Primary Care Clinics in Office Practice

Published by WB Saunders
Online ISSN: 0095-4543
Publications
Article
A systematic approach to the patient with anorectal complaints allows for an accurate and efficient diagnosis of the underlying problem. The process can be divided into the interview, the examination, treatment, and conveyance of information. Throughout this process, the patient must be reassured and made as comfortable as possible. A successful interaction with the patient leads to a diagnosis and a treatment plan that is acceptable to both the physician and the patient.
 
Article
Clinical information is used to develop differential diagnoses and narrow the possibilities. The history and physical examination motivate our initial diagnostic impression. Clinical laboratory results and further diagnostic maneuvers are used to confirm or refute our initial impressions. These tests and procedures are not perfect; they sometimes yield false results, which taken alone, might lead to misguided therapeutic interventions. Concepts of sensitivity, specificity, and predictive value provide the tools needed to integrate new information with initial diagnostic impressions. The concept of overall accuracy provides a quantitative estimate of how well a particular maneuver will perform. ROC curve analysis provides yet another quantitative and visual assessment of a test's performance. Additionally, the statistical tools described by Hanley and McNeil provide objective, quantitative means for comparing the various tests from which the clinician must select. Electronic spreadsheets and dedicated computer software provide relatively user friendly methods for engaging these techniques. Although individual clinicians might not choose to perform such analyses themselves, the discussion in this article should help the busy physician answer the question, "How good is that test?"
 
Article
Providing quality health care involves integrating routine inquiry about domestic violence into ongoing clinical practice. This means asking all women patients, and others who may be at risk, about abuse in their lives. Whether or not a woman chooses to use services or leave her partner, our intervention is very important. Some women return to violent partners several times before they feel safe enough to leave, feel they can survive on their own, or can accept that the person they love will not change. Make sure that she has follow-up for her medical problems and appropriate referrals for mental health and substance abuse problems when indicated.
 
Article
To be optimally effective, chemotherapy for tuberculosis must eliminate both the large rapidly dividing population of bacilli and the smaller slowly dividing one (bacterial persisters). Nine months of isoniazid and rifampin, even when given largely twice-weekly, achieves rapid sputum conversion, permits few treatment failures or relapses, and is not fraught with excessive toxicity. As used in Arkansas, the complete course of therapy entails less than 100 doses, which makes the cost less than that of any other regimen in common use in the United States.
 
Article
The treatment of hypertension must be based on pathophysiologic grounds. The drugs that have been used in the classic stepped-care approach are still useful, but the rationale for their usage should not be based on the presumption that all hypertension is mediated by salt and water. Thus, the adolescent obtains greater benefits from a beta-adrenergic blocking drug or a centrally acting antihypertensive. The individual with heart failure may benefit more from a converting enzyme inhibitor than a vasodilator. In cerebrovascular disease with hypertension, dosage must be reduced owing to the enhanced sensitivity of response. New drugs are discussed, and their place in the armamentarium is evaluated.
 
Article
Even when all available preventive strategies are strongly encouraged, the diagnosis of cancer will often be encountered in the primary care setting. Patients will look to their personal physician for advice in dealing with their illness and commonly ask, "What would you do?" Knowing the patient well, whether he or she desires to fight for every possible day of life or apparently welcomes an earlier death with freedom from life prolongation therapies, is the basis for helping the patient to choose alternatives. Informed decisions by the physician are facilitated by appropriate classification and staging of the tumor. Entrusted to the primary physician are numerous responsibilities that include team management, aiding the patient and family to cope with the illness, and maintaining a quality life with the best possible functional status. Both patient and physician must fully understand and share what is known about the cancer in order to individualize treatment with the proper level of care. Modern cancer care is highly sophisticated and changeable; to do it well requires a special interest and attention from the physician.
 
Article
The magnitude of the smoking problem is overwhelming. The annual mortality and expense are staggering. The task of changing this apocalyptic problem seems impossible. The solution, however, is not remote: It begins with each physician and with each individual patient who smokes. A consistent attitude of nonacceptance of the smoking habit with recommendations and support for discontinuation can make a significant impact on the problem. Extension of this attitude into community affairs and regional and national politics will result in increased public awareness and eventually in the majority rejecting this costly habit.
 
Article
Gallstone disease continues to be one of the more common abdominal problems that prompts medical evaluation, particularly in the elderly population. The presentation is diverse, and the treatment options varied. Primary care physicians need to be familiar with the differential diagnosis, evaluation, and therapeutic options available. LC has emerged as the preferred treatment for patients with symptomatic gallstone disease.
 
Article
Overuse injuries are caused by intrinsic and extrinsic factors. Exercise exposes even the most subtle anatomic imperfections and extrinsic influences. Overuse that is not musculoskeletal in nature and new information pertaining to the role of bursae are discussed. Treatment philosophy is approached with an emphasis on history taking.
 
Article
This article summarizes epidemiologic data available on work-related morbidity and mortality and describes the occupational health surveillance systems currently in use. The NIOSH top 10 priority occupational illnesses and injuries and the year 2000 objectives for occupational health are described. Finally, statistics regarding occupational medicine specialists are presented.
 
Article
As we move into the new century, we continue to focus on ways to prevent disease, promote health, and prolong life. We have made enormous strides in some arenas, including deaths from infectious diseases caused by mass immunization, improved sanitation, better nutrition, heart disease caused by risk factor modification, and some cancers caused by smoking cessation and screening for early detection. Although we have made progress, many challenges remain.
 
Article
The 2009 influenza A (H1N1) pandemic provided a major test to the public health system in the United States and abroad. Although the virus was rapidly identified, it took longer than expected to bring an effective vaccine to market. During the interim the virus demonstrated a predilection for infecting younger persons, particularly those with medical conditions such as asthma or pregnancy, placing them at risk. Early treatment with neuraminidase inhibitors was found to be of some benefit. When the 2009 H1N1 influenza A vaccine became available, there were distribution issues in matching the number of doses to areas of need.
 
Article
Various presentations of viral hepatitis and the role of laboratory values in differential diagnosis are illustrated through hypothetical clinical cases. A 'panel' or 'profile' approach when using the available serum markers can be useful in avoiding some of the common pitfalls of laboratory diagnosis.
 
Article
Chronic vague abdominal pain is an extremely common complaint in children over 5 years, with a peak incidence in the 8 to 10 year group. In over 90 per cent of the cases no serious underlying organic disease will be discovered. Most disease states can be ruled out by a careful history, a meticulous physical examination, and a few simple laboratory tests such as urinalysis, sedimentation rate, hemoglobin, white blood count determination, and examination of a blood smear. If organic disease is present there are often clues in the history and the examination. The kidney is often the culprit—an intravenous pyelogram should be done if disease is suspected. Barium enema is the next most valuable test. Duodenal ulcers and abdominal epilepsy are rare and are over-diagnosed. If no organic cause is found, the parents must be convinced that the pain is real, and that “functional” does not mean “imaginary.” This is best explained by comparing with “headache”—the headache resulting from stress and tension hurts every bit as much as the headache caused by a brain tumor or other intracranial pathology. Having convinced the patient and his parents that no serious disease exists, no further investigation should be carried out unless new signs or symptoms appear. The child must be returned to full activity immediately.
 
Article
Acute abdominal pain is a complaint seen commonly in the outpatient setting that has a broad and often confusing differential diagnosis. Although many presentations can be managed on an outpatient basis, several gastrointestinal causes of abdominal pain demand thoughtful consideration with subsequent referral to a higher level of care for appropriate diagnosis and treatment. To achieve this goal, outpatient physicians must have an understanding of the mechanisms of abdominal pain, as well as the common gastrointestinal causes that carry potentially higher morbidity and mortality.
 
Article
Chronic abdominal pain can be a symptom of organic illness in children or may indicate the presence of a psychosomatic illness. Helpful procedures and lines of questioning to differentiate between organic or psychosomatic illness are suggested. Once psychosomatic illness is diagnosed, certain principles of therapy should be followed by the family physician.
 
Article
In this article, the incidence of acute abdominal pain in primary care practice, its etiology and pathogenesis, and the evaluation of the patient with pain are discussed. Special attention is given to the differential diagnosis of both surgical and nonsurgical diseases that can present with abdominal pain as the major manifestation.
 
Article
The management of patients with abnormal uterine bleeding requires a logical, rational approach, and an awareness of etiologic factors. A careful history and examination should attempt to answer these questions: (1) Is the bleeding truly from the uterus? (2) Is the bleeding superimposed upon ovulatory cycles or (3) is the bleeding anovulatory? The endometrial biopsy obtained during the bleeding episode, and the basal temperature chart are diagnostically useful. Massive uterine bleeding not due to a complication of pregnancy, neoplasis, or blood dyscrasia, usually responds immediately to curettage, done in operating room or office; follow-up hormonal therapy with progesterone and a progestational agent should control the episode. More chronic forms of abnormal uterine bleeding are approached by identifying and treating the etiologic cause. If the cause is not correctable (e.g., obesity), most patients will respond satisfactorily to the cyclic administration of a progestational agent, or, if indicated, to induction of ovulation.
 
Article
Triage of the abnormal Papanicolaou smear in pregnancy requires colposcopic evaluation and directed biopsy. If histologic cervical intraepithelial neoplasia is confirmed, the patient can be managed with observations and can be re-evaluated in the postpartum period. If evidence of microinvasion is present, conization must be performed. For patients with invasive disease, a delay in therapy until fetal maturity is achieved does not compromise survival.
 
Article
This article reviewed some common ET abnormalities. Unifocal PVCs seen during exercise does not increase risk, whereas complex arrhythmias in both asymptomatic patients and those with coronary artery disease increase the patients long-term risk. Three responses are indicative of severe disease: complex arrhythmias at low workloads, EIH, and ST-segment elevation in areas without previous myocardial infarction. Patients showing these responses need further testing and cardiac consultation. Isolated enferior ST-segment depression is seldom useful diagnostically and often a false-positive response.
 
Article
Sickle cell and abnormal hemoglobin screening programs should not be undertaken lightly but rather should have a specific purpose or purposes. If the aim is to detect only sickle hemoglobin, a certain strategy is necessary. If the goal is to detect all abnormal hemoglobins and genetic counseling is planned, another approach should be used. A simple solubility test detects sickle hemoglobin with high reliability, but deals with no other abnormal hemoglobins. Hemoglobin electrophoresis, followed by other tests as indicated, is then necessary to ascertain other abnormal hemoglobins in addition to hemoglobin S.
 
Article
The problem of identifying abnormal patterns of growth in the pediatric population has been approached based on a schema that is dictated by the normal physiologic events that occur at each of the phases of infancy, childhood, and pubertal growth. These phases of growth have specific and quantifiable normal patterns, which provide a reference means for defining truly abnormal patterns of growth. The clinical evaluation, therefore, is dependent on and somewhat unique to the particular age group of the child whose growth is in question. By approaching the work-up in this age-specific manner, the clinician can direct his or her attention to the parameters of growth that are most critical to that particular phase, look for explanations that are the most likely, and, it is hoped, avoid unnecessary testing and referral.
 
Article
The pap smear is a safe, easy, and inexpensive method for the screening of large numbers of sexually active women for the presence of neoplasia of the cervix. When the pap smear is reported as being abnormal, it is highly accurate. Unfortunately, some cytology laboratories report lesions as “Class II” or “atypical.” These reports are not helpful to the clinician and require further evaluation. Most sexually active women are at “high risk” for the development of cervical neoplasia because of early sexual activity for multiple sexual partners. All women at high risk should have annual pap smears. If a woman has a pap smear that suggests the presence of CIN (dysplasia or carcinoma in situ), colposcopy should be performed. This office procedure allows for the detection of the areas causing the abnormal cytology. Colposcopy can often allow outpatient therapy of CIN lesions. Conization should be performed only when the colposcopic examination is unsatisfactory or patient or lesion factors are not favorable for office therapy. Hysterectomy is not recommended for treatment of cervical dysplasia or carcinoma in situ.
 
Article
A prolonged latent phase should be treated with rest; a protracted disorder with expectant management; and an arrest of labor with oxytocin therapy once CPD has been excluded.
 
Article
Cryotherapy of dermal abnormalities is a commonly used technique in the field of primary care. To perform cryotherapy effectively, one must understand the principles of cryoablation and how they apply to specific skin disorders. One also must be familiar with the various types of equipment that are used to perform cryotherapy. With this understanding cryotherapy easily can be integrated into outpatient primary care.
 
Article
Each of the five true hyponatremias is discussed as a defect in the free water-excreting mechanisms of the body, in order to formulate a rational approach to diagnosis and treatment. One artificial and three real causes of elevations in plasma sodium are also discussed.
 
Article
A thorough understanding of the events and hormonal changes which accompany puberty can be successfully utilized to diagnose adolescent menstrual disorders. Knowledge regarding the maturational events within the hypothalamic-pituitary-ovarian axis and the expected times at which positive feedback leading to ovulation occurs is helpful in the design of optimal therapeutic regimens. It should be emphasized that the immature hypothalamic-pituitary-ovarian axis is extremely sensitive to low doses of estrogen and suppression may hinder maturation to normal cyclic activity. Therefore, forms of therapy other than oral contraceptives should be sought and prescribed for adolescents with menstrual disorders.
 
Article
Spontaneous abortion rates vary with maternal age, but the overall incidence is approximately 2% of clinically recognized pregnancies. The incidence of clinically unrecognized loss is approximately 20%. Most early fetal losses are caused by abnormal karyotypes. Other causes include heavy caffeine use, acute alcohol consumption, and smoking. Ultrasonographic examination, which includes yolk sac configuration and crown-rump length determination can help differentiate between normal and abnormal pregnancies. After 8 weeks' gestation, hormonal assays are decreased. Conservative management of spontaneous abortions can be considered if patients have low beta-hCG levels and no residual tissue detected using ultrasonography. Complications of spontaneous abortion include maternal death, bleeding, and infection. Consideration should be given to the psychological health of women and their partners who experience spontaneous abortion, particularly if they exhibit depression, guilt, and grief reactions.
 
Article
Infertility, treatment with reproductive technologies, and abortion are among the most emotionally weighty and philosophically contentious experiences in most patients' lives. They involve the most intimate body parts and behaviors and the most heartfelt hopes and profound disappointments. They can strain relationships with partners, relatives, and friends. The primary care practitioner who is informed about the psychological impact of these experiences can play an essential role in interpreting medical information; helping patients think through their own values, resources, and options; facilitating communication between members of a couple and with their friends and family; providing emotional support; and identifying and treating psychiatric disorders that sometimes occur before, during, or after these experiences.
 
Article
A range of medical and scientific developments that have occurred since the 1973 US Supreme Court decision in Roe v Wade have important implications for the future of abortion. Included among these developments are the rise of neonatal intensive care and the subsequent lowering of the time of fetal viability, the widespread use of the sonogram, growing concern for the association between fetal health and women's occupational health, and the dilemmas posed by late abortions that can result in a live birth. A key feature of both the legal developments and medical changes since Roe v Wade has been their focus on evaluation of the fetus rather than the rights of women. Despite the complexities of the situation, there remain important reasons for keeping abortion legal in the US. Should the abortion decision be overturned, a rapid return to high rates of illegal abortion can be expected. To deprive women of choice in the area of procreation would also lower their status as human beings. If the prochoice movement demonstrates an unwillingness to face the implications of the new medical and scientific knowledge and recognize the difficulty of the abortion decision, it will open itself to charges that it is as dogmatic and rigid as antiabortion forces. There is a need for open discussion of the moral nature of abortion decisions and recognition that legal freedom does not necessarily confer moral wisdom.
 
Article
Anorectal abscesses and fistulas are seen commonly in the primary care practice. An abscess forms as the result of obstruction of an anal gland, with resulting retrograde infection. An anal fistula simply represents the chronic phase of a perianal abscess. The history generally is diagnostic, and special studies usually are not required. Treatment is surgical, with good results.
 
Article
Epithelial cysts and cutaneous abscesses account for a significant percentage of visits to primary care physicians. The majority of these skin problems can be handled in the office setting. In this article, a variety of modes of treatment for these common lesions are outlined.
 
Article
Antacids interfere with gastrointestinal drug absorption by either increasing or decreasing the rate at which a drug is absorbed, or the total quantity absorbed. Antacids influence drug absorption by alteration of ionization state or solubility, factors dependent upon pH. Antacids also delay gastric emptying and are capable of chelation and adsorption with susceptible products. Many of these factors participate to produce the effect on gastrointestinal drug absorption in individual patients.
 
Article
This article presents a psychodynamic approach to the understanding and treatment of abstaining and bulemic anorexics. While the abstainer starves herself to the point of emaciation and the bulemic may gorge to the point of obesity, the underlying emotional conflicts of the two groups of patients are the same. The ego (character structure) of the bulemic is not as perfectionistic and rigid as that of the abstainer, so the patient is periodically overwhelmed not only by impulses to gorge but also by impulses of all kinds. A description of the clinical syndrome, the physiological findings and details of the laboratory diagnosis of anorexia nervosa are provided. Family psychodynamics which are viewed as etiologic are presented. A psychodynamic therapeutic approach is described and examples of the treatment of an abstaining and bulemic patient are detailed. The crucial therapeutic role of the family physician is explored with emphasis on the importance of the physician's encouraging the patient to bring up questions about food and eating with the psychiatrist because such preoccupations mask other conflicts.
 
Article
Misuse and abuse of prescription medication can be a difficult clinical area for physicians. Prior to prescribing any mood-altering medication, the physician should screen for patients at risk for abuse by asking about an individual or family history of alcohol or other drug abuse. When prescribing a psychoactive medication, the clinician should be sure that there is a clear clinical indication and should identify a therapeutic end-point and time limit. Nonpharmacologic interventions should be emphasized when appropriate. When misuse rather than abuse is suspected, the intervention may be one of education and simplification or clarification of the therapeutic contract. Physicians should recognize apparent drug-seeking behaviors and feel comfortable questioning for possible alcohol or other drug-related problems so that drug abuse can be identified as an additional problem requiring attention. Physicians should be comfortable with assertively denying drugs to drug-seeking patients when appropriate. Although sometimes difficult, to do otherwise would be to facilitate the continuation of a potentially serious problem. The potential frustration and aggravation of dealing with prescription drug abuse can be minimized by thoughtful attention to prevention, the development of a rational style of prescribing, and the appropriate use of intervention.
 
Article
The present state of knowledge in the field of child abuse and neglect is reviewed, and the role of the primary care physician in the recognition, management, treatment, and prevention of child abuse is discussed.
 
Article
Psychoactive substances have been used by humans from the earliest recorded times, and evidence shows that from the beginning some people have used drugs excessively, thus developing problems. From the 1960s to the 1980s, there has been a dramatic upswing in the use of alcohol and illicit substances, but some evidence demonstrates that this trend is beginning to reverse. Current substance abuse is estimated to cost US society about $152 billion and cause over 75,000 deaths annually. Research and treatment efforts have increased significantly over the past two decades. Although the exact cause of substance abuse disorders is unknown, evidence indicates that it is a complex interaction between biologic predispositions, and psychologic and social factors. The majority of research seems to indicate that at least in a subtype of patients with more severe abuse, genetic factors appear to be the single most important influence. Considerable research is underway to further clarify these factors, and it is reasonable to expect that we will soon have a much clearer understanding of the cause of these disorders. In turn, this understanding should lead to a better understanding of the optimal treatment for the millions of patients and families afflicted with substance abuse disorders.
 
Article
Child abuse is an age-old problem for which we have had documentary records for as long as we have had recorded history. This article reviews the ethical dilemmas, diagnosis, interviewing guidelines, physical examination, and treatment for child physical abuse. Also discussed are unusual manifestations and differential diagnosis.
 
Article
Child abuse is a common pediatric problem that can be recognized and treated appropriately by all primary care physicians who care for children. One of the necessary skills in this process involves being prepared to interface with the legal system. The physician is mandated to report suspected child abuse according to his or her state laws. He or she must be aware of the legal recourses for child protection in cases when the child remains at risk. When interacting with the child, a number of legal considerations can guide the physician in obtaining information with history, physical examination, and specimen collection. Finally, the physician may be called to testify. An understanding of how to prepare for court and how to conduct oneself in court is the final necessary skill for the primary care physician who sees children. This article provides the primary care physician with a practical understanding of the legal considerations in child abuse.
 
Article
This article has discussed the most common sequelae of victimization with regard to incest, rape, and battering. Although legislators and law-enforcement officials have traditionally been viewed as having primary responsibility for the prevention and control of violence, it is now known that physicians must also act in this regard. Their action is especially required with regard to victim assessment and treatment. Physicians serve as the entry points not only to the health care system, but also to other resources for victims of violence. By identifying their victimized patients and by understanding the antecedents of their patients' symptoms, physicians can go much further in meeting their patients' needs for physical, mental, and social well-being. Given the scope and impact of violence, physicians have a moral and ethical obligation to inquire about the possibility of current violence, past violence, or both in their patients' lives.
 
Article
Patients with alcohol problems come to their primary care physicians at different points along the spectrum of experiences with alcohol; therefore, physicians need to be able to respond with a variety of interventions. In addition, patients present in different stages of change, and physicians need to be aware of where the patient is in that continuum. Evidence shows that less intensive, outpatient treatment may be as beneficial as inpatient treatment for some patients and that primary care physicians can offer some of their patients relatively simple interventions that are effective. Medications such as disulfiram offer little in the treatment of alcoholism but may be of benefit in selected situations. Of greater benefit are more complex psychosocial interventions carried out by a team of health care professionals.
 
Article
Primary care physicians should be aware of the popular street drugs being abused in their practice areas. A basic understanding of the drugs and their use will make the physician more credible in the eyes of the patient. Patients may present a variety of symptoms associated with their chemical abuse. Specific presenting complaints, physical findings, and laboratory tests will help establish the diagnosis of substance abuse. After the diagnosis is established, a drug treatment program can bring about a seemingly miraculous recovery from the disease of chemical dependency, to the lasting benefit of the patient and the patient's family.
 
Article
Use and abuse of both licit and illicit drugs is common. Although certain variables can appropriately serve as markers for increased risk, the possibility of substance abuse should be considered in all pregnant women. Alcohol is the leading identified cause of teratogenesis by drugs or environmental agents; most other drugs of abuse do not increase the risk of congenital malformations on a large scale. Substance abuse can produce significant degrees of toxicity in both pregnant women and their offspring. Screening and counseling of pregnant women concerning past and present use of tobacco, alcohol, and illicit drugs should be routine. Prenatal care must include increased surveillance for drug-related complications; coordinated, comprehensive, family-oriented drug treatment; and social services. Rehabilitation and support efforts should continue after delivery and address issues that lead to and maintain patterns of abuse. The drug-exposed neonate must be anticipated and evaluated with a knowledge of the maternal drug abuse history and specific drug risks, including neonatal abstinence syndrome. Continuing care of the child should address the increased risk of developmental and behavioral problems from both prenatal exposures and continuing socioenvironmental barriers.
 
WHO Pain Ladder  
Article
The epidemic of prescription drug abuse has reached a critical level, which has received national attention. This article provides insight into the epidemiology of prescription drug abuse, explains regulatory issues, and provides guidelines for the assessment and management of pain, particularly with long-term opioid therapy. Using informed consent forms, treatment agreements, and risk documentation tools and regularly monitoring the 4 A's help to educate patients and guide management based on treatment goals. By using universal precautions, and being aware of aberrant behaviors, physicians may feel more confident in identifying and addressing problematic behaviors.
 
Article
Elder abuse is a tragedy both for the individual and for society because it occupies a pivotal position in the family life cycle of violence. Great variety exists among victims, abusers, and situations; thus, no single model is adequate to explain cause and direct treatment. Primary care physicians must be alert to the possibility of elder abuse in their patients and aware of resources within their community for managing cases once identified. Federal laws and regulations must take a proactive, long-term approach to the solution of this problem and must respect the autonomy of competent elderly patients.
 
Article
This article focuses on the problem of tobacco cessation in the patient recovering from alcohol or other substance abuse. The authors review the epidemiology of the problem, specific health risks to this population from continued tobacco use, and recent research findings that address previous treatment concerns. Recommendations for counseling by physicians are made. These include an algorithm for determining the patient's stage of readiness for making a quit attempt, specific counseling tasks based on the patients stage, and motivational counseling strategies aimed at increasing the patients motivation to quit.
 
Article
Adult survivors of child sexual abuse suffer a range of physical, psychological, and interpersonal aftereffects. These patients are increasingly evident in health care settings where they seek medical or psychological treatment for symptoms related to the abuse. The recognition of an abuse history as the traumatic antecedent is critical in differential diagnosis, treatment, and management. This paper reviews the aftereffects of child sexual abuse and provides recommendations to the primary care professional about identifying and treating adult survivors in their practices.
 
Top-cited authors
Avron Lipschitz
  • National and Kapodistrian University of Athens
D.E. Greydanus
  • Western Michigan University
Seth Smith
  • Cuesta College
Sharon Moe
  • Indiana University School of Medicine
Steven D Vannoy
  • University of Massachusetts Boston