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Effect of Mechanical Thrombectomy Without vs With Intravenous Thrombolysis on Functional Outcome Among Patients With Acute Ischemic StrokeThe SKIP Randomized Clinical Trial

Educational Objective
To learn about the treatment of patients with acute ischemic stroke.
1 Credit CME
Key Points

Question  In patients with acute large vessel occlusion stroke, is mechanical thrombectomy alone noninferior to combined intravenous thrombolysis using 0.6-mg/kg alteplase plus mechanical thrombectomy regarding functional outcomes?

Findings  In this randomized clinical trial of 204 patients, a favorable functional outcome occurred in 59.4% of those randomized to mechanical thrombectomy alone and in 57.3% of those randomized to combined intravenous thrombolysis plus mechanical thrombectomy (odds ratio, 1.09 [95% confidence limit below the noninferiority margin of 0.74]).

Meaning  The findings failed to demonstrate noninferiority of mechanical thrombectomy alone, compared with combined intravenous thrombolysis plus mechanical thrombectomy, for favorable functional outcome following acute large vessel occlusive ischemic stroke, although the wide confidence intervals around the effect estimate also did not allow a conclusion of inferiority.

Abstract

Importance  Whether intravenous thrombolysis is needed in combination with mechanical thrombectomy in patients with acute large vessel occlusion stroke is unclear.

Objective  To examine whether mechanical thrombectomy alone is noninferior to combined intravenous thrombolysis plus mechanical thrombectomy for favorable poststroke outcome.

Design, Setting, and Participants  Investigator-initiated, multicenter, randomized, open-label, noninferiority clinical trial in 204 patients with acute ischemic stroke due to large vessel occlusion enrolled at 23 hospital networks in Japan from January 1, 2017, to July 31, 2019, with final follow-up on October 31, 2019.

Interventions  Patients were randomly assigned to mechanical thrombectomy alone (n = 101) or combined intravenous thrombolysis (alteplase at a 0.6-mg/kg dose) plus mechanical thrombectomy (n = 103).

Main Outcomes and Measures  The primary efficacy end point was a favorable outcome defined as a modified Rankin Scale score (range, 0 [no symptoms] to 6 [death]) of 0 to 2 at 90 days, with a noninferiority margin odds ratio of 0.74, assessed using a 1-sided significance threshold of .025 (97.5% CI). There were 7 prespecified secondary efficacy end points, including mortality by day 90. There were 4 prespecified safety end points, including any intracerebral hemorrhage and symptomatic intracerebral hemorrhage within 36 hours.

Results  Among 204 patients (median age, 74 years; 62.7% men; median National Institutes of Health Stroke Scale score, 18), all patients completed the trial. Favorable outcome occurred in 60 patients (59.4%) in the mechanical thrombectomy alone group and 59 patients (57.3%) in the combined intravenous thrombolysis plus mechanical thrombectomy group, with no significant between-group difference (difference, 2.1% [1-sided 97.5% CI, −11.4% to ∞]; odds ratio, 1.09 [1-sided 97.5% CI, 0.63 to ∞]; P = .18 for noninferiority). Among the 7 secondary efficacy end points and 4 safety end points, 10 were not significantly different, including mortality at 90 days (8 [7.9%] vs 9 [8.7%]; difference, –0.8% [95% CI, –9.5% to 7.8%]; odds ratio, 0.90 [95% CI, 0.33 to 2.43]; P > .99). Any intracerebral hemorrhage was observed less frequently in the mechanical thrombectomy alone group than in the combined group (34 [33.7%] vs 52 [50.5%]; difference, –16.8% [95% CI, –32.1% to –1.6%]; odds ratio, 0.50 [95% CI, 0.28 to 0.88]; P = .02). Symptomatic intracerebral hemorrhage was not significantly different between groups (6 [5.9%] vs 8 [7.7%]; difference, –1.8% [95% CI, –9.7% to 6.1%]; odds ratio, 0.75 [95% CI, 0.25 to 2.24]; P = .78).

Conclusions and Relevance  Among patients with acute large vessel occlusion stroke, mechanical thrombectomy alone, compared with combined intravenous thrombolysis plus mechanical thrombectomy, failed to demonstrate noninferiority regarding favorable functional outcome. However, the wide confidence intervals around the effect estimate also did not allow a conclusion of inferiority.

Trial Registration  umin.ac.jp/ctr Identifier: UMIN000021488

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Article Information

Corresponding Author: Kazumi Kimura, MD, PhD, Department of Neurology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan (k-kimura@nms.ac.jp).

Accepted for Publication: November 18, 2020.

Author Contributions: Drs Kimura and Suzuki had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. The first and subsequent drafts of the manuscript were written by Drs Suzuki and Kimura, incorporating input from all authors.

Concept and design: Suzuki, Matsumaru, Fujimoto, Higashida, Kimura.

Acquisition, analysis, or interpretation of data: Suzuki, Takeuchi, Morimoto, Kanazawa, Takayama, Kamiya, Shigeta, Okubo, Hayakawa, Ishii, Koguchi, Takigawa, Inoue, Naito, Ota, Hirano, Kato, Ueda, Iguchi, Akaji, Tsuruta, Miki, Fujimoto, Higashida, Iwasaki, Aoki, Nishiyama, Otsuka, Kimura.

Drafting of the manuscript: Suzuki, Higashida, Kimura.

Critical revision of the manuscript for important intellectual content: Suzuki, Matsumaru, Takeuchi, Morimoto, Kanazawa, Takayama, Kamiya, Shigeta, Okubo, Hayakawa, Ishii, Koguchi, Takigawa, Inoue, Naito, Ota, Hirano, Kato, Ueda, Iguchi, Akaji, Tsuruta, Miki, Fujimoto, Iwasaki, Aoki, Nishiyama, Otsuka, Kimura.

Statistical analysis: Suzuki, Higashida, Otsuka.

Obtained funding: Suzuki, Kimura.

Administrative, technical, or material support: Suzuki, Takeuchi, Morimoto, Kanazawa, Takayama, Kamiya, Shigeta, Okubo, Ishii, Koguchi, Inoue, Naito, Ota, Hirano, Kato, Ueda, Iguchi, Akaji, Tsuruta, Miki, Higashida, Iwasaki, Aoki, Nishiyama, Kimura.

Supervision: Matsumaru, Fujimoto, Otsuka, Kimura.

Conflict of Interest Disclosures: Dr Suzuki reported receiving grants from the Japanese Society for Neuroendovascular Therapy during the conduct of the study and a scholarship to study abroad from the Uehara Memorial Foundation. Dr Matsumaru reported receiving personal fees from Medtronic Co Ltd, Stryker Co Ltd, Sanofi Co Ltd, Daiichi Sankyo Co Ltd, Otsuka Pharmaceutical Co Ltd, and Biomedical Solutions outside the submitted work. Dr Takeuchi reported receiving lecture fees from Stryker Co Ltd outside the submitted work. Dr Kamiya reported receiving personal fees from Daiichi Sankyo Co Ltd and grants from Bristol-Myers Squibb Co Ltd outside the submitted work. Dr Hirano reported receiving personal fees from Bayer Healthcare Co Ltd, Daiichi Sankyo Co Ltd, Nippon Boehringer Ingelheim Co Ltd, Bristol-Myers Squibb Co Ltd, Medtronic Co Ltd, Sanofi Co Ltd, Otsuka Pharmaceutical Co Ltd, Mitsubishi Tanabe Pharma Co, CSL Behring KK, Astellas Pharma Inc, and Pfizer Japan Inc outside the submitted work. Dr Iguchi reported receiving grants and personal fees from Sanofi SA, Daiichi-Sankyo Co Ltd, and Boehringer Ingelheim GmbH, Bayer AG; personal fees from Pfizer Inc and Bristol-Myers Squibb; and lecture fees from Bayer Healthcare Co Ltd, Pfizer Japan Inc, Nippon Boehringer Ingelheim Co Ltd, Takeda Pharmaceutical Co Ltd, Otsuka Pharmaceutical Co Ltd, and Daiichi Sankyo Co Ltd outside the submitted work. Dr Fujimoto reported receiving personal fees from Daiichi Sankyo Co Ltd, Bayer Yakuhin Ltd, Nippon Boehringer Ingelheim Co Ltd, Bristol-Myers Squibb Co, Pfizer Japan Inc, Takeda Pharmaceutical Co Ltd, Otsuka Pharmaceutical Co Ltd, Sanofi KK, MSD KK, and Dai-Nippon Sumitomo Pharma Co Ltd outside the submitted work. Dr Nishiyama reported receiving personal fees from Daiichi Sankyo Co Ltd outside the submitted work. Dr Kimura reported receiving grants from 38th Mihara Cerebrovascular Disorder Research Promotion Fund Ltd during the conduct of the study and grants from Teijin Pharma Ltd, Medtronic Co Ltd, Pfizer Japan Inc, Daiichi Sankyo Co, and Nippon Boehringer Ingelheim Co Ltd, personal fees from Daiichi Sankyo Co, personal fees from Bayer Healthcare Co Ltd and personal fees from Nippon Boehringer Ingelheim Co Ltd and Bristol-Myers Squibb Co Ltd outside the submitted work. No other disclosures were reported.

Funding/Support: Funding was provided by the Japanese Society for Neuroendovascular Therapy.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Group Information: The SKIP Study Investigators are listed in Supplement 3.

Additional Contributions: We thank Akio Morita, MD, PhD (Department of Neurosurgery, Nippon Medical School Hospital, Tokyo, Japan), as the independent data monitoring committee without compensation and Hiroyuki Yokota, MD, PhD (Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital, Tokyo, Japan), as the event evaluation committee without compensation.

Data Sharing Statement: See Supplement 4.

References
1.
Jovin  TG , Chamorro  A , Cobo  E ,  et al; REVASCAT Trial Investigators.  Thrombectomy within 8 hours after symptom onset in ischemic stroke.   N Engl J Med. 2015;372(24):2296-2306. doi:10.1056/NEJMoa1503780PubMedGoogle ScholarCrossref
2.
Berkhemer  OA , Fransen  PS , Beumer  D ,  et al; MR CLEAN Investigators.  A randomized trial of intraarterial treatment for acute ischemic stroke.   N Engl J Med. 2015;372(1):11-20. doi:10.1056/NEJMoa1411587PubMedGoogle ScholarCrossref
3.
Campbell  BC , Mitchell  PJ , Kleinig  TJ ,  et al; EXTEND-IA Investigators.  Endovascular therapy for ischemic stroke with perfusion-imaging selection.   N Engl J Med. 2015;372(11):1009-1018. doi:10.1056/NEJMoa1414792PubMedGoogle ScholarCrossref
4.
Saver  JL , Goyal  M , Bonafe  A ,  et al; SWIFT PRIME Investigators.  Stent-retriever thrombectomy after intravenous t-PA vs t-PA alone in stroke.   N Engl J Med. 2015;372(24):2285-2295. doi:10.1056/NEJMoa1415061PubMedGoogle ScholarCrossref
5.
Goyal  M , Demchuk  AM , Menon  BK ,  et al; ESCAPE Trial Investigators.  Randomized assessment of rapid endovascular treatment of ischemic stroke.   N Engl J Med. 2015;372(11):1019-1030. doi:10.1056/NEJMoa1414905PubMedGoogle ScholarCrossref
6.
Bracard  S , Ducrocq  X , Mas  JL ,  et al; THRACE investigators.  Mechanical thrombectomy after intravenous alteplase versus alteplase alone after stroke (THRACE): a randomised controlled trial.   Lancet Neurol. 2016;15(11):1138-1147. doi:10.1016/S1474-4422(16)30177-6PubMedGoogle ScholarCrossref
7.
Muir  KW , Ford  GA , Messow  CM ,  et al; PISTE Investigators.  Endovascular therapy for acute ischaemic stroke: the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) randomised, controlled trial.   J Neurol Neurosurg Psychiatry. 2017;88(1):38-44. doi:10.1136/jnnp-2016-314117PubMedGoogle ScholarCrossref
8.
Jauch  EC , Saver  JL , Adams  HP  Jr ,  et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology.  Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.   Stroke. 2013;44(3):870-947. doi:10.1161/STR.0b013e318284056aPubMedGoogle ScholarCrossref
9.
Turc  G , Bhogal  P , Fischer  U ,  et al.  European Stroke Organisation (ESO)—European Society for Minimally Invasive Neurological Therapy (ESMINT) Guidelines on Mechanical Thrombectomy in Acute Ischaemic StrokeEndorsed by Stroke Alliance for Europe (SAFE).   Eur Stroke J. 2019;4(1):6-12. doi:10.1177/2396987319832140PubMedGoogle ScholarCrossref
10.
Toyoda  K , Koga  M , Iguchi  Y ,  et al.  Guidelines for intravenous thrombolysis (recombinant tissue–type plasminogen activator), the third edition, March 2019: a guideline from the Japan Stroke Society.   Neurol Med Chir (Tokyo). 2019;59(12):449-491. doi:10.2176/nmc.st.2019-0177 PubMedGoogle ScholarCrossref
11.
Goyal  M , Menon  BK , van Zwam  WH ,  et al; HERMES collaborators.  Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trials.   Lancet. 2016;387(10029):1723-1731. doi:10.1016/S0140-6736(16)00163-XPubMedGoogle ScholarCrossref
12.
Broeg-Morvay  A , Mordasini  P , Bernasconi  C ,  et al.  Direct mechanical intervention versus combined intravenous and mechanical intervention in large artery anterior circulation stroke: a matched-pairs analysis.   Stroke. 2016;47(4):1037-1044. doi:10.1161/STROKEAHA.115.011134PubMedGoogle ScholarCrossref
13.
Mistry  EA , Mistry  AM , Nakawah  MO ,  et al.  Mechanical thrombectomy outcomes with and without intravenous thrombolysis in stroke patients: a meta-analysis.   Stroke. 2017;48(9):2450-2456. doi:10.1161/STROKEAHA.117.017320PubMedGoogle ScholarCrossref
14.
Hacke  W , Donnan  G , Fieschi  C ,  et al; ATLANTIS Trials Investigators; ECASS Trials Investigators; NINDS rt-PA Study Group Investigators.  Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials.   Lancet. 2004;363(9411):768-774. doi:10.1016/S0140-6736(04)15692-4PubMedGoogle ScholarCrossref
15.
Suzuki  K , Kimura  K , Takeuchi  M ,  et al.  The randomized study of endovascular therapy with versus without intravenous tissue plasminogen activator in acute stroke with ICA and M1 occlusion (SKIP study).   Int J Stroke. 2019;14(7):752-755. doi:10.1177/1747493019840932PubMedGoogle ScholarCrossref
16.
Yamaguchi  T , Mori  E , Minematsu  K ,  et al; Japan Alteplase Clinical Trial (J-ACT) Group.  Alteplase at 0.6 mg/kg for acute ischemic stroke within 3 hours of onset: Japan Alteplase Clinical Trial (J-ACT).   Stroke. 2006;37(7):1810-1815. doi:10.1161/01.STR.0000227191.01792.e3PubMedGoogle ScholarCrossref
17.
Hirano  T , Sasaki  M , Mori  E , Minematsu  K , Nakagawara  J , Yamaguchi  T ; Japan Alteplase Clinical Trial II Group.  Residual vessel length on magnetic resonance angiography identifies poor responders to alteplase in acute middle cerebral artery occlusion patients: exploratory analysis of the Japan Alteplase Clinical Trial II.   Stroke. 2010;41(12):2828-2833. doi:10.1161/STROKEAHA.110.594333PubMedGoogle ScholarCrossref
18.
Goyal  M , Fargen  KM , Turk  AS ,  et al.  2C or not 2C: defining an improved revascularization grading scale and the need for standardization of angiography outcomes in stroke trials.   J Neurointerv Surg. 2014;6(2):83-86. doi:10.1136/neurintsurg-2013-010665PubMedGoogle ScholarCrossref
19.
Mori  E , Minematsu  K , Nakagawara  J , Yamaguchi  T , Sasaki  M , Hirano  T ; Japan Alteplase Clinical Trial II Group.  Effects of 0.6 mg/kg intravenous alteplase on vascular and clinical outcomes in middle cerebral artery occlusion: Japan Alteplase Clinical Trial II (J-ACT II).   Stroke. 2010;41(3):461-465. doi:10.1161/STROKEAHA.109.573477PubMedGoogle ScholarCrossref
20.
National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group.  Tissue plasminogen activator for acute ischemic stroke.   N Engl J Med. 1995;333(24):1581-1587. doi:10.1056/NEJM199512143332401PubMedGoogle ScholarCrossref
21.
Wahlgren  N , Ahmed  N , Dávalos  A ,  et al; SITS-MOST investigators.  Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study.   Lancet. 2007;369(9558):275-282. doi:10.1016/S0140-6736(07)60149-4PubMedGoogle ScholarCrossref
22.
Weber  R , Nordmeyer  H , Hadisurya  J ,  et al.  Comparison of outcome and interventional complication rate in patients with acute stroke treated with mechanical thrombectomy with and without bridging thrombolysis.   J Neurointerv Surg. 2017;9(3):229-233. doi:10.1136/neurintsurg-2015-012236PubMedGoogle ScholarCrossref
23.
Adams  HP  Jr , Bendixen  BH , Kappelle  LJ ,  et al.  Classification of subtype of acute ischemic stroke: definitions for use in a multicenter clinical trial: TOAST, Trial of Org 10172 in Acute Stroke Treatment.   Stroke. 1993;24(1):35-41. doi:10.1161/01.STR.24.1.35PubMedGoogle ScholarCrossref
24.
Leker  RR , Pikis  S , Gomori  JM , Cohen  JE .  Is bridging necessary? a pilot study of bridging versus primary stentriever-based endovascular reperfusion in large anterior circulation strokes.   J Stroke Cerebrovasc Dis. 2015;24(6):1163-1167. doi:10.1016/j.jstrokecerebrovasdis.2015.01.008PubMedGoogle ScholarCrossref
25.
Rai  AT , Boo  S , Buseman  C ,  et al.  Intravenous thrombolysis before endovascular therapy for large vessel strokes can lead to significantly higher hospital costs without improving outcomes.   J Neurointerv Surg. 2018;10(1):17-21. doi:10.1136/neurintsurg-2016-012830PubMedGoogle ScholarCrossref
26.
Coutinho  JM , Liebeskind  DS , Slater  LA ,  et al.  Combined intravenous thrombolysis and thrombectomy vs thrombectomy alone for acute ischemic stroke: a pooled analysis of the SWIFT and STAR studies.   JAMA Neurol. 2017;74(3):268-274. doi:10.1001/jamaneurol.2016.5374PubMedGoogle ScholarCrossref
27.
Abilleira  S , Ribera  A , Cardona  P ,  et al; Catalan Stroke Code and Reperfusion Consortium.  Outcomes after direct thrombectomy or combined intravenous and endovascular treatment are not different.   Stroke. 2017;48(2):375-378. doi:10.1161/STROKEAHA.116.015857PubMedGoogle ScholarCrossref
28.
Minnerup  J , Wersching  H , Teuber  A ,  et al; REVASK Investigators.  Outcome after thrombectomy and intravenous thrombolysis in patients with acute ischemic stroke: a prospective observational study.   Stroke. 2016;47(6):1584-1592. doi:10.1161/STROKEAHA.116.012619PubMedGoogle ScholarCrossref
29.
Dávalos  A , Pereira  VM , Chapot  R , Bonafé  A , Andersson  T , Gralla  J ; Solitaire Group.  Retrospective multicenter study of Solitaire FR for revascularization in the treatment of acute ischemic stroke.   Stroke. 2012;43(10):2699-2705. doi:10.1161/STROKEAHA.112.663328PubMedGoogle ScholarCrossref
30.
Mulder  MJ , Berkhemer  OA , Fransen  PS ,  et al; MR CLEAN investigators.  Treatment in patients who are not eligible for intravenous alteplase: MR CLEAN subgroup analysis.   Int J Stroke. 2016;11(6):637-645. doi:10.1177/1747493016641969PubMedGoogle ScholarCrossref
31.
Nogueira  RG , Gupta  R , Jovin  TG ,  et al.  Predictors and clinical relevance of hemorrhagic transformation after endovascular therapy for anterior circulation large vessel occlusion strokes: a multicenter retrospective analysis of 1122 patients.   J Neurointerv Surg. 2015;7(1):16-21. doi:10.1136/neurintsurg-2013-010743PubMedGoogle ScholarCrossref
32.
Katsanos  AH , Malhotra  K , Goyal  N ,  et al.  Intravenous thrombolysis prior to mechanical thrombectomy in large vessel occlusions.   Ann Neurol. 2019;86(3):395-406. doi:10.1002/ana.25544PubMedGoogle ScholarCrossref
33.
Phan  K , Dmytriw  AA , Lloyd  D ,  et al.  Direct endovascular thrombectomy and bridging strategies for acute ischemic stroke: a network meta-analysis.   J Neurointerv Surg. 2019;11(5):443-449. doi:10.1136/neurintsurg-2018-014260PubMedGoogle ScholarCrossref
34.
Kaesmacher  J , Mordasini  P , Arnold  M ,  et al.  Direct mechanical thrombectomy in tPA-ineligible and -eligible patients versus the bridging approach: a meta-analysis.   J Neurointerv Surg. 2019;11(1):20-27. doi:10.1136/neurintsurg-2018-013834PubMedGoogle ScholarCrossref
35.
Fiorelli  M , Bastianello  S , von Kummer  R ,  et al.  Hemorrhagic transformation within 36 hours of a cerebral infarct: relationships with early clinical deterioration and 3-month outcome in the European Cooperative Acute Stroke Study I (ECASS I) cohort.   Stroke. 1999;30(11):2280-2284. doi:10.1161/01.STR.30.11.2280PubMedGoogle ScholarCrossref
36.
Molina  CA , Alvarez-Sabín  J , Montaner  J ,  et al.  Thrombolysis-related hemorrhagic infarction: a marker of early reperfusion, reduced infarct size, and improved outcome in patients with proximal middle cerebral artery occlusion.   Stroke. 2002;33(6):1551-1556. doi:10.1161/01.STR.0000016323.13456.E5PubMedGoogle ScholarCrossref
37.
Dzialowski  I , Pexman  JH , Barber  PA , Demchuk  AM , Buchan  AM , Hill  MD ; CASES Investigators.  Asymptomatic hemorrhage after thrombolysis may not be benign: prognosis by hemorrhage type in the Canadian alteplase for stroke effectiveness study registry.   Stroke. 2007;38(1):75-79. doi:10.1161/01.STR.0000251644.76546.62PubMedGoogle ScholarCrossref
38.
Lei  C , Wu  B , Liu  M , Chen  Y .  Asymptomatic hemorrhagic transformation after acute ischemic stroke: is it clinically innocuous?   J Stroke Cerebrovasc Dis. 2014;23(10):2767-2772. doi:10.1016/j.jstrokecerebrovasdis.2014.06.024PubMedGoogle ScholarCrossref
39.
van Kranendonk  KR , Treurniet  KM , Boers  AMM ,  et al; MR CLEAN investigators.  Hemorrhagic transformation is associated with poor functional outcome in patients with acute ischemic stroke due to a large vessel occlusion.   J Neurointerv Surg. 2019;11(5):464-468. doi:10.1136/neurintsurg-2018-014141PubMedGoogle ScholarCrossref
40.
Yang  P , Zhang  Y , Zhang  L ,  et al; DIRECT-MT Investigators.  Endovascular Thrombectomy with or without Intravenous Alteplase in Acute Stroke.   N Engl J Med. 2020;382(21):1981-1993. doi:10.1056/NEJMoa2001123PubMedGoogle ScholarCrossref
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