The comparative effectiveness of direct oral anti-coagulants and low molecular weight heparins for prevention of recurrent venous thromboembolism in cancer: The CANVAS pragmatic randomized trial.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 12020-12020
Author(s):  
Deborah Schrag ◽  
Hajime Uno ◽  
Rachel Pam Greenerger Rosovsky ◽  
Cynthia Rutherford ◽  
Kristen Marie Sanfilippo ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Comparative Effectiveness ◽  
Pragmatic Trial ◽  
Study Drug ◽  
Recurrent Venous Thromboembolism ◽  
The Us ◽  
Recurrent Vte ◽  
The Difference ◽  
To Receive

12020 Background: Previous randomized trials in cancer patients suggest that DOACs are non-inferior to LMWH for preventing recurrent VTE but have higher risk of bleeding. However, the balance of benefits and burdens remains uncertain. Objective: The CANVAS pragmatic trial compared recurrent VTE, bleeding and death in cancer patients following an initial VTE treated with either DOAC or LMWH therapy. Methods: CANVAS was an unblinded hybrid comparative effectiveness non-inferiority trial, with randomized and preference cohorts. Between 12/16 and 4/20, 671 participants were randomized and followed for 6-months. Between 12/16 and 12/17, 140 participants declined randomization, chose their preferred anticoagulant and were followed for 6-months. The preference cohort was closed when predetermined stopping criteria were met. Final follow-up was 11/30/20. Randomized patients were assigned 1:1 to receive either a DOAC or a LMWH. If assigned to LMWH, transitions to warfarin were allowed. Physicians and patients could choose among any DOAC or LMWH. Doses were suggested based on FDA-approved labeling but not mandated. Patients from 67 practices in the US with any invasive solid tumor, lymphoma, multiple myeloma or CLL and a diagnosis of symptomatic or radiographically detected VTE within 30 days of enrollment were eligible. The 1° analysis was conducted in the randomized modified-into to treat popululation, (all subjects who received study drug). The 1° outcome was recurrent VTE. The aim was to establish noninferiority of anticoagulation with a DOAC as defined by the upper limit of the 2-sided 90% CI for the difference in the event rate at 6 months of < 3%. Secondary outcomes included death and bleeding. Hypothesis testing included only the randomized cohort but propensity score adjusted results for the preference and combined cohorts are also shown. Results: The non-inferiority criteria for recurrent VTE was met. Conclusions: Among adult cancer patients with VTE, the use of a DOAC compared with a LMWH resulted in a noninferior risk of recurrent VTE with no differences in rates of bleeding or death in randomized patients. Clinical trial information: NCT02744092. [Table: see text]

scholarly journals Risk of Recurrent Venous Thromboembolism and Bleeding in Patients with Cancer Associated Thrombosis

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 18-18
Author(s):  
Doaa Attia ◽  
Xuefei Jia ◽  
Mailey L Wilks ◽  
Barbara Tripp ◽  
Christopher D'Andrea ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Cancer Patients ◽  
Major Bleeding ◽  
Research Funding ◽  
Cleveland Clinic ◽  
Treatment Groups ◽  
Recurrent Venous Thromboembolism ◽  
Recurrent Vte ◽  
Cancer Associated Thrombosis

Background: The treatment paradigm for cancer associated thrombosis (CAT) has evolved over recent years from using low molecular weight heparin (LMWH) to direct oral anticoagulants (DOACs). Some randomized trials suggest decreased rates of recurrent venous thromboembolism (VTE) in CAT patients treated with DOACs compared to LMWH but also reported increased rates of bleeding. The Cleveland Clinic Taussig Cancer Center has been treating cancer thrombosis in a centralized CAT clinic since 2014. Here we report our rates of bleeding and recurrent VTE in cancer patients treated with anticoagulation. Methods: We prospectively followed cancer patients referred to our clinic from 8/2014-10/2019. A total of 1548 patients were referred to the clinic, of whom 462 were diagnosed with an acute VTE. VTE events, including deep venous thrombosis, pulmonary embolism, and visceral thrombosis, were noted. The comparison of bleeding rates (defined using ISTH criteria for major and clinically relevant non major bleeding, CRNMB) among treatment groups (LMWH vs DOACs) was examined using chi-square test. Rate of recurrent VTE was analyzed using a competing model in which death was treated as a competing risk. Results: The study population comprised 462 patients with acute VTE with a mean age of 62.67±12.23 and 51.8 % males. Of these, 234 (52.9%) received LMWH, 161(36.4%) received DOACs, and 47 (10.6%) received other agents including warfarin for initial anticoagulation. Overall, the 6-month, 1 year, and 2-year VTE recurrence rate was 5.9%, 6.6%, 7.9%, respectively. Recurrent VTE rates were similar for LMWHs, DOACs and other agents (P&gt;0.05). Of 368 patients for whom follow-up data was available, 74 (16.7%) had bleeding event , of which 25 (33.8%) had major bleeding and 49 (66.4%) had CRNMB at 6 month follow-up with no difference across three treatment groups (p=0.56). Conclusion: In this real-world practice setting, rates of recurrent VTE and bleeding were similar for DOACs and LMWH suggesting that with careful patient selection the concern for higher bleeding with DOACs in cancer patients can be safely overcome. Disclosures McCrae: Momenta Pharmaceuticals: Consultancy; Novartis: Honoraria; Rigel: Consultancy; Dova: Consultancy. Khorana:Merck: Research Funding; Medscape: Honoraria; Leo Pharma: Honoraria; Seattle Genetics: Honoraria; Pharmacyte: Honoraria; Pharmacyclics: Honoraria; Array: Other: Research funding (to institution); Janssen: Honoraria; Bayer: Honoraria; Pfizer: Honoraria; Sanofi: Honoraria; BMS: Honoraria, Research Funding; Leap: Research Funding.

A New Multiparametric Classification in Lung Cancer Patients - S.M.I.G.

1983 ◽  
Vol 69 (5) ◽  
pp. 437-443 ◽  
Author(s):  
Claudio Modini ◽  
Mario Albertucci ◽  
Franco Cicconetti ◽  
Donatella Tirindelli Danesi ◽  
Renzo Cristiani ◽  
...  
Keyword(s):  
Lung Cancer ◽  
Growth Rate ◽  
Mortality Rate ◽  
Cancer Patients ◽  
Cell Type ◽  
Tnm System ◽  
Lung Cancer Patients ◽  
The Difference

The classification of bronchogenic carcinoma as a function of the prognosis is still an open field. The evaluation of stage, by use of the TNM system, and histologic cell type is not sufficient to guarantee a correct prognosis. The growth rate of the neoplasm is another important parameter. We propose a classification that takes into account the stage (S), histologic cell type (M), immune status (I) and the growth rate of the primary tumor (G): S.M.I.G. We studied 90 lung cancer patients according to the S.M.I.G. classification and we observed that their prognoses were directly correlated with their S.M.I.G. scores (the higher the score, the higher the 10-month mortality rate). The mortality rates within the first 10 months of follow-up were respectively 0%, 0%, 36.36%, 68%, 90.9% for the 5 groups obtained by S.M.I.G. The difference is statistically significant (P < 0.0075) and there is a linear correlation between the mortality rate and the score assigned to each group (R = 0.943; P < 0.05). The S.M.I.G. classification can predict the prognosis more efficiently than the usual classification (TNM) and histological cell type.

scholarly journals Improved relapse recovery in paediatric compared to adult multiple sclerosis

Brain ◽  
2020 ◽  
Vol 143 (9) ◽  
pp. 2733-2741
Author(s):  
Tanuja Chitnis ◽  
Greg Aaen ◽  
Anita Belman ◽  
Leslie Benson ◽  
Mark Gorman ◽  
...  
Keyword(s):  
Multiple Sclerosis ◽  
Functional System ◽  
Progressive Multiple Sclerosis ◽  
Age Related ◽  
Younger Age ◽  
Disability Status ◽  
The Us ◽  
The Difference ◽  
Effect Of Age

Abstract Incomplete relapse recovery contributes to disability accrual and earlier onset of secondary progressive multiple sclerosis. We sought to investigate the effect of age on relapse recovery. We identified patients with multiple sclerosis from two longitudinal prospective studies, with an Expanded Disability Status Scale (EDSS) score within 30 days after onset of an attack, and follow-up EDSS 6 months after attack. Adult patients with multiple sclerosis (n = 632) were identified from the Comprehensive Longitudinal Investigations in Multiple Sclerosis at Brigham study (CLIMB), and paediatric patients (n = 132) from the US Network of Paediatric Multiple Sclerosis Centers (NPMSC) registry. Change in EDSS was defined as the difference in EDSS between attack and follow-up. Change in EDSS at follow-up compared to baseline was significantly lower in children compared to adults (P = 0.001), as were several functional system scores. Stratification by decade at onset for change in EDSS versus age found for every 10 years of age, EDSS recovery is reduced by 0.15 points (P &lt; 0.0001). A larger proportion of children versus adults demonstrated improvement in EDSS following an attack (P = 0.006). For every 10 years of age, odds of EDSS not improving increase by 1.33 times (P &lt; 0.0001). Younger age is associated with improved recovery from relapses. Age-related mechanisms may provide novel therapeutic targets for disability accrual in multiple sclerosis.

Randomized Trial of Radiotherapy Versus Concurrent Chemoradiotherapy Followed by Adjuvant Chemotherapy in Patients With American Joint Committee on Cancer/International Union Against Cancer Stage III and IV Nasopharyngeal Cancer of the Endemic Variety

2005 ◽  
Vol 23 (27) ◽  
pp. 6730-6738 ◽  
Author(s):  
Joseph Wee ◽  
Eng Huat Tan ◽  
Bee Choo Tai ◽  
Hwee Bee Wong ◽  
Swan Swan Leong ◽  
...  
Keyword(s):  
Distant Metastasis ◽  
Nasopharyngeal Cancer ◽  
Disease Free Survival ◽  
Free Survival ◽  
The Difference ◽  
Intent To Treat ◽  
To Receive ◽  
Disease Free ◽  
Treat Analysis

Purpose The Intergroup 00-99 Trial for nasopharyngeal cancer (NPC) showed a benefit of adding chemotherapy to radiotherapy. However, there were controversies regarding the applicability of the results to patients in endemic regions. This study aims to confirm the findings of the 00-99 Trial and its applicability to patients with endemic NPC. Patients and Methods Between September 1997 and May 2003, 221 patients were randomly assigned to receive radiotherapy (RT) alone (n = 110) or chemoradiotherapy (CRT; n = 111). Patients in both arms received 70 Gy in 7 weeks using standard RT portals and techniques. Patients on CRT received concurrent cisplatin (25 mg/m2 on days 1 to 4) on weeks 1, 4, and 7 of RT and adjuvant cisplatin (20 mg/m2 on days 1 to 4) and fluorouracil (1,000 mg/m2 on days 1 to 4) every 4 weeks (weeks 11, 15, and 19) for three cycles after completion of RT. All patients were analyzed by intent-to-treat analysis. The median follow-up time was 3.2 years. Results Distant metastasis occurred in 38 patients on RT alone and 18 patients on CRT. The difference in 2-year cumulative incidence was 17% (95% CI, 14% to 20%; P = .0029). The hazard ratio (HR) for disease-free survival was 0.57 (95% CI, 0.38 to 0.87; P = .0093). The 2- and 3-year overall survival (OS) rates were 78% and 85% and 65% and 80% for RT alone and CRT, respectively. The HR for OS was 0.51 (95% CI, 0.31 to 0.81; P = .0061). Conclusion This report confirms the findings of the Intergroup 00-99 Trial and demonstrates its applicability to endemic NPC. This study also confirms that chemotherapy improves the distant metastasis control rate in NPC.

Updated Survival Analyses after Prolonged Follow-Up of the Phase 2, Multicenter CREST Study of Bortezomib in Relapsed or Refractory Multiple Myeloma.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 2717-2717 ◽  
Author(s):  
Sundar Jagannath ◽  
Bart Barlogie ◽  
James R. Berenson ◽  
David Siegel ◽  
D. Irwin ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Phase 2 ◽  
Initial Report ◽  
Refractory Multiple Myeloma ◽  
Kaplan Meier ◽  
Phase 2 Study ◽  
The Difference ◽  
Dose Levels ◽  
To Receive

Abstract Background: The initial report of the CREST phase 2 study (Br J Haematol2004;127:165–72) demonstrated the substantial activity of bortezomib (VELCADE®, Vc) at two different dose levels in patients with relapsed or refractory multiple myeloma (MM). Here, we provide an updated analysis of overall survival (OS) after prolonged follow-up (median >5 years). Methods: 54 patients were enrolled to receive Vc 1.0 mg/m2 (n=28) or 1.3 mg/m2 (n=26) on days 1, 4, 8, and 11 of a 21-day cycle, for up to 8 cycles. Dexamethasone (dex) 20 mg on the day of and day after each Vc dose was added for 16 (57%) patients in the 1.0 mg/m2 group and 12 (46%) patients in the 1.3 mg/m2 group, upon suboptimal response to Vc alone. A total of 17 (31%) patients continued to receive Vc ± dex in an extension study, 12 (43%) from the 1.0 mg/m2 and 5 (19%) from the 1.3 mg/m2 groups. Patients received a median of 3 (range, 1–7) prior regimens. Median time from diagnosis to first Vc dose was 2 years. In the 1.0 and 1.3 mg/m2 groups, respectively, mean age was 64 vs 60 years, 50% vs 35% of patients were male, 54% vs 65% had IgG MM, 58% vs 48% had β2-microglobulin ≥4 mg/L, and 29% vs 48% had abnormal cytogenetics. Response rate (CR+PR, EBMT criteria) to Vc alone was 30% vs 38%, and to Vc ± dex was 37% vs 50% in the 1.0 and 1.3 mg/m2 groups. OS from first dose of Vc in each dose group was analyzed using the Kaplan-Meier method. Results: Median OS in the 1.0 and 1.3 mg/m2 groups was 26.8 months and 60.0 months, after median follow-up of 61 and 65 months, respectively (Figure). In the 1.0 mg/m2 group, 21 (75%) patients have died; the 1- and 2-year OS rates were 82% and 54%, respectively. In the 1.3 mg/m2 group, only 14/26 (54%) patients have died; 1- and 2-year OS rates were 81% and 69%, respectively. Conclusions: Vc ± dex was active in relapsed or refractory MM at both the 1.0 mg/m2 and 1.3 mg/m2 dose levels and was associated with notable OS, particularly in patients treated with the approved Vc dose of 1.3 mg/m2. The difference in OS between dose groups suggests that the higher dose of Vc is more active. Figure. Kaplan-Meier analyses of OS in patients who received Vc 1.0 mg/m2 (n=28) or 1.3 mg/m2 (n=26). Figure Figure

Prevalence of recurrent thrombosis in cancer patients with isolated gonadal vein thrombosis: A retrospective study.

2012 ◽  
Vol 30 (15_suppl) ◽  
pp. e19645-e19645
Author(s):  
Suebpong Tanasanvimon ◽  
Naveen Garg ◽  
Chitra Viswanathan ◽  
Milind M. Javle ◽  
Mylene Truong ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Metastatic Disease ◽  
Vena Cava ◽  
Cancer Center ◽  
Vein Thrombosis ◽  
Gonadal Vein ◽  
Radiology Reports ◽  
Recurrent Vte ◽  
Active Cancer

e19645 Background: The natural history of isolated gonadal vein thrombosis (GVT) occurring in cancer patients (pts) is not well described in the medical literature. GVT in cancer pts it is of uncertain clinical significance. Methods: Utilizing a software program allowing a searchable database of radiology reports, the computerized tomographic scan (CT) reports of pts at a single cancer center from January 1, 2004 to June 30, 2011, were searched for the term “gonadal vein thrombus”. Pts included in this analysis had a diagnosis of cancer, isolated GVT (i.e. no evidence of thrombosis at another site), and at least six months of follow-up information. Results: 162 cancer pts with GVT were identified for analysis [median age 57.8 ± 12 years, right GVT 89 pts (54.9%), left GVT 59 pts (36.4%), bilateral 14 pts (8.6%)]; the majority of the pts (96, 59.3%) had a non-gynecologic malignancy. At the time of diagnosis of GVT the majority of pts were receiving chemotherapy (84, 51.9%); 70 pts (43.2%) had surgery within the prior six months (the most common being hysterectomy, 127 pts, 78.6%). The majority of pts in this study had metastatic disease (93, 57.4%) as well as active cancer (138, 85.1%, defined as GVT occurring at the time of cancer diagnosis, disease recurrence, metastatic disease, or treatment for cancer within the prior six months); median follow-up time was 22 months. A minority of pts received anticoagulation (28pts, 17.2%). Twenty-two pts (13.6%) developed a recurrent venous thromboembolic event (VTE); these events were pulmonary embolism (12 pts, 7.4%), deep venous thrombosis (5 pts, 3.1%), inferior vena cava thrombosis (4 pts, 2.5%). Median time to development of re-thrombosis was 7 months (range 2-13.5 months). Active cancer was the only risk factor significantly associated with recurrent VTE (p = 0.047); pts with prior hysterectomy had a significantly reduced risk of recurrent VTE (p = 0.036). Conclusions: Incidental isolated GVT identified in cancer pts has a high risk of recurrent VTE (13.6%). Based upon specific pts risk factors for VTE, treatment of an incidentally detected GVT in cancer pts with anticoagulation, as per guidelines for other VTE sites, may be indicated.

Risk of recurrent venous thromboembolism after a first oestrogen-associated episode

2010 ◽  
Vol 104 (09) ◽  
pp. 498-503 ◽  
Author(s):  
Grégoire Le Gal ◽  
Michael Kovacs ◽  
Marc Carrier ◽  
Kimberley Do ◽  
Susan Kahn ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Oral Contraceptives ◽  
Hormone Replacement ◽  
Anticoagulant Treatment ◽  
Exogenous Oestrogen ◽  
Recurrent Venous Thromboembolism ◽  
Recurrent Vte ◽  
Post Menopausal ◽  
Age Range

SummaryThe use of exogenous oestrogen in women with otherwise unprovoked venous thromboembolism (VTE) could be considered sufficient explanation to classify VTE as provoked if the risk of recurrent VTE after 3–6 months of anticoagulant treatment is similar to the risk of recurrent VTE observed after a surgery or prolonged immobilisation. Our objective was to assess the risk of recurrent VTE in women after a first unprovoked episode on oestrogen. The REVERSE study is a cohort study of patients with a first unprovoked VTE treated with anticoagulant treatment for 5–7 months. The risk of recurrent VTE during follow-up was compared between women users and non users of oestrogen at the time of index VTE. Among the 646 patients included, 314 were women, of them 67 were current users of oestrogen at the time of their VTE: 49 were on oral contraceptives and 18 on post-menopausal hormone replacement therapy (HRT). No significant association was found between oestrogen exposure, either oral contraceptives or HRT, and a lower risk of recurrent VTE after adjustment for age, or analysis restricted to women in the same age range as oestrogen contraceptives and HRT users, respectively. The risk of recurrent VTE is low in women after a first otherwise unprovoked oestrogen-associated VTE. However, this risk is not significantly lower than in women whose VTE was not related to oestrogen use.

Non-OO blood type influences the risk of recurrent venous thromboembolism

2013 ◽  
Vol 110 (12) ◽  
pp. 1172-1179 ◽  
Author(s):  
Esteban Gándara ◽  
Michael J. Kovacs ◽  
Susan R. Kahn ◽  
Philip S. Wells ◽  
David A. Anderson ◽  
...  
Keyword(s):  
Risk Factor ◽  
Venous Thromboembolism ◽  
Anticoagulant Therapy ◽  
Oral Anticoagulation ◽  
Blood Type ◽  
Increased Risk ◽  
Recurrent Venous Thromboembolism ◽  
Abo Blood Type ◽  
Recurrent Vte

SummaryThe role of ABO blood type as a risk factor for recurrent venous thromboembolism (VTE) in patients with a first unprovoked VTE who complete oral anticoagulation therapy is unknown. The aim of this study was to determine if non-OO blood type is a risk factor for recurrent VTE in patients with a first unprovoked VTE who completed 5–7 months of anticoagulant therapy. In an ongoing cohort study of patients with unprovoked VTE who discontinued oral anticoagulation after 5–7 months of therapy, six single nucleotide polymorphisms sites were tested to determine ABO blood type using banked DNA. The main outcome was objectively proven recurrent VTE. Mean follow-up for the cohort was 4.19 years (SD 2.16). During 1,553 patient-years of follow-up, 101 events occurred in 380 non-OO patients (6.5 events per 100 patient years; 95% CI 5.3–7.7) compared to 14 events during 560 patient years of follow-up in 129 OO patients (2.5 per 100 patient years; 95% CI 1.2–3.7), the adjusted hazard ratio was 1.98 (1.2–3.8). In conclusion, non-OO blood type is associated with a statistically significant and clinically relevant increased risk of recurrent VTE following discontinuation of anticoagulant therapy for a first episode of unprovoked VTE.

scholarly journals 1179. PCV13 Pediatric Routine Schedule Completion and Adherence Before and During the COVID-19 Pandemic in the US

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S682-S682
Author(s):  
Liping Huang ◽  
Jennifer L Nguyen ◽  
Johnna Perdrizet ◽  
Tamuno Alfred ◽  
Adriano Arguedas
Keyword(s):  
Booster Dose ◽  
Unintended Consequences ◽  
Mitigation Measures ◽  
Full Time ◽  
Primary Dose ◽  
The Us ◽  
Study Population ◽  
The Difference ◽  
The Relationship

Abstract Background Coronavirus Disease 2019 (COVID) mitigation measures may have unintended consequences, such as reduced or delayed access to routine immunizations. This study examined (1) PCV13 routine vaccination completion and adherence (C&A) among US infants before and during the COVID pandemic and (2) the relationship between primary dose C&A and booster dose C&A. Methods Retrospective data from the Optum’s de-identified Clinformatics Data Mart Database were used to create 3 cohorts: C1, Pre-COVID; C2, During COVID; C3, Cross-COVID (Figure 1). The completion was defined as number of PCV13 doses received within 8 months of birth, and the adherence was defined number of doses received at ACIP recommended time (@2, 4, 6 months, +/- 5 days). Univariable logistic regression was used to compare the odds of primary dose C&A in cohorts C1 and C3 vs C2 and descriptive analyses were used to explore primary dose C&A in relation to booster dose C&A. Figure 1: Study population and inclusion criteria Results A total of 172,916, 70,049, and 34,854 infants were included in C1, C2, and C3. Among infants with &gt; 8 months of follow-up from birth (N=132,183 for C1&C3, 16,522 for C3), 3-primary dose completion was statistically significantly higher before COVID than during COVID (crude OR = 1.10, 95% CI: 1.06-1.15). The 3-primary dose adherence was also higher before COVID than during COVID (crude OR = 1.10, 95% CI: 1.05-1.15). Among infants with ≥2, 4 and 6 months of follow-up, adherence of each individual dose was consistently higher before COVID than during COVID (1st dose: OR = 1.03, 95% CI: 1.01–1.04; 2nd dose: OR = 1.04, 95% CI: 1.01 – 1.06; 3rd dose: OR = 1.12, 95% CI: 1.08 – 1.15) (Table 1). Booster dose completion was higher in infants who completed or adhered to 3 primary doses than infants who completed or adhered to only 1 or 2 primary doses (Figure 2, Overall) and booster dose C&A was generally higher before COVID than during COVID (Figure 2, Cohort 1 vs. Cohort 3). Table 1. Comparison of completion and adherence of primary dosing series per-COVID vs. during-COVID era Figure 2: Booster dose completion and adherence in relation to primary dosing completion (A) and adherence (B) Conclusion These results indicated that PCV13 full completion was statistically lower during COVID, but the magnitude of the difference in infants was not extensive. Infants who completed or adhered to all three primary doses were more likely to complete or adhere to the booster dose. Further research is warranted as structured datasets mature to capture the full time span of COVID-19 mitigation measures. Disclosures Liping Huang, MD, MA, MS, Pfizer Inc (Employee) Jennifer L Nguyen, ScD, MPH, Pfizer Inc. (Employee) Johnna Perdrizet, MPH, Pfizer Inc (Employee) Tamuno Alfred, PhD, Pfizer Inc. (Employee) Adriano Arguedas, MD, Pfizer (Employee)

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