CINXE.COM

Just a moment...

<!DOCTYPE html><html lang="en-US"><head><title>Just a moment...</title><meta http-equiv="Content-Type" content="text/html; charset=UTF-8"><meta http-equiv="X-UA-Compatible" content="IE=Edge"><meta name="robots" content="noindex,nofollow"><meta name="viewport" content="width=device-width,initial-scale=1"><style>*{box-sizing:border-box;margin:0;padding:0}html{line-height:1.15;-webkit-text-size-adjust:100%;color:#313131;font-family:system-ui,-apple-system,BlinkMacSystemFont,Segoe UI,Roboto,Helvetica Neue,Arial,Noto Sans,sans-serif,Apple Color Emoji,Segoe UI Emoji,Segoe UI Symbol,Noto Color Emoji}body{display:flex;flex-direction:column;height:100vh;min-height:100vh}.main-content{margin:8rem auto;max-width:60rem;padding-left:1.5rem}@media (width <= 720px){.main-content{margin-top:4rem}}.h2{font-size:1.5rem;font-weight:500;line-height:2.25rem}@media (width <= 720px){.h2{font-size:1.25rem;line-height:1.5rem}}#challenge-error-text{background-image:url(data:image/svg+xml;base64,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);background-repeat:no-repeat;background-size:contain;padding-left:34px}@media (prefers-color-scheme:dark){body{background-color:#222;color:#d9d9d9}}</style><meta http-equiv="refresh" content="390"></head><body class="no-js"><div class="main-wrapper" role="main"><div class="main-content"><noscript><div class="h2"><span id="challenge-error-text">Enable JavaScript and cookies to continue</span></div></noscript></div></div><script>(function(){window._cf_chl_opt={cvId: '3',cZone: "jamanetwork.com",cType: 'managed',cRay: '92b221225cb6fda3',cH: 'dnSz1sGN6hQY3..F4FSM0Sk3NJwXkdII869HbrSFt7o-1743783588-1.2.1.1-QNjBt_JV7K7NCgPOJTausQJmE.qwX8CcCZohguK349iyPE.eyx9QxXatUxPJmXAt',cUPMDTk: "\/?__cf_chl_tk=jy2kFa.sqdEhzwSuUVQxUYKhBj4ANWbNqEl2ivlxBWY-1743783588-1.0.1.1-UtvymZIy9xV4MiCTRw8Dz1tBKssNSnJAroPHcALtcGs",cFPWv: 'g',cITimeS: '1743783588',cTTimeMs: '1000',cMTimeMs: '390000',cTplC: 0,cTplV: 5,cTplB: 'cf',cK: "",fa: "\/?__cf_chl_f_tk=jy2kFa.sqdEhzwSuUVQxUYKhBj4ANWbNqEl2ivlxBWY-1743783588-1.0.1.1-UtvymZIy9xV4MiCTRw8Dz1tBKssNSnJAroPHcALtcGs",md: "0ziD62xenbFWaqLMJygH513Re_7Zua..iRMXgnLdTUQ-1743783588-1.2.1.1-tJhEwlZo29jzCyqHKbT7elf.Vrih_pXJQRJEhgZEJ1AUD1NJakg1Kg9ps675diLbBs4p9UDu9dnu5SIRp52ZEq9MvbqQw7k.lfBVIw7LCKfvoZ_.jpZ3P84EgkA.JnfJp27KMjyqh9dV1INf9fA04eyEn_WKQb7.6337Plh8Xn4nQ_qVb259FiRqAhA5KDyKIb5D7DCHxGsbNRw6mVzVXVZS6X7g9fZHrS2oaruiReeP0GPTu1EITQb3ua6bX0YPF_iWXGMV6tgLVXTSKtS.AZyTVsipk5N0PUv5Y_j1rMejzaOCbvyPt6jBlfYUQp9aMsjZWD1edVF1kHQVGeiCM.X9l4GnZ55_4TnGRQp5z44SYIzsMr3KWnVnByZy8OdK0VEy2jjNBRpOon6UPDxBle0iVCDUzAtRZT9qJGAXUGa8fqeuW6gb805xZGXPl0F4tuXikm7knEqhvB8MxCT0kUDXqvvQW70eX0E2BYKHny00t5gYsxf3JI4ZBGs5K192XYDj5JuSiz7b8G_oi83BACI__nbRONpxSbAjGVt_NBYbP2muJG6Iu4L.w8Oa3Sg80msH8MEVDU0hQIZoU4lmgwF.E5eN1dN98pPSt1GiMR2tshmH7qmqbeW.jCtc0Yqs6ql8QCZ2WkagNjcMkJIJypVIuBInqfu2mCsKf7VSe4J5LHEE8bfa10m1_ISQJRwL5DG9DuzTov7hTBhaqmlkqKumLFUNTLOb9Wi2lWLLyqlfczhddgNRleN2q_MWieCmGfIMTRqVwBaAc6nf__0bUl7AhZo7LJxMTqnNjL4y6eRmFNpyuymBiTeE8DGrJ69CWUHccv2llnDJlRmhdKGjvKlLPeyN2SE1JgDK1y2DT.ZStTnOnREtFuByO9rFR_aBlyeLi1o5lZIt2oY4it7NNJWn7YpZNJ7m4TKc7FyXBlIpODh3SlypT6bX1MKs5r5zFOR_DKgiC3bRwhXNTnwVSnjCrU01YLGj2arf4zw4ZuztnCJYb7q.07PTfDTeJ7NA2qV_iAKGcbH7OMCa_jp69x8d8hDYgbiT3XUtL7GkBo49ugHYLrLbA7dTQQ9vlKDg7at9vO55qPq8T33yuA.VVpPOqBSGAgltQsgFxxB_kaHItlArQQtkbQnQxSap5f7APr3on6JQs984SIPR0TOTkUmvlUiOeadXK9fV2Hzr7fjtgvUc9NBpLmw0jIgH4Qcd",mdrd: "o9KkuoRkfDZRKzOYKL5WSpv9ArB7jhP.xae_Nvw.0do-1743783588-1.2.1.1-0aReqV94CzwWfQL0vREU4SsjD3YH9Bk4zdjv8qBoOTnRNCfoFVGDyh21mD7CCBnxF6_X._.BE7w9Icquag_dcwDVfL3o8ls1IwlhHqTz..JfACuogKnTrHW9vi_B_HxH_UnRgvwhnQEOxeCDJoHgSFNNZ6XZG6QB9lyHfB.hLlovD74Z96HskgqjE8ix1gdsYBGJ7OY4127I3a5Vfzysqp97G.oydFhlXsXMWb.msnTpZWM9Iffeb4qp3yFAAwHCT_wRcbtZkrAqb7wVnpr8E1.gKVlNhGG_rjPtcuTvBMc8dX2xim9m5XT060GXb6yJxBePmgZK4_AHXCU1bdrbiuzlolI.iTRrcufLRCh9M_V9_2fwopnZrACzEM8KBahwUpmbvT3YaVRUPaSpkwhCdJ2ja3mX67AWSD7q5phDS8rdbwYT0yZ7eOLB3quDGxNaIyfEVrFmNnnkH.Ve2yfRU27olqvftmpKuqnh4akNSLBRTMWfpzzlNwbHSfNlQQW1Jp7G8Z.mzxCOS.KwA9O4ZjAkl2_wkzvBSwY7DUexYNqsnMyG0_8aDBuR9rG1sKS7h.mDJRtrBPR6868R7Onort_CxhVRk34x.CVGLVy0971hg1J7NnOiXxAL4qkobAUizReyJH1LWKCAqlSN3drmir04Zi1kL4Hn2Qt5Um4Q9oCYYrQsREd9bdg3GPw48taVnTRleoQyQWLLqpi00_kIjABWtRKywTvfe_au.9UeymvDgOQwZF5K5155RkIiMbGo77WvesrACzG.1vLTIG31oY5v9xyz1hpx9DaBe5PCrP9dGPE8DBLKkbkkI1RmTqnvYU.514myjmYh8WJtE7R2KK1EWi7HLRisFQIXqMg.HvAtv8VTJeAebM6Y6yeosNGzY1S6gLjSLNJnGWFNwvjExYjzBi9bTN1CpICF3kg6_H1C7RVtvwj1tisKmC0brOLY2hX6nh3xy1DekZVKY2wKIIcK_.iRL1o0M0n34qM1YtXXs01LZ_r9o71E5j6hmGczg4d2pAiN3GCiE0FPTnZDoagSJWCwfYgZaLxGYNIn1J5qDem59Z3_HIpZ3BFbWb4YrNpzKOOGN3E.ZmVhsrUJFjlhhf3oomXgaSUjKyjgPZFI13CriUjD7DC.WcqL46ADldvBqxSrNdJbyzfoF.Ua7yaEPrz9DkI4I9qZipd2cKSD_bRxv6zRap5Z_yqr91ZWYnSTwmRX30as7ud_8VpLA5viY00I6g8NF3RdjvWTs8KZv_JVmzigRYNXt4Vgl.A4RgvfMrPX9O4H_tmQf1nNzCdLqMq7YnztW3hPj2RDhdS8WE7eMLaSD6IuY9q8msfg0q11czaXxHoLkji6CBfgVPSLtUQYxgdrtFI5Xcnoj0SgGg4OPZ81H7VGcWxHGXgcrbKdO5jMdlya1d3_w4lfsxtHtec1TzznaAd3SMimamVI24WO9kugPY4g1TcYKz4fxgf9lf9oWXOFiOVnbj6wfaazHwqxskTUpoQqyWetW_bevo.7pNP7HeYPZ4WRx_bDkB.USyAUfUbzD4HRj0woKnO7BmV.rvyq6mqWTGp2tKzWKOYnbvtSnxE8D2iMTT8nyhlrA7ksa5duOak38.fKCs075CSRJvKysBVyO3dJYliHakheozeaX2wB1njgkaC.MKd_AsWDIFw6MEFs2kdkP5_tF8PqhmN.jOxBcQPl0RZFK85xvrFy1HL4wZMJ2ktQGawnzAKujwEjmGul5dS4lB6pLyvEw.R3fcRwBMxkQ03ir022psmrz95JlQ3dSkEuRPsiRDPg03lkkC9sd5.w9MZGS4KF4POlYBwQATZQ6sEYrEitFovvMlT9m9nnT3sszlvDdnbzo_9AFti9DR8wNAHs51hwiDdnTCsMGmJPsh_4wxOArIxR0Ezden7dgjisJw01hdV0Z0D4K9TS0.caJrVl7T9vrO0nlzWWw49J4looXrd9rI.de6ZzxMDYoZ8olRCqxifFA0tiwe2Q2LnGS9_rgO8tWrm7jE48nyzB0AaEEfU2eFVYICjJKXXGUzWPuKUyuyTZLSCJoiSwv5wfaQ"};var cpo = document.createElement('script');cpo.src = '/cdn-cgi/challenge-platform/h/g/orchestrate/chl_page/v1?ray=92b221225cb6fda3';window._cf_chl_opt.cOgUHash = location.hash === '' && location.href.indexOf('#') !== -1 ? '#' : location.hash;window._cf_chl_opt.cOgUQuery = location.search === '' && location.href.slice(0, location.href.length - window._cf_chl_opt.cOgUHash.length).indexOf('?') !== -1 ? '?' : location.search;if (window.history && window.history.replaceState) {var ogU = location.pathname + window._cf_chl_opt.cOgUQuery + window._cf_chl_opt.cOgUHash;history.replaceState(null, null, "\/?__cf_chl_rt_tk=jy2kFa.sqdEhzwSuUVQxUYKhBj4ANWbNqEl2ivlxBWY-1743783588-1.0.1.1-UtvymZIy9xV4MiCTRw8Dz1tBKssNSnJAroPHcALtcGs" + window._cf_chl_opt.cOgUHash);cpo.onload = function() {history.replaceState(null, null, ogU);}}document.getElementsByTagName('head')[0].appendChild(cpo);}());</script></body></html>