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  1. Article ; Online: An introduction and practical guide to strategies for analyzing longitudinal data in clinical trials of smoking cessation treatment: Beyond dichotomous point-prevalence outcomes.

    Kypriotakis, George / Bernstein, Steven L / Bold, Krysten W / Dziura, James D / Hedeker, Donald / Mermelstein, Robin J / Weinberger, Andrea H

    Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco

    2024  

    Abstract: Conceptualizing tobacco dependence as a chronic relapsing condition suggests the need to use analytic strategies that reflect that premise. However, clinical trials for smoking cessation typically define the primary endpoint as a measure of abstinence at ...

    Abstract Conceptualizing tobacco dependence as a chronic relapsing condition suggests the need to use analytic strategies that reflect that premise. However, clinical trials for smoking cessation typically define the primary endpoint as a measure of abstinence at a single timepoint distal to the intervention, typically 3-12 months. This reinforces the concept of tobacco outcomes as a dichotomous state-one is, or is not, abstinent. Fortunately, there are several approaches available to handle longitudinal data that reflect the relapsing and remitting nature of tobacco use during treatment studies. In this paper, sponsored by the Society for Research on Nicotine and Tobacco's Treatment Research Network, we present an introductory overview of these techniques and their application in smoking cessation clinical trials. Topics discussed include models to examine abstinence outcomes (e.g., trajectory models of abstinence, models for transitions in smoking behavior, models for time to event), models that examine reductions in tobacco use, and models to examine joint outcomes (e.g., examining changes in use of more than one tobacco product). Finally, we discuss three additional relevant topics (i.e., heterogeneity of effects, handling missing data, power and sample size) and provide summary information about the type of model that can be used based on the type of data collected and the focus of the study. We encourage investigators to familiarize themselves with these techniques and use them in the analysis of data from clinical trials of smoking cessation treatment. IMPLICATIONS: Clinical trials of tobacco dependence treatment typically measure abstinence 3-12 months after participant enrollment. However, because smoking is a chronic relapsing condition, these measures of intervention success may not accurately reflect the common trajectories of tobacco abstinence and relapse. Several analytical techniques facilitate this type of outcome modeling. This paper is meant to be an introduction to these concepts and techniques to the global nicotine and tobacco research community including which techniques can be used for different research questions with visual summaries of which types of models can be used for different types of data and research questions.
    Language English
    Publishing date 2024-01-12
    Publishing country England
    Document type Journal Article
    ZDB-ID 1452315-2
    ISSN 1469-994X ; 1462-2203
    ISSN (online) 1469-994X
    ISSN 1462-2203
    DOI 10.1093/ntr/ntae005
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  2. Article: Modeling human health behavior with a new index that measures connectivity.

    Bernstein, Steven L / Li, Fangyong / Abujarad, Fuad / Grant, David R / D'Onofrio, Gail / Dziura, James

    Preventive medicine reports

    2023  Volume 33, Page(s) 102172

    Abstract: Objective: Health behavior is an important determinant of health. Adherence to medication and abstinence from harmful substances are two critical health behaviors. Although conceptually related, both are assessed using disparate measures. The goal of ... ...

    Abstract Objective: Health behavior is an important determinant of health. Adherence to medication and abstinence from harmful substances are two critical health behaviors. Although conceptually related, both are assessed using disparate measures. The goal of this study was to develop and test a new index, gamma, which models health behavior by quantifying the connectedness of discrete incidents of health behavior.
    Study design and setting: We derive gamma from first principles and use it to reanalyze data from a published trial of treatment for alcohol use disorders. We model a primary endpoint, changes in binge drinking, using gamma and a traditional measure: change in number of monthly binges. The original trial was conducted in an urban hospital emergency department in the U.S.
    Results: Incorporating gamma into the model provided additional insights into the relationship between the intervention and long-term changes in drinking.
    Conclusion: Gamma provides an additional tool to model the effects of interventions on outcomes in trials of substance use interventions or medication adherence. Gamma measures the pattern of behavior and may increase the explanatory power of models assessing differences between various treatments. The gamma index offers the possibility of novel real-time interventions to promote healthy behaviors.
    Language English
    Publishing date 2023-03-15
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2785569-7
    ISSN 2211-3355
    ISSN 2211-3355
    DOI 10.1016/j.pmedr.2023.102172
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  3. Article ; Online: Sample size calculation in hierarchical

    Tian, Zizhong / Esserman, Denise / Tong, Guangyu / Blaha, Ondrej / Dziura, James / Peduzzi, Peter / Li, Fan

    Statistics in medicine

    2022  Volume 41, Issue 4, Page(s) 645–664

    Abstract: Motivated by a suicide prevention trial with hierarchical treatment allocation (cluster-level and individual-level treatments), we address the sample size requirements for testing the treatment effects as well as their interaction. We assume a linear ... ...

    Abstract Motivated by a suicide prevention trial with hierarchical treatment allocation (cluster-level and individual-level treatments), we address the sample size requirements for testing the treatment effects as well as their interaction. We assume a linear mixed model, within which two types of treatment effect estimands (controlled effect and marginal effect) are defined. For each null hypothesis corresponding to an estimand, we derive sample size formulas based on large-sample z-approximation, and provide finite-sample modifications based on a t-approximation. We relax the equal cluster size assumption and express the sample size formulas as functions of the mean and coefficient of variation of cluster sizes. We show that the sample size requirement for testing the controlled effect of the cluster-level treatment is more sensitive to cluster size variability than that for testing the controlled effect of the individual-level treatment; the same observation holds for testing the marginal effects. In addition, we show that the sample size for testing the interaction effect is proportional to that for testing the controlled or the marginal effect of the individual-level treatment. We conduct extensive simulations to validate the proposed sample size formulas, and find the empirical power agrees well with the predicted power for each test. Furthermore, the t-approximations often provide better control of type I error rate with a small number of clusters. Finally, we illustrate our sample size formulas to design the motivating suicide prevention factorial trial. The proposed methods are implemented in the R package H2x2Factorial.
    MeSH term(s) Cluster Analysis ; Correlation of Data ; Humans ; Linear Models ; Research Design ; Sample Size
    Language English
    Publishing date 2022-01-02
    Publishing country England
    Document type Journal Article ; Research Support, N.I.H., Extramural
    ZDB-ID 843037-8
    ISSN 1097-0258 ; 0277-6715
    ISSN (online) 1097-0258
    ISSN 0277-6715
    DOI 10.1002/sim.9284
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  4. Article ; Online: Use of peripheral arterial tonometry in detection of abnormal coronary flow reserve.

    Gaeta, Marina / Nowroozpoor, Armin / Dziura, James / D'Onofrio, Gail / Sinusas, Albert J / Safdar, Basmah

    Microvascular research

    2021  Volume 138, Page(s) 104223

    Abstract: Background: We assessed the utility of EndoPAT, a device that measures reactive hyperemia index (RHI) as a clinical screening tool for identifying low coronary flow reserve (CFR). Distinguishing normal from low CFR aids assessment for coronary ... ...

    Abstract Background: We assessed the utility of EndoPAT, a device that measures reactive hyperemia index (RHI) as a clinical screening tool for identifying low coronary flow reserve (CFR). Distinguishing normal from low CFR aids assessment for coronary microvascular dysfunction (CMD) or large vessel coronary artery disease (CAD).
    Methods: From June 2014-May 2019, in a convenience sample, we measured RHI in adults undergoing clinically indicated cardiac Rubidium-82 positron emission tomography/computed tomography (PET/CT) at a single center. Exclusion criteria were inability to consent, lack of English proficiency, and physical limitation. We defined low RHI as <1.67 and low CFR as <2.5. Distribution of RHI was skewed so we used its natural logarithm (LnRHI) to calculate Pearson correlation and area under the curve (AUC).
    Results: Of 265 patients with PET/CT, we enrolled 131, and 100 had adequate data. Patients had a mean age of 61 years (SD = 12), 46% were female, 29% non-white. Thirty-six patients had low RHI, and 60 had depressed CFR. LnRHI did not distinguish patients with low from normal CFR (AUC = 0.53; 95% Cl, 0.41-0.64) and did not correlate with CFR (r = -0.021, p = 0.83). Low RHI did not distinguish patients with traditional CAD risk factors, presence of calcification, or perfusion defect (p > 0.05). Conversely, mean augmentation index, a measure of arterial stiffness, was higher with low RHI (p = 0.005) but not CFR (p = 0.625). RHI was lower in patients we identified as CMD (low CFR, no perfusion defect and calcium score of 0) (1.88 versus 2.21, p = 0.35) although we were underpowered (n = 12) to meet statistical significance.
    Conclusions: Peripheral RHI is insufficient as a clinical screening tool for low CFR as measured by cardiac PET/CT. Differences in vascular pathology assessed by each method may explain this finding.
    MeSH term(s) Aged ; Aged, 80 and over ; Coronary Circulation ; Coronary Disease/diagnosis ; Coronary Disease/physiopathology ; Female ; Fingers/blood supply ; Fractional Flow Reserve, Myocardial ; Humans ; Hyperemia/physiopathology ; Male ; Manometry ; Middle Aged ; Plethysmography ; Positron Emission Tomography Computed Tomography ; Predictive Value of Tests ; Reproducibility of Results
    Language English
    Publishing date 2021-07-10
    Publishing country United States
    Document type Comparative Study ; Journal Article ; Research Support, N.I.H., Extramural
    ZDB-ID 80307-8
    ISSN 1095-9319 ; 0026-2862
    ISSN (online) 1095-9319
    ISSN 0026-2862
    DOI 10.1016/j.mvr.2021.104223
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  5. Article ; Online: What do we do with our under-enrolled single-center COVID-19 clinical trials?

    Lee, Shing M / Esserman, Denise / Cheung, Ken / Dziura, James / Peduzzi, Peter / Sobieszczyk, Magdalena

    Clinical trials (London, England)

    2021  Volume 18, Issue 6, Page(s) 741–742

    MeSH term(s) COVID-19 ; Humans ; SARS-CoV-2
    Language English
    Publishing date 2021-07-03
    Publishing country England
    Document type Letter ; Research Support, N.I.H., Extramural
    ZDB-ID 2138796-5
    ISSN 1740-7753 ; 1740-7745
    ISSN (online) 1740-7753
    ISSN 1740-7745
    DOI 10.1177/17407745211027246
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  6. Article ; Online: Health services access, utilization, and barriers for Arabic-speaking refugees resettled in Connecticut, USA.

    Elreichouni, Ali / Aly, Sarah / Maciejewski, Kaitlin / Salem, Islam / Ghossein, Noah / Mankash, M Salah / Dziura, James / Mowafi, Hani

    BMC health services research

    2022  Volume 22, Issue 1, Page(s) 1337

    Abstract: Background: Arabic-speaking refugees are the largest group of refugees arriving in the United States since 2008, yet little is known about their rates of healthcare access, utilization, and satisfaction after the end of the Refugee Medical Assistance ( ... ...

    Abstract Background: Arabic-speaking refugees are the largest group of refugees arriving in the United States since 2008, yet little is known about their rates of healthcare access, utilization, and satisfaction after the end of the Refugee Medical Assistance (RMA) period.
    Methods: This study was a cross-sectional observational study. From January to December 2019, a household survey was conducted of newly arrived Arabic-speaking refugees in Connecticut between 2016 and 2018. Households were interviewed in Arabic either in person or over the phone by one of five researchers. Descriptive statistics were generated for information collected on demographics, prevalence of chronic conditions, patterns of health seeking behavior, insurance status and patient satisfaction using the Patient Satisfaction Questionnaire (PSQ-18).
    Results: Sixty-five households responded to the survey representing 295 Arabic-speaking refugees - of which 141 (48%) were children. Forty-seven households (72%) reported 142 chronic medical conditions among 295 individuals, 62 persons (21%) needed daily medication, 285 (97%) persons were insured. Median patient satisfaction was > 4.0 out of 5 for 6 of 7 domains of the PSQ-18 but wide variation (scores from 1.0 - 5.0).
    Conclusion: Arabic-speaking refugees in Connecticut participating in this study were young. The majority remained insured after their Refugee Medical Assistance lapsed. They expressed median high satisfaction with health services but with wide variation. Inaccessibility of health services in Arabic and difficulty obtaining medications remain areas in need of improvement.
    MeSH term(s) Child ; United States ; Humans ; Refugees ; Cross-Sectional Studies ; Connecticut ; Health Services ; Health Services Accessibility
    Language English
    Publishing date 2022-11-11
    Publishing country England
    Document type Observational Study ; Journal Article
    ZDB-ID 2050434-2
    ISSN 1472-6963 ; 1472-6963
    ISSN (online) 1472-6963
    ISSN 1472-6963
    DOI 10.1186/s12913-022-08733-5
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  7. Article ; Online: Improving patient and clinician safety during COVID-19 through rapidly adaptive simulation and a randomised controlled trial: a study protocol.

    Evans, Leigh V / Ray, Jessica M / Bonz, James W / Joseph, Melissa / Gerwin, Jeffrey N / Dziura, James D / Venkatesh, Arjun K / Wong, Ambrose H

    BMJ open

    2022  Volume 12, Issue 5, Page(s) e058980

    Abstract: Introduction: COVID-19 required healthcare systems to iteratively adapt for safe and up-to-date care as knowledge of the disease rapidly evolved. Rates of COVID-19 infections continue to fluctuate and patients without COVID-19 increasingly return to the ...

    Abstract Introduction: COVID-19 required healthcare systems to iteratively adapt for safe and up-to-date care as knowledge of the disease rapidly evolved. Rates of COVID-19 infections continue to fluctuate and patients without COVID-19 increasingly return to the emergency department (ED) for care. This leads to new challenges and threats to patient and clinician safety as suspected patients with COVID-19 need to be quickly detected and isolated among other patients with non-COVID-19-related illnesses. At the front lines, emergency physicians also face continued personal safety concerns and increased work burden, which heighten stress and anxiety, especially given the prolonged course of the pandemic. Burnout, already a serious concern for emergency physicians due to the cumulative stresses of their daily practice, may present as a longer-term outcome of these acute stressors.
    Methods and analysis: We will implement a rapidly adaptive simulation-based approach to understand and improve physician preparedness while decreasing physician stress and anxiety. First, we will conduct semi-structured qualitative interviews and human factor observations to determine the challenges and facilitators of COVID-19 preparedness and mitigation of physician stress. Next, we will conduct a randomised controlled trial to test the effectiveness of a simulation preparedness intervention on physician physiological stress as measured by decreased heart rate variability on shift and anxiety as measured by the State-Trait Anxiety Inventory.
    Ethics and dissemination: The protocol was reviewed and approved by the Agency for Healthcare Research and Quality for funding, and ethics approval was obtained from the Yale University Human Investigation Committee in 2020 (HIC# 2000029370 and 2000029372). To support ongoing efforts to address clinician stress and preparedness, we will strategically disseminate the simulation intervention to areas most impacted by COVID-19. Using a virtual telesimulation and webinar format, the dissemination efforts will provide hands-on learning for ED and hospital administrators as well as simulation educators.
    Trial registration number: NCT04614844.
    MeSH term(s) Burnout, Professional ; COVID-19 ; Humans ; Pandemics ; Randomized Controlled Trials as Topic ; SARS-CoV-2 ; United States
    Language English
    Publishing date 2022-05-19
    Publishing country England
    Document type Clinical Trial Protocol ; Journal Article ; Research Support, N.I.H., Extramural
    ZDB-ID 2599832-8
    ISSN 2044-6055 ; 2044-6055
    ISSN (online) 2044-6055
    ISSN 2044-6055
    DOI 10.1136/bmjopen-2021-058980
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  8. Article ; Online: Differences in faculty feedback for high, expected, and below-expected clinically performing emergency medicine residents.

    Coughlin, Ryan F / Tsyrulnik, Alina / Gottlieb, Michael / Bod, Jessica / Barnicle, Ryan / Dziura, James / Della-Giustina, David / Goldflam, Katja

    AEM education and training

    2022  Volume 6, Issue 5, Page(s) e10788

    Abstract: Objectives: A lifelong pursuit such as medicine is frequently paired with a framework of "deliberate practice" for improvement. It is unclear whether the quality of feedback varies across different learner levels. Our study aims to assess whether a ... ...

    Abstract Objectives: A lifelong pursuit such as medicine is frequently paired with a framework of "deliberate practice" for improvement. It is unclear whether the quality of feedback varies across different learner levels. Our study aims to assess whether a difference exists in the quality of feedback delivered to high-, expected-, and below-expected performer emergency medicine (EM) residents based on their attending-identified performance level.
    Methods: We conducted a retrospective review of written EM resident feedback collected between November 2018 and March 2021. Clinical performance level was subjectively determined by attending faculty in their feedback. Feedback was coded on a scale from 0-5 based on the presence (1) or absence (0) of the items modified from the Ende's SMART criteria: Specific (S), Measurable (M), Achievable (A), Relevant (R), and Time-bound (T). The primary outcome was any total modified SMART criteria score difference concerning performance level using logistic regression with Generalized Estimating Equations (GEE). Secondary outcomes were differences for individual criteria.
    Results: We analyzed 1284 evaluations (311 high performers, 930 expected performers, and 43 below-expected performers) of 94 unique residents from 66 different evaluators. Mean total modified SMART scores were significantly higher in high and below-expected performers than those designated as expected performers by faculty evaluators. Achievable and Relevant written feedback was provided to high performers in a significantly larger proportion than expected and below-expected performers. Only 278 out of 1284 evaluations met criteria for Specific.
    Conclusions: Mean total modified SMART feedback scores were significantly greater in high performers and below-expected performers when compared to expected performers. Achievable and Relevant feedback was provided in greater proportions to high performer residents compared to expected and below-expected performers. These findings are a challenge to academic faculty to engage in quality feedback delivery for residents at all performance levels.
    Language English
    Publishing date 2022-09-17
    Publishing country United States
    Document type Journal Article
    ISSN 2472-5390
    ISSN (online) 2472-5390
    DOI 10.1002/aet2.10788
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  9. Article ; Online: Gender Differences in Guideline-Directed Medical Therapy for Cardiovascular Disease Among Young Veterans.

    Dhruva, Sanket S / Dziura, James / Bathulapalli, Harini / Rosman, Lindsey / Gaffey, Allison E / Davis, Melinda B / Brandt, Cynthia A / Haskell, Sally G

    Journal of general internal medicine

    2022  Volume 37, Issue Suppl 3, Page(s) 806–815

    Abstract: Background: There is an increasing burden of cardiovascular disease, including coronary artery disease (CAD) and heart failure (HF), among women Veterans. Clinical practice guidelines recommend multiple pharmacotherapies that can reduce risk of ... ...

    Abstract Background: There is an increasing burden of cardiovascular disease, including coronary artery disease (CAD) and heart failure (HF), among women Veterans. Clinical practice guidelines recommend multiple pharmacotherapies that can reduce risk of mortality and adverse cardiovascular outcomes.
    Objective: To determine if there are disparities in the use of guideline-directed medical therapy by gender among Veterans with incident CAD and HF.
    Design: Retrospective.
    Participants: Veterans (934,504; 87.8% men and 129,469; 12.2% women) returning from Operations Enduring Freedom, Iraqi Freedom, and New Dawn.
    Main measures: Differences by gender in the prescription of Class 1, Level of Evidence A guideline-directed medical therapy among patients who developed incident CAD and HF at 30 days, 90 days, and 12 months after diagnosis. For CAD, medications included statins and antiplatelet therapy. For HF, medications included beta-blockers and renin-angiotensin-aldosterone system inhibitors.
    Key results: Overall, women developed CAD and HF at a younger average age than men (mean 45.8 vs. 47.7 years, p<0.001; and 43.7 vs. 45.4 years, p<0.02, respectively). In the 12 months following a diagnosis of incident CAD, the odds of a woman receiving a prescription for at least one CAD drug was 0.85 (95% confidence interval [CI], 0.68-1.08) compared to men. In the 12 months following a diagnosis of incident HF, the odds of a woman receiving at least one HF medication was 0.54 (95% CI, 0.37-0.79) compared to men.
    Conclusions: Despite guideline recommendations, young women Veterans have approximately half the odds of being prescribed guideline-directed medical therapy within 1-year after a diagnosis of HF. These results highlight the need to develop targeted strategies to minimize gender disparities in CVD care to prevent adverse outcomes in this young and growing population.
    MeSH term(s) Cardiovascular Diseases/drug therapy ; Cardiovascular Diseases/epidemiology ; Coronary Artery Disease/diagnosis ; Female ; Heart Failure/drug therapy ; Heart Failure/epidemiology ; Humans ; Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use ; Male ; Platelet Aggregation Inhibitors/therapeutic use ; Retrospective Studies ; Sex Factors ; Veterans
    Chemical Substances Hydroxymethylglutaryl-CoA Reductase Inhibitors ; Platelet Aggregation Inhibitors
    Language English
    Publishing date 2022-08-30
    Publishing country United States
    Document type Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't ; Research Support, U.S. Gov't, Non-P.H.S.
    ZDB-ID 639008-0
    ISSN 1525-1497 ; 0884-8734
    ISSN (online) 1525-1497
    ISSN 0884-8734
    DOI 10.1007/s11606-022-07595-1
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  10. Article ; Online: Real-world effectiveness of the Bright Bodies healthy lifestyle intervention for childhood obesity.

    Samuels, Stephanie L / Hu, Pamela / Maciejewski, Kaitlin R / Li, Fangyong / Dziura, James / Savoye, Mary / Sharifi, Mona

    Obesity (Silver Spring, Md.)

    2022  Volume 31, Issue 1, Page(s) 203–213

    Abstract: Objective: This study aimed to examine the extent to which Bright Bodies, a high-intensity, family-based pediatric weight management intervention, improved BMI for participants since publication of the randomized controlled trial establishing efficacy ... ...

    Abstract Objective: This study aimed to examine the extent to which Bright Bodies, a high-intensity, family-based pediatric weight management intervention, improved BMI for participants since publication of the randomized controlled trial establishing efficacy in 2007 and to describe adaptations to the program.
    Methods: For participants enrolled from 2008 to 2018, linear mixed-effects models were used to estimate monthly change in BMI expressed as percentage of the 95th percentile (%BMIp95) during participants' first beginner-level program.
    Results: The sample included 396 youth individuals (mean age: 11.7  [SD 2.8] years, 61.6% female, 37.1% non-Hispanic Black, 26.3% Hispanic or Latino, 53.8% with public insurance, 80.1% with severe obesity). Across the 11 years, participants' %BMIp95 reduced on average by 1.63% (95% CI: 1.44%-1.82%) per month during their first program (mean duration: 10 weeks) after adjusting for age, sex, season and year, starting %BMIp95, race and ethnicity, and insurance category. Greater reduction in %BMIp95 was associated with male versus female sex, spring/fall versus winter seasons, enrollment in 2008 to 2018 versus 2015 to 2018, and higher starting %BMIp95 (p value for all <0.001). Adaptations since 2007 included pragmatic changes to increase engagement and address funding shortages.
    Conclusions: These results suggest sustained clinical effectiveness of Bright Bodies in the context of real-world adaptations.
    MeSH term(s) Adolescent ; Humans ; Child ; Male ; Female ; Pediatric Obesity/prevention & control ; Pediatric Obesity/complications ; Body Mass Index ; Obesity, Morbid/complications ; Treatment Outcome ; Black People
    Language English
    Publishing date 2022-12-10
    Publishing country United States
    Document type Randomized Controlled Trial ; Journal Article ; Research Support, N.I.H., Extramural
    ZDB-ID 2230457-5
    ISSN 1930-739X ; 1071-7323 ; 1930-7381
    ISSN (online) 1930-739X
    ISSN 1071-7323 ; 1930-7381
    DOI 10.1002/oby.23627
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