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Association of Neighborhood Socioeconomic Status With Withdrawal of Life-Sustaining Therapies After Intracerebral Hemorrhage

Melmed, Kara R; Lewis, Ariane; Kuohn, Lindsey; Marmo, Joanna; Rossan-Raghunath, Nirmala; Torres, Jose; Muralidharan, Rajanandini; Lord, Aaron S; Ishida, Koto; Frontera, Jennifer A
BACKGROUND AND OBJECTIVES/OBJECTIVE:Mortality after intracerebral hemorrhage (ICH) is common. Neighborhood socioeconomic status (nSES) is an important social determinant of health (SDoH) that can affect clinical outcome. We hypothesize that SDoH, including nSES, contribute to differences in withdrawal of life-sustaining therapies (WLSTs) and mortality in patients with ICH. METHODS:tests. We performed multivariable analysis using backward stepwise logistic regression. RESULTS:≤ 0.01 for both). In multivariable analysis adjusting for age and clinical severity scores, patients who lived in zip codes with high-income levels were more likely to have WLST (adjusted odds ratio [aOR] 1.88; 95% CI 1.29-2.74) and mortality before discharge (aOR 1.5; 95% CI 1.06-2.13). DISCUSSION/CONCLUSIONS:SDoH, including nSES, are associated with WLST after ICH. This has important implications for the care and management of patients with ICH.
PMID: 38237088
ISSN: 1526-632x
CID: 5624412

Video Analyses of Sudden Unexplained Deaths in Toddlers

Gould, Laura; Reid, Codi-Ann; Rodriguez, Alcibiades J; Devinsky, Orrin; ,
BACKGROUND AND OBJECTIVES/OBJECTIVE:More than 2,900 US children aged younger than 4 years die from unknown causes each year, accounting for more than 219,000 life years lost annually. They are mostly sleep-related and unwitnessed with unremarkable autopsies, limiting our understanding of death mechanisms. We sought to understand potential mechanisms of death by evaluating videos of sudden deaths in toddlers. METHODS:In our registry of 301 sudden unexplained child deaths, a series of 7 consecutively enrolled cases with home video recordings of the child's last sleep period were independently assessed by 8 physicians for video quality, movement, and sound. RESULTS:Four boys and 3 girls (13-27 months at death) with terminal videos shared similar demographic features to the 293 other registry cases without video recordings. Five video recordings were continuous and 2 were triggered by sound or motion. Two lacked audio. All continuous recordings included a terminal convulsive event lasting 8-50 seconds; 4 children survived for >2.5 minutes postconvulsion. Among discontinuous videos, time lapses limited review; 1 suggested a convulsive event. Six were prone with face down, and 1 had autopsy evidence of airway obstruction. Primary cardiac arrhythmias were not supported; all 7 children had normal cardiac pathology and whole-exome sequencing identified no known cardiac disease variants. DISCUSSION/CONCLUSIONS:Audio-visual recordings in 7 toddlers with unexplained sudden deaths strongly implicate that deaths were related to convulsive seizures, suggesting that many unexplained sleep-related deaths may result from seizures.
PMID: 38175965
ISSN: 1526-632x
CID: 5628382

Evaluating Large Language Models in Extracting Cognitive Exam Dates and Scores

Zhang, Hao; Jethani, Neil; Jones, Simon; Genes, Nicholas; Major, Vincent J; Jaffe, Ian S; Cardillo, Anthony B; Heilenbach, Noah; Ali, Nadia Fazal; Bonanni, Luke J; Clayburn, Andrew J; Khera, Zain; Sadler, Erica C; Prasad, Jaideep; Schlacter, Jamie; Liu, Kevin; Silva, Benjamin; Montgomery, Sophie; Kim, Eric J; Lester, Jacob; Hill, Theodore M; Avoricani, Alba; Chervonski, Ethan; Davydov, James; Small, William; Chakravartty, Eesha; Grover, Himanshu; Dodson, John A; Brody, Abraham A; Aphinyanaphongs, Yindalon; Masurkar, Arjun; Razavian, Narges
IMPORTANCE/UNASSIGNED:Large language models (LLMs) are crucial for medical tasks. Ensuring their reliability is vital to avoid false results. Our study assesses two state-of-the-art LLMs (ChatGPT and LlaMA-2) for extracting clinical information, focusing on cognitive tests like MMSE and CDR. OBJECTIVE/UNASSIGNED:Evaluate ChatGPT and LlaMA-2 performance in extracting MMSE and CDR scores, including their associated dates. METHODS/UNASSIGNED:Our data consisted of 135,307 clinical notes (Jan 12th, 2010 to May 24th, 2023) mentioning MMSE, CDR, or MoCA. After applying inclusion criteria 34,465 notes remained, of which 765 underwent ChatGPT (GPT-4) and LlaMA-2, and 22 experts reviewed the responses. ChatGPT successfully extracted MMSE and CDR instances with dates from 742 notes. We used 20 notes for fine-tuning and training the reviewers. The remaining 722 were assigned to reviewers, with 309 each assigned to two reviewers simultaneously. Inter-rater-agreement (Fleiss' Kappa), precision, recall, true/false negative rates, and accuracy were calculated. Our study follows TRIPOD reporting guidelines for model validation. RESULTS/UNASSIGNED:For MMSE information extraction, ChatGPT (vs. LlaMA-2) achieved accuracy of 83% (vs. 66.4%), sensitivity of 89.7% (vs. 69.9%), true-negative rates of 96% (vs 60.0%), and precision of 82.7% (vs 62.2%). For CDR the results were lower overall, with accuracy of 87.1% (vs. 74.5%), sensitivity of 84.3% (vs. 39.7%), true-negative rates of 99.8% (98.4%), and precision of 48.3% (vs. 16.1%). We qualitatively evaluated the MMSE errors of ChatGPT and LlaMA-2 on double-reviewed notes. LlaMA-2 errors included 27 cases of total hallucination, 19 cases of reporting other scores instead of MMSE, 25 missed scores, and 23 cases of reporting only the wrong date. In comparison, ChatGPT's errors included only 3 cases of total hallucination, 17 cases of wrong test reported instead of MMSE, and 19 cases of reporting a wrong date. CONCLUSIONS/UNASSIGNED:In this diagnostic/prognostic study of ChatGPT and LlaMA-2 for extracting cognitive exam dates and scores from clinical notes, ChatGPT exhibited high accuracy, with better performance compared to LlaMA-2. The use of LLMs could benefit dementia research and clinical care, by identifying eligible patients for treatments initialization or clinical trial enrollments. Rigorous evaluation of LLMs is crucial to understanding their capabilities and limitations.
PMCID:10888985
PMID: 38405784
CID: 5722422

Neural Mechanisms Determining the Duration of Task-free, Self-paced Visual Perception

Baror, Shira; Baumgarten, Thomas J; He, Biyu J
Humans spend hours each day spontaneously engaging with visual content, free from specific tasks and at their own pace. Currently, the brain mechanisms determining the duration of self-paced perceptual behavior remain largely unknown. Here, participants viewed naturalistic images under task-free settings and self-paced each image's viewing duration while undergoing EEG and pupillometry recordings. Across two independent data sets, we observed large inter- and intra-individual variability in viewing duration. However, beyond an image's presentation order and category, specific image content had no consistent effects on spontaneous viewing duration across participants. Overall, longer viewing durations were associated with sustained enhanced posterior positivity and anterior negativity in the ERPs. Individual-specific variations in the spontaneous viewing duration were consistently correlated with evoked EEG activity amplitudes and pupil size changes. By contrast, presentation order was selectively correlated with baseline alpha power and baseline pupil size. Critically, spontaneous viewing duration was strongly predicted by the temporal stability in neural activity patterns starting as early as 350 msec after image onset, suggesting that early neural stability is a key predictor for sustained perceptual engagement. Interestingly, neither bottom-up nor top-down predictions about image category influenced spontaneous viewing duration. Overall, these results suggest that individual-specific factors can influence perceptual processing at a surprisingly early time point and influence the multifaceted ebb and flow of spontaneous human perceptual behavior in naturalistic settings.
PMID: 38357932
ISSN: 1530-8898
CID: 5635852

Effect of anesthetic strategies on distal stroke thrombectomy in the anterior and posterior cerebral artery

Meyer, Lukas; Stracke, Christian Paul; Broocks, Gabriel; Wallocha, Marta; Elsharkawy, Mohamed; Sporns, Peter B; Piechowiak, Eike I; Kaesmacher, Johannes; Maegerlein, Christian; Hernandez Petzsche, Moritz Roman; Zimmermann, Hanna; Naziri, Weis; Abdullayev, Nuran; Kabbasch, Christoph; Behme, Daniel; Thormann, Maximilian; Maus, Volker; Fischer, Sebastian; Möhlenbruch, Markus A; Weyland, Charlotte Sabine; Langner, Soenke; Ernst, Marielle; Jamous, Ala; Meila, Dan; Miszczuk, Milena; Siebert, Eberhard; Lowens, Stephan; Krause, Lars Udo; Yeo, Leonard Ll; Tan, Benjamin Y Q; Gopinathan, Anil; Gory, Benjamin; Galvan Fernandez, Jorge; Schüller Arteaga, Miguel; Navia, Pedro; Raz, Eytan; Shapiro, Maksim; Arnberg, Fabian; Zeleňák, Kamil; Martínez-Galdámez, Mario; Alexandrou, Maria; Kastrup, Andreas; Papanagiotou, Panagiotis; Dorn, Franziska; Kemmling, André; Psychogios, Marios-Nikos; Andersson, Tommy; Chapot, René; Fiehler, Jens; Hanning, Uta
BACKGROUND:Numerous questions regarding procedural details of distal stroke thrombectomy remain unanswered. This study assesses the effect of anesthetic strategies on procedural, clinical and safety outcomes following thrombectomy for distal medium vessel occlusions (DMVOs). METHODS:Patients with isolated DMVO stroke from the TOPMOST registry were analyzed with regard to anesthetic strategies (ie, conscious sedation (CS), local (LA) or general anesthesia (GA)). Occlusions were in the P2/P3 or A2-A4 segments of the posterior and anterior cerebral arteries (PCA and ACA), respectively. The primary endpoint was the rate of complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3) and the secondary endpoint was the rate of modified Rankin Scale score 0-1. Safety endpoints were the occurrence of symptomatic intracranial hemorrhage and mortality. RESULTS:Overall, 233 patients were included. The median age was 75 years (range 64-82), 50.6% (n=118) were female, and the baseline National Institutes of Health Stroke Scale score was 8 (IQR 4-12). DMVOs were in the PCA in 59.7% (n=139) and in the ACA in 40.3% (n=94). Thrombectomy was performed under LA±CS (51.1%, n=119) and GA (48.9%, n=114). Complete reperfusion was reached in 73.9% (n=88) and 71.9% (n=82) in the LA±CS and GA groups, respectively (P=0.729). In subgroup analysis, thrombectomy for ACA DMVO favored GA over LA±CS (aOR 3.07, 95% CI 1.24 to 7.57, P=0.015). Rates of secondary and safety outcomes were similar in the LA±CS and GA groups. CONCLUSION/CONCLUSIONS:LA±CS compared with GA resulted in similar reperfusion rates after thrombectomy for DMVO stroke of the ACA and PCA. GA may facilitate achieving complete reperfusion in DMVO stroke of the ACA. Safety and functional long-term outcomes were comparable in both groups.
PMID: 37142393
ISSN: 1759-8486
CID: 5509162

ONC201 (Dordaviprone) in Recurrent H3 K27M-Mutant Diffuse Midline Glioma

Arrillaga-Romany, Isabel; Gardner, Sharon L; Odia, Yazmin; Aguilera, Dolly; Allen, Joshua E; Batchelor, Tracy; Butowski, Nicholas; Chen, Clark; Cloughesy, Timothy; Cluster, Andrew; de Groot, John; Dixit, Karan S; Graber, Jerome J; Haggiagi, Aya M; Harrison, Rebecca A; Kheradpour, Albert; Kilburn, Lindsay; Kurz, Sylvia C; Lu, Guangrong; MacDonald, Tobey J; Mehta, Minesh; Melemed, Allen S; Nghiemphu, Phioanh Leia; Ramage, Samuel C; Shonka, Nicole; Sumrall, Ashley; Tarapore, Rohinton; Taylor, Lynne; Umemura, Yoshie; Wen, Patrick Y
PURPOSE/OBJECTIVE:Histone 3 (H3) K27M-mutant diffuse midline glioma (DMG) has a dismal prognosis with no established effective therapy beyond radiation. This integrated analysis evaluated single-agent ONC201 (dordaviprone), a first-in-class imipridone, in recurrent H3 K27M-mutant DMG. METHODS:Fifty patients (pediatric, n = 4; adult, n = 46) with recurrent H3 K27M-mutant DMG who received oral ONC201 monotherapy in four clinical trials or one expanded access protocol were included. Eligible patients had measurable disease by Response Assessment in Neuro-Oncology (RANO) high-grade glioma (HGG) criteria and performance score (PS) ≥60 and were ≥90 days from radiation; pontine and spinal tumors were ineligible. The primary end point was overall response rate (ORR) by RANO-HGG criteria. Secondary end points included duration of response (DOR), time to response (TTR), corticosteroid response, PS response, and ORR by RANO low-grade glioma (LGG) criteria. Radiographic end points were assessed by dual-reader, blinded independent central review. RESULTS:The ORR (RANO-HGG) was 20.0% (95% CI, 10.0 to 33.7). The median TTR was 8.3 months (range, 1.9-15.9); the median DOR was 11.2 months (95% CI, 3.8 to not reached). The ORR by combined RANO-HGG/LGG criteria was 30.0% (95% CI, 17.9 to 44.6). A ≥50% corticosteroid dose reduction occurred in 7 of 15 evaluable patients (46.7% [95% CI, 21.3 to 73.4]); PS improvement occurred in 6 of 34 evaluable patients (20.6% [95% CI, 8.7 to 37.9]). Grade 3 treatment-related treatment-emergent adverse events (TR-TEAEs) occurred in 20.0% of patients; the most common was fatigue (n = 5; 10%); no grade 4 TR-TEAEs, deaths, or discontinuations occurred. CONCLUSION/CONCLUSIONS:ONC201 monotherapy was well tolerated and exhibited durable and clinically meaningful efficacy in recurrent H3 K27M-mutant DMG.
PMID: 38335473
ISSN: 1527-7755
CID: 5632032

Gene-environment interactions: Epstein-Barr virus infection and risk of pediatric-onset multiple sclerosis

Ziaei, Amin; Solomon, Olivia; Casper, T Charles; Waltz, Michael; Weinstock-Guttman, Bianca; Aaen, Greg; Wheeler, Yolanda; Graves, Jennifer; Benson, Leslie; Gorman, Mark; Rensel, Mary; Mar, Soe; Lotze, Tim; Greenberg, Benjamin; Chitnis, Tanuja; Waldman, Amy T; Krupp, Lauren; James, Judith A; Hart, Janace; Barcellos, Lisa F; Waubant, Emmanuelle
BACKGROUND AND OBJECTIVE/UNASSIGNED:Prior Epstein-Barr virus (EBV) infection is associated with an increased risk of pediatric-onset multiple sclerosis (POMS) and adult-onset multiple sclerosis (MS). It has been challenging to elucidate the biological mechanisms underlying this association. We examined the interactions between candidate human leukocyte antigen (HLA) and non-HLA variants and childhood EBV infection as it may provide mechanistic insights into EBV-associated MS. METHODS/UNASSIGNED:Cases and controls were enrolled in the Environmental and Genetic Risk Factors for Pediatric MS study of the US Network of Pediatric MS Centers. Participants were categorized as seropositive and seronegative for EBV-viral capsid antigen (VCA). The association between prior EBV infection and having POMS was estimated with logistic regression. Interactions between EBV serostatus, major HLA MS risk factors, and non-HLA POMS risk variants associated with response to EBV infection were also evaluated with logistic regression. Models were adjusted for sex, age, genetic ancestry, and the mother's education. Additive interactions were calculated using relative risk due to interaction (RERI) and attributable proportions (APs). RESULTS/UNASSIGNED:(AP = 0.30, 95% CI = 0.03 to 0.58). CONCLUSION/UNASSIGNED:POMS risk variant. Our results suggest an important role of antigen-presenting cells (APCs) in EBV-associated POMS risk.
PMID: 38332747
ISSN: 1477-0970
CID: 5632482

Inflammatory biomarkers for neurobehavioral dysregulation in former American football players: findings from the DIAGNOSE CTE Research Project

van Amerongen, Suzan; Pulukuri, Surya V; Tuz-Zahra, Fatima; Tripodis, Yorghos; Cherry, Jonathan D; Bernick, Charles; Geda, Yonas E; Wethe, Jennifer V; Katz, Douglas I; Alosco, Michael L; Adler, Charles H; Balcer, Laura J; Ashton, Nicholas J; Blennow, Kaj; Zetterberg, Henrik; Daneshvar, Daniel H; Colasurdo, Elizabeth A; Iliff, Jeffrey J; Li, Gail; Peskind, Elaine R; Shenton, Martha E; Reiman, Eric M; Cummings, Jeffrey L; Stern, Robert A; ,
BACKGROUND:Traumatic encephalopathy syndrome (TES) is defined as the clinical manifestation of the neuropathological entity chronic traumatic encephalopathy (CTE). A core feature of TES is neurobehavioral dysregulation (NBD), a neuropsychiatric syndrome in repetitive head impact (RHI)-exposed individuals, characterized by a poor regulation of emotions/behavior. To discover biological correlates for NBD, we investigated the association between biomarkers of inflammation (interleukin (IL)-1β, IL-6, IL-8, IL-10, C-reactive protein (CRP), tumor necrosis factor (TNF)-α) in cerebrospinal fluid (CSF) and NBD symptoms in former American football players and unexposed individuals. METHODS:Our cohort consisted of former American football players, with (n = 104) or without (n = 76) NBD diagnosis, as well as asymptomatic unexposed individuals (n = 55) from the DIAGNOSE CTE Research Project. Specific measures for NBD were derived (i.e., explosivity, emotional dyscontrol, impulsivity, affective lability, and a total NBD score) from a factor analysis of multiple self-report neuropsychiatric measures. Analyses of covariance tested differences in biomarker concentrations between the three groups. Within former football players, multivariable linear regression models assessed relationships among log-transformed inflammatory biomarkers, proxies for RHI exposure (total years of football, cumulative head impact index), and NBD factor scores, adjusted for relevant confounding variables. Sensitivity analyses tested (1) differences in age subgroups (< 60, ≥ 60 years); (2) whether associations could be identified with plasma inflammatory biomarkers; (3) associations between neurodegeneration and NBD, using plasma neurofilament light (NfL) chain protein; and (4) associations between biomarkers and cognitive performance to explore broader clinical symptoms related to TES. RESULTS:CSF IL-6 was higher in former American football players with NBD diagnosis compared to players without NBD. Furthermore, elevated levels of CSF IL-6 were significantly associated with higher emotional dyscontrol, affective lability, impulsivity, and total NBD scores. In older football players, plasma NfL was associated with higher emotional dyscontrol and impulsivity, but also with worse executive function and processing speed. Proxies for RHI exposure were not significantly associated with biomarker concentrations. CONCLUSION/CONCLUSIONS:Specific NBD symptoms in former American football players may result from multiple factors, including neuroinflammation and neurodegeneration. Future studies need to unravel the exact link between NBD and RHI exposure, including the role of other pathophysiological pathways.
PMCID:10854026
PMID: 38336728
ISSN: 1742-2094
CID: 5632112

Endovascular Thrombectomy Treatment Effect in Direct vs Transferred Patients With Large Ischemic Strokes: A Prespecified Analysis of the SELECT2 Trial

Sarraj, Amrou; Hill, Michael D; Hussain, M Shazam; Abraham, Michael G; Ortega-Gutierrez, Santiago; Chen, Michael; Kasner, Scott E; Churilov, Leonid; Pujara, Deep K; Johns, Hannah; Blackburn, Spiros; Sundararajan, Sophia; Hu, Yin C; Herial, Nabeel A; Budzik, Ronald F; Hicks, William J; Arenillas, Juan F; Tsai, Jenny P; Kozak, Osman; Cordato, Dennis J; Hanel, Ricardo A; Wu, Teddy Y; Portela, Pere Cardona; Gandhi, Chirag D; Al-Mufti, Fawaz; Maali, Laith; Gibson, Daniel; Pérez de la Ossa, Natalia; Schaafsma, Joanna D; Blasco, Jordi; Sangha, Navdeep; Warach, Steven; Kleinig, Timothy J; Shaker, Faris; Sitton, Clark W; Nguyen, Thanh; Fifi, Johanna T; Jabbour, Pascal; Furlan, Anthony; Lansberg, Maarten G; Tsivgoulis, Georgios; Sila, Cathy; Bambakidis, Nicholas; Davis, Stephen; Wechsler, Lawrence; Albers, Greg W; Grotta, James C; Ribo, Marc; Campbell, Bruce C; Hassan, Ameer E; ,; ,; Vora, Nirav; Manning, Nathan W; Cheung, Andrew; Aghaebrahim, Amin N; Paipa Merchán, Andres J; Sahlein, Daniel; Requena Ruiz, Manuel; Elijovich, Lucas; Arthur, Adam; Al-Shaibi, Faisal; Samaniego, Edgar A; Duncan, Kelsey R; Opaskar, Amanda; Ray, Abhishek; Xiong, Wei; Sunshine, Jeffery; DeGeorgia, Michael; Tjoumakaris, Stavropoula; Mendes Pereira, Vitor; ,
IMPORTANCE/UNASSIGNED:Patients with large ischemic core stroke have poor clinical outcomes and are frequently not considered for interfacility transfer for endovascular thrombectomy (EVT). OBJECTIVE/UNASSIGNED:To assess EVT treatment effects in transferred vs directly presenting patients and to evaluate the association between transfer times and neuroimaging changes with EVT clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This prespecified secondary analysis of the SELECT2 trial, which evaluated EVT vs medical management (MM) in patients with large ischemic stroke, evaluated adults aged 18 to 85 years with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) as well as an Alberta Stroke Program Early CT Score (ASPECTS) of 3 to 5, core of 50 mL or greater on imaging, or both. Patients were enrolled between October 2019 and September 2022 from 31 EVT-capable centers in the US, Canada, Europe, Australia, and New Zealand. Data were analyzed from August 2023 to January 2024. INTERVENTIONS/UNASSIGNED:EVT vs MM. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Functional outcome, defined as modified Rankin Scale (mRS) score at 90 days with blinded adjudication. RESULTS/UNASSIGNED:A total of 958 patients were screened and 606 patients were excluded. Of 352 enrolled patients, 145 (41.2%) were female, and the median (IQR) age was 66.5 (58-75) years. A total of 211 patients (59.9%) were transfers, while 141 (40.1%) presented directly. The median (IQR) transfer time was 178 (136-230) minutes. The median (IQR) ASPECTS decreased from the referring hospital (5 [4-7]) to an EVT-capable center (4 [3-5]). Thrombectomy treatment effect was observed in both directly presenting patients (adjusted generalized odds ratio [OR], 2.01; 95% CI, 1.42-2.86) and transferred patients (adjusted generalized OR, 1.50; 95% CI, 1.11-2.03) without heterogeneity (P for interaction = .14). Treatment effect point estimates favored EVT among 82 transferred patients with a referral hospital ASPECTS of 5 or less (44 received EVT; adjusted generalized OR, 1.52; 95% CI, 0.89-2.58). ASPECTS loss was associated with numerically worse EVT outcomes (adjusted generalized OR per 1-ASPECTS point loss, 0.89; 95% CI, 0.77-1.02). EVT treatment effect estimates were lower in patients with transfer times of 3 hours or more (adjusted generalized OR, 1.15; 95% CI, 0.73-1.80). CONCLUSIONS AND RELEVANCE/UNASSIGNED:Both directly presenting and transferred patients with large ischemic stroke in the SELECT2 trial benefited from EVT, including those with low ASPECTS at referring hospitals. However, the association of EVT with better functional outcomes was numerically better in patients presenting directly to EVT-capable centers. Prolonged transfer times and evolution of ischemic change were associated with worse EVT outcomes. These findings emphasize the need for rapid identification of patients suitable for transfer and expedited transport. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT03876457.
PMCID:10853865
PMID: 38363872
ISSN: 2168-6157
CID: 5806072

Subclinical Atrial Fibrillation and Stroke Risk: Time to Put the Horse Back in Front of the Cart? [Editorial]

Rosso, Michela; Cucchiara, Brett L
PMID: 38240297
ISSN: 2047-9980
CID: 5806042