An interventional study of Rhythmic median nerve stimulation and Arrhythmic median nerve stimulation in Tourette Syndrome, Tic Disorders and Tic Disorder, Chronic Motor or Vocal, sponsored by Washington University School of Medicine. Completed at 1 site in United States. Open to participants aged 15 Years to 64 Years. Per ClinicalTrials.gov, last updated 2023-10-05.
Sponsored by Washington University School of Medicine · Not applicable, Interventional, and Treatment
Results from the University of Nottingham suggested that rhythmic median nerve stimulation (MNS) improves tic symptoms in Tourette syndrome (TS). The investigators will (1) provide a first replication of their study, (2) test the hypothesized electrophysiological mechanism and rule out a placebo effect as cause for the symptomatic benefit, and (3) gather information on the duration of effect after the end of stimulation and on individual characteristics that predict improvement with simulation. Completion of these Aims will give a clear go/no-go signal for a future clinical trial of chronic MNS delivered by a yet-to-be-developed wristwatch-style device.
NOTE: This study is not intended to evaluate a specific device for future use. Rather it is a study to determine the action of pulsed electrical stimulation on tic symptoms and to gain early evidence of effectiveness. This is a non-significant risk device study.
Chronic tic disorders (CTD), including Tourette syndrome (TS), are associated with a substantially reduced quality of life. Medication treatments are no more than 50-60% effective in randomized controlled trials, and are often discontinued due to unacceptable side effects. Behavioral therapies require ability to participate in therapy and a specially trained therapist, but weekly visits to psychologists are impractical for many Americans, especially in rural areas. Patients strongly desire new treatment options.
In June, 2020, Stephen Jackson's group at the University of Nottingham published a fascinating report in Current Biology on a potential novel treatment for tics. The radical new idea arose from observations associating movement inhibition with 8-14 Hz activity in motor cortex. They first showed that rhythmic 12 Hz peripheral stimulation of the median nerve evoked synchronous contralateral EEG activity over primary sensorimotor cortex, whereas arrhythmic stimulation at the same mean rate did not. As hypothesized, median nerve stimulation (MNS) at 12 Hz created small but statistically significant effects on initiation of voluntary movements. Importantly, they also demonstrated that this stimulation did not meaningfully impair concentration, suggesting that the effect did not operate through simple distraction. They went on to test 10 Hz MNS in 19 TS patients, and demonstrated using blinded video ratings a significant reduction in tic number and severity during 1-minute stimulation epochs vs 1-minute no-stimulation epochs. They noted that in some participants, benefit lasted beyond the end of the stimulation epoch. Videos accompanying the publication showed dramatic benefit during MNS in some subjects. Although the authors appropriately noted the steps needed to generalize these results to clinical practice, news reports already have led a number of TS patients to contact them asking for treatment. The Nottingham group has referred such inquiries from the U.S. to me as leader of our Wash.U. Tourette Association of America (TAA) Center of Excellence.
The hypotheses of this project are that the tic benefits reported by the Nottingham investigators are replicable, that they are specific to rhythmic stimulation, which alone entrained cortical activity, rather than to a placebo effect, and that they endure past the end of stimulation.
This project (a) will replicate the Nottingham findings using identical methods, and (b) will test rhythmic MNS against a placebo treatment (arrhythmic MNS at the same mean frequency). It also will gather additional preliminary data needed for a future R01 application, including response and tolerability with longer (5-minute) stimulation blocks, and the duration of benefit after the end of a stimulation block.
240 studies on the registry are indexed under Tourette Syndrome; 40 are open to participants now.
This study's enrollment of 34 is close to the median of 36 across 183 interventional studies indexed under Tourette Syndrome.
Browse Tourette Syndrome studies →Washington University School of Medicine is the lead sponsor of 1,803 studies on the registry; 271 are open to participants now.
Of its 329 completed or terminated interventional studies of FDA-regulated products, 216 (66%) have results posted.
Counted across the registry records on this site, refreshed daily.
Go through the criteria one by one — yes, no or not sure — and take the list to your doctor or the study team. Kept in this browser only.
Exclusion Criteria:
Underlined terms in the criteria open these too. Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
Before you join, the study team explains what taking part involves — its purpose, what happens, the risks and possible benefits — and answers your questions, so you can decide freely. Consent is usually recorded on a form (the informed consent form, ICF) signed by you or, where the law allows, by someone legally authorised to decide for you.
You can keep asking questions during the study, you are told of new information that matters, and you can choose to leave at any time.
The American Psychiatric Association’s manual of mental health diagnoses. DSM-5 (2013, revised as DSM-5-TR in 2022) replaced DSM-IV, and some studies still name the older edition. “Meets DSM criteria for …” means diagnosed by that edition’s diagnostic criteria, usually by a clinician in an interview.
Informed consent
Before you join, the study team explains what taking part involves — its purpose, what happens, the risks and possible benefits — and answers your questions, so you can decide freely. Consent is usually recorded on a form (the informed consent form, ICF) signed by you or, where the law allows, by someone legally authorised to decide for you.
You can keep asking questions during the study, you are told of new information that matters, and you can choose to leave at any time.
Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
DSM diagnostic criteria
The American Psychiatric Association’s manual of mental health diagnoses. DSM-5 (2013, revised as DSM-5-TR in 2022) replaced DSM-IV, and some studies still name the older edition. “Meets DSM criteria for …” means diagnosed by that edition’s diagnostic criteria, usually by a clinician in an interview.
Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
Participants will complete two stimulation sessions, at least a week apart. The first session involves rhythmic MNS and the second uses arrhythmic MNS.
Device: Rhythmic median nerve stimulation · Device: Arrhythmic median nerve stimulation
Participants will complete two stimulation sessions, at least a week apart. The first session involves arrhythmic MNS and the second uses rhythmic MNS.
Device: Rhythmic median nerve stimulation · Device: Arrhythmic median nerve stimulation
Square-wave 200 µs pulses triggered by computer at 12 Hz, at the threshold for thumb movement (expected \~2-15mA), applied to surface electrodes over the median nerve at the right wrist (conductive gel, 30 mm apart center-to-center, anode distal). This is a non-significant risk device study.
Also known as: Rhythmic MNS
Square-wave 200 µs pulses triggered by computer at random intervals with a mean rate of 12 Hz (as described in Morera Maiquez et al., 2020), at the threshold for thumb movement (expected \~2-15mA), applied to surface electrodes over the median nerve at the right wrist (conductive gel, 30 mm apart center-to-center, anode distal). This is a non-significant risk device study.
Also known as: Arrhythmic MNS
Change in Tic Frequency From When MNS is Turned Off
The number of tics per minute is assessed by an expert rater blind to condition and time point. Mean tic frequency was compared in on vs. off 1-minute stimulation epochs on the rhythmic MNS day. This analysis replicates that of Study 3 in the Morera Maiquez et al 2020 citation, who reported tics in the last 40 seconds of the block to minimize carryover effects. A Mixed Models Analysis was used to test statistical significance; it included a factor for possible within-day carryover effect and used a logarithmic transformation for tic count. Data reported here have been back-transformed to the number of tics in the last 40 s of the stimulation blocks.
Time frame: During the 1-minute on and 1-minute off blocks of rhythmic MNS stimulation (total 4 blocks)
Change in Tic Severity From When MNS is Turned Off
Severity is rated on a 5-point scale for each occurrence of any tic. The scale is the Intensity item from the Yale Global Tic Severity Scale \[YGTSS\], which uses integer scores from 0 (no tics) to 5 (severe intensity). Mean tic severity was compared in on vs. off 1-minute stimulation epochs on the rhythmic MNS day. This analysis replicates that of Study 3 in the Morera Maiquez et al 2020 citation.
Time frame: During the 1-minute on and 1-minute off blocks of rhythmic MNS stimulation (total 4 blocks)
Change in Tic Frequency During Rhythmic MNS (vs. Arrhythmic MNS)
The number of tics per minute is assessed by an expert rater blind to condition and time point. Change in tic frequency from baseline (stimulation off) is compared between 5-minute MNS-on epochs on the rhythmic vs. the arrhythmic day. Subjects who do not complete both stimulation visits will not be included in this analysis. The hypothesized change is greater improvement (off to on) with rhythmic vs. arrhythmic stimulation. This analysis includes the first six 5-minute blocks on each MNS day (i.e., the blocks that all participants complete). MNS was administered throughout blocks 6 and 8 only. Tic frequency in block 0 (baseline, before any stimulation) on the same day was a covariate in the statistical model.
Time frame: During 5-minute MNS stimulation on or off blocks 0, 5, 6, 7, 8 and 9
Change in Tic Severity During Rhythmic MNS (vs. Arrhythmic MNS)
Overall tic severity for each 5-minute block is rated once on a 5-point scale by an expert blind to condition and time point. The scale is the Intensity item from the Yale Global Tic Severity Scale \[YGTSS\], which uses integer scores from 0 (no tics) to 5 (severe intensity). Change in tic severity from baseline (stimulation off) is compared between 5-minute MNS-on epochs on the rhythmic vs. the arrhythmic day. Subjects who do not complete both stimulation visits will not be included in this analysis. The hypothesized change was greater improvement (off to on) with rhythmic vs. arrhythmic stimulation. This analysis includes the first six 5-minute blocks on each MNS day (i.e., the blocks that all participants complete). MNS was administered throughout blocks 6 and 8 only. Tic frequency in block 0 (baseline, before any stimulation) on the same day was a covariate in the statistical model.
Time frame: During 5-minute MNS stimulation on or off blocks 0, 5, 6, 7, 8 and 9
Change in Tic Severity After MNS Ends
We compared the change in tic frequency from baseline, during each 1-minute-long period following the end of stimulation. Here baseline means the tic frequency during the last 5 minutes of MNS from the same day (block 8). Last observation carried forward was used for participants who had less than 20 minutes of data following block 8.
Time frame: up to 20 minutes after the end of stimulation at each study visit up to 1 month
CGI-I, Participant
Clinical Global Impression of Improvement (CGI-I), rated by participant. The CGI-I is a 7-point scale ranging from 1 = very much improved to 7 = very much worse.
Time frame: 5-25 minutes after the end of stimulation at each study visit up to 1 month
CGI-I, Investigator
Clinical Global Impression of Improvement (CGI-I), rated by investigator. The CGI-I is a 7-point scale ranging from 1 = very much improved to 7 = very much worse.
Time frame: 5-25 minutes after the end of stimulation at each study visit up to 1 month
Rating of Therapeutic Effect Using the CGI Efficacy Index
Participant rates peak improvement experienced during the visit using the 4-point scale of the CGI (Unchanged or worse; Minimal - Slight improvement that doesn't decrease the overall impact of symptoms\*; Moderate - Decided improvement. Partial remission of symptoms; Marked - Vast improvement. Complete or nearly complete remission of all symptoms). \* = "Minimal" option anchor text slightly edited from original. The number provided is the number of participants who rated each visit as moderate or marked.
Time frame: 5-25 minutes after the end of stimulation at each study visit up to 1 month
VAS (Visual Analog Scale) Rating of Premonitory Urge Severity
Participant rates the maximal severity of any premonitory urges over the preceding minute, from 0=no premonitory urge to 100=maximally uncomfortable premonitory urge, using a Visual Analog Scale.
Time frame: At the end of each 5-min. MNS on or off block through block 9, at each study visit
Rating of Discomfort Using the CGI Efficacy Index (Edited)
Participant rates peak discomfort experienced during the visit using the 4-point scale of the CGI: "Overall, today, how much DISCOMFORT did the stimulation cause? If discomfort is the wrong word, please substitute any negative effects or side effects of stimulation. (No discomfort; Discomfort noticeable, but not severe enough to concern me or to turn it off; Enough discomfort, impairment of functioning or social embarrassment that I would only keep it on if the benefit was considerable; Caused discomfort, impairment of functioning or social embarrassment to a degree that any treatment benefit was not worth leaving it on). The number provided is the number of visits where discomfort is rated as none or minimal.
Time frame: 5-25 minutes after the end of stimulation at each study visit up to 1 month
Blindedness Assessment
Participants guess at each study visit whether they received the active or sham MNS condition, and rate their certainty for that guess on a 0-3 scale (0 = pure guess, 3 = certain). The number reported here is the number of visits for which the participant guessed correctly (active vs. sham MNS).
Time frame: 5-25 minutes after the end of stimulation at each study visit up to 1 month
Participants were recruited through clinical referrals, referrals from the University of Nottingham research team, advertising and word of mouth. Recruitment began in June, 2021, with the first subject enrolled in July, 2021. Study completion was in April, 2022.
| Milestone | Experimental: Rhythmic MNS, Then Arrhythmic MNS | Experimental: Arrhythmic MNS, Then Rhythmic MNS |
|---|---|---|
| Started | 16 | 16 |
| Completed study visit 1 | 16 | 16 |
| Completed study visit 2 | 16 | 16 |
| Completed | 16 | 16 |
| Not completed | 0 | 0 |
The number of tics per minute is assessed by an expert rater blind to condition and time point. Mean tic frequency was compared in on vs. off 1-minute stimulation epochs on the rhythmic MNS day. This analysis replicates that of Study 3 in the Morera Maiquez et al 2020 citation, who reported tics in the last 40 seconds of the block to minimize carryover effects. A Mixed Models Analysis was used to test statistical significance; it included a factor for possible within-day carryover effect and used a logarithmic transformation for tic count. Data reported here have been back-transformed to the number of tics in the last 40 s of the stimulation blocks.
| Tic frequency (number of tics in 40 s) | All Participants |
|---|---|
| Stimulation Off | 12.1 (9.3 to 15.8) |
| Stimulation On | 8.9 (6.6 to 11.8) |
Severity is rated on a 5-point scale for each occurrence of any tic. The scale is the Intensity item from the Yale Global Tic Severity Scale \[YGTSS\], which uses integer scores from 0 (no tics) to 5 (severe intensity). Mean tic severity was compared in on vs. off 1-minute stimulation epochs on the rhythmic MNS day. This analysis replicates that of Study 3 in the Morera Maiquez et al 2020 citation.
| units on a scale | All Participants |
|---|---|
| Stimulation Off | 2.5 (2.2 to 2.7) |
| Stimulation On | 2.3 (2.0 to 2.6) |
The number of tics per minute is assessed by an expert rater blind to condition and time point. Change in tic frequency from baseline (stimulation off) is compared between 5-minute MNS-on epochs on the rhythmic vs. the arrhythmic day. Subjects who do not complete both stimulation visits will not be included in this analysis. The hypothesized change is greater improvement (off to on) with rhythmic vs. arrhythmic stimulation. This analysis includes the first six 5-minute blocks on each MNS day (i.e., the blocks that all participants complete). MNS was administered throughout blocks 6 and 8 only. Tic frequency in block 0 (baseline, before any stimulation) on the same day was a covariate in the statistical model.
| Tic frequency (number of tics in 5 min.) | All Participants |
|---|---|
| Arrhythmic Block 5 | 85.8 (69.2 to 102.4) |
| Arrhythmic Block 6 | 63.3 (46.5 to 80.2) |
| Arrhythmic Block 7 | 74.2 (57.3 to 91.2) |
| Arrhythmic Block 8 | 57.7 (40.8 to 74.5) |
| Arrhythmic Block 9 | 65.0 (48.4 to 81.6) |
| Rhythmic Block 5 | 85.9 (69.7 to 102.1) |
| Rhythmic Block 6 | 61.8 (45.4 to 78.2) |
| Rhythmic Block 7 | 67.5 (51.0 to 83.9) |
| Rhythmic Block 8 | 57.6 (41.2 to 74.0) |
| Rhythmic Block 9 | 68.4 (52.2 to 84.7) |
Overall tic severity for each 5-minute block is rated once on a 5-point scale by an expert blind to condition and time point. The scale is the Intensity item from the Yale Global Tic Severity Scale \[YGTSS\], which uses integer scores from 0 (no tics) to 5 (severe intensity). Change in tic severity from baseline (stimulation off) is compared between 5-minute MNS-on epochs on the rhythmic vs. the arrhythmic day. Subjects who do not complete both stimulation visits will not be included in this analysis. The hypothesized change was greater improvement (off to on) with rhythmic vs. arrhythmic stimulation. This analysis includes the first six 5-minute blocks on each MNS day (i.e., the blocks that all participants complete). MNS was administered throughout blocks 6 and 8 only. Tic frequency in block 0 (baseline, before any stimulation) on the same day was a covariate in the statistical model.
| units on a scale | All Participants |
|---|---|
| Arrhythmic Block 5 | 3.4 (3.1 to 3.6) |
| Arrhythmic Block 6 | 3.2 (2.9 to 3.5) |
| Arrhythmic Block 7 | 3.4 (3.1 to 3.6) |
| Arrhythmic Block 8 | 3.0 (2.7 to 3.3) |
| Arrhythmic Block 9 | 3.1 (2.8 to 3.3) |
| Rhythmic Block 5 | 3.3 (3.0 to 3.6) |
| Rhythmic Block 6 | 3.2 (2.9 to 3.4) |
| Rhythmic Block 7 | 3.2 (2.9 to 3.5) |
| Rhythmic Block 8 | 3.1 (2.8 to 3.3) |
| Rhythmic Block 9 | 3.1 (2.8 to 3.3) |
We compared the change in tic frequency from baseline, during each 1-minute-long period following the end of stimulation. Here baseline means the tic frequency during the last 5 minutes of MNS from the same day (block 8). Last observation carried forward was used for participants who had less than 20 minutes of data following block 8.
| Tic frequency (tics per minute) | All Participants |
|---|---|
| Final Block Of Stimulation, rhythmic days | 7.1 (3.95 to 12.4) |
| 20 minutes after stimulation, rhythmic days | 12 (5 to 17.75) |
| Final Block Of Stimulation, arrhythmic days | 8 (3.7 to 18.7) |
| 20 minutes after stimulation, arrhythmic days | 10 (5 to 22) |
Clinical Global Impression of Improvement (CGI-I), rated by participant. The CGI-I is a 7-point scale ranging from 1 = very much improved to 7 = very much worse.
| units on a scale | All Participants |
|---|---|
| Rhythmic Day | 2.69 ± 1.03 |
| Arrhythmic Day | 2.39 ± 0.99 |
Clinical Global Impression of Improvement (CGI-I), rated by investigator. The CGI-I is a 7-point scale ranging from 1 = very much improved to 7 = very much worse.
| units on a scale | All Participants |
|---|---|
| Rhythmic Day | 2.41 ± 0.91 |
| Arrhythmic Day | 2.56 ± 1.01 |
Participant rates peak improvement experienced during the visit using the 4-point scale of the CGI (Unchanged or worse; Minimal - Slight improvement that doesn't decrease the overall impact of symptoms\*; Moderate - Decided improvement. Partial remission of symptoms; Marked - Vast improvement. Complete or nearly complete remission of all symptoms). \* = "Minimal" option anchor text slightly edited from original. The number provided is the number of participants who rated each visit as moderate or marked.
| Participants | All Participants |
|---|---|
| Rhythmic Day | 20 |
| Arrhythmic Day | 23 |
Participant rates the maximal severity of any premonitory urges over the preceding minute, from 0=no premonitory urge to 100=maximally uncomfortable premonitory urge, using a Visual Analog Scale.
| units on a scale | All Participants |
|---|---|
| Arrhythmic Block 5 | 50.1 (43.7 to 56.6) |
| Arrhythmic Block 6 | 36.5 (30.0 to 43.1) |
| Arrhythmic Block 7 | 43.0 (36.5 to 49.6) |
| Arrhythmic Block 8 | 32.0 (25.4 to 38.7) |
| Arrhythmic Block 9 | 38.4 (31.9 to 45.0) |
| Rhythmic Block 5 | 50.3 (43.8 to 56.8) |
| Rhythmic Block 6 | 34.1 (27.6 to 40.7) |
| Rhythmic Block 7 | 45.5 (39.0 to 52.1) |
| Rhythmic Block 8 | 32.8 (26.3 to 39.4) |
| Rhythmic Block 9 | 40.5 (34.1 to 47.0) |
Participant rates peak discomfort experienced during the visit using the 4-point scale of the CGI: "Overall, today, how much DISCOMFORT did the stimulation cause? If discomfort is the wrong word, please substitute any negative effects or side effects of stimulation. (No discomfort; Discomfort noticeable, but not severe enough to concern me or to turn it off; Enough discomfort, impairment of functioning or social embarrassment that I would only keep it on if the benefit was considerable; Caused discomfort, impairment of functioning or social embarrassment to a degree that any treatment benefit was not worth leaving it on). The number provided is the number of visits where discomfort is rated as none or minimal.
| Visits | All Participants |
|---|---|
| Rating of Discomfort Using the CGI Efficacy Index (Edited) | 57 |
Participants guess at each study visit whether they received the active or sham MNS condition, and rate their certainty for that guess on a 0-3 scale (0 = pure guess, 3 = certain). The number reported here is the number of visits for which the participant guessed correctly (active vs. sham MNS).
| treatment guess on a given study visit | All Participants |
|---|---|
| Guessed correctly | 30 |
| Guessed incorrectly | 34 |
Collected over From enrollment through final study visit, up to 1 month. Non-serious events are listed at a 0% frequency threshold.
| Group | Deaths | Serious | Other |
|---|---|---|---|
| Experimental: Rhythmic MNS | 0/32 (0%) | 0/32 (0%) | 4/32 (12.5%) |
| Experimental: Arrhythmic MNS | 0/32 (0%) | 0/32 (0%) | 3/32 (9.4%) |
| Event | Experimental: Rhythmic MNS | Experimental: Arrhythmic MNS |
|---|---|---|
| HeadacheNervous system disorders | 1/32 | 0/32 |
| ItchNervous system disorders | 1/32 | 0/32 |
| Age, Continuous(years) | Experimental: Rhythmic MNS, Then Arrhythmic MNS | Experimental: Arrhythmic MNS, Then Rhythmic MNS | Total |
|---|---|---|---|
| Mean | 36.81 ± 16.81 | 31.25 ± 16.16 | 34.03 ± 16.51 |
| Sex: Female, Male(Participants) | Experimental: Rhythmic MNS, Then Arrhythmic MNS | Experimental: Arrhythmic MNS, Then Rhythmic MNS | Total |
|---|---|---|---|
| Female | 4 | 7 | 11 |
| Male | 12 | 9 | 21 |
| Ethnicity (NIH/OMB)(Participants) | Experimental: Rhythmic MNS, Then Arrhythmic MNS | Experimental: Arrhythmic MNS, Then Rhythmic MNS | Total |
|---|---|---|---|
| Hispanic or Latino | 0 | 1 | 1 |
| Not Hispanic or Latino | 16 | 15 | 31 |
| Unknown or Not Reported | 0 | 0 | 0 |
| Race (NIH/OMB)(Participants) | Experimental: Rhythmic MNS, Then Arrhythmic MNS | Experimental: Arrhythmic MNS, Then Rhythmic MNS | Total |
|---|---|---|---|
| American Indian or Alaska Native | 0 | 0 | 0 |
| Asian | 1 | 0 | 1 |
| Native Hawaiian or Other Pacific Islander | 0 | 0 | 0 |
| Black or African American | 0 | 1 | 1 |
| White | 15 | 14 | 29 |
| More than one race | 0 | 1 | 1 |
| Unknown or Not Reported | 0 | 0 | 0 |
| Region of Enrollment(participants) | Experimental: Rhythmic MNS, Then Arrhythmic MNS | Experimental: Arrhythmic MNS, Then Rhythmic MNS | Total |
|---|---|---|---|
| United States | 16 | 16 | 32 |
PDFs hosted by the registry, ClinicalTrials.gov.
Plan to share: Yes — Video recordings will not be shared, as they cannot feasibly be de-identified. All other individual participant data (excluding PHI) will be collected and stored on REDCap (redcap.wustl.edu) and will be shared on the Open Science Framework (OSF, at https://osf.io/mtbzf/).
Supporting information: Study protocol, Statistical analysis plan, Informed consent form
Time frame: The study protocol is available now (https://osf.io/mtbzf/). Statistical Analysis Plan (SAP) will be available before enrolling the first participant.
Access criteria: Individual participant data (IPD) will be freely available under a CC0 license (Creative Commons public domain dedication, https://creativecommons.org/publicdomain/zero/1.0/).
Data sharing details ↗ · osf.io
This study is completed, as verified in Sep 2023. You cannot join it, but the record below documents what was studied.
Get an email when the registry record changes — status, dates, results — or when someone posts here.
Sign in to followQuestions and observations about this study, from anyone following it. Not medical advice, and not a channel to the study team — their contact details are on the registry record.
Sign in to join the discussion. Reading takes no account; posting does. You choose a display name, and a pseudonym is the default.
Nothing here yet. If you are running this trial, taking part in it, or weighing whether to, this is the place to say so.
Washington University School of Medicine →