Bruce R Lindgren

University of Minnesota Duluth, Duluth, Minnesota, United States

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Publications (99)303.09 Total impact

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    ABSTRACT: Background The continued growth in the uses of umbilical cord blood (UCB) will require the development of meaningful postthaw quality assays. This study examines both conventional and new measures for assessing UCB quality after long-term storage.Study Design and Methods The first arm of the study involved thawing UCB in storage for short (approx. 1 year) and long periods of time (>11 years). Conventional postthaw measures (colony-forming units [CFU], total nucleated cell counts, CD34+45+) were quantified in addition to apoptosis. The second arm of the study involved taking units stored in liquid nitrogen and imposing a storage lesion by storing the units in −80°C for various periods of time. After storage lesion, the units were thawed and assessed.ResultsIn the first arm of the study, there was little difference in the postthaw measures between UCB stored for short and long periods of time. There was a slight increase in the percentage of CD34+45+ cells with time in storage and a reduction in the number of cells expressing apoptosis markers. When moved from liquid nitrogen to −80°C storage, the nucleated cell count varied little but there was a distinct decrease in frequency of CFUs and increase in percentage of cells expressing both early and late markers of apoptosis.Conclusion Nucleated cell counts do not reflect damage to hematopoietic progenitors during long-term storage. Expression of caspases and other markers of apoptosis provide an early biomarker of damage during storage, which is consistent with other measures such as CFU and percentage of CD34+45+ cells.
    Transfusion 01/2015; · 3.57 Impact Factor
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    ABSTRACT: Smokeless tobacco products sold in the United States vary significantly in yields of nicotine and tobacco-specific nitrosamines (TSNA). With the passage of the Family Smoking Prevention and Tobacco Control Act, the Food and Drug Administration now has the authority to establish product standards. However, limited data exist determining the relative roles of pattern of smokeless tobacco use versus constituent levels in the smokeless tobacco product in exposure of users to carcinogens. In this study, smokeless tobacco users of brands varying in nicotine and TSNA content were recruited from three different regions in the U.S. Participants underwent two assessment sessions. During these sessions, demographic and smokeless tobacco use history information along with urine samples to assess biomarkers of exposure and effect were collected. During the time between data collection, smokeless tobacco users recorded the amount and duration of smokeless tobacco use on a daily basis using their diary cards. Results showed that independent of pattern of smokeless tobacco use and nicotine yields, levels of TSNA in smokeless tobacco products played a significant role in carcinogen exposure levels. Product standards for reducing levels of TSNA in smokeless tobacco products are necessary to decrease exposure to these toxicants and potentially to reduce risk for cancer. Cancer Prev Res; 1-7. ©2014 AACR. ©2014 American Association for Cancer Research.
    Cancer Prevention Research 12/2014; · 5.27 Impact Factor
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    ABSTRACT: AOM/OM occurred earlier in the first 6 months of life in the vaccine group.•Maternal receipt of vaccine did not affect OM incidence after 6 months of age.•Mothers’ perception of receiving vaccine may have influenced infant clinic visits.•Treatment groups were balanced for examined risk and demographic variables.•Infant pneumococcal abs of vaccinated mothers vs. placebo mothers were inferior.
    Vaccine 10/2014; · 3.49 Impact Factor
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    ABSTRACT: Use of cross matching or HLA matching for donor selection is the basis of managing patients refractory to platelet (PLT) transfusion. Because of changes in patient care, we evaluated the effect of cross matching and HLA matching in patients refractory to PLT transfusion.
    Transfusion 06/2014; · 3.57 Impact Factor
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    ABSTRACT: Background The blood recall process is intended to remove from use products that may be harmful, but characteristics of recalls nationally have not been reported.Study Design and Methods We analyzed recalls of all blood products for 2010 and categorized the reason for the recall, the organizations producing the recalled products, and the Food and Drug Administration (FDA) district in which the blood was collected.ResultsDuring 2010, there were 2468 recalls involving 8278 blood products. None of the recalls was considered to have a reasonable probability of causing serious adverse health consequences or death (FDA Class I). The most common reasons for recalls were donation and donor qualification (73%) and finished product quality control (14%). The FDA class of recalls varied by recall reason, month of the year, FDA district, number of units of blood collected per FDA district, and number of units of blood collected by the blood center. The number of recalls per 100,000 units of blood and the reason for recall varied by FDA district and blood centers collecting smaller numbers of units had more recalls.Conclusion The absence of Class I recalls suggests a high level of quality and safety in the US blood supply. Organizations that collected larger numbers of units of blood had fewer recalls and there may be some FDA influences since the number and reason for the recalls varied by FDA district.
    Transfusion 06/2014; · 3.57 Impact Factor
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    ABSTRACT: Tobacco smoking by pregnant women is a major public health hazard with both short- and long-term effects on offspring. This study describes the presence and level of the nicotine metabolite cotinine in newborn dried blood spots (DBS) and compares it with the reported maternal smoking recorded on state birth registries. We hypothesize that cotinine in DBS may be a useful measure of newborn in utero tobacco exposure. An observational, cross-sectional study of 1414 DBS obtained from California, Michigan, New York, and Washington newborn screening programs was carried out. Cotinine levels in DBS were quantified by liquid chromatography tandem mass spectrometry analysis and compared with maternal smoking as reported in vital statistics data. Cotinine ≥0.3 ng/g was detected in 35% of newborn DBS, including DBS of 29% of newborns whose mothers reportedly did not smoke cigarettes during pregnancy, some of whom were presumably exposed to environmental tobacco smoke. Twelve percent of the newborn DBS had cotinine levels that were ≥9.0 ng/g (equivalent to 6 ng/mL plasma, a level that indicates active smoking of the mother), although 41% of the mothers of these infants reportedly did not smoke. These data confirm that reported smoking during pregnancy is an imperfect measure of prenatal tobacco smoke exposure. Cotinine assessment in newborns may improve surveillance of tobacco use during pregnancy.
    PEDIATRICS 05/2014; · 5.30 Impact Factor
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    ABSTRACT: DNA hypermethylation and histone deacetylation are pathways of leukemia resistance. We investigated the tolerability and efficacy of decitabine and vorinostat plus chemotherapy in relapse/refractory acute lymphoblastic leukemia (ALL). Decitabine (15mg/m2 iv) and vorinostat (230mg/m2 PO div BID) were given days 1-4 followed by vincristine, prednisone, PEG-asparaginase and doxorubicin. Genome wide methylation profiles were performed in 8 matched patient bone marrow (BM) samples taken at day 0 and day 5 (post-decitabine). The median age was 16 (range, 3–54) years. All patients had a prior BM relapse, with five relapsing after allogeneic transplant. The most common non-hematological toxicities possibly related to decitabine or vorinostat were infection with neutropenia (grade 3; n=4) and fever/neutropenia (grade 3, n=4; grade 4, n=1). Of the 13 eligible patients, four achieved complete remission without platelet recovery (CRp), two partial response (PR), one stable disease (SD), one progressive disease (PD), two deaths on study and three patients who did not have end of therapy disease evaluations for an overall response rate of 46.2% (CRp + PR). Following decitabine, significant genome-wide hypo-methylation was observed. Comparison of clinical responders with non-responders identified methylation profiles of clinical and biological relevance. Decitabine and vorinostat followed by re-Induction chemotherapy was tolerable and demonstrated clinical benefit in relapsed patients with ALL. Methylation differences were identified between responders and non-responders indicating inter-patient variation, which could impact clinical outcome. This study was registered at www.clinicaltrials.gov as NCT00882206.
    American Journal of Hematology 05/2014; · 3.48 Impact Factor
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    ABSTRACT: Although social support is an integral element in smoking cessation, the literature presents mixed findings regarding the type(s) of social support that are most helpful. The Partner Interaction Questionnaire (PIQ) is commonly used to measure social support in this context. We explored the possibility that more nuanced distinctions between items on the PIQ than what is customarily used could improve the prediction of cessation. Baseline PIQ responses of smokers enrolled in a cessation program was submitted to an exploratory factor analysis. Emergent factors were used to predict cessation at several time points. Four factors emerged, which differed from the two subscales that are typically used. The four-factor version predicted cessation; the two-factor version did not. Identifying the types of social support that predict smoking cessation depend on our ability to measure social support. More nuanced measures will likely clarify the role of social support in cessation.
    Annals of Behavioral Medicine 11/2013; · 4.20 Impact Factor
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    ABSTRACT: Objectives. We assessed tobacco smoke exposure (TSE), defined according to detection of cotinine, in dried blood spots collected from children for lead screening. Methods. We analyzed dried blood spots collected from a national sample of 1541 Black and White children and submitted to a commercial laboratory for lead analysis. We used an anonymous administrative data set including information on children's characteristics in conducting our analyses. Results. Cotinine was detected in 61% of dried blood spots; 17% of samples had cotinine levels above 3 nanograms per gram. Median cotinine levels were significantly higher among Black than White children (0.66 ng/g vs 0.30 ng/g) and among Medicaid recipients (0.94 ng/g vs < 0.3 ng/g). In multivariate analyses, significant increases in cotinine levels were associated with Black (vs White) race, older age, Medicaid coverage, higher state smoking rate, and higher average winter temperature. Detectable cotinine levels were significantly associated with higher lead levels. Conclusions. TSE is highly prevalent among children undergoing lead screening, and exposure levels are greater among Black children and children on Medicaid. TSE may contribute to lead exposure. Concurrent lead screening and biological screening for TSE may be a feasible approach to increasing childhood TSE detection. (Am J Public Health. Published online ahead of print October 17, 2013: e1-e6. doi:10.2105/AJPH.2013.301315).
    American Journal of Public Health 10/2013; · 3.93 Impact Factor
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    ABSTRACT: Abstract Background: Lung transplantation is now a standard intervention for patients with advanced lung disease. Home monitoring of pulmonary function and symptoms has been used to follow the progress of lung transplant recipients in an effort to improve care and clinical status. The study objective was to determine the relative performance of a computer-based Bayesian algorithm compared with a manual nurse decision process for triaging clinical intervention in lung transplant recipients participating in a home monitoring program. Materials and Methods: This randomized controlled trial had 65 lung transplant recipients assigned to either the Bayesian or nurse triage study arm. Subjects monitored and transmitted spirometry and respiratory symptoms daily to the data center using an electronic spirometer/diary device. Subjects completed the Short Form-36 (SF-36) survey at baseline and after 1 year. End points were change from baseline after 1 year in forced expiratory volume at 1 s (FEV1) and quality of life (SF-36 scales) within and between each study arm. Results: There were no statistically significant differences between groups in FEV1 or SF-36 scales at baseline or after 1 year.: Results were comparable between nurse and Bayesian system for detecting changes in spirometry and symptoms, providing support for using computer-based triage support systems as remote monitoring triage programs become more widely available. Conclusions: The feasibility of monitoring critical patient data with a computer-based decision system is especially important given the likely economic constraints on the growth in the nurse workforce capable of providing these early detection triage services.
    Telemedicine and e-Health 10/2013; · 1.40 Impact Factor
  • American Journal of Hematology 06/2013; · 3.48 Impact Factor
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    ABSTRACT: OBJECTIVES/HYPOTHESIS: Many head and neck surgeons believe that young patients with head and neck cancer (HNCA) have poorer outcomes than older patients, whereas the evidence in the literature is mixed. We sought to review our HNCA population to evaluate for survival differences between young and older patients. STUDY DESIGN: Matched pair retrospective cohort study. METHODS: A matched pair retrospective cohort study was completed of mucosal HNCA patients at our academic center (2003-2008). Patients aged 45 or less when diagnosed were identified as cases and matched one-to-one to controls by site of tumor, stage of disease, and gender. Risk factors, disease and treatment variables, and survival outcomes were compared between groups. In addition, a subset survival analysis was completed with oropharyngeal cancer patients and nonoropharyngeal cancer patients. RESULTS: There were 87 cases matched to 87 controls. Despite no difference in T and N stage between groups, cases more frequently underwent neck dissection. On Kaplan-Meier and multivariate analysis, overall survival was marginally better for all young patients, whereas disease-free survival was significantly better. Within the subgroup analysis, the statistically significant disease-free survival advantage was lost for young patients with oropharyngeal cancer but maintained for all other sites. CONCLUSIONS: In this cohort, young HNCA patients had mildly improved overall survival but statistically greater disease-free survival. There was no statistically significant survival difference between young and older patients with oropharyngeal cancer, potentially secondary to a human papillomavirus effect. LEVEL OF EVIDENCE: 2b. Laryngoscope, 2013.
    The Laryngoscope 05/2013; · 2.03 Impact Factor
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    ABSTRACT: Tobacco use is the major preventable cause of premature death in the United States. Second-hand smoke (SHS) exposure also contributes to a number of premature deaths as well as other negative health outcomes. An accurate assessment of tobacco smoke exposure is critical to understanding these disease processes. The plasma concentration of cotinine, the primary metabolite of nicotine, is widely accepted as a quantitative measure of tobacco and SHS exposure. However, it is not always feasible to collect plasma. Dried blood spots (DBS), which are collected routinely from newborns and often from young children for lead screening, provide an alternative sampling method. We have developed a quantitative high throughput liquid chromatography tandem mass spectrometry method for the analysis of cotinine in DBS. The limit of quantitation was 0.3 ng/g (∼ 0.2 ng/ml plasma). Cotinine levels in DBS from 83 smokers and 99 non-smokers exposed to SHS were determined. Plasma cotinine concentrations in these subjects ranged from <0.02 to 443 ng/ml. Cotinine was detected in DBS from 157 subjects, and the correlation between cotinine in plasma and DBS was excellent, 0.992 (P<0.001). We also determined the ratio of trans 3'-hydroxycotinine to cotinine, a measure of nicotine metabolism, in DBS from smokers. This ratio in DBS was well correlated with the ratio in plasma, 0.94 (P<0.001). In a small study, we confirmed the feasibility of using extant DBS collected for lead screening to assess SHS exposure in children.Journal of Exposure Science and Environmental Epidemiology advance online publication, 27 February 2013; doi:10.1038/jes.2013.7.
    Journal of Exposure Science and Environmental Epidemiology 02/2013; · 3.19 Impact Factor
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    ABSTRACT: INTRODUCTION: We examined the characteristics, attitudes, beliefs, and exposure to tobacco products in a cohort of rural dwelling Alaska Native (AN) people. METHODS: We conducted a study of 400 of AN adult tobacco users and nonusers living in Southwestern Alaska. Questionnaires covered variables such as demographics, tobacco-use history, current tobacco use and dependence scales, general health status, attitudes and beliefs about tobacco, and quitting history. RESULTS: The study population smoked 7.8 cigarettes per day compared with 16.8 on average for the U.S. population: a significant proportion of the population engaged in dual use of cigarettes and smokeless tobacco products. Over one third (40.9%), first tried tobacco at age 11 or younger. The mean measures of tobacco addiction (e.g., Fagerstrom Test for Nicotine Dependence, Severson Scale of Smokeless Tobacco Dependence) scores were lower compared with other U.S. populations.Conclusions:Very high tobacco-use prevalence, dual product use, and early tobacco use are observed in Southwestern AN people. Unexpectedly these did not appear to be correlated with heavier individual tobacco use or higher levels of addiction in this population.
    Nicotine & Tobacco Research 09/2012; · 2.48 Impact Factor
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    ABSTRACT: Objective Factors leading patients with head and neck cancer (HNCA) to seek radiation or chemoradiation in an academic center versus the community are incompletely understood, as are the effects of site of treatment on treatment completion and survival.Study DesignHistorical cohort study.SettingTertiary academic center, community practices.MethodsA historical cohort study was completed of patients with mucosal HNCA identified by International Classification of Disease, Ninth Revision (ICD-9) codes receiving consultation at the authors' institution from 2003 to 2008. Patients who received primary and adjuvant radiation at an academic center or in the community were included. The authors compared treatment completion rates and performed univariate and multivariate analyses of treatment outcomes.ResultsOf 388 patients, 210 completed treatment at an academic center and 145 at a community center (33 excluded, location unknown). Patients with HNCA undergoing radiation at an academic site had more advanced disease (P = .024) and were more likely to receive concurrent chemotherapy. Academic hospitals had a higher percentage of noncurrent smokers, higher median income, and higher percentage of oropharyngeal tumors. There was no significant difference in the rate of planned treatment completion between community and academic centers (93.7% vs 94.7%, P > .81) or rate of treatment breaks (22.4% vs 28.4%, P > .28). On Kaplan-Meier analysis, the 5-year survival rate was 53.2% (95% confidence interval [CI], 45.3%-61.1%) for academic centers and 32.8% (95% CI, 22.0%-43.6%) for community hospitals (P < .001).Conclusion In this cohort, although treatment completion and treatment breaks were similar between academic and community centers, survival rates were higher in patients treated in an academic setting.
    Otolaryngology Head and Neck Surgery 08/2012; · 1.72 Impact Factor
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    ABSTRACT: BACKGROUND: For patients with thrombocytopenia without bleeding risk factors, a platelet transfusion trigger of 10 × 10(9) /L is recommended. No studies have evaluated the clinicians' decision-making process leading to trigger changes. STUDY DESIGN AND METHODS: We report on the evaluation of trigger changes and the relation with bleeding. Eighty patients previously enrolled in the SPRINT trial represent the patient population for the current analysis. RESULTS: Seventy-four patients had a starting trigger of 10 × 10(9) /L. Only a minority of patients treated with chemotherapy alone (3/12, 25%) and autologous transplant (6/15, 40%) had a change in their trigger in contrast to the majority of allogeneic transplant (37/47, 79%; p = 0.001 and p = 0.009, respectively, when compared to allogeneic transplant group). Bleeding was the main reason reported by clinicians for a trigger change, but the occurrence of significant bleeding (Grade 2-4) was similar in patients with or without a trigger change (51 and 54%, p = 1.00). Clinicians were influenced by the bleeding system: Grade 1 mucocutaneous bleeding leading to a trigger change was overrepresented (71% of cases), as was Grade 2 genitourinary bleeding not leading to a trigger change (57% of cases). CONCLUSION: A universal trigger of 10 × 10(9) /L may not be maintained in a diverse population of patients with their respective bleeding risk factors. Because the trigger is changed often, it may not be as effective as previously believed.
    Transfusion 06/2012; · 3.57 Impact Factor
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    ABSTRACT: The prevalence of tobacco use, both cigarette smoking and smokeless, including iqmik (homemade smokeless tobacco prepared with dried tobacco leaves mixed with alkaline ash), and of tobacco-related cancer is high in Alaskan Native people (AN). To investigate possible mechanisms of increased cancer risk we studied levels of nicotine and tobacco-specific nitrosamines (TSNA) in tobacco products and biomarkers of tobacco toxicant exposure in Southwestern AN people. Participants included 163 cigarette smokers, 76 commercial smokeless tobacco, 20 iqmik, 31 dual cigarette smokers and smokeless tobacco, and 110 nontobacco users. Tobacco use history, samples of tobacco products used, and blood and urine samples were collected. Nicotine concentrations were highest in cigarette tobacco and TSNAs highest in commercial smokeless tobacco products. The AN participants smoked on average 7.8 cigarettes per day. Nicotine exposure, assessed by several biomarker measures, was highest in iqmik users, and similar in smokeless tobacco and cigarette smokers. TSNA exposure was highest in smokeless tobacco users, and polycyclic aromatic hydrocarbon exposure was highest in cigarette smokers. Despite smoking fewer cigarettes per day, AN cigarette smokers had similar daily intake of nicotine compared to the general U.S. population. Nicotine exposure was greatest from iqmik, likely related to its high pH due to preparation with ash, suggesting high addiction potential compared to other smokeless tobacco products. TSNA exposure was much higher with smokeless tobacco than other product use, possibly contributing to the high rates of oral cancer. Impact: Our data contribute to an understanding of the high addiction risk of iqmik use and of the cancer-causing potential of various forms of tobacco use among AN people.
    Cancer Epidemiology Biomarkers & Prevention 04/2012; 21(6):934-42. · 4.56 Impact Factor
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    ABSTRACT: Pre-menopausal women with cancer are at risk of therapy-associated infertility, premature menopause, and sexual dysfunction. However, it is unknown whether oncologists adequately address these risks during treatment planning. We conducted a study to evaluate physician-patient discussions addressing the impact of cancer treatment and actual treatment effects on fertility, menopause status, and general sexual health. A questionnaire was administered in four oncology clinics specializing in breast, gynecologic, general hematology-oncology, and blood and marrow transplantation (BMT) cancer care at a single institution. Eligible participants were pre-menopausal at the time of diagnosis and either actively receiving or within 24 months from completion of treatment. Participants completed the questionnaire at enrollment and at 1-year follow-up. Of the 104 eligible women, a majority were satisfied with the quality (68%) and length (66%) of reproductive health discussions, with the highest satisfaction levels in the gynecologic cancer clinic (85%) and the lowest levels in the BMT clinic (53%). Fertility preservation was desired by 20% of women, including some >40 years old. Women were more interested in discussing treatment impact on menopause status and sexual health than fertility. Rates of discussions on treatment impact on sexual health were low despite 77% of women reporting severe sexual dysfunction at 1-year follow-up. One-third of women are dissatisfied with the quality and length of discussions regarding the impact of cancer treatment on reproductive health. There is notably inadequate counseling on the effect of treatment on fertility in women > 40 and on sexual function in all women. Oncologists must offer better resources and improve communication on the effect of treatment on reproductive health to pre-menopausal women with cancer.
    Journal of Cancer. 01/2012; 3:217-25.
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    ABSTRACT: Tobacco dependence disorder is a chronic relapsing condition, yet treatment is delivered in discrete episodes of care that yield disappointing long-term quit rates. We conducted a randomized controlled trial from June 1, 2004, through May 31, 2009, to compare telephone-based chronic disease management (1 year; longitudinal care [LC]) with evidence-based treatment (8 weeks; usual care [UC]) for tobacco dependence. A total of 443 smokers each received 5 telephone counseling calls and nicotine replacement therapy by mail for 4 weeks. They were then randomized to UC (2 additional calls) or LC (continued counseling and nicotine replacement therapy for an additional 48 weeks). Longitudinal care targeted repeat quit attempts and interim smoking reduction for relapsers. The primary outcome was 6 months of prolonged abstinence measured at 18 months of follow-up. At 18 months, 30.2% of LC participants reported 6 months of abstinence from smoking, compared with 23.5% in UC (unadjusted, P = .13). Multivariate analysis showed that LC (adjusted odds ratio, 1.74; 95% CI, 1.08-2.80), quit attempts in past year (1.75; 1.06-2.89), baseline cigarettes per day (0.95; 0.92-0.99), and smoking in the 14- to 21-day interval post-quit (0.23; 0.14-0.38) predicted prolonged abstinence at 18 months. The LC participants who did not quit reduced smoking more than UC participants (significant only at 12 months). The LC participants received more counseling calls than UC participants (mean, 16.5 vs 5.8 calls; P < .001), longer total duration of counseling (283 vs 117 minutes; P < .001), and more nicotine replacement therapy (4.7 vs 2.4 boxes of patches; P < .001). A chronic disease management approach increases both short- and long-term abstinence from smoking. clinicaltrials.gov Identifier: NCT00309296.
    Archives of internal medicine 11/2011; 171(21):1894-900. · 11.46 Impact Factor
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    ABSTRACT: We developed an instrument to measure the satisfaction of lung transplant recipients with home monitoring. The survey comprised 15 items, each scored on a five-point Likert-type scale (from strongly disagree to strongly agree). Three additional free-text items enabled subjects to provide comments. The survey had a scoring range of 15-75. In a test group of 43 patients, the internal consistency (Cronbach's alpha) was 0.93 overall for all questions. The intra-class correlation for scores from the same 27 patients approximately 2.5 months apart was 0.77 for the total score. The survey was used to evaluate subject satisfaction in a randomized controlled trial of a computerized algorithm for triaging lung transplant recipients. Surveys were mailed to 50 study subjects and were returned by 32 (64% return rate). Ninety percent of respondents were satisfied with the home monitoring programme and would recommend it to other patients.
    Journal of telemedicine and telecare 11/2011; 18(1):42-6. · 0.92 Impact Factor

Publication Stats

1k Citations
303.09 Total Impact Points

Institutions

  • 1991–2014
    • University of Minnesota Duluth
      • • Medical School
      • • Department of Computer Science
      Duluth, Minnesota, United States
  • 1991–2011
    • University of Minnesota Twin Cities
      • • Department of Laboratory Medicine and Pathology
      • • Department of Otolaryngology
      • • School of Public Health
      • • College of Veterinary Medicine
      • • School of Nursing
      • • Department of Pediatrics
      • • Division of Biostatistics
      Minneapolis, MN, United States
  • 2006
    • Saint Catherine University
      Minneapolis, Minnesota, United States
    • University of Minnesota Medical Center, Fairview
      Minneapolis, Minnesota, United States
  • 2002
    • Medical University of South Carolina
      Charleston, South Carolina, United States
  • 1998
    • Johns Hopkins Bloomberg School of Public Health
      • Department of Biostatistics
      Baltimore, MD, United States