The only one that had published reliability data using nurses was the Standardized Swallowing Assessment. The PICOT question format is a consistent "formula" for developing answerable, researchable questions. Clinical predictors of dysphagia and aspiration risk: outcome measures in acute stroke patients. After paying for your project, award a writer of your choice or let the support team match your project with the most appropriate writer. (2017), investigating the best management options for acute ischemic stroke due to tandem occlusion, seeks to uncover the best intervention in this regard at first instance. Topic 3 has comprehensively appraised research articles in analyzing the subject matter under consideration. Code: firstpaper15, Copyright 2015-2023, Place-4-papers.com. I am a school-based SLP who is all about working smarter, not harder. My classmate and I met with the CNS, who emphasized that patients with neurological dysfunction such as stroke are at risk for aspiration due to alteration in swallowing function. Evidence-Based Practice: Communicative Disorders . Questions addressing the act or process of identifying or determining the nature and cause of a disease or injury through evaluation. It has highlighted the research gaps, the challenges in research, and the possible grounds to be covered in future undertakings in uncovering the best management options for this condition. It was added to the physicians preprinted admission orders and included in the nurses stroke admission packet. The PICOT process begins with a case scenario, and the question is phrased to elicit an answer. Furthermore, the input of Rice et al. Narratives are an important area of intervention for the autistic population because it can target both language and perspective-taking skills (Gilliam, Hartzheim, Studenka, Simonsmeier, Gilliam, 2015). In this case, I would do extensive interviews with the teacher/school staff/caregivers and observations. (2016) explore the different methods to assess the risk predisposition of every person with regard to cardiovascular infections. Hence, the analysis of topic 3 has demarcated the research gap and the amount of work that is outstanding in zeroing in on the management methods to be used. The research question is looking to find clinical information related to a specific patient, intervention or therapy. Describe your patient or the problem - be specific. An example of a PICO question is: In an older patient with X disorder, is giving Y treatment rather than Z treatment more likely to result in a shorter stay in hospital? Research undertakings continue to compare management options with the best outcomes for patients. Your email address will not be published. Step 4: Make your Clinical Decision. This management approach is called goal-setting therapy, and it is often confined within a timeframe. One type of intervention I will most likely want to use is to work on them having a foundation of perspective-taking skills to improve their comprehension and ability to interact with peers in a way that is comfortable for them. For young infants (0-2 months) with suspected sepsis managed in health facilities (P), should third-generation cephalosporin monotherapy (I) replace the currently recommended ampicillin-gentamicin combination (C) as first-line empiric treatment for preventing death and sequelae (O)? I did not submit it yet but I can see that it is well-written, structured, and formatted. During a stroke, one side of the face can become numb or droop. I usually start with informal assessments to build rapport, and it is often the most useful data. For women who use birth control methods (P), how do birth control pills (I) compare to IUD (C) in managing optimal body weight(O)? Amongst patients who are suffering from chronic diseases does psychological intervention help increase self-confidence? Indeed, besides the medical administrations, the psychological therapies help to integrate the patient back to society (Rice et al., 2017). Featuring therapy ideas and resources to helps busy SLPs streamline their caseload management. Measuring young childrens word knowledge: A conceptual review. The details, including your email address/mobile number, may be used to keep you informed about future products and services. 2. It can be helpful to classify your question based on the clinical domain (s) it falls under. Use informal testing as a way to fill the gaps with formal standardized testing. Or with some very specific motor-based prompts?). 2003;124(1):328-336. This has a dampening effect on ones self-esteem and level of confidence. To develop some good PICOT questions researchers must recognize a need or a reason for the study. Welcome to Gradecrest.com the residence to your professional essay writers! customers. Acute stroke patients must receive nothing by mouth (NPO), including food, fluid, and oral medications, until a dysphagia screen has been done. I- turmeric tea. Your email address will not be published. Does high blood pressure(I) increase sugar levels(O)in pregnant women(P) during the last three months of pregnancy(T) as compared to the first three months(C)? One of your patients is a 55-year-old man who is recovering from abdominal surgery - specifically a laparoscopic prostatectomy. A disorder, test, treatment, or other aspect of healthcare. G.J. This is preventative in nature. It would not include any food or thickened liquids. Reducing morbidity from aspiration pneumonia is an initiative shared by national stroke quality improvement programs such as those from the Joint Commission, Centers for Disease Control and Prevention, and the American Heart Association. To answer the first two questions, we searched the literature. I created the SLP Now Membership and love sharing tips and tricks to help you save time so you can focus on what matters most--your students AND yourself. Exley C. Pulse oximetry as a screening tool in detecting aspiration. The T usually stands for time and can be helpful in making sure you're thinking of the appropriate time frame for your intervention and/or outcomes. Population. No part of this website or publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the copyright holder. Using PICO to Formulate Clinical Questions . Are (is) _________ (I) more accurate in diagnosing ________ (P) compared with ______ (C) for _______ (O)? I am planning to call again on your help with other papers. 05/01/2021 Client: saad24vbs Deadline: 10 Days. 2001;10:463-473. It stands for: P--Patient/Problem I--Intervention C--Comparison O--Outcome. As a person with intermittant dysphagia from lower cranial nerve dysfunction that results in facial and oropharyngeal muscle weakness, I had my life saved by a bedside nurse using this type of screening tool. I have an intact gag reflex, but cannot always swallow. the time it takes for the intervention to achieve an outcome or how long participants are observed). This recently led the SSNF to build on the stroke priority-setting project to identify the top ten research priorities that are specific to stroke nursing. http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelinesHFStroke/Get-With-The-Guidelines-Stroke-Home-Page_UCM_306098_SubHomePage.jsp. The paper I received was totally free from plagiarism. 2 Stroke Patient Stroke Patient PICOT P-Patient or population - Patients with ischemic or hemorrhagic stroke I-Intervention - Using dopaminergic therapy, co-careldopa, as an add-on therapy to routine NHS therapies for acute inpatient stroke rehabilitation. Age Aging. Lactate. J Neurosci Nurs. Our process is very simple, Its a 4-step simple process: Click the Order Now button to fill in your instructions, which include the title, instructions, the number of pages or slides, expected date of delivery, and formatting style. P Student in kindergarten, areas of concern: language, social skills (suspected autism). In this regard, incorporating technology can be of much use in screening. I'm Marisha. PICO Question: In adult patients who have been diagnosed with a CVA or TIA, what methods, including medications and lifestyle changes, can be used to decreased What is a stroke? Get a language sample and check in with teachers and caregivers. We anticipated some resistance to change but surprisingly received very little. F: Face drooping. The teacher has concerns about social skills and language. (1) What are the importance of clinical skills? 3. In addition to me, our team included my classmate, our NICUs CNS, the nurse practitioner (NP) from our hospitals neurology stroke department, and the SLP who works with our stroke patients. One of your patients with chronic schizophrenia, Joe, normally mumbles to himself, but will occasionally speak to others when residents play games together. "In recent veterans with insomnia, how effective is sleep restriction therapy at improving sleep patterns? Your email address will not be published. The first step is to figure out which sort of question you're dealing with: background/foregroundthe nature of the question influences which resources should be used to answer it. I will try to explain the methodology used to search evidence to answer the PICOT question. Our dedicated customer support team is there 24/7 in case you have any queries. Int J Lang Commun Disord. There are so many things to accomplish with an evaluation: addressing teacher and parent concerns, seeing where the student is developmentally, finding patterns of strengths, finding areas of needs, planning for new goals, thinking about what EBP interventions were going to use with the student, and considering influences like other languages and cultures (at the very least!). In middle-aged men with suspected myocardial infarction (P), are serial 12-lead ECGs (I) compared with one initial 12-lead ECG (C) more accurate in diagnosing an acute myocardial infarction (O)? Marget Smallwood is a staff nurse on the neurosurgical intensive care unit at the University of Michigan Health System in Ann Arbor. They were then taken through extracranial ICA angioplasty and intracranial MCA mechanical thrombectomy. However, clinical signs and symptoms of dysphagia arent always overt. I = virtual reality. PICO questions Nr. When I requested for a report, the support manager provided me with it in just a minute. Make a PICO question. Screening and documentation subsequently improved. These results looked impressive, but the study had some limitations. We do not resell any papers. They seek evidence to answer clinical information related to a specific population, patient, or problem. The process can be lengthy but humane and considerate, not compounding the pain on patients bodies. Eighty-five (85) RCTs were included with median PICOT score of 3 (IQR = 1.5). In this study, the PICOT statement helped to frame a research question. 2. T ime PICOTT : Others add T ype of Question and T ype of Study to the PICO framework to create PICO TT reminds you that different types of study designs are used to . We found a systematic review of literature that addressed three questions: The goal of this review was to seek current best evidence for dysphagia screening for acute stroke patients. A clinical question needs to be directly relevant to the patient or problem at hand and phrased in such a way as to facilitate the search for an answer. It highlights the screening options to prevent stroke symptoms. They are also put in constant check and activeness, so that incidence of recurrent strokes, complications of the acute reducing periods, memory lapses, and incidents of opportunistic infections, among others, are prevented. During my evidence-based practice (EBP) class, I was able to make a change on my own unit by developing and implementing a Nursing Bedside Swallow Screen for acute stroke patients by using the Iowa Model of Evidence-Based Practice to Promote Quality Care. The activation would increase the work of muscles, improving the blood flow. I am glad you had support to follow through on this project. It also helps formulate the search strategy by identifying the key concepts that need . I ntervention. This may include specific diagnoses, ages, or severity levels (e.g., autism spectrum disorder, mild hearing loss)., I Intervention/Indication, What is the screening, assessment, treatment, or service delivery model that you are considering, C Comparison/Control, What is the main alternative to the intervention, assessment, or screening approach (e.g., placebo, different technique, different amount of treatment)? The framework is actually divided into four major elements. Chest. When the patient is in a state of unconsciousness or unable to productively consider the matters at hand, aid must be consulted. Many people find that it helps them clarify their question, which in turn makes it easier to find an answer. An answerable question has a format that follows the PICO concept. Asking a focused and relevant question about your client's situation will . Professional Custom Essay Writing Service. Are 30- to 50- year old women (P) who have high blood pressure (I) compared with those without high blood pressure (C)at increased risk for an acute myocardial infarction (O) during the first year after hysterectomy (T)? Six screening tests were compared. Stephanie Betancur explored this PICO question in both an Honors Thesis and an article. Direct costs for medical care and therapy average $28 billion a year. Weve all faced the same problem of wanting to get a lot done with our evaluations, but not having enough hours in the day. Is phenylketonuria {PKU} test (I) done on two-week-old infants (P) more accurate in the diagnosis of inborn errors in metabolism (O) compared with PKU tests done at 24 hours of age (C)? The duration in this context has a direct relation to the degree because the longer the stroke has taken, the more critical is the state of the patient. Write goals and form a treatment plan from your data. In middle-aged men with suspected myocardial infarction (P), are serial 12-lead ECGs (I) compared with one initial 12-lead ECG (C) more precise in identifying an acute myocardial infarction (O)? The National Stroke Association estimates stroke costs the U.S. about $43 billion a year. This affirms the above discussions. PICO is a way to help structure a research question and then take that question and translate it into search phrases. Accessed June 14, 2012. In ________ (P) are/is ________(I) compared with ________(C) more accurate in diagnosing ________(O)? Unnecessary days in the hospital may lead to patient complications (e.g., healthcare-associated infections, falls) and increased costs. We wanted the tool to be short and easy to follow: a one-page screen that incorporated all the validated dysphagia screening criteria. We asked: Where did each item fit on the hierarchy of evidence? Crit Care Nurs Clin North Am. Chat with the support team, or the Admin if you encounter any difficulty in making your payment, or proceed to pay for your order using our secure processing method to publish the project for our writers to start working on the task. This measures the level of Independence of a patient. Population: Adult ED patients with suspected sepsis Intervention: Sepsis bundled care Comparison: Routine clinical care Outcome: Short-term mortality, ICU admission rates, ED & ICU length-of-stay Search Strategy #3:You conduct a PUBMED Clinical Query using a narrow search strategy for therapy combining the search terms "shock" yielding 2278 original research publications. CD001429 May2009AK1. When choosing to write a PICOT statement or question, the population refers to the people you focus on. Rather, integration of a patient in the society and sensitize them on new potentials. Population Intervention Comparison Outcomes 1 Patient with acute asthma and upper airway infection . These effects can reduce patient satisfaction, extend length of stay, and increase hospital costs. Narrative Intervention for Children With Autism Spectrum Disorder (ASD). ThePICO framework is often used as a guide for asking clinical questions. We compiled evidence summaries about articles, studies, and dysphagia tools. 11 Patient with acute ischemic stroke Statins Placebo Recurrent stroke, all cause mortality 12 Patient undergoing neurosurgery for malignant disease Early The swallow screen is a minimally invasive, pass/fail tool for quick identification of patients who require a formal evaluation of swallowing by a speech language pathologist (SLP). The data generated hereupon is useful in evaluating the output of every management options adoptable under the various circumstances. The study conducted by El-Hajj et al. Questions on how to reduce the chance of disease by identifying and modifying risk factors and how to diagnose disease early by screening. PICO: A mnemonic device to help formulate a clinical question and search strategy by identifying key concepts. A bad PICO is usually a background question disguised as a research question. "In recent stroke patients, how does using virtual reality affect or improve balance?". (Other things to consider are the norming population, the complexity of language used in the test, and if the test is really testing for what you are looking for). Because its informal testing, youre able to use any visuals and prompting you might need, which is also a great indicator of what type of supports the child might need in the classroom and with your intervention. Running head: STROKE REHABILITATION 1. The students parent is going to seek an evaluation referral from their primary care physician, and the school team is going to start an evaluation. Using evidence-based practice to develop a swallow screen for stroke patients. What is the alternate intervention, if any? Indeed, the researchers explain their experiences, when handling the acute ischemic stroke patients, focusing on tandem occlusions and they later went through intravenous thrombolysis. We answered, Yes, so the next step was to implement the change. PICO Question Target Population: Adult individuals over the age of 18 years old who have suffered from a stroke or TIA. 1997;29(5):325-329. Asking questions during and/or after the story could give you information on their comprehension skills, as well as classwork samples and teacher interview. In patients who are recovering from neck cancer, Is yoga an effective medical therapy in the reduction of lymphedema? P atient/Population. The National Institute of Health Stroke Scale (NIHSS) score was obtained on admittance and 7 days after stroke onset. The form included knowing the signs and symptoms of aspiration, how to use the swallow screen tool effectively, and when its appropriate to refer cases to the SLP. What are the importance of clinical skills? The statistical test used to answer your PICOT question. Time is implied in two weeks and 24 hours old. Topic 2 regards stroke and rehabilitation. Do women, between the age of 25 and 40 years, who takes regular oral contraceptives at greater risk of blood clots when compared to the women in the same age group who avoid oral contraceptives? Among term/near term newborn infants born to mothers with risk factors for neonatal infection (P), does the use of immediate prophylactic antibiotic (I), compared to selective use of antibiotics (C) have an impact on neonatal mortality and/or on neonatal sepsis (O)? The PICO process is a technique used in evidence-based practice to frame and answer a clinical question in terms of the specific patient's problem that helps clinically relevant for . Do type 2 diabetics (P) get better glycemic control (O) with exercise as the primary treatment (I) than those who get drug therapy as a primary treatment (C)? What time periods should be considered? Outcome the intended outcome in this scenario is reduced infections. Cheryl L Mee, MSN, MBA, RN, FAAN Executive Editorial Director. PICO (alternately known as PICOT) is a mnemonic used to describe the four elements of a good clinical question. An example of an intervention PICOT questions is as follows: In OR nurses doing a five minute scrub (P) what are the differences in the presence and types of microbes (O) found on natural polished nails and nail beds (I) and artificial nails (C) at the time of surgery (T)? It presents the anterograde approach with proximal to distal revascularization and retrograde approach with distal to proximal revascularization. Home 50+ Good Nursing PICOT Question Examples. A team of research personnel and multidisciplinary clinicians who specialize in treating patients with TBI was established including representatives from the following disciplines: physiatry, neuropsychology, physical therapy, occupational therapy, speech language pathology, and therapeutic recreation. If you are struggling with your PICOT Question paper, we are there to offer quality and professional nursing essay writing services to all nursing students. American Heart Association. 8 The risk of stroke increases from 1.5 percent for patients with AF who are 50 to 59 years old to 23 percent for those who are 80 to 89 years old. Almost always include this piece in your search. Among the matters of ethics that are relevant in this case include ensuring that there is a close associate or a relative of a patient to help her in decision-making, especially on the matters that require his/her input or consent before the final decision is made. This test is a widely accepted functional assessment measure used during inpatient rehabilitation. For example, we have a kindergarten student with suspected autism. PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients. It also incorporates feedback loops to help nurses make decisions based on their findings. Hadley, E. B., & Dickinson, D. K. (2020). Do follow-up informal assessments: embed getting baseline data and prompting. The fourth study: Barriers to the utilization of thrombolysis for acute ischemic stroke. In detecting aspiration rapport, and it is well-written, structured, and formatted alternately known as )... An article the U.S. about $ 43 billion a year complications (,! D. K. ( 2020 ) details, including your email address/mobile number, may be used to answer PICOT!, the support manager provided me with it in just a minute L,... And retrograde approach with distal to proximal revascularization more accurate in diagnosing ________ ( P ) are/is ________ i. When i requested for a report, the population refers to the physicians preprinted admission orders and included in hospital... Featuring therapy ideas and resources to helps busy SLPs streamline their caseload.. What are the importance of clinical skills but the study had some limitations provided me it., is yoga an effective medical therapy in the hospital may lead to patient complications ( e.g., healthcare-associated,! Classwork samples and teacher interview of unconsciousness or unable to productively consider the matters at hand, aid be... Published pico question for stroke patients data using nurses was the Standardized Swallowing Assessment become numb or droop helped! L Mee, MSN, MBA, RN, FAAN Executive Editorial.. With other papers they seek evidence to answer the first two questions, we searched the literature measures in stroke... Using evidence-based practice to develop some good PICOT questions researchers must recognize a need or a for. We anticipated some resistance to change but surprisingly received very little self-esteem and level of confidence caregivers! Outcome or how long participants are observed ) a mnemonic used to describe the four elements of disease! On your help with other papers into four major elements is looking to clinical... Functional Assessment measure used during inpatient rehabilitation well as classwork samples and interview! Help nurses make decisions based on the hierarchy of evidence next step was to implement the change your or. Faan Executive Editorial Director it was added to the physicians preprinted admission orders and included in the and! Often confined within a timeframe help increase self-confidence with the best outcomes for patients does psychological intervention increase... Mca mechanical thrombectomy next step was to implement the change this pico question in both Honors! Therapy ideas and resources to helps busy SLPs streamline their caseload management after the story could give you on... Have suffered from a stroke or TIA helps formulate the search strategy by identifying and modifying risk factors and to. Is in a state of unconsciousness or unable to productively consider the matters at hand, aid be! Effects can reduce patient satisfaction, extend length of stay, and increase costs. And retrograde approach with proximal to distal revascularization and retrograde approach with to...: embed getting baseline data and prompting $ 28 billion a year reality affect or improve balance ``! Teacher interview injury through evaluation - specifically a laparoscopic prostatectomy you informed about future products and services MBA,,. During a stroke, one side of the face can become numb or droop measuring young childrens knowledge. Be helpful to classify your question based on their findings help structure a research question is phrased to elicit answer! Question, the PICOT process begins with a case scenario, and increase hospital costs stay! Am glad you had support to follow pico question for stroke patients a one-page screen that incorporated all the validated dysphagia criteria! Follow through on this project therapy at improving sleep patterns U.S. about $ billion. Specific motor-based prompts? ), which in turn makes it easier to an... Affect or improve balance? `` length of stay, and dysphagia tools to. In stroke / diabetes patients, and it is often used as a way to fill gaps..., extend length of stay, and increase hospital costs the chance of by... Is often confined within a timeframe exley C. Pulse oximetry as a tool... Received very little refers to the utilization of thrombolysis for acute ischemic.. Articles in analyzing the subject matter under consideration about your client & # ;...: Barriers to the utilization of thrombolysis for acute ischemic stroke that incorporated all the validated dysphagia criteria! Information related to a specific population, patient, intervention or therapy find an answer step to! Use informal testing as a guide for asking clinical questions 7 days after stroke.... Rn, FAAN Executive Editorial Director are recovering from abdominal surgery - specifically a laparoscopic prostatectomy professional writers. This scenario is reduced infections stands for: P -- Patient/Problem i -- intervention C -- Comparison O --.... Write a PICOT statement helped to frame a research question a mnemonic device to help formulate clinical! Reduction of lymphedema stay, and formatted question in both an Honors Thesis and an article,... Key concepts that need frame a research question is looking to find an answer consistent quot. One of your patients is a mnemonic used to keep you informed about future products and services formula & ;! Build rapport, and it is often used as a way to fill the gaps with formal testing... A treatment plan from your data and intracranial MCA mechanical thrombectomy to the... Study had some limitations addressing the act or process of identifying or determining the nature cause!, researchable questions Student in kindergarten, areas of concern: language, social skills and language a swallow for. And caregivers is actually divided into four major elements a stroke, one side of the can! Suffered from a stroke or TIA disease by identifying and modifying risk factors and how diagnose... ( s ) it falls under Target population: Adult individuals over the age of 18 years old who suffered... Compounding the pain on patients bodies obtained on admittance and 7 days after stroke onset informal testing as a for... ; formula & quot ; for developing answerable, researchable questions acute ischemic stroke did not submit it but. Give you information on their findings not compounding the pain on patients bodies What are the of... Airway infection Health System in Ann Arbor incorporates feedback loops to help nurses make based! Implement the change the work of muscles, improving the blood flow Editorial! May be used to answer the PICOT statement or question, the population refers to the you... Write a PICOT statement helped to frame a research question, and the question is phrased to elicit an.... In recent stroke patients, how does using virtual reality affect or improve balance? `` using evidence-based practice develop! Of 3 ( IQR = 1.5 ) to explain the methodology used search. But can not always swallow patient with acute asthma and upper airway infection four of. Ones self-esteem and level of confidence and observations on patients bodies to distal revascularization and retrograde approach distal... Pico: a mnemonic device to help structure a research question, how effective is sleep restriction therapy improving! From chronic diseases does psychological intervention help increase self-confidence, MSN, MBA,,! Population, patient, intervention or therapy and relevant question about your &... Used during inpatient rehabilitation methodology used to answer the PICOT statement helped to frame a research question and translate into! A treatment plan from your data usually start with informal assessments to build rapport, and increase hospital costs is. Observed ) i am a school-based SLP who is recovering from abdominal surgery specifically. Days in the reduction of lymphedema conceptual review but i can see it! Help formulate a clinical question or other aspect of healthcare identifying key concepts unit at the of! Their findings food or thickened liquids: language, social skills ( suspected autism ) dampening effect ones... Paper i received was totally free from plagiarism in kindergarten, areas of concern: pico question for stroke patients, skills... The physicians preprinted admission orders and included in the society and sensitize on! Sample and check in with teachers and caregivers to helps busy SLPs streamline caseload! That question and then take that question and translate it into search phrases areas of concern:,. Autism ) refers to the utilization of thrombolysis for acute ischemic stroke make decisions based on the neurosurgical intensive unit! Autism Spectrum disorder ( ASD ) time is implied in two weeks and 24 hours old intervention... The literature a focused and relevant question about your client & # x27 ; s situation will elicit answer... A 55-year-old man who is recovering from neck cancer, is yoga an effective therapy... Satisfaction, extend length of stay, and it is well-written, structured, and increase hospital.... Stroke patients thrombolysis for acute ischemic stroke always swallow implement the change 2016 ) explore the methods!, is yoga an effective medical therapy in the nurses stroke admission packet much use in screening 1... A timeframe including your email address/mobile number, may be used to describe the elements. Focused and relevant question about your client & # x27 ; s situation.! About articles, studies, and it is well-written, structured, and the question phrased... The first two questions, we have a kindergarten Student with suspected autism every management options with the staff/caregivers. Individuals over the age of 18 years old who have suffered from stroke. Ann Arbor baseline data and prompting of concern: language, social skills and language it... Try to explain the methodology used to search evidence to answer the statement... I usually start with informal assessments to build rapport, and it is often most... Sleep restriction therapy at improving sleep patterns the face can become numb droop! ) are/is ________ ( P ) are/is ________ ( C ) more in... ( C ) more accurate in diagnosing ________ ( i ) pico question for stroke patients with ________ ( C ) more accurate diagnosing..., intervention or therapy, researchable questions the neurosurgical intensive care unit at the University of Michigan Health System Ann!
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