Rajendu Srivastava

University of Utah, Salt Lake City, Utah, United States

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Publications (65)220.76 Total impact

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    ABSTRACT: Patient handoffs are a key source of communication failures and adverse events in hospitals. Despite Accreditation Council for Graduate Medical Education requirements for residency training programs to provide formal handoff skills training and to monitor handoffs, well-established curricula and validated skills assessment tools are lacking. Developing a handoff curriculum is challenging because of the need for standardized processes and faculty development, cultural resistance to change, and diverse institution- and unit-level factors. In this article, the authors apply a logic model to describe the process they used from June 2010 to February 2014 to develop, implement, and disseminate an innovative, comprehensive handoff curriculum in pediatric residency training programs as a fundamental component of the multicenter Initiative for Innovation in Pediatric Education-Pediatric Research in Inpatient Settings Accelerating Safe Sign-outs (I-PASS) Study. They describe resources, activities, and outputs, and report preliminary learner outcomes using data from resident and faculty evaluations of the I-PASS Handoff Curriculum: 96% of residents and 97% of faculty agreed or strongly agreed that the curriculum promoted acquisition of relevant skills for patient care activities. They also share lessons learned that could be of value to others seeking to adopt a structured handoff curriculum or to develop large-scale curricular innovations that involve redesigning firmly established processes. These lessons include the importance of approaching curricular implementation as a transformational change effort, assembling a diverse team of junior and senior faculty to provide opportunities for mentoring and professional development, and linking the educational intervention with the direct measurement of patient outcomes.
    Academic medicine: journal of the Association of American Medical Colleges 06/2014; 89(6):876-84. · 2.34 Impact Factor
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    ABSTRACT: Children with inherited leukodystrophies have high hospitalization rates, often associated with infection. We studied whether potentially modifiable risk factors (preexisting indwelling central intravenous access, urinary catheter, hardware, or mechanical ventilation; and influenza vaccine) were associated with infection-related hospitalization in children with leukodystrophy. Central intravenous access was associated with sepsis (odds ratio [OR] 9.8); urinary catheter was associated with urinary tract infections (OR 9.0); lack of seasonal vaccination was associated with influenza (OR 6.4); and mechanical ventilation was associated with pneumonia (OR 2.7). We conclude that potentially modifiable risk factors are significantly associated with infection and hospitalization in children with leukodystrophies.
    Annals of Clinical and Translational Neurology. 04/2014;
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    ABSTRACT: BACKGROUND Guidelines help inform standardization of care for quality improvement (QI). The Pediatric Research in Inpatient Settings network published a prioritization list of inpatient conditions with high prevalence, cost, and variation in resource utilization across children's hospitals. The methodological quality of guidelines for priority conditions is unknown.OBJECTIVE To rate the methodological quality of national guidelines for 20 priority pediatric inpatient conditions.DESIGNWe searched sources including PubMed for national guidelines published from 2002 to 2012. Guidelines specific to 1 organism, test or treatment, or institution were excluded. Guidelines were rated by 2 raters using a validated tool (Appraisal of Guidelines for Research and Evaluation) with an overall rating on a 7-point scale (7 = the highest). Inter-rater reliability was measured with a weighted kappa coefficient.RESULTSSeventeen guidelines met inclusion criteria for 13 conditions; 7 conditions yielded no relevant national guidelines. The highest methodological-quality guidelines were for asthma, tonsillectomy, and bronchiolitis (mean overall rating 7, 6.5, and 6.5, respectively); the lowest were for sickle cell disease (2 guidelines) and dental caries (mean overall rating 4, 3.5, and 3, respectively). The overall weighted kappa was 0.83 (95% confidence interval 0.78–0.87).CONCLUSIONS We identified a group of moderate to high methodological-quality national guidelines for priority pediatric inpatient conditions. Hospitals should consider these guidelines to inform QI initiatives. Journal of Hospital Medicine 2014. © 2014 Society of Hospital Medicine
    Journal of Hospital Medicine 03/2014; · 1.40 Impact Factor
  • Hospital pediatrics. 03/2014; 4(2):69-77.
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    ABSTRACT: To (1) identify the major expenses for same-day adenotonsillectomy (T&A) and the costs for postoperative complication encounters in a children's hospital and (2) compare differences for variations in costs by surgeon. Observational cohort study. Tertiary children's hospital. A standardized activity-based hospital accounting system was used to determine total hospital costs per encounter (not including professional fees for surgeons or anesthetists) for T&A cases at a tertiary children's hospital from 2007 to 2012. Hospital costs were subdivided into categories, including operating room (OR), OR supplies, postanesthesia care unit (PACU), same-day services (SDS), anesthesia, pharmacy, and other. Costs for postoperative complication encounters were included to identify a mean total cost per case per surgeon. The study cohort included 4824 T&As performed by 14 different surgeons. The mean cost per T&A was $1506 (95% confidence interval, $1492-$1519, with a range of $1156-$1828 for the lowest and highest cost per case per surgeon; P < .01). Including the cost for postoperative complications, the mean cost increased to $1599 ($1570-$1629). The largest cost categories included OR (31.9%), SDS (28.1%), and OR supplies (15.6%). A large portion of T&A expenses are due to OR and supply costs. Significant differences in costs between surgeons for outpatient T&A were identified. Studies to understand the reasons for this variation and the impact on outcomes are needed. If this variation does not affect patient outcomes, then reducing this variation may improve health care value by limiting waste.
    Otolaryngology Head and Neck Surgery 02/2014; · 1.73 Impact Factor
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    ABSTRACT: To determine whether dexamethasone use in children undergoing tonsillectomy is associated with increased risk of postoperative bleeding. Retrospective cohort study using a multihospital administrative database. Thirty-six US children's hospitals. Children undergoing same-day tonsillectomy between the years 2004 and 2010. We used discrete time failure models to estimate the daily hazards of revisits for bleeding (emergency department or hospital admission) up to 30 days after surgery as a function of dexamethasone use. Revisits were standardized for patient characteristics, antibiotic use, year of surgery, and hospital. Of 139,715 children who underwent same-day tonsillectomy, 97,242 (69.6%) received dexamethasone and 4182 (3.0%) had a 30-day revisit for bleeding. The 30-day cumulative standardized risk of revisits for bleeding was greater with dexamethasone use (3.11% vs 2.71%; standardized difference 0.40% [95% confidence interval, 0.13%-0.67%]; P = .003), and the increased risk was observed across all age strata. Dexamethasone use was associated with a higher standardized rate of revisits for bleeding in the postdischarge time periods of days 1 through 5 but not during the peak period for secondary bleeding, days 6 and 7. In a real-world practice setting, dexamethasone use was associated with a small absolute increased risk of revisits for bleeding. However, the upper bound of this risk increase does not cross published thresholds for a minimal clinically important difference. Given the benefits of dexamethasone in reducing postoperative nausea and vomiting and the larger body of evidence from trials, these results support guideline recommendations for the routine use of dexamethasone.
    Otolaryngology Head and Neck Surgery 02/2014; · 1.73 Impact Factor
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    ABSTRACT: To describe the quality of care for routine tonsillectomy at US children's hospitals. We conducted a retrospective cohort study of low-risk children undergoing same-day tonsillectomy between 2004 and 2010 at 36 US children's hospitals that submit data to the Pediatric Health Information System Database. We assessed quality of care by measuring evidence-based processes suggested by national guidelines, perioperative dexamethasone and no antibiotic use, and outcomes, 30-day tonsillectomy-related revisits to hospital. Of 139 715 children who underwent same-day tonsillectomy, 10 868 (7.8%) had a 30-day revisit to hospital. There was significant variability in the administration of dexamethasone (median 76.2%, range 0.3%-98.8%) and antibiotics (median 16.3%, range 2.7%-92.6%) across hospitals. The most common reasons for revisits were bleeding (3.0%) and vomiting and dehydration (2.2%). Older age (10-18 vs 1-3 years) was associated with a greater standardized risk of revisits for bleeding and a lower standardized risk of revisits for vomiting and dehydration. After standardizing for differences in patients and year of surgery, there was significant variability (P < .001) across hospitals in total revisits (median 7.8%, range 3.0%-12.6%), revisits for bleeding (median 3.0%, range 1.0%-8.8%), and revisits for vomiting and dehydration (median 1.9%, range 0.3%-4.4%). Substantial variation exists in the quality of care for routine tonsillectomy across US children's hospitals as measured by perioperative dexamethasone and antibiotic use and revisits to hospital. These data on evidence-based processes and relevant patient outcomes should be useful for hospitals' tonsillectomy quality improvement efforts.
    PEDIATRICS 02/2014; 133(2):280-8. · 4.47 Impact Factor
  • Douglas C Barnhart, Jay G Berry, Rajendu Srivastava
    JAMA pediatrics. 02/2014; 168(2):188-9.
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    ABSTRACT: To determine the impact of gastrojejunal tube (GJT) feedings in children with neurological impairment (NI) on GERD and/or dysfunctional swallowing related visits and their associated costs. A retrospective cohort study of children with NI and GERD who underwent GJT placement at the study hospital from 12/99 - 10/06. Visits (emergency department, radiology, and hospitalizations) were reviewed from the time of birth until one year following GJT placement and classified as either not GERD and/or dysfunctional swallowing related or GERD and/or dysfunctional swallowing related (e.g. pneumonias). Incident rate ratios (IRR) were calculated by dividing the post GJT visit rate by the pre GJT visit rate. Other outcomes included associated costs, fundoplications, and deaths. 33 patients met inclusion criteria. The IRR for total visits was 1.78 (95% Confidence Interval (CI) 1.12 - 2.81) and for GERD and/or dysfunctional swallowing related visits 2.88 (95% CI 1.68 - 4.94). Feeding tube related visits (IRR 5.36, 95% CI 2.73 - 10.51) accounted for the majority. GERD and/or dysfunctional swallowing related costs per child per year were low overall, with no difference from pre-GJT versus post-GJT placement, $1,851 versus $4601, p = 0.89. 7 (21%) children underwent Nissen fundoplication and 4 (12%) died within a year of GJT placement. Two deaths involved jejunal perforation. Children with NI and GERD who were treated with GJT feedings have significantly more GERD and/or dysfunctional swallowing related visits in the following year. The majority of these visits are due to procedural complications which are inexpensive. However, there is mortality associated with the GJT and some children proceed to a fundoplication.
    Journal of pediatric gastroenterology and nutrition 10/2013; · 2.18 Impact Factor
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    ABSTRACT: Inherited leukodystrophies are progressive, debilitating neurological disorders with few treatment options and high mortality rates. Our objective was to determine national variation in the costs for leukodystrophy patients and to evaluate differences in their care. We developed an algorithm to identify inherited leukodystrophy patients in deidentified data sets using a recursive tree model based on International Classification of Disease, 9th Edition, Clinical Modification, diagnosis and procedure charge codes. Validation of the algorithm was performed independently at two institutions, and with data from the Pediatric Health Information System (PHIS) of 43 US children's hospitals, for a 7-year period between 2004 and 2010. A recursive algorithm was developed and validated, based on six International Classification of Disease, 9th Edition, Clinical Modification, codes and one procedure code that had a sensitivity up to 90% (range 61-90%) and a specificity up to 99% (range 53-99%) for identifying inherited leukodystrophy patients. Inherited leukodystrophy patients comprise 0.4% of admissions to children's hospitals and 0.7% of costs. During 7 years, these patients required $411 million of hospital care, or $131,000/patient. Hospital costs for leukodystrophy patients varied at different institutions, ranging from two to 15 times more than the average pediatric patient. There was a statistically significant correlation between higher volume and increased cost efficiency. Increased mortality rates had an inverse relationship with increased patient volume that was not statistically significant. We developed and validated a code-based algorithm for identifying leukodystrophy patients in deidentified national datasets. Leukodystrophy patients account for $59 million of costs yearly at children's hospitals. Our data highlight potential to reduce unwarranted variability and improve patient care.
    Pediatric Neurology 09/2013; 49(3):156-162.e1. · 1.42 Impact Factor
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    ABSTRACT: IMPORTANCE Gastrostomy tube (GT) placement is the most common gastrointestinal operation performed on neonates. Concomitant fundoplication is used variably to prevent complications of gastroesophageal reflux, but its effectiveness is unproven. OBJECTIVE To compare the effect of fundoplication at the time of GT placement vs GT placement alone on subsequent reflux-related hospitalizations in infants with neurological impairment. DESIGN, SETTING, AND PARTICIPANTS Retrospective, observational cohort study, defined by birth between January 1, 2005, and December 31, 2010, at 42 children's hospitals in the United States, with a 1-year follow-up period among 4163 infants with neurological impairment who underwent GT placement with or without fundoplication during their neonatal intensive care unit stay. INTERVENTION Fundoplication and GT placement vs GT placement alone. MAIN OUTCOMES AND MEASURES One-year postprocedural reflux-related hospitalization rates, defined as hospitalization for asthma, mechanical ventilation, gastroesophageal reflux disease, and aspiration or other types of pneumonia. Propensity to undergo concomitant fundoplication was modeled using demographics, prior procedures (tracheostomy and mechanical ventilation), and prior diagnoses (eg, pneumonia, gastroesophageal reflux disease, and other comorbidities). RESULTS Overall, 4163 of 42 796 infants (9.7%) with neurological impairment admitted to the neonatal intensive care unit underwent GT placement alone or with fundoplication. Infants who concomitantly underwent fundoplication had more reflux-related hospitalizations during the first year than those who underwent GT placement alone (mean, 1.02; 95% CI, 0.93-1.10 vs mean, 0.92; 95% CI, 0.91-1.00). Of 1404 infants who underwent fundoplication, 1027 (73.1%) were matched based on propensity scores. The mean difference of the matched cohort for any reflux-related hospitalizations was -0.05 (95% CI, -0.20 to 0.15) per year. CONCLUSIONS AND RELEVANCE Infants with neurological impairment who underwent fundoplication at the time of GT placement did not have a reduced rate of reflux-related hospitalizations during the first year compared with those who underwent GT placement alone, despite propensity score matching. This may be due to a lack of effectiveness of fundoplication in preventing these complications or due to differences in the patient groups that were inadequately accounted for in the matching.
    JAMA pediatrics. 08/2013;
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    ABSTRACT: OBJECTIVE: To test the hypothesis that children's hospitals with shorter length of stay (LOS) for hospitalized patients have higher all-cause readmission rates. STUDY DESIGN: Longitudinal, retrospective cohort study of the Pediatric Health Information System of 183 616 admissions within 43 US children's hospitals for appendectomy, asthma, gastroenteritis, and seizure between July 2009 and June 2011. Admissions were stratified by medical complexity, based on whether patients had a complex chronic health condition, were neurologically impaired, or were assisted with medical technology. Outcome measures include LOS; all-cause readmission rates within 3, 7, 15, and 30 days; and the association between hospital-specific mean LOS and all-cause readmission rates as determined by linear regression. RESULTS: Mean LOS was <3 days for all patients across all conditions, except for appendectomy in complex patients (mean LOS 3.7 days, 95% CI 3.47-4.01). Condition-specific 3-, 7-, 15-, and 30-day all-cause readmission rates for noncomplex patients were all <5%. Condition-specific readmission rates for complex patients ranged from <1% at 3 days for seizures to 16% at 30 days for gastroenteritis. There was no linear association between hospital-specific, condition-specific mean LOS, stratified by medical complexity, and all-cause readmission rates at any time interval within 30 days (all P values ≥.10). CONCLUSION: In children's hospitals, LOS is short and readmission rates are low for asthma, appendectomy, gastroenteritis, and seizure admissions. In the conditions studied, there is no association between shorter hospital-specific LOS and higher readmission rates within the LOS observed.
    The Journal of pediatrics 05/2013; · 4.02 Impact Factor
  • The Journal of pediatrics 05/2013; 162(5):887-888.e1. · 4.02 Impact Factor
  • Rajendu Srivastava, Ron Keren
    JAMA The Journal of the American Medical Association 01/2013; 309(4):396-8. · 29.98 Impact Factor
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    ABSTRACT: Pediatric hospitalists care for many hospitalized children in community and academic settings, and they must partner with administrators, other inpatient care providers, and researchers to assure the reliable delivery of high-quality, safe, evidence-based, and cost-effective care within the complex inpatient setting. Paralleling the growth of the field of pediatric hospital medicine is the realization that innovations are needed to address some of the most common clinical questions. Some of the unique challenges facing pediatric hospitalists include the lack of evidence for treating common conditions, children with chronic complex conditions, compressed time frame for admissions, and the variety of settings in which hospitalists practice. Most pediatric hospitalists are engaged in some kind of quality improvement (QI) work as hospitals provide many opportunities for QI activity and innovation. There are multiple national efforts in the pediatric hospital medicine community to improve quality, including the Children’s Hospital Association (CHA) collaboratives and the Value in Pediatrics Network (VIP). Pediatric hospitalists are also challenged by the differences between QI and QI research; understanding that while improving local care is important, to provide consistent quality care to children we must study single-center and multicenter QI efforts by designing, developing, and evaluating interventions in a rigorous manner, and examine how systems variations impact implementation. The Pediatric Research in Inpatient Setting (PRIS) network is a leader in QI research and has several ongoing projects. The Prioritization project and Pediatric Health Information System Plus (PHIS+) have used administrative data to study variations in care, and the IIPE-PRIS Accelerating Safe Sign-outs (I-PASS) study highlights the potential for innovative QI research methods to improve care and clinical training. We address the importance, current state, accomplishments, and challenges of QI and QI research in pediatric hospital medicine; define the role of the PRIS Network in QI research; describe an exemplary QI research project, the I-PASS Study; address challenges for funding, training and mentorship, and publication; and identify future directions for QI research in pediatric hospital medicine.
    Academic Pediatrics. 01/2013; 13(6):S54–S60.
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    ABSTRACT: Unnecessarily broad-spectrum antibiotic prescribing for ambulatory pediatric urinary tract infection may result from clinicians not having antibiograms specific to this population. Comparing an existing hospital-based with a proposed ambulatory uropathogen antibiogram for children in Utah, Escherichia coli accounted for a larger percentage and was more susceptible to narrower-spectrum antibiotics, demonstrating the potential need for ambulatory pediatric antibiograms.
    Journal of the Pediatric Infectious Diseases Society. 12/2012; 1(4):333-336.
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    ABSTRACT: OBJECTIVES: To determine the costs for children with leukodystrophies and whether high costs are associated with characteristic clinical features or resources use. STUDY DESIGN: We determined health care costs in a population cohort of 122 patients with leukodystrophies, including inpatient, outpatient, and emergency department use, during a 9-year period. We analyzed differences in patients with high costs (>85th percentile) and their health care use. RESULTS: Patients with leukodystrophy had significant variability in resource use, with the top 15th percentile of patients accounting for 73% of costs ($9.6 million). The majority of costs, 81% ($10.8 million), arose from inpatient hospitalization. High-cost patients had more and longer hospitalizations, increased requirements for intensive unit care and mechanical ventilation, and significantly more infections. Importantly, bone marrow transplantation did not solely account for the difference between high-cost and low-cost groups. CONCLUSION: Inpatient hospitalization is the greatest source of health care resource use in patients with leukodystrophies. A minority of patients account for the majority of costs, primarily attributable to an increased volume of hospitalization. Strategies to improve care and reduce costs will need to reduce inpatient stays and target modifiable reasons for hospitalization.
    The Journal of pediatrics 10/2012; · 4.02 Impact Factor
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    ABSTRACT: OBJECTIVE To use information about prevalence, cost, and variation in resource utilization to prioritize comparative effectiveness research topics in hospital pediatrics. DESIGN Retrospective analysis of administrative and billing data for hospital encounters. SETTING Thirty-eight freestanding US children's hospitals from January 1, 2004, through December 31, 2009. PARTICIPANTS Children hospitalized with conditions that accounted for either 80% of all encounters or 80% of all charges. MAIN OUTCOME MEASURES Condition-specific prevalence, total standardized cost, and interhospital variation in mean standardized cost per encounter, measured in 2 ways: (1) intraclass correlation coefficient, which represents the fraction of total variation in standardized costs per encounter due to variation between hospitals; and (2) number of outlier hospitals, defined as having more than 30% of encounters with standardized costs in either the lowest or highest quintile across all encounters. RESULTS Among 495 conditions accounting for 80% of all charges, the 10 most expensive conditions accounted for 36% of all standardized costs. Among the 50 most prevalent and 50 most costly conditions (77 in total), 26 had intraclass correlation coefficients higher than 0.10 and 5 had intraclass correlation coefficients higher than 0.30. For 10 conditions, more than half of the hospitals met outlier hospital criteria. Surgical procedures for hypertrophy of tonsils and adenoids, otitis media, and acute appendicitis without peritonitis were high cost, were high prevalence, and displayed significant variation in interhospital cost per encounter. CONCLUSIONS Detailed administrative and billing data can be used to standardize hospital costs and identify high-priority conditions for comparative effectiveness research-those that are high cost, are high prevalence, and demonstrate high variation in resource utilization.
    JAMA Pediatrics 10/2012; · 4.28 Impact Factor
  • Rajendu Srivastava, Christopher P Landrigan
    Journal of Hospital Medicine 10/2012; 7(8):661-4. · 1.40 Impact Factor
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    ABSTRACT: OBJECTIVES: We sought to determine the yield of cardiac testing and to identify predictors of cardiac disease in infants with an apparent life-threatening event (ALTE). DESIGN: Retrospective longitudinal cohort study. SETTING: Paediatric hospital providing primary and tertiary care that is part of an integrated healthcare system. PATIENTS: Infants hospitalised for an ALTE from 1999 to 2003. MAIN EXPOSURES: Cardiac testing used at time of ALTE and results, and clinical risk factors for cardiac disease. OUTCOME MEASURES: Short-term (during hospitalisation) and long-term (through November 2009) follow-up for any diagnosis of significant cardiac anatomic or rhythm abnormality. RESULTS: Study criteria were met by 485 infants (mean age 1.9, SD±2.2 months; 49% boys). Cardiac testing was performed on 219 (45%) patients during ALTE hospitalisation, identifying two patients with significant cardiac disease (cardiomyopathy, ventricular pre-excitation). During 7.7 years of follow-up, three additional significant cardiac diagnoses (ventricular pre-excitation, frequent ventricular ectopy, moderate aortic stenosis) were identified. All cardiac tests had low positive predictive value (PPV). Significant cardiac disease was associated with prematurity (22% vs 80%, p=0.002), but not age, gender, prior ALTE or rescue breaths. CONCLUSIONS: This longitudinal study of an ALTE cohort revealed significant cardiac disease in <1% of patients. Prematurity was the only clinical predictor identified. ECG was sensitive for identifying significant cardiac disease, but routine testing warrants further investigation because of the low PPV.
    Archives of Disease in Childhood 09/2012; · 3.05 Impact Factor

Publication Stats

614 Citations
220.76 Total Impact Points


  • 2005–2014
    • University of Utah
      • • Primary Children's Medical Center
      • • Department of Pediatrics
      • • Division of Pediatric Inpatient Medicine
      • • Division of Pediatric Neurology
      Salt Lake City, Utah, United States
  • 2006–2012
    • Boston Children's Hospital
      • Division of General Pediatrics
      Boston, Massachusetts, United States
  • 2011
    • SickKids
      • Division of Paediatric Medicine
      Toronto, Ontario, Canada
  • 2010
    • Seattle Children's Hospital
      Seattle, Washington, United States
  • 2003
    • Harvard Medical School
      • Department of Medicine
      Boston, MA, United States