CME – Shared Decision Making: Perceptions of Emergency Physicians

CME – Shared Decision Making: Perceptions of Emergency Physicians

Shared decision making (SDM) involves physicians and patients collaboratively discussing potential management strategies when there is more than one reasonable treatment option to consider. Together, decisions are reached based on the available evidence and patient preference. “SDM can enhance patient knowledge and satisfaction and help ensure that medical decisions are closely aligned with patients’ values,” explains Hemal K. Kanzaria, MD, MS. It can be challenging to integrate SDM into ED care because of its fast-paced environment. In addition, EDs must manage high-acuity patients and there are varying levels of treatment uncertainty throughout emergency medicine (EM). For example, EPs may face pressure to make rapid decisions to increase throughput. Some ED patients may also be unable to seek decision-making help from family, friends, and trusted individuals. Furthermore, patients may express that they want their clinicians take a more dominant role in decision-making when the stakes are high. Studies analyzing SDM in EM have shown that this approach appears to be feasible and that many of these challenges can be overcome. “Greater efforts are being made to achieve patient-centered care with SDM, but few studies have examined the viewpoints of frontline EM physicians,” says Dr. Kanzaria. “A better understanding of the perceptions of EPs on this topic is critical to increasing adoption of SDM in EM.” Surveying Emergency Physicians In a study published in Academic Emergency Medicine, Dr. Kanzaria and colleagues surveyed EPs on the frequency with which SDM may be appropriate in their clinical practice. The authors also examined perceptions on the potential for SDM to reduce medically unnecessary diagnostic testing, the barriers to employing SDM in the ED, and...
Symptomatic Knee OA on the Rise

Symptomatic Knee OA on the Rise

Throughout the United States, the rate of knee replacement operations has surged in recent years. Experts have speculated that the increased prevalence of knee pain or of symptomatic knee osteoarthritis (OA) is due to an aging and increasingly obese U.S. population, which in turn may be the cause for the increase in knee surgeries. However, formal assessments of the secular trend of knee pain and symptomatic knee OA have been lacking. In the Annals of Internal Medicine, David T. Felson, MD, MPH, and colleagues addressed this void when they conducted a study examining whether a change in the prevalence of knee pain and symptomatic OA could be attributed to age, BMI, and radiographic knee OA. “It’s largely unknown if the increase in knee replacements was due to patients seeking the procedure more often,” explains Dr. Felson. “We also don’t have a great deal of data on the trends in knee OA.” Key Findings For their study, Dr. Felson and colleagues collected data from six National Health and Nutrition Examination Surveys (NHANES) conducted between 1971 and 2004 and from three examination periods in the Framingham Osteoarthritis (FOA) study between 1983 and 2005. “We wanted to see if the prevalence of knee OA had increased over time,” Dr. Felson says. In all samples studied, the age-adjusted prevalence of knee pain and symptomatic knee OA increased substantially over time. Between 1974 and 1994, the prevalence of knee pain—with adjustment for age and BMI—increased by about 65% among Caucasian and Mexican men and women and among African-American women in NHANES (Figure 1). In FOA, the age and BMI-adjusted prevalence of knee pain and...
CME: Repeat Operations After Breast Conservation Surgery

CME: Repeat Operations After Breast Conservation Surgery

Previous long-term research has found that there appears to be no difference in disease-free or overall survival between partial and total mastectomy for the treatment of invasive breast cancer. Despite these studies, substantial controversy remains regarding the definition of being free of tumor. “Until recently, no guidelines were available that described an adequate margin width for invasive or non-invasive breast cancer,” explains Lee G. Wilke, MD, FACS. “This lack of consensus has led to significant variations in reexcision rates for these patients.” She adds that the financial, psychological, and cosmetic effects of these repeat surgeries are important to patients and increase the burden of breast cancer therapy. Identifying Key Determinants In a study published in JAMA Surgery, Dr. Wilke and colleagues examined women who underwent initial breast conservation surgery (BCS) to determine the proportion that received a subsequent partial mastectomy or mastectomy. The study included more than 316,000 patients with stage 0 to II breast cancer who underwent initial BCS. Patients who were neoadjuvantly treated or whose conditions were diagnosed by excisional biopsy were excluded from the analysis. Information was collected from the National Cancer Data Base (NCDB), a large observational database of accredited cancer centers from the Commission on Cancer that contains data on more than 70% of patients treated for cancer in the U.S. The NCDB afforded an opportunity to observe differences among patient, tumor, and facility groups that were associated with repeat surgeries. “Our results showed that about one-quarter of patients undergoing an initial BCS had at least one additional operation,” Dr. Wilke says. About two-thirds of this group had a complete lumpectomy while the remaining...
CME: Postoperative Cardiac Issues After Arthroplasty

CME: Postoperative Cardiac Issues After Arthroplasty

Cardiac events are major postoperative complications that can occur in patients undergoing total knee arthroplasty and total hip arthroplasty. Some studies have shown that serious cardiac complications, including myocardial infarction and cardiac arrest, account for 7% to 20% of all major systemic complications following these procedures. “Hospitals are increasingly implementing performance-based outcome metrics and penalizing those with high readmission rates after elective procedures like these,” explains Andrew J. Schoenfeld, MD, MSc. “As such, it’s important to look at risk factors that may play a role in the development of cardiac complications after total knee arthroplasty and total hip arthroplasty.” Little is known about how patient-based risk factors affect risks for postoperative cardiac complications among total knee and hip arthroplasty recipients. Understanding these risk factors can help clinicians counsel their patients before their surgery. By identifying high-risk patients, targeted interventions can be developed to improve patient outcomes and reduce the incidence of unplanned hospital readmissions and morbidity after total knee and hip arthroplasty. A Detailed Investigation Previous studies on adverse postoperative cardiac outcomes after arthroplasty may be limited because their samples usually come from individual centers and the surgeons performing these procedures may have extensive experience. In the Journal of Bone & Joint Surgery, Dr. Schoenfeld and colleagues had a study published that examined the rates, risk factors, and time of occurrence for cardiac complications at 30 days following total knee and hip arthroplasty. “Our study sample included more than 46,000 patients undergoing either primary unilateral total knee arthroplasty or total hip arthroplasty at numerous medical centers in the United States participating in the American College of Surgeons’ National Surgical...
Recertification Blues: A Useless Exam

Recertification Blues: A Useless Exam

I recently took the American Board of Surgery MOC exam. This will make the third time in my career that I have recertified in General Surgery and I am more convinced than ever that there must be a better way. Taking a three-hour exam every 10 years is a poor way to assess my competence as a surgeon, and given the type of questions I saw on the exam, it doesn’t even seem a good way to evaluate my basic knowledge of my craft. To be fair, most of the questions had some basic clinical relevance. All too often the wording of the question seemed designed to trip the examinee up, or mislead one into a false assumption. Then there were the questions that had little or no relevance to my actual practice. It is necessary that I know the appropriate chemotherapy regimen for a premenopausal woman with a triple negative breast cancer? Yes, it is somewhat relevant, but it seems enough to know that she needs aggressive treatment without knowing the exact combination of agents the Oncologist should use. Even if that were useful to me, my DEA license does not extend to giving antineoplastic drugs. It would be illegal and malpractice for me to do so. “Several professional boards have already done away with the traditional recertification exams in favor of more continuous and nuanced evaluations. It is time for Surgery to do the same.”   All too many of the questions on the exam were on material just as irrelevant or obscure. Why? I took time from my practice to study material that I will not...
The CDI Burden in Surgery

The CDI Burden in Surgery

Despite increased national attention, the incidence of Clostridium difficile infection (CDI) and its associated financial and human costs continue to grow. In fact, the problem has become so critical that CMS would no longer reimburse hospitals for claims associated with this potentially preventable infection if it is acquired during the hospital stay. There are also concerns that new strains of the infection may cause resistance to traditional antibiotic regimens. Recent data have also shown that the burden of CDI is increasing among surgical patients. This is concerning given that surgical care accounts for about 40% to 50% of all hospital stays and healthcare dollars. “Surgery patients frequently receive prophylactic antibiotics and have longer inpatient hospital exposure,” explains Zaid M. Abdelsattar, MD, MSc. Previous reports on how CDI affects surgical patients has been limited by the use of administrative data and failure to capture cases diagnosed after discharge, and reports from single-center studies. A Large-Scale Analysis In a study published in Infection Control & Hospital Epidemiology, Dr. Abdelsattar and colleagues conducted a large-scale analysis of patients with postoperative CDI after 40 different surgeries at 52 academic and community hospitals for a period of about 1 year. The purpose of the analysis—which included more than 35,000 patients in total—was to identify CDI risk factors and determine the impact of the infection on resource utilization. According to the results, only about 0.5% of the study group developed CDI after surgery, but postoperative CDI rates varied significantly between surgical procedures. Three surgical groups had higher adjusted odds ratios (aOR) of postoperative CDI: Lower-extremity amputations: aOR,3.5. Gastric or esophageal operations: aOR, 2.1. Bowel resection...
Opioid Abuse Screening in the ED

Opioid Abuse Screening in the ED

Using screening tools for various substance use problems in the ED can be powerful but can also be time consuming and costly and may require additional staff resources. Some studies suggest that computerized screening may be a solution to this dilemma because they require less staff time and allow scores to be calculated with fewer errors. As tablet computers have become lighter and less expensive and have a longer battery life, screening ED patients with these devices may improve delivery of care. Over the past decade, opioid prescription abuse in the United States has increased exponentially, with deaths from overdose rising to epidemic proportions. In a study published in the Western Journal of Emergency Medicine, Scott G. Weiner, MD, MPH, and colleagues evaluated the feasibility of using an electronic tablet version of a screener for opioid prescription abuse potential in the ED. The authors used the Revised Screener and Opioid Assessment for Patients with Pain (SOAPP®-R), a proprietary screening measure that was previously developed and validated in pain clinic patients. Promising Results For the study, 93 adults being considered for ED discharge with a prescription for an opioid were approached and 82 consented to participate. “All patients completed the screening without assistance and no additional staff resources were required,” says Dr. Weiner. “The median time to completion was just 148 seconds, and 95% completed the screening in less than 5 minutes. In addition, 93% of patients rated the ease of completion as very easy. Our results demonstrate that it is feasible to electronically administer a screening tool for opioid abuse potential to ED patients in a time-efficient manner.” Important...
Why Hospital Rankings are Bogus

Why Hospital Rankings are Bogus

The Leapfrog Group has announced its annual list of America’s top hospitals for quality and safety with 98 hospitals receiving the honor. Unlike some other hospital rating schemes, Leapfrog’s does not factor in reputation. You won’t find any of the usual suspects on Leapfrog’s list. Instead, Leapfrog uses surveys and publicly available quality and safety data. Leapfrog’s top 98 included 62 urban, 24 rural, and 12 children’s hospitals. Of the 86 urban and rural hospitals, only three were university hospitals—University of California Davis Medical Center, University of California Irvine Medical Center, and University of Tennessee Medical Center. New York managed to place only one hospital on the Leapfrog list. Other interesting anomalies are that for several states such as Connecticut, Indiana, and Maryland, among others, no hospitals made the list, and of the 21 California hospitals that did, 17 are Kaiser-affiliated. “How can those seven hospitals be among Leapfrog’s top 98 in the country for patient quality and safety, yet be sanctioned by Medicare for safety problems?” Here’s where it gets interesting. Seven of the urban and rural hospitals also appear on Medicare’s list of 758 hospitals slated to receive a 1% reduction in payments in 2016 because of “high rates of potentially avoidable infections and complications such as blood clots, bed sores and falls.” Five of the seven—Kaiser Foundation Hospital-Antioch and Kaiser Foundation Hospital-Oakland/Richmond in California, Pennsylvania’s Geisinger Medical Center, Parkland Health and Hospital System in Texas, and Sterling Regional Medcenter in Colorado—were also penalized by Medicare in 2015. The two other hospitals on both lists are Reading Hospital in Pennsylvania and Midwestern Regional Medical Center in Illinois....
CME: Identifying Smoking-Related Disease

CME: Identifying Smoking-Related Disease

Among current and former adult smokers, symptoms like productive cough, dyspnea, and exercise intolerance may be viewed as a part of normal aging, particularly among older former smokers. Smoking cessation may reduce respiratory symptom severity and slow the rate of lung function decline, but it does not eliminate progressive lung disease risk. Few studies have assessed the effects of smoking on patients without COPD. A group of researchers has suspected that spirometry may be insensitive to early disease or subclinical lung pathology and that current and former cigarette smokers without spirometric evidence of COPD may have impairments in physical function, quality of life, and respiratory symptoms that can go untreated. High-resolution CT scanning in this patient population may demonstrate significant lung disease, but comprehensive data has been lacking. Finding Hidden Lung Disease “There are no disease-modifying treatments for patients identified with smoking-related lung disease,” explains Elizabeth A. Regan, MD, PhD, “but there are many treatments that improve their symptoms, allow them to breath better, enable them to exercise, and improve quality of life.” For a study published in JAMA Internal Medicine, Dr. Regan and colleagues set out to determine whether or not patients with a heavy smoking history, but who did not meet spirometric criteria for COPD, had hidden lung disease. Dr. Regan and colleagues completed evaluations on more than 10,000 current and former smokers aged 45 to 80 with at least a 10 pack-year smoking history and a comparison group of more than 100 never smokers of similar ages. Evaluations included high-resolution chest CT scans, spirometry, 6-minute walking tests, and multiple questionnaires about respiratory symptoms, comorbidities, and quality...
CME: Illustrating the Importance of Cholesterol

CME: Illustrating the Importance of Cholesterol

The Foundation of the National Lipid Association, the Preventive Cardiovascular Nurses Association, and Mended Hearts recently launched Cholesterol Counts, a program designed to accumulate internet-based information on how much people in the United States know about their cholesterol. “The program gathers data on how much patients care about their cholesterol and whether they are treated if their cholesterol levels are high,” says Ralph M. Vicari, MD, FACC. “The goal of the program is to get a pulse of cholesterol knowledge in the U.S. and find where gaps may exist. The program is also designed to help determine whether healthcare professionals are discussing cholesterol levels with patients.” The Cholesterol Counts program has surveyed more than 12,000 adults, including approximately 200 adults in each of the 50 states. The poll, which is available online at www.CholesterolCounts.com, was conducted online by Harris Poll on behalf of Sanofi and Regeneron Pharmaceuticals. The results are weighted demographically and attitudinally so that they are representative of the national population and the population of each state. Concerning Results Initial results from the Cholesterol Counts poll were released in 2015, and showed that 71% of Americans surveyed are not sure of or do not recall their LDL cholesterol levels despite the fact that this is a critical health factor that can increase risks for heart attack and stroke (Figure). “This finding is concerning because patients need to know their cholesterol levels and goals so that they talk to their physicians to help manage it and assess their risk for potential cardiac events,” says Dr. Vicari. He recommends that clinicians make a concerted effort to write down cholesterol...
Conference Highlights: SABCS 2015

Conference Highlights: SABCS 2015

New research was presented at SABCS 2015, the San Antonio Breast Cancer Symposium, from December 8 to 12 in San Antonio. The features below highlight some of the studies that emerged from the conference. —————————————————————-   A Group Intervention for Obesity Among Survivors The Particulars: Previous research has indicated that obesity increases the risk for breast cancer and poor outcomes. Endocrine therapy for breast cancer can compound the issue because of side effects like musculoskeletal pain and weight gain. Structured group interventions for obese breast cancer patients who have an abnormal lipid metabolism may be effective for obesity during adjuvant endocrine therapy. Data Breakdown: For a study, obese breast cancer survivors who were undergoing endocrine therapy participated in a structured group intervention for 3 weeks. The once-weekly intervention consisted of 15 minutes of nutrition education, a 30-minute group health coaching program, and a 45-minute group aerobic exercise. Participants were also asked to perform the same activities at home using an instructional DVD. When comparing measurements taken at baseline with those taken after the intervention, the researchers observed significant decreases in body weight, BMI, triglyceride levels, total cholesterol levels, and fatigue. Take Home Pearls: Short-term structured interventions for obese women with breast cancer appear to effect behavioral changes that promote health. As a result, this can lead to favorable changes in obesity, triglyceride and cholesterol levels, and cancer-related fatigue. —————————————————————-   Breast Cancer Treatment & Fertility The Particulars: Data are lacking on the level of information that clinicians provide to women with breast cancer regarding how their treatments for cancer may impact fertility. Data Breakdown: For a study, women with...
Choose to Make a Difference

Choose to Make a Difference

The universe we live in is billions of years old. Our lives here are a blink of an eye in comparison. Many of us travel this journey merely existing. Others live the adventure and find the purpose. The difference we make in the lives of others is tremendous. Yet, many of us fail to react to this calling. As doctors, we are in a unique position to forge a positive impact in the lives of numerous others. It is not just our ability to heal diseases or ease pain and suffering but the standard we set. Patients look up to us. Yesterday, a 12 year old came to me for a physical and she told me all about her recent power point presentation. It was for career day, and she wants to be a doctor. And not just any doctor, but a doctor like me. Kids look up to us. We need to be a positive role model to them. Several elderly patients come to see me, I believe, just because they don’t know anyone else to talk to. Sure, I am busy like every other doctor. But, instead of rushing those patients out the door, pull up a chair and spend a few moments with them. These patients may not need much medical care, but they taught me a great deal from their vast stores of wisdom. And they were truly happy to find comfort from another person for a moment. Many of them are abandoned by their families and by society at large. Just 5 minutes can make a world of difference to them. “The difference we...
CME: Understanding and Implementing Pneumococcal Vaccination Recommendations for Adults

CME: Understanding and Implementing Pneumococcal Vaccination Recommendations for Adults

The pneumococcal disease immunization schedule for adults in the United States is relatively complex. Two types of pneumococcal vaccines are to be administered in a variety of combinations and at different intervals based on a patient’s age (younger than 65 years vs aged 65 years and older), underlying risk conditions, and pneumococcal vaccination history. Vaccine recommendations such as those for influenza require only one dose of vaccine to be administered to every U.S. adult every year. Little effort is required by clinicians beyond checking for serious adverse reactions to past doses, which are extremely rare. For pneumococcal disease, the vaccine recommendations are less straightforward. The adult pneumococcal recommendations from the CDC Advisory Committee on Immunization Practices (ACIP) may seem complex to busy healthcare professionals and their patients. For example, whereas ACIP carefully differentiates recommendations for those with “chronic conditions” versus “immunocompromising conditions,” clinicians may not distinguish between these categories with their patients. The National Foundation for Infectious Diseases (NFID) is dedicated to educating healthcare professionals and the public about the burden of vaccine-preventable diseases and the importance of vaccinating according to ACIP recommendations. To promote widespread education about vaccines, NFID created a dedicated webpage with pneumococcal vaccination resources for healthcare professionals. Online Tools The NFID Pneumococcal Vaccination Resources page (www.adultvaccination.org/professional-resources/pneumo) includes a variety of fact sheets, templates, and assessment tools. Of key importance is the guidance provided on vaccinating higher-risk adults who are younger than 65 years (Table). Whereas most patients who need the 13-valent pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23) also require a second PPSV23 dose at least 5 years after the first...
Smoking Cessation After PCI

Smoking Cessation After PCI

It has been well-documented in clinical studies that smoking cessation after patients undergo PCI can improve outcomes. Some research has identified certain predictors of smoking cessation after PCI, including previous cigarette consumption and the number of coexisting coronary artery disease risk factors. Few studies, however, have assessed current trends in smoking cessation after PCI and looked at the potential impact of smoke-free policies that are being enacted throughout many parts of the United States. “Historically, patients who undergo PCI are a group that has more difficulty quitting smoking than others,” says Randal J. Thomas, MD, MS. The Effect of Smoke-Free Policies In a study published in the February 15, 2015 issue of the American Journal of Cardiology, Dr. Thomas and colleagues assessed trends and predictors of smoking cessation after PCI in Olmsted County, Minnesota. The investigators conducted the research at a time when local and statewide smoke-free public policies were enacted in Olmsted County. The study followed 2,306 patients who underwent their first PCI from 1999 to 2009 for 12 months. The researchers conducted structured telephone surveys at 6 and 12 months after PCI to assess smoking status and quit rates during the 10-year period. The authors paid particular attention to quite rates around two dates when three smoke-free ordinances were implemented to reduce secondhand tobacco exposure in Olmsted County. The first date was January 1, 2002, when an ordinance was passed requiring restaurants to be smoke-free. The second was October 1, 2007, when ordinances required both workplaces and the entire state of Minnesota to be smoke-free. The data were then analyzed according to three time periods: 1991 to 2001, 2002...
A Novel Approach for TMJ Dislocation 

A Novel Approach for TMJ Dislocation 

Anterior temporomandibular joint (TMJ) dislocations are among the most common non-traumatic dislocations of the jaw. Although non-traumatic TMJ dislocations are infrequent in the ED, it is important to find useful methods for managing these patients in order to improve patient outcomes in a safer and more effective manner. The traditional approaches to managing TMJ have numerous disadvantages, including the risk of bite injuries, which in turn increases the risk of transmitting diseases like hepatitis and HIV. Traditional approaches also require procedural sedation because the application of additional force to manually manipulate the mandible can be difficult and painful. In addition to these disadvantages, repeated attempts may be necessary before successfully reducing the dislocated TMJ. Another complication with traditional approaches is that they may inadvertently fracture the mandibular or condyle. Other techniques for reducing TMJ have also been tested, but these strategies still require procedural sedation and manual reduction. “Traditional approaches to TMJ can be time consuming, difficult, and sometimes ineffective,” explains Julie A. Gorchynski, MD, MSC, FACEP, FAAEM. “They can also be risky to patients and emergency physicians because it involves intraoral manual manipulation of the mandible as well as procedural sedation.” A New Technique In a prospective study published in the Journal of Emergency Medicine, Dr. Gorchynski and colleagues evaluated a simple and novel syringe technique for reducing acutely non-traumatic TMJ dislocations using a hands-free approach. The technique requires that a syringe be placed between the posterior molars as they slide over the syringe to glide the anteriorly displaced condyle back into its normal position. Over the 3-year study period, researchers collected information on demographics, mechanisms, duration of...
Examining Patient Desires for ED Function

Examining Patient Desires for ED Function

Average ED wait times in the United States vary considerably, but some locations have particularly long wait times. This time spent in the waiting room often frustrates patients and their families as other ED visitors receive care while those who are waiting are given few, if any, updates. Some research has explored educating patients while they wait to be seen by ED personnel, and this appears to be a potentially valuable tool. “Some studies suggest that providing education in the ED waiting room is of interest to patients,” says Jeffrey Druck, MD. In a study published in the Western Journal of Emergency Medicine, Dr. Druck, Paul Leccese, and colleagues aimed to determine baseline knowledge of ED and hospital processes among ED patients. “One of our goals was to establish types of information that waiting room patients wanted, including expected wait times, causes of delays, and the triage process,” explains Leccese. “We also wanted to see how they would like this information to be delivered.” In addition, the study asked participants what they expected regarding wait times for labs, imaging studies, and admission. The authors also assessed links between racial groups and their desire for information as well as whether or not patients wanted educational health materials. New Data For the study, a 32-question survey was administered to patients and showed that 55% of the 544 respondents indicated that they had a primary care physician (PCP). Of these patients, about 53% reported calling a PCP before they came to the ED. About 72% of participants wanted to know about delays, but just 25% wanted to know others’ wait times. “While...
Liver Cancer: Decreasing Morbidity & Mortality

Liver Cancer: Decreasing Morbidity & Mortality

Research has shown that the 5-year survival rate among patients with cancers of the liver undergoing resection is high. Many candidates, however, will not undergo these procedures because of the high morbidity and mortality risk associated with them. “Over the past 20 years, liver cancer surgery has become safer and more effective,” explains T. Peter Kingham, MD, FACS. “One of the reasons for this has been advances in surgical treatment.” Specifically, there has been greater use of hepatic parenchymal preservation, a surgical approach in which less liver is resected. These procedures can benefit patients with single tumors or multiple tumors confined to one side of the liver. Analyzing Changes in Outcomes In a study published in the Journal of the American College of Surgeons, Dr. Kingham and colleagues at Memorial Sloan Kettering (MSK) Cancer Center analyzed the correlation between hepatic resection, mortality, and complication rates using data compiled over 19 years. They analyzed hospital records of all patients who underwent both major and minor hepatectomy for a malignant liver cancer diagnosis at MSK. Patients were divided into three equal groups according to time period: early (1993-1999), middle (2000-2006), and late (2007-2012). Surgical morbidity and mortality rates were then compared between the time periods. According to the results, the 90-day mortality rate decreased over the three time periods from 5% to less than 2% for all patients involved in the analysis. Overall, the complication rate dropped from 53% to 20%. “The number of major hepatectomies decreased from two-thirds of cases to about one-third,” Dr. Kingham adds. The transfusion rate and liver dysfunction also decreased significantly over the study period. Interestingly,...
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