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COVID-19 Severity Is Tripled in the Diabetes Community: A Prospective Analysis of the Pandemic's Impact in Type 1 and Type 2 Diabetes.
Gregory JM, Slaughter JC, Duffus SH, Smith TJ, LeStourgeon LM, Jaser SS, McCoy AB, Luther JM, Giovannetti ER, Boeder S, Pettus JH, Moore DJ
(2021) Diabetes Care 44: 526-532
MeSH Terms: COVID-19, Comorbidity, Diabetes Mellitus, Type 1, Diabetes Mellitus, Type 2, Electronic Health Records, Female, Hospitalization, Humans, Hypertension, Male, Middle Aged, Odds Ratio, Prospective Studies, Severity of Illness Index
Show Abstract · Added December 7, 2020
OBJECTIVE - To quantify and contextualize the risk for coronavirus disease 2019 (COVID-19)-related hospitalization and illness severity in type 1 diabetes.
RESEARCH DESIGN AND METHODS - We conducted a prospective cohort study to identify case subjects with COVID-19 across a regional health care network of 137 service locations. Using an electronic health record query, chart review, and patient contact, we identified clinical factors influencing illness severity.
RESULTS - We identified COVID-19 in 6,138, 40, and 273 patients without diabetes and with type 1 and type 2 diabetes, respectively. Compared with not having diabetes, people with type 1 diabetes had adjusted odds ratios of 3.90 (95% CI 1.75-8.69) for hospitalization and 3.35 (95% CI 1.53-7.33) for greater illness severity, which was similar to risk in type 2 diabetes. Among patients with type 1 diabetes, glycosylated hemoglobin (HbA), hypertension, race, recent diabetic ketoacidosis, health insurance status, and less diabetes technology use were significantly associated with illness severity.
CONCLUSIONS - Diabetes status, both type 1 and type 2, independently increases the adverse impacts of COVID-19. Potentially modifiable factors (e.g., HbA) had significant but modest impact compared with comparatively static factors (e.g., race and insurance) in type 1 diabetes, indicating an urgent and continued need to mitigate severe acute respiratory syndrome coronavirus 2 infection risk in this community.
© 2020 by the American Diabetes Association.
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14 MeSH Terms
Aerosolized Calfactant for Newborns With Respiratory Distress: A Randomized Trial.
Cummings JJ, Gerday E, Minton S, Katheria A, Albert G, Flores-Torres J, Famuyide M, Lampland A, Guthrie S, Kuehn D, Weitkamp JH, Fort P, Abu Jawdeh EG, Ryan RM, Martin GC, Swanson JR, Mulrooney N, Eyal F, Gerstmann D, Kumar P, Wilding GE, Egan EA, AERO-02 STUDY INVESTIGATORS
(2020) Pediatrics 146:
MeSH Terms: Administration, Oral, Aerosols, Biological Products, Cohort Studies, Female, Gestational Age, Humans, Infant, Newborn, Intensive Care Units, Neonatal, Intubation, Intratracheal, Male, Nebulizers and Vaporizers, Prospective Studies, Pulmonary Surfactants, Respiratory Distress Syndrome, Newborn
Show Abstract · Added April 16, 2021
BACKGROUND - Exogenous surfactants to treat respiratory distress syndrome (RDS) are approved for tracheal instillation only; this requires intubation, often followed by positive pressure ventilation to promote distribution. Aerosol delivery offers a safer alternative, but clinical studies have had mixed results. We hypothesized that efficient aerosolization of a surfactant with low viscosity, early in the course of RDS, could reduce the need for intubation and instillation of liquid surfactant.
METHODS - A prospective, multicenter, randomized, unblinded comparison trial of aerosolized calfactant (Infasurf) in newborns with signs of RDS that required noninvasive respiratory support. Calfactant was aerosolized by using a Solarys nebulizer modified with a pacifier adapter; 6 mL/kg (210 mg phospholipid/kg body weight) were delivered directly into the mouth. Infants in the aerosol group received up to 3 treatments, at least 4 hours apart. Infants in the control group received usual care, determined by providers. Infants were intubated and given instilled surfactant for persistent or worsening respiratory distress, at their providers' discretion.
RESULTS - Among 22 NICUs, 457 infants were enrolled; gestation 23 to 41 (median 33) weeks and birth weight 595 to 4802 (median 1960) grams. In total, 230 infants were randomly assigned to aerosol; 225 received 334 treatments, starting at a median of 5 hours. The rates of intubation for surfactant instillation were 26% in the aerosol group and 50% in the usual care group ( < .0001). Respiratory outcomes up to 28 days of age were no different.
CONCLUSIONS - In newborns with early, mild to moderate respiratory distress, aerosolized calfactant at a dose of 210 mg phospholipid/kg body weight reduced intubation and surfactant instillation by nearly one-half.
Copyright © 2020 by the American Academy of Pediatrics.
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MeSH Terms
Prolonged Tracheal Intubation and the Association Between Patent Ductus Arteriosus and Bronchopulmonary Dysplasia: A Secondary Analysis of the PDA-TOLERATE trial.
Clyman RI, Kaempf J, Liebowitz M, Erdeve O, Bulbul A, Håkansson S, Lindqvist J, Farooqi A, Katheria A, Sauberan J, Singh J, Nelson K, Wickremasinghe A, Dong L, Hassinger DC, Aucott SW, Hayashi M, Heuchan AM, Carey WA, Derrick M, Fernandez E, Sankar M, Leone T, Perez J, Serize A, PDA-TOLERATE Trial Investigators
(2021) J Pediatr 229: 283-288.e2
MeSH Terms: Bronchopulmonary Dysplasia, Ductus Arteriosus, Patent, Female, Humans, Infant, Newborn, Intubation, Intratracheal, Male, Prospective Studies, Respiration, Artificial, Severity of Illness Index, Time Factors
Show Abstract · Added January 7, 2021
In the PDA-TOLERATE trial, persistent (even for several weeks) moderate to large patent ductus arteriosus (PDA) was not associated with an increased risk of BPD when the infant required <10 days of intubation. However, in infants requiring intubation for ≥10 days, prolonged PDA exposure (≥11 days) was associated with an increased risk of moderate/severe BPD.
Copyright © 2020 Elsevier Inc. All rights reserved.
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11 MeSH Terms
Association of uterine fibroids with birthweight and gestational age.
Zhao SK, Wu P, Jones SH, Torstenson ES, Hartmann KE, Velez Edwards DR
(2020) Ann Epidemiol 50: 35-40.e2
MeSH Terms: Adult, Birth Weight, Cohort Studies, Female, Fetal Development, Gestational Age, Humans, Leiomyoma, Pregnancy, Prospective Studies, Ultrasonography, Uterine Neoplasms
Show Abstract · Added August 5, 2020
PURPOSE - To determine if fibroids or their characteristics are associated with birthweight and/or gestational age, and to assess the impact of race or ethnicity.
METHODS - Right from the Start (2000-2012) is a prospective cohort that enrolled women from the southern US in early pregnancy. Transvaginal ultrasounds were used to measure fibroid characteristics and confirm gestational age. Date of birth and birthweight were obtained from vital or medical records. We assessed whether fibroid presence, number, type, and volume were associated with birthweight and/or gestational age using multivariate analysis of covariance, accounting for a priori confounders.
RESULTS - Among 3926 women, 416 had one or more fibroids. Mean infant birthweight and gestational age were similar among women with and without fibroids. When adjusting for race or ethnicity, all associations were attenuated. Overall, women with and without fibroids had infants of similar birthweight (-20 grams, 95% confidence interval [CI] -77, 36) and gestational age (0.4 days, 95% CI -0.9, 1.8). Women with three or more fibroids were more likely to have lighter infants (-201 grams, 95% CI -345, -58).
CONCLUSIONS - Race or ethnicity substantially confounds the associations. The clinical belief that uterine fibroids impair fetal growth is supported only by a significant decrease in birthweight for women with multiple fibroids.
Copyright © 2020 Elsevier Inc. All rights reserved.
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12 MeSH Terms
Week-by-week alcohol consumption in early pregnancy and spontaneous abortion risk: a prospective cohort study.
Sundermann AC, Velez Edwards DR, Slaughter JC, Wu P, Jones SH, Torstenson ES, Hartmann KE
(2021) Am J Obstet Gynecol 224: 97.e1-97.e16
MeSH Terms: Abortion, Spontaneous, Adult, Alcohol Drinking, Cohort Studies, Female, Gestational Age, Humans, Pregnancy, Prenatal Care, Prospective Studies, Risk Factors, United States, Young Adult
Show Abstract · Added August 5, 2020
BACKGROUND - Half of women use alcohol in the first weeks of gestation, but most stop once pregnancy is detected. The relationship between timing of alcohol use cessation in early pregnancy and spontaneous abortion risk has not been determined.
OBJECTIVE - This study aimed to evaluate the association between week-by-week alcohol consumption in early pregnancy and spontaneous abortion.
STUDY DESIGN - Participants in Right from the Start, a community-based prospective pregnancy cohort, were recruited from 8 metropolitan areas in the United States (2000-2012). In the first trimester, participants provided information about alcohol consumed in the prior 4 months, including whether they altered alcohol use; date of change in use; and frequency, amount, and type of alcohol consumed before and after change. We assessed the association between spontaneous abortion and week of alcohol use, cumulative weeks exposed, number of drinks per week, beverage type, and binge drinking.
RESULTS - Among 5353 participants, 49.7% reported using alcohol during early pregnancy and 12.0% miscarried. Median gestational age at change in alcohol use was 29 days (interquartile range, 15-35 days). Alcohol use during weeks 5 through 10 from last menstrual period was associated with increased spontaneous abortion risk, with risk peaking for use in week 9. Each successive week of alcohol use was associated with an 8% increase in spontaneous abortion relative to those who did not drink (adjusted hazard ratio, 1.08; 95% confidence interval, 1.04-1.12). This risk is cumulative. In addition, risk was not related to number of drinks per week, beverage type, or binge drinking.
CONCLUSION - Each additional week of alcohol exposure during the first trimester increases risk of spontaneous abortion, even at low levels of consumption and when excluding binge drinking.
Copyright © 2020 Elsevier Inc. All rights reserved.
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13 MeSH Terms
Primary prevention of venous thromboembolism with apixaban for multiple myeloma patients receiving immunomodulatory agents.
Cornell RF, Goldhaber SZ, Engelhardt BG, Moslehi J, Jagasia M, Harrell S, Rubinstein SM, Hall R, Wyatt H, Piazza G
(2020) Br J Haematol 190: 555-561
MeSH Terms: Aged, Comorbidity, Consolidation Chemotherapy, Factor Xa Inhibitors, Female, Hemorrhage, Humans, Immunologic Factors, Lenalidomide, Maintenance Chemotherapy, Male, Middle Aged, Multiple Myeloma, Myocardial Infarction, Pilot Projects, Proof of Concept Study, Prospective Studies, Pulmonary Embolism, Pyrazoles, Pyridones, Stroke, Thalidomide, Thrombophilia, Venous Thromboembolism, Venous Thrombosis
Show Abstract · Added May 29, 2020
Immunomodulatory drugs (IMiDs) have improved survival of patients with multiple myeloma (MM) and comprise the therapeutic backbone at all phases of therapy. Although well-tolerated, IMiDs increase rates of venous thromboembolism (VTE). In this phase IV, single-arm pilot study, fifty patients with MM on IMiDs received apixaban 2·5 mg orally twice daily for primary prevention of VTE and were prospectively monitored for six months. The primary safety outcomes were rates of major haemorrhage and clinically relevant non-major haemorrhage over six months. The primary efficacy outcome was the rate of symptomatic VTE over six months. IMiDs used were lenalidomide (58%) or pomalidomide (42%). During the six-month evaluation period, no patients experienced major haemorrhage or VTE. Three patients experienced clinically relevant, non-major haemorrhage which was managed medically, and all were able to resume apixaban. One patient stopped therapy shortly after initiation due to an allergic reaction to apixaban. No patients experienced stroke, myocardial infarction, or death. In this pilot study, low-dose apixaban was safe and well-tolerated as a primary prevention therapy of VTE for patients with MM receiving IMiDs. Further studies are needed to validate low-dose apixaban as a standard primary prevention anti-thrombotic strategy for patients with MM receiving IMiDs.
© 2020 British Society for Haematology and John Wiley & Sons Ltd.
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25 MeSH Terms
Development and Validation of a Penicillin Allergy Clinical Decision Rule.
Trubiano JA, Vogrin S, Chua KYL, Bourke J, Yun J, Douglas A, Stone CA, Yu R, Groenendijk L, Holmes NE, Phillips EJ
(2020) JAMA Intern Med 180: 745-752
MeSH Terms: Aged, Anti-Bacterial Agents, Clinical Decision Rules, Drug Hypersensitivity, Female, Humans, Male, Middle Aged, Penicillins, Prospective Studies, Risk Assessment
Show Abstract · Added March 30, 2020
Importance - Penicillin allergy is a significant public health issue for patients, antimicrobial stewardship programs, and health services. Validated clinical decision rules are urgently needed to identify low-risk penicillin allergies that potentially do not require penicillin skin testing by a specialist.
Objective - To develop and validate a penicillin allergy clinical decision rule that enables point-of-care risk assessment of patient-reported penicillin allergies.
Design, Setting, and Participants - In this diagnostic study, a multicenter prospective antibiotic allergy-tested cohort of 622 patients from 2 tertiary care sites in Melbourne, Australia (Austin Health and Peter MacCallum Cancer Centre) was used for derivation and internal validation of a penicillin allergy decision rule. Backward stepwise logistic regression was used to derive the model, including clinical variables predictive of a positive penicillin allergy test result. Internal validation of the final model used bootstrapped samples and the model scoring derived from the coefficients. External validation was performed in retrospective penicillin allergy-tested cohorts consisting of 945 patients from Sydney and Perth, Australia, and Nashville, Tennessee. Patients who reported a penicillin allergy underwent penicillin allergy testing using skin prick, intradermal, or patch testing and/or oral challenge (direct or after skin testing). Data were collected from June 26, 2008, to June 3, 2019, and analyzed from January 9 to 12, 2019.
Main Outcomes and Measures - The primary outcome for the model was any positive result of penicillin allergy testing performed during outpatient or inpatient assessment.
Results - From an internal derivation and validation cohort of 622 patients (367 female [59.0%]; median age, 60 [interquartile range{IQR}, 48-71] years) and an external validation cohort of 945 patients (662 female [70.1%]; median age, 55 [IQR, 38-68] years), the 4 features associated with a positive penicillin allergy test result on multivariable analysis were summarized in the mnemonic PEN-FAST: penicillin allergy, five or fewer years ago, anaphylaxis/angioedema, severe cutaneous adverse reaction (SCAR), and treatment required for allergy episode. The major criteria included an allergy event occurring 5 or fewer years ago (2 points) and anaphylaxis/angioedema or SCAR (2 points); the minor criterion (1 point), treatment required for an allergy episode. Internal validation showed minimal mean optimism of 0.003 with internally validated area under the curve of 0.805. A cutoff of less than 3 points for PEN-FAST was chosen to classify a low risk of penicillin allergy, for which only 17 of 460 patients (3.7%) had positive results of allergy testing, with a negative predictive value of 96.3% (95% CI, 94.1%-97.8%). External validation resulted in similar findings.
Conclusions and Relevance - In this study, PEN-FAST was found to be a simple rule that accurately identified low-risk penicillin allergies that do not require formal allergy testing. The results suggest that a PEN-FAST score of less than 3, associated with a high negative predictive value, could be used by clinicians and antimicrobial stewardship programs to identify low-risk penicillin allergies at the point of care.
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11 MeSH Terms
Randomised trial of azithromycin to eradicate in preterm infants.
Viscardi RM, Terrin ML, Magder LS, Davis NL, Dulkerian SJ, Waites KB, Ambalavanan N, Kaufman DA, Donohue P, Tuttle DJ, Weitkamp JH, Hassan HE, Eddington ND
(2020) Arch Dis Child Fetal Neonatal Ed 105: 615-622
MeSH Terms: Anti-Bacterial Agents, Azithromycin, Bronchopulmonary Dysplasia, Double-Blind Method, Drug Administration Schedule, Female, Gestational Age, Humans, Infant, Extremely Premature, Infant, Newborn, Infant, Premature, Diseases, Intensive Care Units, Neonatal, Intention to Treat Analysis, Male, Prospective Studies, Respiratory Tract Infections, Risk Factors, Ureaplasma Infections
Show Abstract · Added April 16, 2021
OBJECTIVE - To test whether azithromycin eradicates from the respiratory tract in preterm infants.
DESIGN - Prospective, phase IIb randomised, double-blind, placebo-controlled trial.
SETTING - Seven level III-IV US, academic, neonatal intensive care units (NICUs).
PATIENTS - Infants 24-28 weeks' gestation (stratified 24-26; 27-28 weeks) randomly assigned within 4 days following birth from July 2013 to August 2016.
INTERVENTIONS - Intravenous azithromycin 20 mg/kg or an equal volume of D5W (placebo) every 24 hours for 3 days.
MAIN OUTCOME MEASURES - The primary efficacy outcome was -free survival. Secondary outcomes were all-cause mortality, clearance, physiological bronchopulmonary dysplasia (BPD) at 36 weeks' postmenstrual age, comorbidities of prematurity and duration of respiratory support.
RESULTS - One hundred and twenty-one randomised participants (azithromycin: n=60; placebo: n=61) were included in the intent-to-treat analysis (mean gestational age 26.2±1.4 weeks). Forty-four of 121 participants (36%) were positive (azithromycin: n=19; placebo: n=25). -free survival was 55/60 (92% (95% CI 82% to 97%)) for azithromycin compared with 37/61 (61% (95% CI 48% to 73%)) for placebo. Mortality was similar comparing the two treatment groups (5/60 (8%) vs 6/61 (10%)). Azithromycin effectively eradicated in all azithromycin-assigned colonised infants, but 21/25 (84%) -colonised participants receiving placebo were culture positive at one or more follow-up timepoints. Most of the neonatal mortality and morbidity was concentrated in 21 infants with lower respiratory tract colonisation. In a subgroup analysis, physiological BPD-free survival was 5/10 (50%) (95% CI 19% to 81%) among azithromycin-assigned infants with lower respiratory tract colonisation versus 2/11 (18%) (95% CI 2% to 52%) in placebo-treated infants.
CONCLUSION - A 3-day azithromycin regimen effectively eradicated respiratory tract colonisation in this study.
TRIAL REGISTRATION NUMBER - NCT01778634.
© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.
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Genetic Susceptibility for Atrial Fibrillation in Patients Undergoing Atrial Fibrillation Ablation.
Shoemaker MB, Husser D, Roselli C, Al Jazairi M, Chrispin J, Kühne M, Neumann B, Knight S, Sun H, Mohanty S, Shaffer C, Thériault S, Rinke LL, Siland JE, Crawford DM, Ueberham L, Zardkoohi O, Büttner P, Geelhoed B, Blum S, Aeschbacher S, Smith JD, Van Wagoner DR, Freudling R, Müller-Nurasyid M, Montgomery J, Yoneda Z, Wells Q, Issa T, Weeke P, Jacobs V, Van Gelder IC, Hindricks G, Barnard J, Calkins H, Darbar D, Michaud G, Kääb S, Ellinor P, Natale A, Chung M, Nazarian S, Cutler MJ, Sinner MF, Conen D, Rienstra M, Bollmann A, Roden DM, Lubitz S
(2020) Circ Arrhythm Electrophysiol 13: e007676
MeSH Terms: Aged, Atrial Fibrillation, Body Surface Potential Mapping, Catheter Ablation, Female, Follow-Up Studies, Genetic Predisposition to Disease, Humans, Male, Middle Aged, Multifactorial Inheritance, Polymorphism, Single Nucleotide, Preoperative Period, Prognosis, Prospective Studies, Recurrence
Show Abstract · Added March 24, 2020
BACKGROUND - Ablation is a widely used therapy for atrial fibrillation (AF); however, arrhythmia recurrence and repeat procedures are common. Studies examining surrogate markers of genetic susceptibility to AF, such as family history and individual AF susceptibility alleles, suggest these may be associated with recurrence outcomes. Accordingly, the aim of this study was to test the association between AF genetic susceptibility and recurrence after ablation using a comprehensive polygenic risk score for AF.
METHODS - Ten centers from the AF Genetics Consortium identified patients who had undergone de novo AF ablation. AF genetic susceptibility was measured using a previously described polygenic risk score (N=929 single-nucleotide polymorphisms) and tested for an association with clinical characteristics and time-to-recurrence with a 3 month blanking period. Recurrence was defined as >30 seconds of AF, atrial flutter, or atrial tachycardia. Multivariable analysis adjusted for age, sex, height, body mass index, persistent AF, hypertension, coronary disease, left atrial size, left ventricular ejection fraction, and year of ablation.
RESULTS - Four thousand two hundred seventy-six patients were eligible for analysis of baseline characteristics and 3259 for recurrence outcomes. The overall arrhythmia recurrence rate between 3 and 12 months was 44% (1443/3259). Patients with higher AF genetic susceptibility were younger (<0.001) and had fewer clinical risk factors for AF (=0.001). Persistent AF (hazard ratio [HR], 1.39 [95% CI, 1.22-1.58]; <0.001), left atrial size (per cm: HR, 1.32 [95% CI, 1.19-1.46]; <0.001), and left ventricular ejection fraction (per 10%: HR, 0.88 [95% CI, 0.80-0.97]; =0.008) were associated with increased risk of recurrence. In univariate analysis, higher AF genetic susceptibility trended towards a higher risk of recurrence (HR, 1.08 [95% CI, 0.99-1.18]; =0.07), which became less significant in multivariable analysis (HR, 1.06 [95% CI, 0.98-1.15]; =0.13).
CONCLUSIONS - Higher AF genetic susceptibility was associated with younger age and fewer clinical risk factors but not recurrence. Arrhythmia recurrence after AF ablation may represent a genetically different phenotype compared to AF susceptibility.
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Association of neuronal repair biomarkers with delirium among survivors of critical illness.
Hayhurst CJ, Patel MB, McNeil JB, Girard TD, Brummel NE, Thompson JL, Chandrasekhar R, Ware LB, Pandharipande PP, Ely EW, Hughes CG
(2020) J Crit Care 56: 94-99
MeSH Terms: Aged, Biomarkers, Brain-Derived Neurotrophic Factor, Critical Illness, Delirium, Female, Humans, Inflammation, Male, Middle Aged, Multivariate Analysis, Patient Discharge, Prevalence, Prospective Studies, Respiratory Insufficiency, Shock, Survivors, Treatment Outcome, Ubiquitin Thiolesterase
Show Abstract · Added January 27, 2020
PURPOSE - Delirium is prevalent but with unclear pathogenesis. Neuronal injury repair pathways may be protective. We hypothesized that higher concentrations of neuronal repair biomarkers would be associated with decreased delirium in critically ill patients.
MATERIALS AND METHODS - We performed a nested study of hospital survivors within a prospective cohort that enrolled patients within 72 h of respiratory failure or shock. We measured plasma concentrations of ubiquitin carboxyl-terminal-esterase-L1 (UCHL1) and brain-derived neurotrophic factor (BDNF) from blood collected at enrollment. Delirium was assessed twice daily using the CAM-ICU. Multivariable regression was used to examine the associations between biomarkers and delirium prevalence/duration, adjusting for covariates and interactions with age and IL-6 plasma concentration.
RESULTS - We included 427 patients with a median age of 59 years (IQR 48-69) and APACHE II score of 25 (IQR 19-30). Higher plasma concentration of UCHL1 on admission was independently associated with lower prevalence of delirium (p = .04) but not associated with duration of delirium (p = .06). BDNF plasma concentration was not associated with prevalence (p = .26) or duration of delirium (p = .36).
CONCLUSIONS - During critical illness, higher UCHL1 plasma concentration is associated with lower prevalence of delirium; BDNF plasma concentration is not associated with delirium. Clinical trial number: NCT00392795; https://clinicaltrials.gov/ct2/show/NCT00392795.
Copyright © 2019 Elsevier Inc. All rights reserved.
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19 MeSH Terms