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Active, Not Recruiting

NCT Number: NCT03655223

Early Check: Expanded Screening in Newborns

Early Check provides voluntary screening of newborns for a selected panel of conditions. The study has three main objectives: 1) develop and implement an approach to identify affected infants, 2) address the impact on infants and families who screen positive, and 3) evaluate the Early Check program. The Early Check screening will lead to earlier identification of newborns with rare health conditions in addition to providing important data on the implementation of this model program. Early diagnosis may result in health and development benefits for the newborns. Infants who have newborn screening in North Carolina will be eligible to participate, equating to over 120,000 eligible infants a year. Over 95% of participants are expected to screen negative. Newborns who screen positive and their parents are invited to additional research activities and services. Parents can enroll eligible newborns on the Early Check electronic Research Portal. Screening tests are conducted on residual blood from existing newborn screening dried blood spots. Confirmatory testing is provided free-of-charge for infants who screen positive, and carrier testing is provided to mothers of infants with fragile X. Affected newborns have a physical and developmental evaluation. Their parents have genetic counseling and are invited to participate in surveys and interviews. Ongoing evaluation of the program includes additional parent interviews.

Active, Not Recruiting

This study is active but is not currently recruiting participants.

Key information

Conditions

Spinal Muscular Atrophy 17 Alpha-Hydroxylase Deficiency 3-Hydroxy-3-Methylglutaric Aciduria 3-Hydroxy-3-Methylglutaryl-CoA Lyase Deficiency 3-Hydroxyacyl-CoA Dehydrogenase Deficiency 3-Methylcrotonyl CoA Carboxylase 1 Deficiency 3-Methylcrotonyl CoA Carboxylase 2 Deficiency 3-Phosphoglycerate Dehydrogenase Deficiency Abnormalities, Multiple Acidemia, isovaleric Acrodermatitis Enteropathica Adenine Phosphoribosyltransferase Deficiency Adrenal hyperplasia, congenital, type 5 Adrenocorticotropic Hormone Deficiency Adrenoleukodystrophy, Neonatal Agat Deficiency Albinism Albinism, Oculocutaneous Alport Syndrome, Autosomal Recessive Alport Syndrome, X-Linked Amaurosis congenita of Leber, type 2 Amino Acid Metabolism, Inborn Errors Anemia Anemia, Hemolytic Anemia, Hemolytic, Congenital Anemia, Sickle Cell Angelman Syndrome Aortic Stenosis, Supravalvular Aortic Valve Disease Aortic Valve Stenosis Apparent Mineralocorticoid Excess Arginine-Glycine Amidinotransferase Deficiency Argininosuccinic Aciduria Arrhythmias, Cardiac Ataxia With Isolated Vitamin E Deficiency Ataxia with vitamin E deficiency Autosomal Recessive Nonsyndromic Hearing Loss Avitaminosis Barth Syndrome Basal Ganglia Diseases Basal ganglia disease, biotin-responsive Beta ketothiolase deficiency Beta-Thalassemia Beta-ketothiolase Deficiency Bile acid synthesis defect, congenital, 2 Biotin-Responsive Basal Ganglia Disease Biotinidase Deficiency Blood Coagulation Disorders Blood Coagulation Disorders, Inherited Blood Platelet Disorders Bone Diseases Bone Diseases, Developmental Bone Diseases, Endocrine Bone Diseases, Metabolic Brain Diseases Brain Diseases, Metabolic Brain Diseases, Metabolic, Inborn Brown-Vialetto-Van Laere syndrome CBAS1 Calcium Metabolism Disorders Canavan Disease Carbamoyl Phosphate Synthetase I Deficiency Disease Carbamoyl-Phosphate Synthase I Deficiency Disease Carbohydrate Metabolism, Inborn Errors Carbonic Anhydrase VA Deficiency Cardiac Conduction System Disease Cardiovascular Abnormalities Cardiovascular Diseases Carnitine Palmitoyl Transferase 1A Deficiency Carnitine Palmitoyltransferase II Deficiency Carnitine palmitoyl transferase 2 deficiency Carnitine-Acylcarnitine Translocase Deficiency CblF Central Hypoventilation Syndrome With or Without Hirschsprung Disease Central Nervous System Diseases Cerebrotendinous Xanthomatoses Cholesterol Ester Storage Disease Choroid Diseases Chromosome Disorders Chronic Disease Chronic Granulomatous Disease Citrullinemia Citrullinemia, Type I Coagulation Protein Disorders Collagen Diseases Combined Immunodeficiency Due to ZAP70 Deficiency Congenital Abnormalities Congenital Bile Acid Synthesis Defect Type 2 Congenital Disorder of Glycosylation Type 1B Congenital Hyperinsulinism Congenital Hypothyroidism Congenital Isolated Thyroid Stimulating Hormone Deficiency Congenital Lipoid Adrenal Hyperplasia Due to STAR Deficiency Congenital, Hereditary, and Neonatal Diseases and Abnormalities Connective Tissue Diseases Creatine Transporter Deficiency Creatine deficiency, X-linked Cystic Fibrosis Cystinosis DIAR1 Deficiency Diseases Demyelinating Diseases Developmental and Epileptic Encephalopathy 2 Diabetes Mellitus Diabetes Mellitus, Permanent Neonatal Diabetes Mellitus, Permanent Neonatal, With Neurologic Features Digestive System Diseases Dihydropteridine Reductase Deficiency Disease Disease Attributes Dravet Syndrome Duchenne Muscular Dystrophy Dwarfism Dyslipidemias Endocrine Gland Neoplasms Endocrine System Diseases Epilepsies, Myoclonic Epilepsy Epilepsy, Early-Onset, Vitamin B6-Dependent Epilepsy, Generalized Epileptic Syndromes Eye Diseases Eye Diseases, Hereditary Eye Neoplasms Factor VII Deficiency Factor X Deficiency Familial Hypophosphatemic Rickets Female Urogenital Diseases Female Urogenital Diseases and Pregnancy Complications Fragile X - Premutation Fragile X Syndrome Fructose 1,6 Bisphosphatase Deficiency Fructose Intolerance Fructose Metabolism, Inborn Errors Fructose-1,6-Diphosphatase Deficiency G6PD Deficiency GSD1C Galactokinase Deficiency Galactosemias Genetic Diseases, Inborn Genetic Diseases, X-Linked Glucose Metabolism Disorders Glucose Transporter Type 1 Deficiency Syndrome Glucosephosphate Dehydrogenase Deficiency Glut1 Deficiency Syndrome Glutaric Acidemia I Glutaryl-CoA Dehydrogenase Deficiency Glutathione Synthetase Deficiency Glycogen Storage Disease Glycogen Storage Disease IB Glycogen Storage Disease IC Glycogen Storage Disease II Glycogen Storage Disease IXB Glycogen Storage Disease IXC Glycogen Storage Disease Type I Glycogen Storage Disease Type IB Glycogen Storage Disease Type II Glycogen Storage Disease Type IXA1 Glycogen Storage Disease, Type IXA2 Granulomatous Disease, Chronic Gtp Cyclohydrolase I Deficiency Guanidinoacetate Methyltransferase Deficiency Gyrate Atrophy HHH syndrome HSDB Hair Diseases Heart Defects, Congenital Heart Diseases Heart Valve Diseases Hematologic Diseases Hemic and Lymphatic Diseases Hemoglobinopathies Hemophilia A Hemophilia B Hemorrhagic Disorders Hepatolenticular Degeneration Hereditary Central Nervous System Demyelinating Diseases Hereditary Fructose Intolerance Hereditary Hypophosphatemic Rickets Heredodegenerative Disorders, Nervous System Hermanski-Pudlak Syndrome Hermansky-Pudlak Syndrome 1 Hermansky-Pudlak Syndrome 4 Histiocytosis Histiocytosis, Non-Langerhans-Cell Holocarboxylase Synthetase Deficiency Homocystinuria Homocystinuria-Megaloblastic Anemia due to Defect in Cobalamin Metabolism, CblE Complementation Type Hyperargininemia Hyperhomocysteinemia Hyperinsulinemic Hypoglycemia, Familial 1 Hyperinsulinemic Hypoglycemia, Familial, 2 Hyperinsulinemic hypoglycemia, familial, 6 Hyperinsulinism Hyperinsulinism-Hyperammonemia Syndrome Hyperparathyroidism, Neonatal Severe Primary Hyperphenylalaninemia, BH4-Deficient, B Hypoglycemia Hypophosphatasia Hypophosphatemia Hypophosphatemia, Familial Hypopigmentation Hypothyroidism Hypothyroidism Due to TSH Receptor Mutations Immune System Diseases Immunologic Deficiency Syndromes Imprinting Disorders Infant, Newborn, Diseases Intellectual Disability Intrinsic Factor Deficiency Isovaleric Acidemia Jervell And Lange-Nielsen Syndrome 2 Jervell and Lange-Nielsen Syndrome 1 Jervell-Lange Nielsen Syndrome Kidney Diseases Krabbe Disease Leber Congenital Amaurosis 2 Leukocyte Disorders Leukodystrophy, Globoid Cell Leukodystrophy, Metachromatic Leukoencephalopathies Liddle Syndrome Lipid Metabolism Disorders Lipid Metabolism, Inborn Errors Lipidoses Liver Diseases Long QT Syndrome Long-chain 3-hydroxyacyl-CoA Dehydrogenase Deficiency Lung Diseases Lymphatic Diseases Lysosomal Acid Lipase Deficiency Lysosomal Storage Diseases Lysosomal Storage Diseases, Nervous System MAHCD MOWS Male Urogenital Diseases Malnutrition Maple Syrup Urine Disease, Type 1A Maple Syrup Urine Disease, Type 1B Maple Syrup Urine Disease, Type 2 Maturity-Onset Diabetes of the Young, Type 4 Medium chain acyl CoA dehydrogenase deficiency Medium-chain Acyl-CoA Dehydrogenase Deficiency Menkes Disease Menkes Kinky Hair Syndrome Mental Disorders Metabolic Diseases Metabolism, Inborn Errors Metachromatic Leukodystrophy Metal Metabolism, Inborn Errors Methylcobalamin Deficiency Type Cbl G (Disorder) Methylcobalamin Deficiency Type cblE Methylenetetrahydrofolate reductase deficiency Methylmalonic Aciduria Due to Methylmalonyl-CoA Mutase Deficiency Methylmalonic Aciduria and Homocystinuria Type cblC Methylmalonic Aciduria cblA Type Methylmalonic Aciduria cblB Type Methylmalonic acidemia with homocystinuria Mineralocorticoid Excess Syndrome, Apparent Mitochondrial Diseases Mitochondrial Trifunctional Protein Deficiency Molybdenum Cofactor Deficiency, Complementation Group A Molybdenum Cofactor Deficiency, Type A Motor Neuron Disease Movement Disorders Mthfr Deficiency Mucinoses Mucopolysaccharidoses Mucopolysaccharidosis I Mucopolysaccharidosis II Mucopolysaccharidosis III Mucopolysaccharidosis IV Mucopolysaccharidosis Type 1 Mucopolysaccharidosis Type 2 Mucopolysaccharidosis Type 3 A Mucopolysaccharidosis Type 6 Mucopolysaccharidosis Type 7 Mucopolysaccharidosis Type IV A Mucopolysaccharidosis VI Mucopolysaccharidosis VII Multiple Carboxylase Deficiency Multiple Endocrine Neoplasia Multiple Endocrine Neoplasia Type 2B Muscular Atrophy, Spinal Muscular Diseases Muscular Disorders, Atrophic Muscular Dystrophies Muscular Dystrophy, Duchenne Musculoskeletal Diseases N-acetyl glutamate synthetase deficiency N-acetylglutamate Synthase Deficiency Neonatal Severe Primary Hyperparathyroidism Neoplasms Neoplasms by Histologic Type Neoplasms by Site Neoplasms, Germ Cell and Embryonal Neoplasms, Glandular and Epithelial Neoplasms, Multiple Primary Neoplasms, Nerve Tissue Neoplasms, Neuroepithelial Neoplastic Syndromes, Hereditary Nephritis Nephritis, Hereditary Nervous System Diseases Neurobehavioral Manifestations Neurodegenerative Diseases Neuroectodermal Tumors Neurologic Manifestations Neuromuscular Diseases Niemann-Pick Disease Type A Niemann-Pick Disease Type C2 Niemann-Pick Disease, Type A Niemann-Pick Disease, Type C Niemann-Pick Disease, Type C1 Niemann-Pick Diseases Niemann-Pick disease, type C2 Nutrition Disorders Nutritional and Metabolic Diseases Obesity Ornithine Aminotransferase Deficiency Ornithine Carbamoyltransferase Deficiency Disease Ornithine Transcarbamylase Deficiency Ornithine Translocase Deficiency Overnutrition Overweight PTSD Pancreatic Agenesis 1 Pancreatic Diseases Pathologic Processes Pathological Conditions, Signs and Symptoms Permanent Neonatal Diabetes Mellitus Peroxisomal Disorders Phagocyte Bactericidal Dysfunction Phenylketonurias Phosphorus Metabolism Disorders Pigmentation Disorders Pitt Hopkins Syndrome Pitt-Hopkins syndrome Pituitary Hormone Deficiency, Combined, 1 Platelet Storage Pool Deficiency Prader-Willi Syndrome Primary Hyperoxaluria Type 1 Primary Hyperoxaluria Type 2 Primary Hyperoxaluria Type 3 Primary Immunodeficiency Diseases Propionic Acidemia Pseudohypoaldosteronism Pseudohypoaldosteronism, Type I Pyridoxal Phosphate-Responsive Seizures Pyridoxamine 5-Prime-Phosphate Oxidase Deficiency Pyridoxine-Dependent Epilepsy Renal Tubular Transport, Inborn Errors Respiratory Tract Diseases Retinal Diseases Retinal Neoplasms Retinoblastoma Rett Syndrome Riboflavin Transporter Deficiency Rickets Rickets, Hypophosphatemic SCD SRD Segawa Syndrome, Autosomal Recessive Severe Combined Immunodeficiency Severe Combined Immunodeficiency Due to Adenosine Deaminase Deficiency Severe Combined Immunodeficiency Due to DCLRE1C Deficiency Severe Combined Immunodeficiency Due to IL-7Ralpha Deficiency Severe Combined Immunodeficiency Due to RAG1 Deficiency Severe Combined Immunodeficiency Due to RAG2 Deficiency Severe Combined Immunodeficiency T-Cell Negative B-Cell Positive Due to Janus Kinase-3 Deficiency (Disorder) Severe Combined Immunodeficiency, X Linked Sex Chromosome Disorders Sickle Cell Disease Skin Diseases Skin Diseases, Genetic Skin and Connective Tissue Diseases Smith-Lemli-Opitz Syndrome Sphingolipidoses Spinal Cord Diseases Steroid Metabolism, Inborn Errors Stickler Syndrome Type 1 Stickler Syndrome Type 2 Stickler syndrome, type 1 Stickler syndrome, type 2 Stress Disorders, Post-Traumatic Stress Disorders, Traumatic Sulfatidosis Supravalvar Aortic Stenosis Thalassemia Thyroid Diseases Thyroid Dyshormonogenesis 1 Thyroid Dyshormonogenesis 2A Thyroid Dyshormonogenesis 3 Thyroid Dyshormonogenesis 5 Thyroid Dyshormonogenesis 6 Transcobalamin II Deficiency Transient Neonatal Diabetes Mellitus Trauma and Stressor Related Disorders Trifunctional Protein Deficiency With Myopathy And Neuropathy Tuberous Sclerosis 1 Tuberous Sclerosis 2 Tyrosinemia, Type I Tyrosinemias Urea Cycle Disorders, Inborn Urogenital Abnormalities Urogenital Diseases Urologic Diseases Usher Syndrome Type 1C Usher Syndrome Type 1D/F Digenic (Diagnosis) Usher Syndrome Type 1G (Diagnosis) Usher Syndrome, Type 1B Usher Syndrome, Type 1F Usher syndrome, type 1C Uveal Diseases VLCAD deficiency Ventricular Outflow Obstruction Very Long Chain Acyl Coa Dehydrogenase Deficiency Vitamin D Deficiency Von Willebrand Disease, Type 3 Waardenburg Syndrome Waardenburg Syndrome Type 1 Waardenburg Syndrome Type 2A Waardenburg Syndrome, Type 2E Waardenburg syndrome type 2 Wilson Disease Wolman Disease X-Linked Combined Immunodeficiency Diseases X-Linked Intellectual Disability Xanthomatosis Xanthomatosis, Cerebrotendinous von Willebrand Diseases

Age range

1 day–31 day

Sex eligibility

All sexes

Study type

Observational

Primary location

RTI International

Research Triangle Park, North Carolina, 27709, United States

About this study

"Background" Newborn screening (NBS) is a state-based public health program that screens babies for a panel of over 30 conditions. It is estimated that about 12,500 newborns each year in the United States are identified with one of the conditions screened in NBS, with each child receiving the benefit of early treatment. For inclusion in newborn screening there must be evidence that pre-symptomatic treatment is more effective than treatment after clinical presentation. Most conditions proposed for newborn screening are rare, however, and researchers have difficulty identifying sufficient numbers of babies to test the benefits of pre-symptomatic identification and treatment. This lack of data is central to challenges that the U.S. Department of Health and Human Services Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC) faces when making federal recommendations to states on which conditions should be included in newborn screening programs. ACHDNC is often asked to consider conditions for inclusion in newborn screening for which there is limited evidence of the natural history, prevalence, and especially about the benefit of early treatment.

"Rationale" That evidence gap, especially in the rare disease context, makes it important to develop and test a system to efficiently generate high-quality data about conditions that have the potential to be candidates for state newborn screening. The Early Check program will address this gap through screening newborns for a carefully selected panel of conditions, offered under a research protocol with biological maternal permission, except in cases where there is a transfer or loss of custody. In cases with a transfer/loss of custody, a legal guardian can grant permission for the infant to join Early Check. Early Check will identify pre-symptomatic infants with rare disorders, accelerate the acquisition of data on the early natural history of rare disorders, and demonstrate the feasibility of a statewide program to offer voluntary opt-in newborn screening for a panel of conditions not currently included in states' standard newborn screening. Further, Early Check will facilitate the public health 'on-boarding' of conditions that are ultimately recommended for state newborn screening programs.

The initial panel of conditions screened in the Early Check program will change over the course of the study. Previously screened conditions have included spinal muscular dystrophy (SMA), fragile X syndrome (FXS), and Duchenne muscular dystrophy (DMD) and related neuromuscular conditions that result in increased levels of creatine kinase (CK-MM). SMA has an approved treatment, nusinersen, which has been demonstrated to improve outcomes in infants with infantile-onset SMA. In addition, infants with a shorter disease duration compared to a longer disease duration had improved outcomes after the start of treatment with nusinersen, suggesting that earlier identification of SMA would benefit affected infants. There is also an approved gene therapy, Zolgensma, for SMA. FXS does not have an approved treatment, although there is evidence that early behavioral intervention services may improve outcomes. Given that the diagnosis of FXS is made on average after the child is three years old, early identification through the screening of newborns may provide benefit to the child. These conditions are rare; SMA has an estimated incidence of 1 in ~10,000, DMD has an estimated incidence of 1 in 4000-5000 males, and FXS has an estimated incidence of 1 in ~4,000 males and 1 in ~4,000-6,000 females. We also completed a sub-study with a secondary permission process that offers mothers the choice to obtain additional data about the gene that causes FXS: specifically, whether the infant has a premutation in the gene, which has an uncertain impact on the infant's learning and development. This uncertainty is the reason why premutation results are offered separately under a sub-study. DMD causes progressive inflammation, fibrosis, and muscle fiber degradation, and weakness. DMD has traditionally been treated with physical therapy, corticosteroids, and ACE inhibitors to delay the progression of skeletal muscle and cardiac damage. In 2016, the FDA approved Eteplirsen (Exondys, 51) a promising treatment for a subset of patients with DMD. In 2017 the FDA approved Emflaza, a corticosteroid also known as deflazacort. In 2019 the FDA approved Vyondys 53 and in 2020 the FDA approved Viltepso for mutations amenable to exon 53 skipping. Early diagnosis allows for treatments that might work best if used presymptomatically.

The current screening panel includes 182 genes for rare conditions that are highly actionable by age 2. An optional secondary panel includes 32 genes that are less actionable, or for which there are treatments under trial, with an additional optional third panel that screens for genetic risk for Type 1 Diabetes.

For a wide range of rare disorders there is evidence that a delayed diagnosis (i.e., the frequently-described diagnostic odyssey as parents search for a diagnosis) can have negative health outcomes on children who miss out on treatments or interventions and on families who experience negative psychosocial impact

In the future, Early Check will continue to integrate new conditions to the screening platform as science advances and funding is secured, and conditions may be removed from the screening platform as associated research questions are answered and/or conditions achieve inclusion in state newborn screening programs (as was the case with SMA and FXS).

The overall research question is whether Early Check is an effective onboarding program to inform newborn screening policy decision-making.

Early Check will also provide the infrastructure to facilitate translational research studies and clinical trials. A dilemma in research in rare diseases is a lack of sufficient numbers of presymptomatic patients. New treatments are being developed for rare diseases at a rapid pace. Presymptomatic treatment often has the best potential for effective treatment. Currently, early identification and intervention is based on the prenatal or early diagnosis of a sibling of a patient with known disease, which greatly limits the numbers of presymptomatic patients available for trials. Newborn screening has the greatest potential to identify presymptomatic infants. Ultimately the research program should more rapidly advance understanding of diseases and treatments, reducing the length of time for appropriate conditions to be added to the recommended panel for inclusion in state newborn screening programs, and provide early identification of affected newborns.

Overall, this project will provide important information about the success of Early Check to feasibly and acceptably implement a large scale, electronically-mediated research approach to accurately identify affected infants. Results of the research activities and the ongoing quality assessment will be used to inform the most efficient and judicious translation of expanded newborn screening into public health in ways that maximize benefit and minimize potential risk of harm to children and families.

Who can participate

Healthy volunteers accepted: Yes

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

  • Newborn has newborn screening in North Carolina
  • Newborn lives in North Carolina or South Carolina
  • Newborn is less than 31 days old
  • Person giving consent must have legal custody of the newborn. When the mother retains custody, they must be the person to give consent.
  • Person giving consent must be able to interact with the online permission portal (available in English and Spanish) and give permission online

Exclusion criteria

  • A newborn screening (NBS) sample is unavailable for the newborn
  • Insufficient NBS sample remains to conduct the screening

Treatment and study plan

Confirmatory Testing

Diagnostic Test

If a newborn's screening test is positive, an experienced genetic counselor will contact the infant's mother by phone to explain the positive screening result and arrange for confirmatory testing and a follow-up appointment. If the confirmatory test is positive, then the child receives a diagnosis of the disease. Children identified with a disorder are referred for treatment, their parents receive information and counseling on what a positive diagnosis means for their child, and they are offered participation in follow-up and registry activities for the disorder.

Primary outcomes

  1. Incidence Rates: Number of newborns who screen positive comparative to the whole sample

    Time frame: Every 6 months for approximately three years

    Incidence rates of infants who screen positive for conditions on the Early Check panel.

Secondary outcomes

  1. Impact of Screening: Semi-structured parent interviews.

    Time frame: Measured within 6 months of participant screening results

    Each project year, we will recruit mothers whose newborns screen negative and mothers whose newborns screen positive to participate in an approximately 30-minute, semi-structured telephone interview about their perceptions of Early Check and the impact of screening results.

Sponsors and collaborators

Lead sponsor

RTI International

Other

Collaborators

  • Asuragen, Inc.
  • Cure SMA
  • Duke University
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
  • GeneDx
  • Illumina, Inc.
  • Janssen Pharmaceuticals
  • Juvenile Diabetes Research Foundation
  • Muscular Dystrophy Association
  • National Center for Advancing Translational Sciences (NCATS)
  • North Carolina Department of Health and Human Services
  • Sarepta Therapeutics, Inc.
  • The John Merck Fund
  • The Leona M. and Harry B. Helmsley Charitable Trust
  • The National Fragile X Foundation
  • University of North Carolina, Chapel Hill
  • Wake Forest University

Registry information

Official study title

Early Check: A Collaborative Innovation to Facilitate Pre-Symptomatic Clinical Trials in Newborns

Important dates

Study start
2018
Primary completion
2026
Study completion
2026
First posted
Aug 31, 2018
Registry last updated
Jul 1, 2026

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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