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Australasian Human Research Ethics Consultancy Services Pty Ltd (AHRECS)

Conversations with an HREC: A Researcher’s perspective0

 

Dr Ann-Maree Vallence and Dr Hakuei Fujiyama
College of Science, Health, Engineering and Education, Murdoch University, Perth, Australia
http://profiles.murdoch.edu.au/myprofile/ann-maree-vallence/
http://profiles.murdoch.edu.au/myprofile/hakuei-fujiyama/

In our careers to date, we have had many formal conversations with members of HRECs across different institutions regarding human research ethics applications and amendments. We have also had many informal conversations with members of HRECs regarding standard operating procedures in the labs we have worked in. In this article, we share our experience engaging with our HREC in a different context, specifically, formal negotiations with our HREC following an adverse incident that occurred during our data collection for one of our projects.

To provide some context, our research often uses non-invasive brain stimulation techniques including transcranial magnetic stimulation (TMS). TMS has been commonly used in research since the mid-1980s, and is considered safe, non-invasive, and painless. TMS involves a brief, high-current electrical pulse delivered through a handheld coil placed over the scalp, which induces a magnetic field that passes through the scalp and skull with little attenuation. The magnetic field induces current flow in the underlying brain tissue, and if the stimulation is sufficiently intense, it will activate the underlying brain cells providing a measure of brain excitability [1, 2]. There are published international guidelines for the safe use of TMS [3, 4] that are used to design the experiments and screen for contraindications to TMS (for example it is routine to exclude any persons who have a history of epilepsy, metal implants in the skull, or cardiac pacemakers). Nonetheless, research using TMS involves a small but finite risk. Occasionally, research participants experience a mild and temporary headache, nausea, muscular problems, dizziness, or fainting during or after TMS.

In a 12-month period in 2017, we experienced three adverse incidents: three participants in our research projects using TMS fainted#. As mentioned above, TMS studies involve a small but known risk of fainting. There have been some reports of syncope in the literature [5-7]. It is proposed that anxiety and exposure to a novel stimulus are likely responsible for fainting in the context of TMS [3, 5-7], however it is not possible to determine whether fainting or syncope is a secondary effect of an emotional response or a direct effect of the TMS on the nervous system.

It was following the reporting of these adverse events that we found ourselves in formal conversations with our HREC as well as informal interactions with several members of the HREC. There were two key steps involved in these conversations worth outlining. First, we invited the members of the HREC to visit the lab and attend a lab meeting in which we were discussing the adverse events. This engagement with the members of the HREC in our lab environment was a mutually beneficial exercise: it helped researchers to fully understand the concerns of the HREC and helped the members of the HREC to better understand our research procedures and aims, and observe our commitment to minimizing the risks associated with our research.

Second, we scrutinised our standard operating procedures to determine what changes we could make to minimize the risk of another adverse event. As outlined above, fainting during a TMS experiment is highly likely to be related to a psycho-physical response, although we cannot rule out the possibility that it is due to a direct effect of TMS on the nervous system. Following the adverse incidents, we have made several changes to our procedures. First, and perhaps most importantly, we send our potential participants a short video so they can see a typical experiment before they enter the lab. Second, when participants come into the lab we ask them if they have had any substantial change to their routine (for example sleep pattern, medication) feel stressed by factors independent of the research, and if they have had food and water in the preceding few hours (we have snacks and water in the lab if participants haven’t eaten). Third, we made changes to our lab setting such as moving to a modern, clinical testing room which was larger and brighter than the old testing room. Fourth, we take time to explain all of the equipment in the lab, not just the equipment being used in that particular experimental session.

Since the implementation of the changes to our standard operating procedures, we have not experienced an adverse event. The entire process of conversing both formally and informally with the HREC has led to improved written communication of our research to potential participants and HREC in the form of new project applications. Additionally, the process led to the development of resources for members of the lab, such as evolving standard operating procedures and a formal (compulsory) lab induction, and resources for potential participants, such as the communication of study information via a combination of written, video, and photo formats. Importantly, the implemention of revised procedures not only improved the safety profile of our experiments, but also it brought us in a better position to conduct high-quality research by enriching our resources in training lab members, communications with participants, and experience in engaging with HRECs. So, what did we learn from our conversation with an HREC? The processes of conversing with the HREC in the context of an adverse event is beneficial and needn’t wait for an adverse event to occur!

#In a 12-month period in 2017”, note that these are the only fainting incidents that we experienced since we have started our role at MU in 2015

References:

1.         Barker AT, Jalinous R and Freeston IL, Non-invasive magnetic stimulation of human motor cortex. Lancet, 1985. 1(8437): p. 1106-7.

2.         Hallett M, Transcranial magnetic stimulation: a primer. Neuron, 2007. 55(2): p. 187-99.

3.         Rossi S, Hallett M, Rossini PM and Pascual-Leone A, Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clin Neurophysiol, 2009. 120(12): p. 2008-39.

4.         Rossi S, Hallett M, Rossini PM and Pascual-Leone A, Screening questionnaire before TMS: An update. Clinical Neurophysiology, 2011. 122(8): p. 1686-1686.

5.         Kirton A, Deveber G, Gunraj C and Chen R, Neurocardiogenic syncope complicating pediatric transcranial magnetic stimulation. Pediatr Neurol, 2008. 39(3): p. 196-7.

6.         Kesar TM, McDonald HS, Eicholtz SP and Borich MR, Case report of syncope during a single pulse transcranial magnetic stimulation experiment in a healthy adult participant. Brain stimulation, 2016. 9(3): p. 471.

7.         Gillick BT, Rich T, Chen M and Meekins GD, Case report of vasovagal syncope associated with single pulse transcranial magnetic stimulation in a healthy adult participant. BMC neurology, 2015. 15(1): p. 248.

Dr Yvonne Haigh
Chair, HREC, Murdoch University. Perth Western Australian

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In 2015, Murdoch University’s HREC received increasing numbers of applications that covered innovative approaches to cognitive neuroscience with a specific focus on TMS (Transcranial Magnetic Stimulation). The topic area covered was very new with significant levels of technical and neuroscience language. While the methods of data collection were relatively unfamiliar for the committee members, several members did undertake some broad reading in order to establish greater familiarity and understanding. However, the applications did refer to different forms of TMS which further exacerbated the committee’s hesitation. In order to establish good rapport between the researchers and the committee, we invited the researchers to present on the topic – TMS. The aim of the presenting was to provide an overview of the variations of the technology, any side effects, international benchmarks and so forth. The committee was certainly reassured with the researchers’ level of experience and expertise. Moreover, it was also apparent the researchers had a sound approach to safety and participants’ wellbeing.
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However, over the ensuing years a range of adverse incidents occurred which involved dizzy spells and fainting in a few cases. The researchers informed the committee and put in place a range of options. The committee was invited to the laboratory to observe and experience the methods. This was particularly helpful and reassuring for the members who attended and enabled a broader discussion with those committee members who could not attend the laboratory. The Manager, Research Ethics & Integrity was also invited to attend a laboratory team meeting where the incidents were discussed, safety procedures revised, and student researchers reminded of their roles and obligations. This meeting enabled a confident report back to the HREC which was aligned with the adverse incident reports and made the committee’s task of reviewing the incidents significantly clearer.
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These conversations and visits resulted in updated procedures (including safety) from the research leaders. This has led to clearer exclusion criteria and additional questions incorporated into the consent process to ensure any known risks are minimised. While adverse incidents are difficult, the outcome in this instance has led to building increased trust between the committee and the research team and a proactive approach from both sides to ensure that new emerging issues are discussed and resolved.
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One of the very clear outcomes of this process has been an increased level of quality in these ethics applications which take less committee time and effort to approve.  While the technology is always evolving, and research in the area is ‘cutting edge’, the possibility that this research may change the lives of participants in these projects is evident in the researchers’ applications. From the committee’s perspective, it has been the open and respectful communication between all parties that has generated both a solid working relationship and enabled high level ethical research. The HREC’s response to a more recent ethics application reviewed since the adverse incidents described begins with the words: “The committee were impressed by the quality of this application and the careful attention to detail. The committee thank the researchers for their ongoing efforts to incorporate suggestions and advice in the collaborative effort to attain ethically strong research and positive outcomes for the community”.

This post may be cited as:
Vallence. A. and Fujiyama, H. (4 February 2020) Conversations with an HREC: A Researcher’s perspective. Research Ethics Monthly. Retrieved from: https://ahrecs.com/human-research-ethics/conversations-with-an-hrec-a-researchers-perspective

A users perspective on the ethics application process in Australia-room for improvement0

 

  1. Suat Chin Ng. MBBS, BMedSc, FRACS. Department of Surgery, Eastern Health, Melbourne, Australia.
  2. Wei Ming Ong MBBS Department of Surgery, Eastern Health, Melbourne, Australia.
  3. Shane Belvedere MBBS Department of Surgery, Melbourne Health, Melbourne, Australia
  4. Creski Gilong. MBBS Department of Surgery, Austin Health, Melbourne, Australia.
  5. Dr Nikolajs Zeps. BSc, PhD Research and Development, Epworth HealthCare, Melbourne, Australia. Eastern Clinical School, Monash University, Melbourne, Australia
  6. Philip Smart MBBS, D.Med.Sci, FRACS. Gastrointestinal Clinical Institute, Epworth HealthCare, Australia  Department of Surgery, Austin Health, Melbourne, Australia.

Compliance with ethical standards is fundamental to conducting human research. While there is a need for a thorough review process to prevent unethical research, the administrative workload required can often be significant. Indeed, researchers largely regard the ethics process as an obstacle that needs to be overcome, rather than a key part of the research process itself. In a recent blog on the AHRECS website entitled “Research Ethics Review as a Box-Ticking Exercise”, A/prof Angela Romano identified a significant problem with our current approach to ethical review as being one that promotes a compliance mentality rather than one that actively encourages appropriate and useful ethical reflection throughout the lifecycle of a research project.

Health and Medical Research is aimed at providing new knowledge to improve the health and wellbeing of the community and the fruits of this work will hopefully translate into tangible benefits for everyone. Significant concerns have been expressed by others that the current processes employed to regulate this work in fulfilment of ethical and legal requirements can itself be unethical. For instance, in a recent Blog by Prof Julian Savulescu he comments that whilst no-one is suggesting that research should not be subject to appropriate regulation and ethical review, given the potential to unnecessarily delay important research, all review processes should be as efficient and proportionate to the risk as is possible. Whilst we cannot immediately fix the lamentable lack of investment in undergraduate and post-graduate training in and practical application of ethics, the processes for review of projects could, in our view, be vastly improved with some fairly low-cost interventions.

What are researchers supposed to do to obtain ethical approval?

We reviewed the webpages of 78 Human Research Ethics Committees (HREC) associated with both public and private health services that we identified from the NHMRC list of registered HRECs. This list is only current to 1st March 2018 and we noted that several of the listed HRECs have in fact closed leaving just 71 that could be assessed. We also excluded from our review websites of small clinics which appear to serve only their own needs, eg IVF clinics.

Our review aimed to assess the ease with which researchers could find the webpages of the HREC, or the office of research and/or governance responsible for research oversight, and the level of information provided in terms of 1) instructions relating to how to make a submission itself, and 2) instructions about ethical considerations that may assist researchers to make a sound submission along the lines of A/Prof Romano’s wishes. We scored these objectively using a binary score of 1 if they had a readily accessible website and 0 if they did not. We scored the information related to the submission process in the same way, that is it was either present or not. We decided to include whether or not there was a clear process for considering low risk research in an expedited way consistent with the National Statement as this provided an insight into whether or not the institution regarded such research in a proportionate manner. We further checked on some of the linked documents and policies provided by the HREC, such as guidance on reporting of Serious Adverse Events (SAEs), to check for consistency and whether they were up to date with current guidelines.

We were surprised to find that 8 of 71 hospital based HRECs did not have a website that we could find. In some instances, the information about the HREC was provided via a central state-based portal where elements of the submission process and key local contact details were provided for each of the HRECs. We checked all of the links present in these websites and found that many were broken and in over half of all cases the links to the relevant policies, procedures, and key guidance documents were significantly out of date.

In contrast, we did find several websites that provided excellent resources such as those provided by the St Vincent’s HREC based in Melbourne and the Bellberry private HREC, which are exemplary in the level of useful information and easily accessible guidance they provide to researchers. We observed that of all of the HREC websites reviewed, 30 of the top 37 HRECs which all had accessible websites with useful information about submission were certified HRECs. Only 6 of the bottom 31, with what we considered to be inadequate levels of guidance information, were certified. This raises an interesting question as to whether the need to become certified led them to invest significantly in all aspects of the administrative process, including the development of useful websites.

Table 1: Key findings overall

CriteriaNo of HRECs scoring 1 (total 71)
Easily accessible information about key functions62 (87%)
Clear instructions about submission process62 (87%)
Additional information to guide applicants about ensuring their project met ethical requirements27 (38%)
Clear and proportionate pathway for low risk research43 (61%)
Up to date policies and guidance documents31 (44%)

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Our findings suggest that many health services that run HRECs could significantly improve the researcher experience by simply upgrading their websites to guide researchers more clearly about what is expected of them. As Angela Romano highlighted, the process should not be a box checking exercise and we suggest that if there was clear guidance about what was substantive ethical considerations that needed to be met rather than simply how to fill in the relevant forms we might achieve this, or at least take a step in the right direction.

Whilst we cannot provide any analytical evidence of a correlation it would not be surprising if the improved guidance provided by some HRECs meant that the time to approval was shorter due to a reduction in non-compliant submissions and perhaps even the quality of submission in terms of covering the substantive ethical concerns likely to arise. It is fair to argue that researchers themselves should take the time and effort to ensure that they find out what is expected of them but we suggest that it would be a highly cost efficient exercise to start by making the websites themselves more useful and geared toward this end.

Would you like to find out the score for your institution’s web site/or have an assessment conducted? If you are a https://www.ahrecs.vip subscriber this can be done for free.  Send an email to enquiry@ahrecs.com to discuss.

We did note in reviewing all of the websites that they were all designed differently and put information in different places and in different formats. We would also like to suggest that there would be some value in establishing a national standard for the presentation of core information regarding ethical submission and that there really is no reason that we can see for such wide variation in the way documents are provided. Efforts to harmonise content are evident in groups of hospitals such as Ramsay Healthcare, and we did note that several institutions now utilise the services of a central HREC, either their own for a group of hospitals or of other (certified) HRECs as part of the National Mutual Acceptance (NMA) scheme. We did not observe a great deal of harmonisation of content though outside of mandatory state-specific forms.
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Australia is committed to fostering health and medical research to improve the lives of patients as demonstrated by the State, Federal and charitable sector financial commitments that run to several billion dollars. Enhancing and harmonising website content would seem one way in which a small amount of effort would go a very long way to boosting our capability of doing ethically sound research.
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References:
National Statement on Ethical Conduct in Human Research 2007 (Updated 2018). The National Health and Medical Research Council, the Australian Research Council and Universities Australia. Commonwealth of Australia, Canberra.

Romano, A. (22 June 2019) Research Ethics Review as a Box-Ticking Exercise Research Ethics Monthly. Retrieved from: https://ahrecs.com/human-research-ethics/research-ethics-review-as-a-box-ticking-exercise

This post may be cited as:
Ng, S. C., Ong, W. M., Belvedere. S., Gilong, C., Zeps, N. & Smart, P. (4 February 2020) A users perspective on the ethics application process in Australia-Room for improvement. Research Ethics Monthly. Retrieved from: https://ahrecs.com/human-research-ethics/a-users-perspective-on-the-ethics-application-process-in-australia-room-for-improvement

It’s the hand you’re dealt: Copyright card games and publishing board games are in!0

Posted by Admin in Research Integrity on December 21, 2019 / Keywords: , , ,
 

Nerida Quatermass | University Copyright Officer | Project Manager, Creative Commons Australia at Queensland University of Technology

As a university copyright officer, I provide copyright information for research and scholarly communication – from ethics applications to publication.

What’s up, Doc?

Copyright questions can often be a manifestation of a larger issue than copyright. For example, a question about the mining or use of Twitter posts while involving third party copyright is also a matter of contract – what use of content is allowed under platform terms. Alternatively, the question might be about copyright, but it’s one where the law doesn’t provide the answer – does the scope of the fair dealing for research exception extend to publication? These types of enquiries illustrate that researchers need to understand copyright and a range of related issues relevant to research and communication.]

Myth-busting

Couple these uncertainties with the fact that there is no harmony in copyright laws between jurisdictions in a global research and communication community, and it means there are sure to be some persistent copyright myths to de-bunk in order to understand what is allowed. For example, the concept of “fair use” of copyright is well known globally and researchers in Australia often ask if the use they want to make of third-party copyright is a “fair use”. They are not aware that they cannot rely on it in Australia and are not generally aware of the “fair dealing” provisions that are available to them. Misinformation combined with limited confident knowledge about re-use rights leave researchers confused and anxious about copyright matters.

Back to basics

The savvy 21st century researcher needs some basic copyright knowledge to feel confident to manage their own copyright, their use of third-party copyright, and related publication matters. Researchers have always been required by traditional publishers to manage copyright, but today funder and institutional requirements for Open Access require a level of knowledge about open licensing and the effect of a Creative Commons licence on communication and reuse.\

Out with the old

Copyright is a pretty dry topic. At Queensland University of Technology, within the Research Support Team I am a member of, a wide range of copyright guidance is available including self-help, workshop and direct enquiry. When we “teach” in traditional workshops I am not confident that transferrable learning occurs in a way that will enable future decision making. In part, I put this down to a lack of engagement in traditionally-delivered workshops and seminars.

Making a game of it

Game play has benefits to adult learning, and this is a direction that copyright education has gone in. The UK Copyright Literacy organisation mantra is “decoding copyright and bringing you enlightenment”. Jane Secker and Chris Morrison (2016) have led the way by creating games which are played in workshops. They have found that the interactivity of a games situation engages learners in training, but is also a drawcard to attend.  Chris and Jane have created two games: Copyright the Card Game which teaches the basics of copyright law and application; and The Publishing Trap which facilitates informed decision making for the research lifecycle including IP and copyright.  Following suit and inspired by this, Tohatoha – Aotearoa New Zealand’s peak open advocacy body have released Creative Commons Release ‘Em Poker – a poker style card game about Creative Commons licensing. This game is correct for all jurisdictions because CC licences are global.

Back to the thorn that is jurisdictional copyright, this year I worked with the Australian Libraries Copyright Committee and a number of librarians to localise Copyright the Card Game to Australian copyright law. The resulting Copyright the Card Came: Australian Edition is correct for Australian law; and it has an Australian look and feel to it.

The proof is in the pudding

This year, Australian librarians and copyright officers have played Copyright the Card Came: Australian Edition in workshops, and professional development programs and at conferences. The feedback has been very positive. The interactive environment and scenario-based play is a positive contribution to learning which has made the copyright workshop a much more enjoyable prospect for teachers and learners.

If you are interested in playing, ask your librarian or copyright officer if they can organise it. Alternatively, all the resources including the card deck and workshop presentation are available online.

A beautiful deck of Creative Commons Release ‘Em Poker cards can be purchased online. Copyright: The Card Game and The Publishing Trap resources can be printed from the websites below.

Copyright the Card Came: Australian Edition

Creative Commons Release ‘Em Poker

The Publishing Trap

Reference

Secker, Jane and Morrison, Chris (2016) Copyright education and training. In: Copyright and E-learning: a Guide for Practitioners. Facet Publishing, London, UK, pp. 211-238. http://eprints.lse.ac.uk/67926/1/Secker_Copyright%20education_2016.pdf

This post may be cited as:

Quatermass, N. (21 December 2019) It’s the hand you’re dealt: Copyright card games and publishing board games are in! Research Ethics Monthly. Retrieved from: https://ahrecs.com/research-integrity/its-the-hand-youre-dealt-copyright-card-games-and-publishing-board-games-are-inhttps://ahrecs.com/research-integrity/its-the-hand-youre-dealt-copyright-card-games-and-publishing-board-games-are-in

Inclusion of Culturally and Linguistically Diverse populations in Clinical Trials:0

 

Nik Zeps
AHRECS Consultant

Clinical trials have enormous value to society as they provide the most robust means of working out whether or not particular treatments used to improve the health of our population work or not. Governments have a stated objective to increase participation in clinical trials based upon a series of assumptions that extend beyond their utility as a means to derive the highest level of reliable evidence about the efficacy and safety of interventions. One of these is that those people who are included derive a tangible benefit from doing so. Whilst this may not be true in all cases, after all up to 50% of people may receive an inferior treatment by definition, there is the potential for people to derive individual benefit, and it is often stated that those involved in a trial receive a higher standard of care than those not included. Certainly, the additional testing and closer scrutiny of people on a trial may equate in some instances to better care, but this should not be seen as a major driver as it could be argued that equitable care should be available as a universal right. A less discussed benefit is the connectedness and satisfaction that people may derive from making a tangible contribution to society through participation in clinical research. Furthermore, there may be indeterminate peer group benefits even if an individual does not benefit.

In an Australian study Smith et al (1) found that CALD people whose preferred language was not-English (PLNE) had the lowest participation rates in clinical trials. Whilst CALD people whose preferred language was English (PLE) had greater levels of enrollment than the PLNE group, they were still underrepresented by population. This has been described across the world and is identified as a pressing concern (2).  Understanding why this is the case is important for a number of reasons. In multiculturally diverse countries like Australia, testing interventions where a significant proportion of the population are not included could result in evidence that is not applicable to those people. This spans across biological differences which may be relevant to drug efficacy or toxicity through to interventions such as screening that may fail to be useful in those populations. Where there is evidence that participation in a clinical trial may present specific advantages there is also the issue of injustice through exclusion of a particular group or groups of persons. Certainly, from an implementation perspective, not including a diverse group of participants and analyzing for cultural and behavioral acceptability may mean that even if an intervention has merit it fails to be taken up.

The reasons for non-inclusion are likely more complex than those of language barriers, although having protocols for clinical trials that specifically exclude people who don’t have higher levels of proficiency in English do not help. It would seem that the language barrier could be soluble through providing greater resources to enable translation services, particular in areas with a clear need for this. Certainly, multi-national trials already have PICFs in multiple languages and these could be readily deployed through use of innovative technologies including eConsent processes.[1] Funders of clinical trials could make it a requirement for such inclusivity and back it up through provision of specific funding for this in any grants they award. Legal means to enforce this, whilst possible, are unlikely to drive systemic change and could have the unintended consequence of making it harder to do any trials at all in an environment already subject to extreme financial pressures.

However, a major reason for low levels of participation in clinical trials may be attributed to equity of access to clinical services in the first place. It is hard to recruit people from the general population into clinical trials, but even harder if specific members of the population don’t come to the health service in the first place. There is relatively little research on this topic and it would seem logical to do this as a priority in parallel with examining why people fail to participate in clinical trials due to language barriers. Perhaps clinical trials are simply the canary alerting us to broader inequities that need greater research and investment. Research into solutions to these inequities is accordingly a priority and may solve clinical trial participation rates as a consequence.

References

  1. Smith A, Agar M, Delaney G, Descallar J, Dobell-Brown K, Grand M, et al. Lower trial participation by culturally and linguistically diverse (CALD) cancer patients is largely due to language barriers. Asia Pac J Clin Oncol. 2018;14(1):52-60.
  2. Clark LT, Watkins L, Pina IL, Elmer M, Akinboboye O, Gorham M, et al. Increasing Diversity in Clinical Trials: Overcoming Critical Barriers. Curr Probl Cardiol. 2019;44(5):148-72.

Nik Zeps participated in the CCV forum at the COSA ASM. A full report of the workshop and research by the CCV and MCCabe centre is forthcoming.

[1] https://ctiq.com.au/wp-content/uploads/eConsent-in-Clinical-Trials-compressed.pdf

This post may be cited as:

Zeps, N. (4 December 2019) Inclusion of Culturally and Linguistically Diverse populations in Clinical Trials. Research Ethics Monthly. Retrieved from: https://ahrecs.com/human-research-ethics/inclusion-of-culturally-and-linguistically-diverse-populations-in-clinical-trials

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