Iloprost Power Disc-15 in Pulmonary Arterial Hypertension

Phase 3

Terminated

Conditions: Pulmonary Arterial Hypertension

Interventions: Drug: Iloprost PD-6
Drug: Iloprost PD-15

Registration Number: NCT00723554

Lead Sponsor: Actelion

Brief Summary: A Phase IIIb, Multicenter, Open-Label Study of Patients With Pulmonary Arterial Hypertension Treated With Iloprost(Inhalation)Evaluating Safety and Inhalation Times When Converting From Power Disc-6 to Power Disc-15 With the I-neb® Adaptive Aerosol Delivery® System (I-neb® AAD®)

Detailed Description: Not available

Recruitment & Eligibility

Status: TERMINATED

Sex: All

Target Recruitment: 63

Inclusion Criteria

Signed informed consent prior to initiation of any study-mandated procedure.
Male or female patients aged 18-85 years.
Patients with symptomatic pulmonary arterial hypertension in New York Heart Association (NYHA) functional class III or IV at the time of initiation of iloprost inhalation (Ventavis®) therapy using the Power Disc-6 (PD-6).
Patients with the following types of pulmonary arterial hypertension (PAH) belonging to World Health Organization (WHO) Group I:
- 1.1: Idiopathic (IPAH)
- 1.2: Familial (FPAH)
- 1.3: Associated with (APAH)
  - 1.3.1: Collagen vascular disease
  - 1.3.2: Congenital systemic-to-pulmonary shunts at least 2 years post surgical repair
  - 1.3.4: Human immunodeficiency virus (HIV) infection
  - 1.3.5: Drugs and toxins
PAH confirmed by the most recent right heart catheterization showing:
- Mean pulmonary arterial pressure (mPAP)≥ 25 mmHg at rest
- Pulmonary capillary wedge pressure (PCWP) ≤ 15 mmHg or left ventricular end diastolic pressure (LVEDP) ≤ 15 mmHg. If both PCWP and LVEDP are available then the LVEDP value is retained for inclusion.
- Pulmonary vascular resistance (PVR) > 240 dyn-sec/cm^5
Compliant with a treatment regimen of commercial iloprost inhalation (Ventavis® 5 μg) using the I-neb® AAD® equipped with the PD-6 for at least 4 weeks prior to screening.
Pulmonary function tests (PFTs) including forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and total lung capacity (TLC), performed within 6 months of screening.
If taking other medications for PAH, these must have been stable for 60 days prior to baseline.
If taking corticosteroids, these must have been stable for 60 days prior to baseline.
Women of childbearing potential with a negative urine pre-treatment pregnancy test at baseline and who:
- consistently and correctly use (from screening and up to 28 days after discontinuation of study drug) a reliable method of contraception with a Pearl index of < 1%,
- are sexually abstinent, or
- have a vasectomized partner.

A woman is considered to have childbearing potential unless she meets at least one of the following criteria:

Previous bilateral salpingo-oophorectomy or hysterectomy
Premature ovarian failure confirmed by a specialist gynecologist
XY genotype, Turner syndrome, uterine agenesis
Is aged > 50 years and not treated with any kind of hormone replacement therapy (HRT) for at least 2 years prior to screening, with amenorrhea for at least 24 consecutive months

Exclusion Criteria

PAH belonging to WHO group II-V.
PAH belonging to WHO group I other than that listed in the inclusion criteria, i.e., PAH associated with:
- 1.3.3: Portal hypertension
- 1.3.6: Other (thyroid disorders, glycogen storage disease, Gaucher disease, hereditary hemorrhagic telangiectasia, hemoglobinopathies, myeloproliferative disorders, splenectomy)
- 1.4: Associated with significant venous or capillary involvement:
  - 1.4.1: Pulmonary veno-occlusive disease (PVOD)
  - 1.4.2: Pulmonary capillary hemangiomatosis (PCH).
Receipt of any prostacyclin or prostacyclin analog other than iloprost within 12 weeks before screening.
Anticipation of the need for intravenous prostacyclin use within 28 days of starting the Power Disc-15 (PD-15).
HIV-seropositive with any of the following:
- Concomitant active opportunistic infections within 6 months prior to screening
- Detectable viral load within 6 months of screening
- CD4+ T-cell count < 200 mm^3 within 3 months of screening
- Changes in antiretroviral regimen within 3 months of screening
- Anticipated changes in antiretroviral regimen during study periods 1 or 2
- Using inhaled pentamidine
Systemic hypotension with systolic blood pressure < 95 mmHg.
Uncontrolled systemic hypertension (systolic blood pressure > 160 mmHg or diastolic blood pressure > 100 mmHg on repeated measurement).
History of left-sided heart disease, including any of the following:
- hemodynamically significant aortic or mitral valve disease
- restrictive or congestive cardiomyopathy
- left ventricular ejection fraction < 40% by multigated radionucleotide angiogram (MUGA), angiography, or echocardiography
- coronary artery disease with continuing symptoms of angina pectoris
- life-threatening cardiac arrhythmias
Atrial septostomy within 1 year.
History of pulmonary embolism prior to diagnosis of PAH unless it can be documented that chronic thromboembolic pulmonary hypertension (CTEPH) has been specifically excluded (e.g., ventilation/perfusion (VQ) scan, pulmonary angiogram).
Restrictive lung disease: TLC < 60% of normal predicted value.
Obstructive lung disease: forced expiratory volume/forced vital capacity (FEV1/FVC) < 0.5 or clinically relevant chronic obstructive lung disease or asthma (including any patient requiring concomitant medication to control symptoms of bronchospasm including as needed (p.r.n.) use).
Clinically relevant bleeding disorder or active bleeding.
Moderate to severe hepatic impairment, i.e., Child-Pugh Class B or C or hepatic cirrhosis.
Pregnant or breast-feeding.
Chronic renal insufficiency, as defined by a creatinine of > 2.5 mg/dL or the requirement for dialysis.
Hemoglobin < 75% of the lower limit of normal range.
Any condition that prevents compliance with the protocol or adherence to therapy or ability to provide informed consent.
Participation in any other clinical trial, except observational, or receipt of an investigational product within 30 days prior to enrollment.

Study & Design

Study Type: INTERVENTIONAL

Study Design: SINGLE_GROUP

Arm && Interventions

Group	Intervention	Description
Iloprost	Iloprost PD-6	The study enrolled patients who were already using iloprost with PD-6 without any safety or tolerability concerns, thereby facilitating a direct comparison of the PD-15 to the PD-6. The single-arm design allowed each patient to serve as his/her own control
Iloprost	Iloprost PD-15	The study enrolled patients who were already using iloprost with PD-6 without any safety or tolerability concerns, thereby facilitating a direct comparison of the PD-15 to the PD-6. The single-arm design allowed each patient to serve as his/her own control

Primary Outcome Measures

Name	Time	Method
Number of Patients Reporting Treatment-emergent Adverse Events (AEs)	From the first dose to last dose of investigational product, an average of approximately 268 days, plus 48 hours	Number of patients reporting at least one treatment-emergent AE/Serious AE
Number of Patients Who Discontinued Iloprost PD-15 Treatment Due to an AE	From the first dose of investigational product to study discontinuation, an average of approximately 268 days	Number of patients reporting at least one treatment-emergent AE/Serious AE leading to discontinuation of study investigational treatment
Number of Patients Reporting Treatment-emergent Serious AEs	From the first to last dose of investigational product, an average of approximately 268 days, plus 48 hours	Number of patients reporting at least one treatment-emergent serious AEs
Systolic Blood Pressure - Iloprost PD-6 (Period 1)	Day 1	Systolic blood pressure was measured immediately prior to first dosing with Iloprost PD-15
Systolic Blood Pressure - Iloprost PD-15 (Period 2)	Day 28	Systolic blood pressure was measured on Day 28 of treatment with Iloprost PD-15
Systolic Blood Pressure - Iloprost PD-15 (Period 3)	an average of approximately 268 days	Systolic blood pressure was measured at the end of study visit
Change in Systolic Blood Pressure - (Period 1 to Period 2)	Day 1 and Day 28	Systolic blood pressure was measured on Day 1 prior to treatment with Iloprost PD-15 (Period 1) and Day 28 of treatment with Iloprost PD-15 (Period 2)
Change in Systolic Blood Pressure - (Period 1 to Period 3)	Day 1 and End of study visit, an average of approximately 268 days	Systolic blood pressure was measured on Day 1 prior to treatment with Iloprost PD-15 (Period 1) and at the end of treatment with Iloprost PD-15 (Period 3)
Diastolic Blood Pressure - Iloprost PD-6 (Period 1)	Day 1	Diastolic blood pressure was measured immediately prior to first dosing with Iloprost PD-15
Diastolic Blood Pressure - Iloprost PD-15 (Period 2)	Day 28	Diastolic blood pressure was measured on Day 28 of treatment with Iloprost PD-15
Diastolic Blood Pressure - Iloprost PD-15 (Period 3)	an average of approximately 268 days	Diastolic blood pressure was measured at the end of study visit
Change in Diastolic Blood Pressure - (Period 1 to Period 2)	Day 1 and Day 28	Diastolic blood pressure was measured on Day 1 prior to treatment with Iloprost PD-15 (Period 1) and Day 28 of treatment with Iloprost PD-15 (Period 2)
Change in Diastolic Blood Pressure - (Period 1 to Period 3)	Day 1 and End of study visit, an average of approximately 268 days	Diastolic blood pressure was measured on Day 1 prior to treatment with Iloprost PD-15 (Period 1) and at the end of treatment with Iloprost PD-15 (Period 3)
Heart Rate - Iloprost PD-6 (Period 1)	Day 1	Heart rate was measured immediately prior to first dosing with Iloprost PD-15
Heart Rate - Iloprost PD-15 (Period 2)	Day 28	Heart rate was measured on Day 28 of treatment with Iloprost PD-15
Heart Rate - Iloprost PD-15 (Period 3)	an average of approximately 268 days	Heart rate was measured at the end of study visit
Change in Heart Rate - (Period 1 to Period 2)	Day 1 and Day 28	Heart rate was measured on Day 1 prior to treatment with Iloprost PD-15 (Period 1) and Day 28 of treatment with Iloprost PD-15 (Period 2)
Change in Heart Rate - (Period 1 to Period 3)	Day 1 and End of study visit, an average of approximately 268 days	Heart rate was measured on Day 1 prior to treatment with Iloprost PD-15 (Period 1) and at the end of treatment with Iloprost PD-15 (Period 3)

Secondary Outcome Measures

Name	Time	Method
Average Inhalation Time - Iloprost PD-6 (Period 1)	average of approximately 28 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Average Inhalation Time - Iloprost PD-15 (Period 2)	average of approximately 28 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Average Inhalation Time - Iloprost PD-15 (Period 3)	average of approximately 240 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Change in Average Inhalation Time - (Period 1 to Period 2)	average approximately 56 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Average Number of Days of Dosing - Iloprost PD-6 (Period 1)	average of approximately 28 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Average Number of Days of Dosing - Iloprost PD-15 (Period 2)	average of approximately 28 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Average Number of Days of Dosing - Iloprost PD-15 (Period 3)	average of approximately 240 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Change in Average Number of Days of Dosing - (Period 1 to Period 2)	average approximately 56 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Average Number of Daily Doses - Iloprost PD-6 (Period 1)	average of approximately 28 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Average Number of Daily Doses - Iloprost PD-15 (Period 2)	average of approximately 28 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Average Number of Daily Doses - Iloprost PD-15 (Period 3)	average of approximately 240 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Change in Average Number of Daily Doses - (Period 1 to Period 2)	average approximately 56 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Percentage of Complete Doses Delivered - Iloprost PD-6 (Period 1)	average of approximately 28 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Percentage of Complete Doses Delivered - Iloprost PD-15 (Period 2)	average of approximately 28 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Percentage of Complete Doses Delivered - Iloprost PD-15 (Period 3)	average of approximately 240 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
Change in Percentage of Complete Doses Delivered - (Period 1 to Period 2)	average approximately 56 days	The time and date of inhalation, inhalation time (minutes), and dose completion status (\<12.5%, ≥12.5 to \<100%, full) were recorded in the memory chip of the I-neb® AAD® each time it was used.
New York Health Association (NYHA) Functional Class - Iloprost PD-6 (Period 1, Prior to First Dose With Iloprost PD-15)	average of approximately 28 days	Disease severity was assessed by NYHA classification of PAH criteria: Class I: no limitation of physical activity (PA). Ordinary PA: no undue dyspnea/fatigue, chest pain, near syncope. Class II: slight limitation of PA. Comfortable at rest. Ordinary PA: undue dyspnea/fatigue, chest pain, near syncope. Class III: marked limitation of PA. Comfortable at rest. Less than ordinary PA: undue dyspnea/fatigue, chest pain, near syncope. Class IV: inability to carry out PA without symptoms. Right heart failure. Dyspnea/fatigue may even have been present at rest. Discomfort increased by any PA.
NYHA Functional Class - Iloprost PD-15 (Period 2, Day 28)	average of approximately 28 days	Disease severity was assessed by NYHA classification of PAH criteria: Class I: no limitation of physical activity (PA). Ordinary PA: no undue dyspnea/fatigue, chest pain, near syncope. Class II: slight limitation of PA. Comfortable at rest. Ordinary PA: undue dyspnea/fatigue, chest pain, near syncope. Class III: marked limitation of PA. Comfortable at rest. Less than ordinary PA: undue dyspnea/fatigue, chest pain, near syncope. Class IV: inability to carry out PA without symptoms. Right heart failure. Dyspnea/fatigue may even have been present at rest. Discomfort increased by any PA.
NYHA Functional Class - Iloprost PD-15 (Period 3, End of Study Visit))	average of approximately 268 days	Disease severity was assessed by NYHA classification of PAH criteria: Class I: no limitation of physical activity (PA). Ordinary PA: no undue dyspnea/fatigue, chest pain, near syncope. Class II: slight limitation of PA. Comfortable at rest. Ordinary PA: undue dyspnea/fatigue, chest pain, near syncope. Class III: marked limitation of PA. Comfortable at rest. Less than ordinary PA: undue dyspnea/fatigue, chest pain, near syncope. Class IV: inability to carry out PA without symptoms. Right heart failure. Dyspnea/fatigue may even have been present at rest. Discomfort increased by any PA.
Number of Patients With Improved, no Change, or Worsening of NYHA Functional Class - (Period 1, Prior to First Dose With Iloprost PD-15 to Period 2, Day 28)	average approximately 28 days	Disease severity was assessed by NYHA classification of PAH criteria: Class I: no limitation of physical activity (PA). Ordinary PA: no undue dyspnea/fatigue, chest pain, near syncope. Class II: slight limitation of PA. Comfortable at rest. Ordinary PA: undue dyspnea/fatigue, chest pain, near syncope. Class III: marked limitation of PA. Comfortable at rest. Less than ordinary PA: undue dyspnea/fatigue, chest pain, near syncope. Class IV: inability to carry out PA without symptoms. Right heart failure. Dyspnea/fatigue may even have been present at rest. Discomfort increased by any PA.
Number of Patients With Improved, no Change, or Worsening of NYHA Functional Class - (Period 1, Prior to First Dose With Iloprost PD-15 to Period 3, End of Study Visit)	average approximately 268 days	Disease severity was assessed by NYHA classification of PAH criteria: Class I: no limitation of physical activity (PA). Ordinary PA: no undue dyspnea/fatigue, chest pain, near syncope. Class II: slight limitation of PA. Comfortable at rest. Ordinary PA: undue dyspnea/fatigue, chest pain, near syncope. Class III: marked limitation of PA. Comfortable at rest. Less than ordinary PA: undue dyspnea/fatigue, chest pain, near syncope. Class IV: inability to carry out PA without symptoms. Right heart failure. Dyspnea/fatigue may even have been present at rest. Discomfort increased by any PA.
Patient Global Self Assessment - Iloprost PD-6 (Period 1, Prior to First Dose With Iloprost PD-15)	average of approximately 28 days	The Patient Global Self Assessment is a 7-point scale that was presented to patients prior to conducting visit-specific study procedures. Patients were asked to compare their current PAH status to their status in the past by selecting one of the following options: markedly better; moderately better; mildly better; no change; mildly worse; moderately worse; or markedly worse. On Day 1 prior to their first dose of iloprost with PD-15 (Baseline), patients were asked to compare their PAH status to that during Screening (if the Screening and Baseline visits were conducted on the same day, then patients were asked to compare their PAH status to that in the past 2 weeks). On Day 28 and at the end of study (EOS) visit, patients were asked to compare their PAH status to that of the previous visit.
Patient Global Self Assessment - Iloprost PD-15 (Period 2, Day 28)	average of approximately 28 days	The Patient Global Self Assessment is a 7-point scale that was presented to patients prior to conducting visit-specific study procedures. Patients were asked to compare their current PAH status to their status in the past by selecting one of the following options: markedly better; moderately better; mildly better; no change; mildly worse; moderately worse; or markedly worse. On Day 1 prior to their first dose of iloprost with PD-15 (Baseline), patients were asked to compare their PAH status to that during Screening (if the Screening and Baseline visits were conducted on the same day, then patients were asked to compare their PAH status to that in the past 2 weeks). On Day 28 and at the EOS visit, patients were asked to compare their PAH status to that of the previous visit.
Patient Global Self Assessment - Iloprost PD-15 (Period 3, End of Study Visit))	average of approximately 268 days	The Patient Global Self Assessment is a 7-point scale that was presented to patients prior to conducting visit-specific study procedures. Patients were asked to compare their current PAH status to their status in the past by selecting one of the following options: markedly better; moderately better; mildly better; no change; mildly worse; moderately worse; or markedly worse. On Day 1 prior to their first dose of iloprost with PD-15 (Baseline), patients were asked to compare their PAH status to that during Screening (if the Screening and Baseline visits were conducted on the same day, then patients were asked to compare their PAH status to that in the past 2 weeks). On Day 28 and at the EOS visit, patients were asked to compare their PAH status to that of the previous visit.
Number of Patients With Improved, no Change, or Worse Patient Global Self Assessment - Change From Previous Visit to Period 2, Day 28	average of approximately 28 days	The Patient Global Self Assessment is a 7-point scale that was presented to patients prior to conducting visit-specific study procedures. Patients were asked to compare their current PAH status to their status in the past by selecting one of the following options: markedly better; moderately better; mildly better; no change; mildly worse; moderately worse; or markedly worse. On Day 1 prior to their first dose of iloprost with PD-15 (Baseline), patients were asked to compare their PAH status to that during Screening (if the Screening and Baseline visits were conducted on the same day, then patients were asked to compare their PAH status to that in the past 2 weeks). On Day 28 and at the EOS visit, patients were asked to compare their PAH status to that of the previous visit.
Number of Patients With Improved, no Change, or Worse Patient Global Self Assessment - Change From Previous Visit to Period 3, End of Study Visit	average of approximately 268 days	The Patient Global Self Assessment is a 7-point scale that was presented to patients prior to conducting visit-specific study procedures. Patients were asked to compare their current PAH status to their status in the past by selecting one of the following options: markedly better; moderately better; mildly better; no change; mildly worse; moderately worse; or markedly worse. On Day 1 prior to their first dose of iloprost with PD-15 (Baseline), patients were asked to compare their PAH status to that during Screening (if the Screening and Baseline visits were conducted on the same day, then patients were asked to compare their PAH status to that in the past 2 weeks). On Day 28 and at the EOS visit, patients were asked to compare their PAH status to that of the previous visit.

Trial Locations

Locations (36): University of South Alabama Medical
🇺🇸
Mobile, Alabama, United States
West Los Angeles VA Healthcare Center
🇺🇸
Los Angeles, California, United States
University of Pittsburgh Medical Center-Presbyterian
🇺🇸
Pittsburgh, Pennsylvania, United States
The Ohio State University Medical Center
🇺🇸
Columbus, Ohio, United States
University of Texas Southwestern Medical Center at Dallas
🇺🇸
Dallas, Texas, United States
Allegheny General Hospital
🇺🇸
Pittsburgh, Pennsylvania, United States
Johns Hopkins University
🇺🇸
Baltimore, Maryland, United States
Children's Hospital Boston
🇺🇸
Boston, Massachusetts, United States
Arizona Pulmonary Associates, Ltd.
🇺🇸
Phoenix, Arizona, United States
Henry Ford Health System
🇺🇸
Detroit, Michigan, United States
Mayo Clinic
🇺🇸
Rochester, Minnesota, United States
INTEGRIS Baptist Medical Center, Inc.
🇺🇸
Oklahoma City, Oklahoma, United States
The Lindner Clinical Trial Center
🇺🇸
Cincinnati, Ohio, United States
University of Cincinnati
🇺🇸
Cincinnati, Ohio, United States
Kaiser Foundation Hospital
🇺🇸
Los Angeles, California, United States
Suncoast Lung Research, LLC
🇺🇸
Sarasota, Florida, United States
Santa Barbara Cottage Hospital
🇺🇸
Santa Barbara, California, United States
Northwestern University
🇺🇸
Chicago, Illinois, United States
Central Florida Pulmonary Group
🇺🇸
Orlando, Florida, United States
LSU Health Sciences Center
🇺🇸
New Orleans, Louisiana, United States
University of Maryland Medical Center
🇺🇸
Baltimore, Maryland, United States
Saint Louis University
🇺🇸
St. Louis, Missouri, United States
Beth Israel Medical Center
🇺🇸
New York, New York, United States
Weill Cornell Medical Center
🇺🇸
New York, New York, United States
Winthrop University Hospital
🇺🇸
Mineola, New York, United States
SUNY Upstate Medical University
🇺🇸
Syracus, New York, United States
The Ohio State University, The Dorothy M. Davis Heart & Lung Research Institute
🇺🇸
Columbus, Ohio, United States
Comprehensive Cardiovascular Care Group LLC
🇺🇸
Milwaukee, Wisconsin, United States
Central Utah Clinic, P.C.
🇺🇸
Provo, Utah, United States
Virginia Commonwealth University Health System
🇺🇸
Richmond, Virginia, United States
Kentuckiana Pulmonary Associates
🇺🇸
Louisville, Kentucky, United States
North Shore Long Island Jewish Health System
🇺🇸
New Hyde Park, New York, United States
Intermountain Medical Center
🇺🇸
Murray, Utah, United States
Temple University Hospital
🇺🇸
Philadelphia, Pennsylvania, United States
Medical University of South Carolina
🇺🇸
Charleston, South Carolina, United States
University of Florida
🇺🇸
Gainesville, Florida, United States