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Journal of General Internal Medicine
Journal Prestige (SJR): 1.612
Citation Impact (citeScore): 2
Number of Followers: 23  
 
  Hybrid Journal Hybrid journal (It can contain Open Access articles)
ISSN (Print) 1525-1497 - ISSN (Online) 0884-8734
Published by Springer-Verlag Homepage  [2658 journals]
  • Letter to the Editor in Response to: My Son, My Interpreter

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      PubDate: 2021-10-20
       
  • Vaccine Hesitancy and Exposure to Misinformation: a Survey Analysis

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      Abstract: Introduction Despite the widespread availability of SARS-CoV-2 vaccines in the USA, vaccine hesitancy continues to represent a significant impediment to the attainment of herd immunity and the end of the COVID-19 pandemic. This survey analysis provides an update for clinical healthcare providers and public health officials regarding current trends in misinformation exposure, as well as common objections to COVID-19 vaccination. Methods We conducted a web-based survey of 600 adults in the state of Florida between June 3 and June 14, 2021. Access to the sample was purchased through an industry-leading market research provider (Prodege MR), and survey respondents were selected using a stratified, quota sampling approach to ensure representativeness. Balanced quotas were determined (by region of the state) for gender, age, race, education, and ethnicity. The survey responses were analyzed using basic descriptive statistics, as well as chi-square testing and a logit regression model. Findings High levels of misinformation exposure were observed among participants, with 73% reporting some exposure to misinformation about COVID-19 vaccines in the past 6 months. Exposure to misinformation was directly correlated with vaccine hesitancy. Among those who did not report any exposure to misinformation, 73.8% of respondents were vaccinated. That number fell to 62.9% with exposure to just one misinformation theme and 52.2% for six or more (χ2 = 11.349; φ = 0.138; p ≤ 0.05). Politicization was also found to be a major factor in vaccine hesitancy, with 73.4% of self-identified Democrats being vaccinated, compared to only 58.5% of Republicans and 56.5% of Independents (χ2 = 16.334; φ = 0.165; p ≤ 0.001). Both misinformation exposure and political affiliation were strong predictors of vaccination even after accounting for other demographic predictors. Discussion The survey results add to previous research on misinformation and vaccine hesitancy by quantifying exposure to specific misinformation themes and identifying its relationship to vaccine hesitancy. Overcoming these impediments to vaccination will require strategic and targeted messaging on the part of public health professionals, which may be aided by collaboration with political thought leaders. Understanding the volume and nature of misinformation themes the public is exposed to regarding COVID-19 vaccines may aid public health officials in targeting this vaccine messaging to more directly address reasons for vaccine hesitancy.
      PubDate: 2021-10-20
       
  • Approaches to Assessing and Adjusting for Selective Outcome Reporting in
           Meta-analysis

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      Abstract: Background Selective or non-reporting of study outcomes results in outcome reporting bias. Objective We sought to develop and assess tools for detecting and adjusting for outcome reporting bias. Design Using data from a previously published systematic review, we abstracted whether outcomes were reported as collected, whether outcomes were statistically significant, and whether statistically significant outcomes were more likely to be reported. We proposed and tested a model to adjust for unreported outcomes and compared our model to three other methods (Copas, Frosi, trim and fill). Our approach assumes that unreported outcomes had a null intervention effect with variance imputed based on the published outcomes. We further compared our approach to these models using simulation, and by varying levels of missing data and study sizes. Results There were 286 outcomes reported as collected from 47 included trials: 142 (48%) had the data provided and 144 (52%) did not. Reported outcomes were more likely to be statistically significant than those collected but for which data were unreported and for which non-significance was reported (RR, 2.4; 95% CI, 1.9 to 3.0). Our model and the Copas model provided similar decreases in the pooled effect sizes in both the meta-analytic data and simulation studies. The Frosi and trim and fill methods performed poorly. Limitations Single intervention of a single disease with only randomized controlled trials; approach may overestimate outcome reporting bias impact. Conclusion There was evidence of selective outcome reporting. Statistically significant outcomes were more likely to be published than non-significant ones. Our simple approach provided a quick estimate of the impact of unreported outcomes on the estimated effect. This approach could be used as a quick assessment of the potential impact of unreported outcomes.
      PubDate: 2021-10-19
       
  • The Use of Corticosteroids or Tocilizumab in COVID-19 Based on
           Inflammatory Markers

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      Abstract: Background The inflammatory cascade is the main cause of death in COVID-19 patients. Corticosteroids (CS) and tocilizumab (TCZ) are available to treat this escalation but which patients to administer it remains undefined. Objective We aimed to evaluate the efficacy of immunosuppressive/anti-inflammatory therapy in COVID-19, based on the degree of inflammation. Design A retrospective cohort study with data on patients collected and followed up from March 1st, 2020, to May 1st, 2021, from the nationwide Spanish SEMI-COVID-19 Registry. Patients under treatment with CS vs. those under CS plus TCZ were compared. Effectiveness was explored in 3 risk categories (low, intermediate, high) based on lymphocyte count, C-reactive protein (CRP), lactate dehydrogenase (LDH), ferritin, and d-dimer values. Patients A total of 21,962 patients were included in the Registry by May 2021. Of these, 5940 met the inclusion criteria for the present study (5332 were treated with CS and 608 with CS plus TCZ). Main Measures The primary outcome of the study was in-hospital mortality. Secondary outcomes were the composite variable of in-hospital mortality, requirement for high-flow nasal cannula (HFNC), non-invasive mechanical ventilation (NIMV), invasive mechanical ventilation (IMV), or intensive care unit (ICU) admission. Key Results A total of 5940 met the inclusion criteria for the present study (5332 were treated with CS and 608 with CS plus TCZ). No significant differences were observed in either the low/intermediate-risk category (1.5% vs. 7.4%, p=0.175) or the high-risk category (23.1% vs. 20%, p=0.223) after propensity score matching. A statistically significant lower mortality was observed in the very high–risk category (31.9% vs. 23.9%, p=0.049). Conclusions The prescription of CS alone or in combination with TCZ should be based on the degrees of inflammation and reserve the CS plus TCZ combination for patients at high and especially very high risk.
      PubDate: 2021-10-18
       
  • Unsheltered vs. Sheltered Adults Experiencing Homelessness: Health Care
           Spending and Utilization

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      PubDate: 2021-10-13
       
  • Modern Day Drapetomania: Calling Out Scientific Racism

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      PubDate: 2021-10-13
       
  • Observational study of patient characteristics associated with a timely
           diagnosis of dementia and mild cognitive impairment without dementia

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      Abstract: Background Timely diagnosis of cognitive impairment is a key goal of the National Plan to Address Alzheimer’s Disease, but studies of factors associated with a timely diagnosis are limited. Objective To identify patient characteristics associated with a timely diagnosis of dementia and mild cognitive impairment (MCI). Design Retrospective observational study using survey data from the Health and Retirement Study (HRS) from 1995-2016 (interview waves 3-13). Participants 4,760 respondents with incident dementia and 1,864 with incident MCI identified using longitudinal measures of cognitive functioning. Main measures Timely or delayed diagnosis based on the timing of a self or proxy report of a healthcare provider diagnosis in relation to respondents first dementia or MCI-qualifying cognitive score, sociodemographic characteristics, health status, health care utilization, insurance provider, and year of first qualifying score. Key results Only 26.0% of the 4,760 respondents with incident dementia and 11.4% of the 1,864 respondents with incident MCI received a timely diagnosis. Non-Hispanic Black respondents and respondents with less than a college degree were significantly less likely to receive a timely diagnosis of either dementia or MCI than Non-Hispanic White respondents (dementia odds ratio (OR): 0.61, 95% CI: 0.50, 0.75; MCI OR: 0.40, 95% CI: 0.23, 0.70) and those with a college degree (dementia OR for less than high school degree: 0.30, 95% CI: 0.23, 0.38; MCI OR: 0.36, 95% CI: 0.22, 0.60). Respondents that lived alone were also less likely to receive a timely diagnosis of dementia (OR: 0.69, 95% CI: 0.59, 0.81), though not MCI. Timely diagnosis of both conditions increased over time. Conclusions Targeting resources for timely diagnosis of cognitive impairment to individuals from racial and ethnic minorities, lower educational attainment, and living alone may improve detection and reduce disparities around timely diagnosis of dementia and MCI.
      PubDate: 2021-10-13
       
  • Multimorbidity and Inpatient Utilization Among Older Adults with Opioid
           Use Disorder in New York City

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      Abstract: Background Nationally, there is a sharp increase in older adults with opioid use disorder (OUD). However, we know little of the acute healthcare utilization patterns and medical comorbidities among this population. Objective This study describes the prevalence of chronic conditions, patterns of inpatient utilization, and correlates of high inpatient utilization among older adults with OUD in New York City (NYC). Design Retrospective longitudinal cohort study. Participants Patients aged ≥55 with OUD hospitalized in NYC in 2012 identified using data from New York State’s Statewide Planning and Research Cooperative System (SPARCS). Main Measures The prevalence of comorbid substance use diagnoses, chronic medical disease, and mental illness was measured using admission diagnoses from the index hospitalization. We calculated the ICD-Coded Multimorbidity-Weighted Index (MWI-ICD) for each patient to measure multimorbidity. We followed the cohort through September 30, 2015 and the outcome was the number of rehospitalizations for inpatient services in NYC. We compared patient-level factors between patients with the highest use of inpatient services (≥7 rehospitalizations) during the study period to low utilizers. We used multiple logistic regression to examine possible correlates of high inpatient utilization. Key Results Of 3669 adults aged ≥55 with OUD with a hospitalization in 2012, 76.4% (n=2803) had a subsequent hospitalization and accounted for a total of 22,801 rehospitalizations during the study period. A total of 24.7% of the cohort (n=906) were considered high utilizers and had a higher prevalence of alcohol and cocaine-related diagnoses, congestive heart failure, diabetes, schizophrenia, and chronic obstructive pulmonary disease. Multivariable predictors of high utilization included being a Medicaid beneficiary (adjusted odds ratio [aOR]=1.70, 95% confidence interval [CI]=1.37–2.11), alcohol-related diagnoses (aOR=1.43, 95% CI: 1.21–1.69), and increasing comorbidity measured by MWI-ICD (highest MWI-ICD quartile: aOR=1.98, 95% CI=1.59–2.48). Conclusions Among older adults with OUD admitted to the hospital, multimorbidity is strongly associated with high inpatient utilization.
      PubDate: 2021-10-13
       
  • Using a Virtual Platform to Teach Residents How to Respond to Bias

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      PubDate: 2021-10-12
       
  • Early Medical Students’ Experiences as System Navigators: Results of
           a Qualitative Study

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      Abstract: Purpose To explore how early meaningful experiential learning in community settings impacted medical students’ application of systems thinking, their perceptions of systems navigation, and their professional identity as health system change agents. Methods Following an immersive Health Systems Science course, first-year medical students partnered with veterans or newly arrived refugee families and served as health system patient navigators embedded within primary care teams for a year. Across two cohorts, fifty-six students participated in the elective. Three voluntary focus groups were conducted each year for a total of six groups with 50 patient navigator students. Inductive content analysis of focus group transcripts was conducted. Results Qualitative analysis produced three major themes: program impact on students, student impact on patients, and student perceptions of the role of healthcare providers. Students reported a rich understanding of social determinants of health. By improving patient awareness of health and well-being, building capacity to understand medical issues, and increasing medication adherence through teaching, students recognized their impact on patient care. The importance of interprofessional collaboration with social workers also emerged and helped shape students’ understanding of how they as physicians are part of a coordinated team working toward better patient care. Conclusion The Case Western Reserve University WR2 curriculum teaches students how to address complex determinants of health and how to consider their role in dynamic health systems. This study highlights rich themes that emerged from students as they recognized the context that creates health for both individuals and communities. It underscores the role of such experiences in reinforcing systems thinking and development of change agency, both contributing to their professional identity formation as physicians.
      PubDate: 2021-10-12
       
  • Effect of an Immersive Primary Care Training Program on Educational and
           Clinical Outcomes in an Internal Medicine Residency Training Program:
           Meeting the Training Needs of a Modern-Day Physician Workforce

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      Abstract: Background Residents planning careers in primary care have unique training needs that are not addressed in traditional internal medicine training programs, where there is a focus on inpatient training. There are no evidence-based approaches for primary care training. Objectives Design and test the effect of a novel immersive primary care training program on educational and clinical outcomes. Design Nested intervention study. Setting, Participants Twelve primary care residents, 86 of their categorical peers, and an 11-year historical cohort of 69 primary care trainees in a large urban internal medicine residency training program. Interventions Two 6-month blocks of primary care immersion alternating with two 6-month blocks of standard residency training during the second and third post-graduate years. Main Measures Total amount of ambulatory and inpatient training time, subjective and objective educational outcomes, clinical performance on cancer screening, and chronic disease management outcomes. Key Results Participants in the intervention increased ambulatory training in both general medicine and specialty medicine and still met all ACGME training requirements. Residents reported improved subjective educational outcomes on a variety of chronic disease management topics and ambulatory care skills. They reported higher satisfaction with the amount of ambulatory training (4.3/5 vs. 3.6/5, p=0.008), attended more ambulatory clinics (242 vs. 154, p<0.001), and carried larger, more complicated panels (173 vs. 90 patients, p<0.001). They also performed better on diabetes management (86% vs. 76% control, p<0.001). Alumni who completed the intervention reported higher primary care career preparation (79% response rate) than those who did not (85% response rate) among an 11-year cohort of primary care alumni (4/5 vs. 3/5, p<0.001). Conclusions A primary care training program that provides clinical immersion in the ambulatory setting improved educational outcomes for trainees and clinical outcomes for their patients. Providing more training in the ambulatory environment should be a priority in graduate medical education.
      PubDate: 2021-10-08
       
  • Differences in Burnout and Intent to Leave Between Women’s Health and
           General Primary Care Providers in the Veterans Health Administration

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      Abstract: Background Although they are a minority of patients served by the Veterans Health Administration (VHA), women Veterans comprise a fast-growing segment of these patients and have unique clinical needs. Women’s health primary care providers (WH-PCPs) are specially trained and designated to provide care for women Veterans. Prior work has demonstrated that WH-PCPs deliver better preventative care and have more satisfied patients than PCPs without the WH designation. However, due to unique clinical demands or other factors, WH-PCPs may experience more burnout and intent to leave practice than general PCPs in the VHA. Objective To examine differences in burnout and intent to leave practice among WH and general PCPs in the VHA. Design Multi-level logistic regression analysis of three cross-sectional waves of PCPs within the VHA using the national All Employee Survey and practice data (2017–2019). We modeled outcomes of burnout and intent to leave practice as a function of WH provider designation, gender, and other demographics and practice characteristics, such as support staff ratio, panel size, and setting. Participants A total of 7903 primary care providers (5152 general PCPs and 2751 WH-PCPs; response rates: 63.9%, 65.7%, and 67.5% in 2017, 2018, and 2019, respectively). Main Measures Burnout and intent to leave practice. Key Results WH-PCPs were more burned out than general PCPs (unadjusted: 55.0% vs. 46.9%, p<0.001; adjusted: OR=1.29, 95% confidence interval [CI] 1.10–1.55) but did not have a higher intention to leave (unadjusted: 33.4% vs. 32.1%, p=0.27; adjusted: OR=1.07, CI 0.81–1.41). WH-PCPs with intentions to leave were more likely to select the response option of “job-related (e.g., type of work, workload, burnout, boredom)” as their primary reason to leave. Conclusions Burnout is higher among WH-PCPs compared to general PCPs, even after accounting for provider and practice characteristics. More research on causes of and solutions for these differences in burnout is needed.
      PubDate: 2021-10-07
       
  • Are Veterans Getting Their Preferred Depression Treatment' A National
           Observational Study in the Veterans Health Administration

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      Abstract: Background Physician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes. Objective To examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment. Design Patient self-report surveys at treatment initiation linked to medical records. Setting Veterans Health Administration (VA) clinics nationally, 2018–2020. Participants A total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White) Main Measures Patient self-reported preferences for medication and psychotherapy on 0–10 self-anchoring visual analog scales (0=“completely unwilling”; 10=“completely willing”). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables. Key Results More patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ21=175.3, p<0.001). A total of 32.1% of patients who preferred (7–10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5–24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0–3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4–7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence. Conclusions Mismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.
      PubDate: 2021-10-06
       
  • Rapid Discontinuation of Chronic, High-Dose Opioid Treatment for Pain:
           Prevalence and Associated Factors

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      Abstract: Purpose To examine the prevalence of rapid discontinuation of chronic, high-dose opioid analgesic treatment, and identify associated patient, clinician, and community factors. Methods Using 2017–2018 retail pharmacy claims data from IQVIA, we identified chronic, high-dose opioid analgesic treatment episodes discontinued during these years and determined the percent of episodes meeting criteria for rapid discontinuation. We used multivariable logistic regression to estimate the probability of rapid discontinuation, conditional on having a discontinued chronic, high-dose opioid treatment episode, as a function of patient, provider, and county characteristics. Results We identified 810,120 new, chronic, high-dose opioid treatment episodes discontinued in 2017 or 2018, of which 72.0% (n=583,415) were rapidly discontinued. Rapid discontinuation was significantly more likely among Medicare (aOR 1.14, 95% CI 1.12 to 1.15) and Medicaid enrollees (aOR 1.03, 95% CI 1.02 to 1.05) compared to the commercially insured; in counties with higher fatal overdose rates (aOR 1.03, 95% CI 1.01 to 1.04) compared to counties with the lowest fatal overdose rates; and in counties with a higher percentage of non-white residents (aOR 1.21 for counties in the highest quartile relative to the lowest, 95% CI 1.19 to 1.24). Likelihood of rapid discontinuation also varied by prescriber specialty. Conclusions Most chronic, high-dose opioid treatment episodes that ended in 2017 or 2018 were discontinued more rapidly than recommended by clinical guidelines, raising concerns about adverse patient outcomes. Our findings highlight the need to understand what drives discontinuation and to inform safer opioid tapering and discontinuation practices.
      PubDate: 2021-10-04
       
  • HbA1c-Triggered Endocrinology Electronic Consultation for Type 2 Diabetes
           Management

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      Abstract: Background Electronic consultation (eConsultation) offers a potential mechanism to increase access to specialty care, address knowledge gaps, and overcome therapeutic inertia in patients with type 2 diabetes (T2DM) being managed by primary care physicians (PCPs). Objective To develop and implement a system to provide unsolicited endocrinology eConsult for T2DM patients with HbA1c 8.5–10.5% managed by PCPs. Design Cluster-randomized matched cohort study with implementation evaluation. Participants PCPs affiliated with Massachusetts General Hospital (MGH). Interventions Unsolicited endocrinology eConsultation. Main Measures The primary clinical outcome was mean change in HbA1c at 6 months. Secondary process outcomes included referral completion rate, prescription rates of glucose-lowering medications, differences in rate of other management recommendations, change in all glucose-lowering medications, and number of face-to-face endocrinology visits. Key Results 161 PCPs were randomly assigned to intervention (n=81) and control (n=80) arms. eConsultations were triggered on 130 patients from intervention arm PCPs. Intervention arm patients had a 0.89 (SD 1.45) decrease in HbA1c compared to 0.69 (SD 1.32) decrease in the control arm (p=0.28). There were significant differences in prescribing of glucose-lowering medications between arms. There was a 19.3% increase in patients prescribed GLP-1 RA or SGLT2i in the intervention arm compared to a 6.9% increase in control (p=0.003). There were also significant increases in prescription rates of metformin (3.1% vs −3.1%, p=0.03) and sulfonylureas (1.5% vs −6.9%, p=0.03). At 6-month follow-up, the intervention arm had 13 in-person endocrinology visits compared to 29 (p=0.012) in the control arm. PCPs were more likely to accept recommendations regarding adherence to or dose adjustment of current medications than initiation of new medications. Conclusions The implementation of an unsolicited endocrinology eConsult system for patients with poorly controlled T2DM is feasible. Unsolicited eConsultation was associated with increased prescribing of glucose-lowering medications without significant difference in HbA1c. Trial Registration Clinicaltrials.gov registration: NCT03542084
      PubDate: 2021-10-04
       
  • Primary Care’s Effects on Costs in the US Veterans Health
           Administration, 2016–2019: an Observational Cohort Study

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      Abstract: Background Enhancing primary care is a promising strategy for improving the efficiency of health care. Previous studies of primary care’s effects on health expenditures have mostly relied on ecological analyses comparing region-wide expenditures rather than spending for individual patients. Objective To compare overall medical expenditures for individual patients enrolled vs. those not enrolled in primary care in the Veterans Health Administration (VHA). Design Cohort study with stratification for clinical risk and multivariable linear regression models adjusted for clinical and demographic confounders of expenditures. Participants In total, 6,009,973 VHA patients in fiscal year (FY) 2019—5,410,034 enrolled with a primary care provider (PCP) and 599,939 without a PCP—and similar numbers in FYs 2016–2018. Main Measures Total annual cost per patient to the VHA (including VHA payments to non-VHA providers) stratified by a composite health risk score previously shown to predict VHA expenditures, and multivariate models additionally adjusted for VHA regional differences, patients’ demographic characteristics, non-VHA insurance coverage, and driving time to the nearest VHA facility. Sensitivity analyses explored different modeling strategies and risk adjusters, as well as the inclusion of expenditures by the Medicare program that covers virtually all elderly VHA patients for care not paid for by the VHA. Key Results Within each health-risk decile, non-PCP patients had higher outpatient, inpatient, and total costs than those with a PCP. After adjustment for health risk and other factors, lack of a PCP was associated 27.4% higher VHA expenditures, $3274 per patient annually (p < .0001). Sensitivity analyses using different risk adjusters and including Medicare’s spending for VHA patients yielded similar results. Conclusions In the VHA system, primary care is associated with substantial cost savings. Investments in primary care in other settings might also be cost-effective.
      PubDate: 2021-10-04
       
  • In Response: Physician Tolerance of Uncertainty

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      PubDate: 2021-10-01
       
  • Reply Physician Tolerance of Uncertainty

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      PubDate: 2021-10-01
       
  • The Importance of Glucose Optimization Prior to FDG-PET Imaging in the
           Diagnosis of Cardiac Sarcoidosis

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      PubDate: 2021-10-01
       
  • Prolapse of the Urinary Bladder into the Groin: a Case of Inguinal Bladder
           Hernia

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      PubDate: 2021-10-01
       
 
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