Alex J Mitchell see www.psycho-oncology.info Acknowledgements Oliver Lord Darren Malone Caroline Carney-Doebbling Nasser A...
Contents <ul><li>Mental Health & Physical Health  </li></ul><ul><ul><li>Mortality | Impairment | Co-morbidity </li></ul></...
Quality of medical care In medical settings Quality of preventive care (mass screening) Quality of Psychiatric medical car...
<ul><li>Physical Health Comorbidity / Mortality </li></ul>
Merikangas (2007) NCS-R (n=5962) : disability days
Days totally out of role per year Alonso (2010) WHO MH Survey n=62,971
How much physical co-morbidity is there in mental ill health?
Sokal 2004 J Nerv Ment Dis 192: 421– 427 NHANES - US Department of Health National Health and Nutrition Examination Survey...
Gili et al (2011) 10,257 Primary care in Spain
Metabolic syndrome meta-analysis in schizophrenia  (Mitchell, DeHert et al unpublished)
MetS in First episode Patients Saddichha S et al. Schizophr Res 2008;101:266-72.
Lawrence & Coghlan  N S W Public Health Bull 2002; 13(7): 155–158  n=240,000
Five-year Mortality rates Hippisley-Cox J et al (2006)  A comparison of survival rates for people with mental health probl...
2. Preventive Health Care Inequality Should vulnerable patients receive similar or enhanced care?
Annual physical health checks ( NSF for mental health/NICE guidance) <ul><li>Blood pressure & weight/BMI </li></ul><ul><li...
Mass Screening activities <ul><li>Mammography </li></ul><ul><li>Pap. Smear </li></ul><ul><li>Lifestyle counselling </li></...
<ul><li>USPST recommendations </li></ul><ul><ul><li>Screening mammography  </li></ul></ul><ul><ul><li>every 1-2 years star...
3. Medical Health Care Inequality Medical monitoring eg HBA1c Medical procedures eg CABG Medical prescribing eg Aspirin po...
Frayne et al.  Arch Intern Med . 2005 Diab care 313,586  Veteran Health Authority patients with diabetes 76,799 (25%) had ...
Quality of Care - MI vs No MI <ul><li>27 examined receipt of medical care in those with and without mental illness </li></...
3b. Inequalities in Procedures CABG –  Coronary artery bypass graft CC -  Cardiac catheterization PTCA –  Percutaneous tra...
Lawrence et al
Any Mental illness HR = 0.86 (0.80-0.92) Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction
Schizophrenia HR = 0.53 (0.44 – 0.64) Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction
3c. Medication Prescribing Inequalities Aspirin ACE Inhibitors Statin / non-statin B-Blockers HAART HRT Chemotherapy
OR =0.94  (0.90-0.96) OR =0.69  (0.57-0.83) OR =0.72  (0.51-1.00) SMI Schz Affective Inequality of Prescribed Meds  ii Med...
OR =0.77  (0.69-0.86) Inequality of Prescribed Meds  ii Medication by ALL
OR =0.79 OR =0.99 ns OR =0.83 OR =0.84 ns Inequality of Prescribed Meds  ii Medication by drug class
OR =0.94 ns OR =0.96
4. Inequality in Physical Care in Psychiatry
Physical Screening of Psychiatric Patients <ul><li>57.6% of inpatients receive a comprehensive physical examination  (Hodg...
Bobes et al (2010) n=1193, 229 psychiatrists
Screening for metabolic side effects in AO clients <ul><li>Review of 1966 case records from 53 teams, Barnes et al (2007) ...
Rothbard et al Psychiatric Services 2009; 60(4); (n=588)
Rothbard et al Proportion of Missed Medical Conditions……
Solution?......is the solution in (more) guidelines?
Summary of Monitoring Protocol American Diabetes Association and the American Psychiatric Association (ADA/ APA/AACE/NAASO...
 
Monitoring Guidelines Simplified Adapted from Cohn TA, Sernyak M. Metabolic monitoring for patients treated with antipsych...
HR= 0.42 (0.34-0.50) Initiating antipsychotics
N=6000 pre-guideline N=18,000 post guideline
Conclusions <ul><li>Co-morbidity and mortality is high </li></ul><ul><li>Excess medical deaths > non-accidental deaths 4:1...
5. Extras - Implication for Mortality
 
 
Quality of Care Influencing=> Mortality? <ul><li>Druss et al 2000 113,653 </li></ul><ul><li>Druss et al 2001 88,241 </li><...
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[ppt] RCpsych - Failing medical care of psychiatric patients (vMar11)

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This is a 30min talk given at the RCPsych liaison conference 2011 on the topic of the failing (suboptimal) medical care provided to psychiatric patients by physicians and psychiatrists. Available in free full text PPT for a limited period.

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  • Days out of role because of health problems are a major source of lost human capital. We examined the relative importance of commonly occurring physical and mental disorders in accounting for days out of role in 24 countries that participated in the World Health Organization (WHO) World Mental Health (WMH) surveys. Face-to-face interviews were carried out with 62 971 respondents (72.0% pooled response rate). Presence of ten chronic physical disorders and nine mental disorders was assessed for each respondent along with information about the number of days in the past month each respondent reported being totally unable to work or carry out their other normal daily activities because of problems with either physical or mental health. Multiple regression analysis was used to estimate associations of specific conditions and comorbidities with days out of role, controlling by basic socio-demographics (age, gender, employment status and country). Overall, 12.8% of respondents had some day totally out of role, with a median of 51.1 a year. The strongest individual-level effects (days out of role per year) were associated with neurological disorders (17.4), bipolar disorder (17.3) and post-traumatic stress disorder (15.2). The strongest population-level effect was associated with pain conditions, which accounted for 21.5% of all days out of role (population attributable risk proportion). The 19 conditions accounted for 62.2% of all days out of role. Common health conditions, including mental disorders, make up a large proportion of the number of days out of role across a wide range of countries and should be addressed to substantially increase overall productivity. Molecular Psychiatry advance online publication, 12 October 2010; doi:10.1038/mp.2010.101
  • Abstract: We studied the medical comorbidity among individuals with serious mental illness who were receiving community-based psychiatric treatment. A total of 200 psychiatric outpatients divided between those with schizophrenia and affective disorder diagnoses were recruited from samples receiving outpatient care at two psychiatric centers. Interviews used questions from national health surveys. Logistic regression analyses compared responses from each sample with those of matched subsets of individuals from the general population. Both patient groups had greater odds of having many medical conditions. The odds of respiratory illnesses remained elevated in the patient groups even after controlling for smoking, as did the odds of diabetes in the affective disorder group after controlling for weight. Persons with serious mental illness who are in outpatient care are more likely to have comorbid medical conditions than persons in the general population. The odds of diabetes, lung diseases, and liver problems are particularly elevated. These findings underscore the need for intensified preventive health interventions and medical services for this population. Key Words: Comorbidity, medical, schizophrenia. ( J Nerv Ment Dis 2004;192: 421– 427) We hoped to overcome these deficiencies by using a thorough survey and a comparison group from the National Health Interview Survey (NHIS; US Department of Health and Human Services, 1998) and the National Health and Nutrition Examination Survey (NHANES; US Department of Health and Human Services, 1988 –1994). The purpose of the current study was to compare the prevalence of a variety of medical comorbidities among persons with schizophrenia and affective disorder (AD) with each other and with the prevalence in a matched control group from the general population. We hypothesized that the mentally ill groups would have higher comorbidity rates than the general population. We then used post hoc analyses to assess the extent to which the modifiable risk factors of smoking and body mass index (BMI) change the odds of having hypertension, diabetes, and respiratory disease in the psychiatric groups, anticipating that such modifiable factors would account for part of the increased comorbidity rates we expected to observe.
  • 65% of depressions treated in primary care Gili M, Garcia-Toro M, Vives M, Armengol S, Garcia-Campayo J, Soriano JB, Roca M. Medical comorbidity in recurrent versus .rstepisode depressive patients. Objective: This study compares the comorbidity of a.ective disorders and medical diseases in primary care patients with either a .rst or recurrent depressive episode. Method: A cross-sectional epidemiological study in primary care centres in Spain was designed. A total of 10 257 primary care patients su.ering a DSM-IV major depressive episode (MDD) were analysed. Depression was assessed using the Montgomery–Asberg Depression Rating Scale (MADRS), and World Health Organization (WHO) medical diagnoses were provided by the patients general practitioner according to medical records revised on the basis of radiology or laboratory test data. Results: A total of 88.6% of recurrent patients and 71.1% of .rstepisode depressive patients reported a medical condition (aOR = 2.61, CI = 2.31–2.93). All medical conditions were more prevalent in the recurrent group than in .rst-episode group, and with the exception of myocardial infarction, psoriasis and migraine, all other crude ORs showed statistically signi.cant di.erences between .rst- and recurrent episodes patients after adjusting for gender, age, education, socioeconomic status and body mass index (BMI). Conclusion: Recurrent depression is associated with a decrement in health that is signi.cantly greater than in .rst-episode depression. Special attention needs to be paid to the physical health in the middleand long-term management of patients with a.ective disorders.
  • Lawrence and Coghlan N S W Public Health Bull 2002; 13(7): 155–158
  • Data on uptake of all of these Bold ones are those recommended in England
  • ACS - Acute coronary syndrome (ACS) CABG – Coronary artery bypass graft CC - Cardiac catheterization PTCA – Percutaneous transluminal coronary angioplasty PCI - Percutaneous coronary intervention
  • ACS - Acute coronary syndrome (ACS) CABG – Coronary artery bypass graft CC - Cardiac catheterization PTCA – Percutaneous transluminal coronary angioplasty PCI - Percutaneous coronary intervention
  • Rfichard hodgson
  • Bobes J, Alegría AA, Saiz-Gonzalez MD, Barber I, Pérez JL, Saiz-Ruiz J. Change in psychiatrists&apos; attitudes towards the physical health care of patients with schizophrenia coinciding with the dissemination of the consensus on physical health in patients with schizophrenia. Eur Psychiatry. 2010 Purpose. – To evaluate the impact of the ‘‘Spanish Consensus on Physical Health in Patients with Schizophrenia’’ on psychiatrists’ evaluations of the physical health of patients with schizophrenia. Method. – Epidemiological, non-interventional, national, multicentre study, with two retrospective, cross-sectional data collection stages in which 229 psychiatrists evaluated 1193 clinical records of patients with schizophrenia (ICD-10) seen in January and September of 2007. Results. – Mean age of the patients was 39.7 11.6 years, 65.5% were men, diagnosed for schizophrenia 14.0 10.3 years ago. Forty percent of the patients suffer from a concomitant disease, the most prevalent being hypercholesterolemia (46.3%), hypertriglyceridaemia (33.5%) and arterial hypertension (26.0%). The difference in the number of patients who had all the physical measurements taken between the two cross-sectional evaluations was 13.8% (CI: 11.8%, 15.7%). The differences for each parameter were: weight 13.7% (CI: 11.7%, 15.6%), BMI 13.58% (CI: 11.6%, 15.5%), waist circumference 14.0% (CI: 12.0%, 15.39%), lipid pro.le 2.9% (CI: 1.9%, 3.9%) and glycaemia 2.6% (CI: 1.7%, 3.5%). Conclusions. – These results imply that the dissemination of the ‘‘Consensus on Physical Health in Schizophrenia Patients’’, and possibly other actions, has made psychiatrists more aware of an integral approach to patients with schizophrenia, promoting increasedmonitoring of the physical health of these patients. 2010 Elsevier Masson SAS. All rights reserved.
  • Rothbard et al PSYCHIATRIC SERVICES April 2009 Vol. 60 No. 4
  • Rothbard et al PSYCHIATRIC SERVICES April 2009 Vol. 60 No. 4
  • Useful consensus-based recommendations for screening and monitoring metabolic risks, specifically among schizophrenia patients, have been developed jointly by the American Diabetes Association and the American Psychiatric Association (ADA/ APA/AACE/NAASO, 2004; World Federation for Mental Health, 2005).
  • Background: This study investigated whether differences in quality of medical care might explain a portion of the excess mortality associated with mental disorders in the year after myocardial infarction. Methods: This study examined a national cohort of 88241 Medicare patients 65 years and older who were hospitalized for clinically confirmed acute myocardial infarction. Proportional hazard models compared the association between mental disorders and mortality before and after adjusting 5 established quality indicators: reperfusion, aspirin, b-blockers, angiotensin-converting enzyme inhibitors, and smoking cessation counseling. All models adjusted for eligibility for each procedure, demographic characteristics, cardiac risk factors and history, admission characteristics, left ventricular function, hospital characteristics, and regional factors. Results: After adjusting for the potential confounding factors, presence of any mental disorder was associated with a 19% increase in 1-year risk of mortality (hazard ratios [HR], 1.19; 95% confidence interval [CI], 1.04-1.36). After adding the 5 quality measures to the model, the association was no longer significant (HR, 1.10; 95% CI, 0.96-1.26). Similarly, while schizophrenia (HR, 1.34; 95% CI, 1.01-1.67) and major affective disorders (HR, 1.11; 95% CI, 1.02-1.20) were each initially associated with increased mortality, after adding the quality variables, neither schizophrenia (HR, 1.23; 95% CI, 0.86-1.60) nor major affective disorder (HR, 1.05; 95% CI, 0.87-1.23) remained a significant predictor. Conclusions: Deficits in quality of medical care seemed to explain a substantial portion of the excess mortality experienced by patients with mental disorders after myo-cardial infarction. The study suggests the potential importance of improving these patients’ medical care as a step toward reducing their excess mortality. Arch Gen Psychiatry. 2001;58:565-572
  • [ppt] RCpsych - Failing medical care of psychiatric patients (vMar11)

    1. 1. Alex J Mitchell see www.psycho-oncology.info Acknowledgements Oliver Lord Darren Malone Caroline Carney-Doebbling Nasser Abdelmawla Brett Thombs Roy Ziegelstein Jim Coyne Marc DeHert Davy Vancampfort Liaison faculty - Mar2011 Failing Medical Care of Psychiatric Patients Latest evidence on suboptimal medical care from physicians and psychiatrists
    2. 2. Contents <ul><li>Mental Health & Physical Health </li></ul><ul><ul><li>Mortality | Impairment | Co-morbidity </li></ul></ul><ul><li>Preventive Health Care Inequality </li></ul><ul><ul><li>Screening | prevention </li></ul></ul><ul><li>Medical Health Care Inequality </li></ul><ul><ul><li>Procedures | prescribing </li></ul></ul><ul><li>Physical and Metabolic Monitoring? </li></ul><ul><ul><li>Guidelines & responsibility </li></ul></ul><ul><li>Implications for Mortality </li></ul>
    3. 3. Quality of medical care In medical settings Quality of preventive care (mass screening) Quality of Psychiatric medical care Medication Prescribing in medical settings Procedures rate & Mortality
    4. 4. <ul><li>Physical Health Comorbidity / Mortality </li></ul>
    5. 5. Merikangas (2007) NCS-R (n=5962) : disability days
    6. 6. Days totally out of role per year Alonso (2010) WHO MH Survey n=62,971
    7. 7. How much physical co-morbidity is there in mental ill health?
    8. 8. Sokal 2004 J Nerv Ment Dis 192: 421– 427 NHANES - US Department of Health National Health and Nutrition Examination Survey , 1988 –1994
    9. 9. Gili et al (2011) 10,257 Primary care in Spain
    10. 10. Metabolic syndrome meta-analysis in schizophrenia (Mitchell, DeHert et al unpublished)
    11. 11. MetS in First episode Patients Saddichha S et al. Schizophr Res 2008;101:266-72.
    12. 12. Lawrence & Coghlan N S W Public Health Bull 2002; 13(7): 155–158 n=240,000
    13. 13. Five-year Mortality rates Hippisley-Cox J et al (2006) A comparison of survival rates for people with mental health problems and the remaining population with specific conditions. Disability Rights Commission. Equal treatment: closing the gap, July 2006 Slide credit: Dr Alan Farmer, Worcestershire Mental Health Partnership NHS Trust
    14. 14. 2. Preventive Health Care Inequality Should vulnerable patients receive similar or enhanced care?
    15. 15. Annual physical health checks ( NSF for mental health/NICE guidance) <ul><li>Blood pressure & weight/BMI </li></ul><ul><li>Lifestyle advice (smoking/diet/exercise/alcohol/drugs) </li></ul><ul><li>Urine/glucose test to exclude diabetes </li></ul><ul><li>Cholesterol check </li></ul><ul><li>Medication side effect monitoring (Include thyroid function & creatinine if on lithium) </li></ul><ul><li>Encourage screening in appropriate groups (cervical smears/mammography/hepatitis/HIV/high prolactin) </li></ul><ul><li>Offer flu vaccination and contraceptive advice </li></ul>
    16. 16. Mass Screening activities <ul><li>Mammography </li></ul><ul><li>Pap. Smear </li></ul><ul><li>Lifestyle counselling </li></ul><ul><li>Blood pressure </li></ul><ul><li>Bowel cancer screening </li></ul><ul><li>Prostate PSA </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Hepatitis & HIV tests </li></ul>
    17. 17. <ul><li>USPST recommendations </li></ul><ul><ul><li>Screening mammography </li></ul></ul><ul><ul><li>every 1-2 years starting at age 40 </li></ul></ul><ul><li>UK NSC (England) </li></ul><ul><ul><li>Age 50-70 every 3 years </li></ul></ul><ul><ul><li>OR of 0.7 </li></ul></ul><ul><ul><li>P<0.0001 </li></ul></ul><ul><ul><li>Receipt of Mammograpy by mental illness </li></ul></ul><ul><ul><li>(Mitchell, Lord currently unpublished) </li></ul></ul>
    18. 18. 3. Medical Health Care Inequality Medical monitoring eg HBA1c Medical procedures eg CABG Medical prescribing eg Aspirin post MI
    19. 19. Frayne et al. Arch Intern Med . 2005 Diab care 313,586 Veteran Health Authority patients with diabetes 76,799 (25%) had mental health conditions (1999) Depression Anxiety Psychosis Mania Substance use disorder Personality disorder 0.8 1.0 1.2 1.4 1.6 No HbA test done 0.8 1.0 1.2 1.4 1.6 No LDL test done 0.8 1.0 1.2 1.4 1.6 No Eye examination done 0.8 1.0 1.2 1.4 1.6 No Monitoring 0.8 1.0 1.2 1.4 1.6 Poor glycemic control 0.8 1.0 1.2 1.4 1.6 Poor lipemic control Odds ratio for:
    20. 20. Quality of Care - MI vs No MI <ul><li>27 examined receipt of medical care in those with and without mental illness </li></ul><ul><ul><li>19/27 showed deficits in care </li></ul></ul><ul><li>10 examined medical care in those with and without substance use disorder (or dual-diagnosis </li></ul><ul><ul><li>10/10 showed deficits in care </li></ul></ul>
    21. 21. 3b. Inequalities in Procedures CABG – Coronary artery bypass graft CC - Cardiac catheterization PTCA – Percutaneous transluminal coronary angioplasty PCI - Percutaneous coronary intervention
    22. 22. Lawrence et al
    23. 23. Any Mental illness HR = 0.86 (0.80-0.92) Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction
    24. 24. Schizophrenia HR = 0.53 (0.44 – 0.64) Meta-Analysis of Procedure Rate (PCI) after Myocardial Infarction
    25. 25. 3c. Medication Prescribing Inequalities Aspirin ACE Inhibitors Statin / non-statin B-Blockers HAART HRT Chemotherapy
    26. 26. OR =0.94 (0.90-0.96) OR =0.69 (0.57-0.83) OR =0.72 (0.51-1.00) SMI Schz Affective Inequality of Prescribed Meds ii Medication by Diagnosis
    27. 27. OR =0.77 (0.69-0.86) Inequality of Prescribed Meds ii Medication by ALL
    28. 28. OR =0.79 OR =0.99 ns OR =0.83 OR =0.84 ns Inequality of Prescribed Meds ii Medication by drug class
    29. 29. OR =0.94 ns OR =0.96
    30. 30. 4. Inequality in Physical Care in Psychiatry
    31. 31. Physical Screening of Psychiatric Patients <ul><li>57.6% of inpatients receive a comprehensive physical examination (Hodgson R, Adeyemo O. Physical examination performed by psychiatrists. International Journal of Psychiatry in Clinical Practice 2004;8:57-60.) </li></ul><ul><li>No dental health target achieved in 428 people with Schizophrenia McCreadie RG, et al The dental health of people with schizophrenia. Acta Psychiatrica Scandinavica 2004;110:306-10 ) </li></ul><ul><li>On screening at admission: 34% of older people had unrecognized medical disorders (Woo BKR, et al. Unrecognized medical disorders in older psychiatric inpatients in a senior behavioral health unit in a university hospital. Journal of Geriatric Psychiatry and Neurology 2003;16:121-5) </li></ul><ul><li>On screening at admission: 29% had physical disorder (80% previously known 20% new diagnoses). These were contributory to diagnosis in 5.5% (Koran LM, et al Medical disorders among patients admitted to a public-sector psychiatric inpatient unit. Psychiatric Services 2002;53:1623-5. </li></ul>
    32. 32. Bobes et al (2010) n=1193, 229 psychiatrists
    33. 33. Screening for metabolic side effects in AO clients <ul><li>Review of 1966 case records from 53 teams, Barnes et al (2007) </li></ul>Slide credit: Dr Alan Farmer, Worcestershire Mental Health Partnership NHS Trust % with recorded measurement over last 12 months Documented diagnosis Documented treatment Blood pressure 26% Hypertension 6% 48% Measure of obesity 17% Blood glucose 28% Diabetes 6% 62% Plasma lipids 22% Dyslipidaemia 6% 37% All of the above 11%
    34. 34. Rothbard et al Psychiatric Services 2009; 60(4); (n=588)
    35. 35. Rothbard et al Proportion of Missed Medical Conditions……
    36. 36. Solution?......is the solution in (more) guidelines?
    37. 37. Summary of Monitoring Protocol American Diabetes Association and the American Psychiatric Association (ADA/ APA/AACE/NAASO, 2004). Base line 4 wk 8 wk 12 wk Quart Ann 5 yr Personal/fam. Hist. X X Weight (BMI) X X X X X Waist circum. X X Blood press. X X X Fasting plasma glucose X X X Fasting lipid profile X X X
    38. 39. Monitoring Guidelines Simplified Adapted from Cohn TA, Sernyak M. Metabolic monitoring for patients treated with antipsychotic medications. Can J Psychiatry 2006;51:492–501.   US-Mount Sinai Australia US-ADA–APA Belgium UK Canada Guidelines Apply to Which Groups? Schizophr, FGA/SGA All patients, FGA/SGA All patients, SGA Schizophr, SGA Schizophr, FGA/SGA Schizophr Biochemical Screening             Fasting plasma glucose (FPG) Yes Yes Yes Yes Yes Yes Random glucose (RG)   Yes     Yes   HbA1c optional     No Yes   OGTT       Yes   Yes Lipids Yes Yes Yes Yes   Yes Physical Examination             Weight Yes Yes Yes Yes   Yes Waist circumference Yes Yes Yes Yes   Yes Height Yes Yes Yes Yes   Yes Hip   Yes Yes       Blood pressure   Yes Yes Yes   Yes Clinical Interview             Family history Yes Yes Yes Yes   Yes Past Medical history Yes Yes Yes Yes   Yes Ethnicity Yes Yes   Yes     Tobacco       Yes   Yes Diet/activity   Yes   Yes   Yes Diabetes signs/symptoms Yes   Yes Yes Yes Yes
    39. 40. HR= 0.42 (0.34-0.50) Initiating antipsychotics
    40. 41. N=6000 pre-guideline N=18,000 post guideline
    41. 42. Conclusions <ul><li>Co-morbidity and mortality is high </li></ul><ul><li>Excess medical deaths > non-accidental deaths 4:1 </li></ul><ul><li>Quality of medical care is below usual standard </li></ul><ul><li>prescribing | procedures after MI </li></ul><ul><li>Physical health monitoring is poor </li></ul><ul><li>Guidelines accumulating but implementation lacking </li></ul>
    42. 43. 5. Extras - Implication for Mortality
    43. 46. Quality of Care Influencing=> Mortality? <ul><li>Druss et al 2000 113,653 </li></ul><ul><li>Druss et al 2001 88,241 </li></ul><ul><li>Jones et al 2005 3,368 </li></ul><ul><li>Kisely et al 2007 13,626 </li></ul><ul><li>Lawrence et al 2003 210,129 p </li></ul><ul><li>Li et al 2007 39,839 * </li></ul><ul><li>Petersen et al 2003 4,340 </li></ul><ul><li>Plomondon et al 2007 14,194 ns </li></ul><ul><li>Young et al 2000 354,195 u </li></ul>

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