and one which requires only small amounts of material. Possible limitations of the method are discussed in the text.
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Affiliation(s)
- H Eagle
- Laboratory of Experimental Therapeutics of the United States Public Health Service and The Johns Hopkins School of Hygiene, Baltimore
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Schmidt S, Picht T, Fleischman R, Prokscha T, Irlbacher K, Vajkoczy P, Brandt S. Navigated multimodal presurgical evaluation of motor representations in patients with perirolandic tumors. KLIN NEUROPHYSIOL 2010. [DOI: 10.1055/s-0030-1250928] [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] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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16
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Newgard CD, Fleischman R, Choo E, Ma OJ, Hedges JR, McConnell KJ. Validation of length of hospital stay as a surrogate measure for injury severity and resource use among injury survivors. Acad Emerg Med 2010; 17:142-50. [PMID: 20370743 DOI: 10.1111/j.1553-2712.2009.00647.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [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
OBJECTIVES While hospital length of stay (LOS) has been used as a surrogate injury outcome when more detailed outcomes are unavailable, it has not been validated. This project sought to validate LOS as a proxy measure of injury severity and resource use in heterogeneous injury populations. METHODS This observational study used four retrospective cohorts: patients presenting to 339 California emergency departments (EDs) with a primary International Classification of Diseases, Ninth Revision (ICD-9), injury diagnosis (years 2005-2006); California hospital injury admissions (a subset of the ED population); trauma patients presenting to 48 Oregon EDs (years 1998-2003); and injured Medicare patients admitted to 171 Oregon and Washington hospitals (years 2001-2002). In-hospital deaths were excluded, as they represent adverse outcomes regardless of LOS. Duration of hospital stay was defined as the number of days from ED admission to hospital discharge. The primary composite outcome (dichotomous) was serious injury (Injury Severity Score [ISS] >or= 16 or ICD-9 ISS <or= 0.90) or resource use (major surgery, blood transfusion, or prolonged ventilation). The discriminatory accuracy of LOS for identifying the composite outcome was evaluated using receiver operating characteristic (ROC) analysis. Analyses were also stratified by age (0-14, 15-64, and >or=65 years), hospital type, and hospital annual admission volume. RESULTS The four cohorts included 3,989,409 California ED injury visits (including admissions), 236,639 California injury admissions, 23,817 Oregon trauma patients, and 30,804 Medicare injury admissions. Composite outcome rates for the four cohorts were 2.1%, 29%, 27%, and 22%, respectively. Areas under the ROC curves for overall LOS were 0.88 (California ED), 0.74 (California admissions), 0.82 (Oregon trauma patients), and 0.68 (Medicare patients). In general, the discriminatory value of LOS was highest among children, tertiary trauma centers, and higher volume hospitals, although this finding differed by the injury population and outcome assessed. CONCLUSIONS Hospital LOS may be a reasonable proxy for serious injury and resource use among injury survivors when more detailed outcomes are unavailable, although the discriminatory value differs by age and the injury population being studied.
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Affiliation(s)
- Craig D Newgard
- Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, OR, USA.
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Affiliation(s)
- H Eagle
- The Laboratory of Experimental Therapeutics of the U. S. Public Health Service and The Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland
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Eagle H, Fleischman R, Musselman AD. THE SERUM CONCENTRATION OF PENICILLIN G IN MICE, RABBITS, AND MEN AFTER ITS INTRAMUSCULAR INJECTION IN AQUEOUS SOLUTION. J Bacteriol 2006; 57:119-26. [PMID: 16561639 PMCID: PMC385478 DOI: 10.1128/jb.57.1.119-126.1949] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- H Eagle
- Laboratory of Experimental Therapeutics of the U. S. Public Health Service and the Johns Hopkins School of Hygiene and Public Health, Baltimore 5, Maryland
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Cooney DA, Yavelow J, Zlotoff R, Bergenstal R, Burg A, Morrison R, Fleischman R. Azotomycin--toxicologic, biochemical and pharmacologic studies in mice. Biochem Pharmacol 1974; 23:3467-89. [PMID: 4155310 DOI: 10.1016/0006-2952(74)90350-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Eagle H, Fleischman R. The Relative Antisyphilitic Activity of Penicillins F, G, K, and X and of Bacitracin, Based on the Amounts Required to Abort Early Syphilitic Infections in Rabbits. J Bacteriol 1948; 55:341-6. [PMID: 16561464 PMCID: PMC518449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023] Open
Affiliation(s)
- H Eagle
- The Laboratory of Experimental Therapeutics of the U. S. Public Health Service and The Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland
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