CINXE.COM

<!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: '92b22126db4b5fff',cH: '2ZeMH0xnmUFhhP.EIz.p6xTAL88xUZTvgiYVVoF1qM0-1743783588-1.2.1.1-_mg5fwWiiMF2rKM6Uhsx0GqRv.y_gh6emiwaM_fRGwdVMR1YKvKBEZDhUs52vkGh',cUPMDTk: "\/?__cf_chl_tk=reierZEbWnSrTklknlxTFO2Nhqfd6Nb2rOqnt2CiCMk-1743783588-1.0.1.1-70rn3FgoltCXx3Xdf_DbBgo3pulrGbYS7ibjH8A0Yiw",cFPWv: 'g',cITimeS: '1743783588',cTTimeMs: '1000',cMTimeMs: '390000',cTplC: 0,cTplV: 5,cTplB: 'cf',cK: "",fa: "\/?__cf_chl_f_tk=reierZEbWnSrTklknlxTFO2Nhqfd6Nb2rOqnt2CiCMk-1743783588-1.0.1.1-70rn3FgoltCXx3Xdf_DbBgo3pulrGbYS7ibjH8A0Yiw",md: "iRbFtFzStcp3kdSZvF1I99KXEdDjYhzG0kBH_6J1Eo4-1743783588-1.2.1.1-r3ZQ5ckLaMv1xc4Vv5_XsGGhhCVP4AWK4lG66aK58zGaA6o5fHpQ0hTzaIDX6v6XIZEUftTSGtexrFcf06Au8wGmTnYPu_uGMiyUM3GegJ50WOvaypwbJ.10wnW1EynlpVFf6ExdPl7ltgOganZZeqUs9AF4rizkObIG0xpfYhBqiX.pJWcQvv46ZxyB8lCcSL7RrgezSYG_3dExwdRJa.RWvoB1KmtsXKlwxyYBsAIcS7mOuqfhapLTqUcuVm6pZVurLZYU5uUuVoBdklFK4JMcR6VGumzyvfWPh7NuRxBwetUn9PD7FunbgFQGKLWIJmDxrT4VhJZNKy5Vcoe8hBG06ld4kfpgVYpuldxWzkcMBLPp1CP4Mign47p8iSQyR4Dr_v0dBZ_Gkl.Y7Rl1TupkmR5VLJyOpIQoFBvDxqr6epa_iJ2JiykTDNGCzHbfdyHP_N_jIRVzBYC0FocFaQ6qNT5ehzNInuzm9bGBYNiSyn1nVuWdoXY4CaexDBxbE5Em3tni2OzJn_6T.Owkpa0GmwS5WQz84ecBhufLArR_USbx2pyY3JYAuOAeqfK4AzplMhH1hhNS80vIKbQNu_NDPYtx1IoRgFCgowUHtxT3ICiMyb8C...3pcMhTtGVKW8yySxTn3A8hCr6gRpUZrCBDgrHJ_Xrg.geLf2nUjj4r2YxZ_EMJ3nIBfR7N_i.0udaCT6Nq6QMcp1gEwfcTepVYBvxDipJBPGMChIC90avPACWvWmMk0eY_hsR0qpbHzv_FPNC0bm1iFcWXLJhh4eBxWMMCElBj05lXwtrqFFDv_mGxquCM.IWVhlnMCbrnSmO.0Vhg303Ai1CmAclJGrVqCcMqMQYPpQxGEbFy5xZ26tnoFJgSWBxY2FHB00r0o9hrkQcXjKOBD2IxEtrIiNS2jNr7zawZ2J4ZX3RQjS752T8kNV73QRbxmypzZwBJgPL9sigjMhHfQntNAgh3DInVjwOGJ4fGaQDGZJZLoxRYrxrzsv1XkZ3YmOc4OnbuxnumLXj8CzgjTYW2cltIzUYLX5df.BAXkR98Gq_dAmODopMZyk5ltTdOPthm.LIqv7Tf52CGZrRGLfqSUGqcpt_9NDJtp3XALAKjV1Ln3NOvaHfQ7QloDF1CbJ8PiSsCGkOK2ppibKd6GDe7offsHn657sf6R2Ep0HsSkWXtwXHo8HgLzQgK_93mmn0Tdks",mdrd: "YWENOReatVSovgiPQ0_YDDxQ9dnA0JkL4KXaeZVfQSU-1743783588-1.2.1.1-zzfPTrkjx8r.RFzFkJu8YVXQGWQ7jF9SmXCS9vyYSqYQpmfWzk5VCxCzADa3bnjmgEEaELILiv9NQoxfVYUVRDr_vpUdRgkyEufM2pGGgqF8cBPGutSTODRM1YJ.ERHm115RUxJjcB4PnfXwOXRIjNYaQ.pYnZjzO_m4o2CfLD9NbTwNi_EpUZyxCwhjb2nXptPvkRphkeqa8OvjZVDnSno8EGue5vlM7MNY8f0ECWWExwqr3luw5ZtBBHVHYDhjWB5q3vPrhM5gs_Cn0R6OvbScv_dgCAiaSwtXv2P3PJv4TKQZFEgakmdb.TTbWi7HMBd36QJWQ78JZ8N8n1DiEPvwctxlPf07OEj4w3M0NUfDP.2N64QnOcRFqCrkNz9YCraLvs.xs3MgUZhyEaKKwCgwkykMvXuQyqbZT7qOLfBafNauEC2IETsyFq0gwrJVasQMI8BCQ2WK8Pv3gURrDQ10y0pZNmnzB850m991IgpOPTCvIvR1N93oZXlnHeq6XQhyIYHZ.iE2m4c7zJ.yPqCHtzw.j5SigjnuhMHCtQjqf2D_UTUZ5rwXkAwEglHZskKQkxhkuYFI_qZHQx8njkj3Xgm.dSdWuoTjTDqcwt1OKPUoxi7gjoGyFw4VPtt_Oy.MiEPCA.5SUbwQiiWsvDWGyWKKfY.4nTqmGSaSvMsNcO2FuSZ2_b7Tl89Vj5SzfTa1PKwWECAgdYM0IpvNZPnTyv6reLyEOkqOTA5qn.cgGP8v6dqR9Mp_2t13bnQgg1Q0V2v0Abpz1UmAVkmqeX5dmxtE75VWgvj9AAOGmvkakaQ77oTuSSIwEsrWFuvvdKU_ZNqtdFq0TpGQksKoUCsCWO7HwzQHxk6ttUMGeocLbyefz_VHFs7tE0wCK1M9wWDLQkscpqhkByZwN2XIv8JvaoNDnff4RztWvwI5cSjvHdETqoSFlcQFYwg6SVG_malFxTef_L9HM9vhWUV8rL3Ej4vHfPaY6SBbSlyJhJ0mYN66nBZaLqONcFAh7rKUqtVEvxW793gBn1LcjpwplCm2jm7wso6lQN5k0CWm3.Z5tk8HHSz06Jl2zzzJ8zPiHrn7wZMaYuMcRAljhkUTnL1Pcq87H6khmwayNBHFDVWLctf27QuWktmSghoh62HF33y8hmsFLb..0k06EySsh2B.XR3msHD_FxgR1vbhut3eZN4CJitNGGv4PrHvgCshOJAJpUToNLNKh2VUO2XYUwk8ifSUR2BFh2YQPaQcevJboKs2wWSEqhuLnsHpWvBKSiGhO_lg46spN4e8ZfmGS71nALl.zuOVC4ehADzAZzvY8xSJWGRu1cFozFU1aKZ.R.FvnXOAxSj7ntmSv9wVJdY_tKuPDZM8hYfIO0ND5F2PEfoYM1.nc_HUCP8IM1PgwRVE8adz4SrcP7FPJCB7Vousoc45sGejSokz9kxx_7NVTZSHRFk2OjHAKujlpLAUAiC.0HEurb3XMgJy0Z8vqXHLZAGD3RMFNfphWQZIrQS0pZU00NpBQAah0hPKsidHKEN87VPzf9VYwFkdtl5GukrIq3o41esxRkk67.m50OEN8Kd4TabSr0ZAFcTvM8pAXWtbMqlqMiEsB6pmKzeIZuX_izyoF0SwRJ.LuQ4bGsXN91HCk8zkeFIe1IyZNx_nK5.BCJoqhiLxAeqk2npDKyxe0vmIgNyZcTr6W2IgPX.VXJ7B_JLOXthVNofVmgYNImSAiVzvPKsfV41lIJI2RS_O4Sl2RL623c7HagI0CN512Aqp.W7nggUmtVhePBT2Cu3VHtO7O.CDMSDazrY.M8QBKStSOst1O4UdSodauzlPh.GAqyPSnq5K2cALpAgMfAGqnXU2v6d2h__oLkELM7rf_G9bQPAFWFWZ2QJwCeBgLqu.CqihweRG0nCV7eCpXTQvkS2ulPCv5keV3t5Tf.PE9EQ_RA2CWx2bAlJ3pdjCOEC.3uoOS9NOP83cKNXmyQG3yX6Z.6gH_7HGaQctV8YwbMX4J8FiZ1lytvB6nsMB.RcOEFwkuleY9Yx1eQzprR6_0O5NFHffWaUDnBgwmA"};var cpo = document.createElement('script');cpo.src = '/cdn-cgi/challenge-platform/h/g/orchestrate/chl_page/v1?ray=92b22126db4b5fff';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=reierZEbWnSrTklknlxTFO2Nhqfd6Nb2rOqnt2CiCMk-1743783588-1.0.1.1-70rn3FgoltCXx3Xdf_DbBgo3pulrGbYS7ibjH8A0Yiw" + window._cf_chl_opt.cOgUHash);cpo.onload = function() {history.replaceState(null, null, ogU);}}document.getElementsByTagName('head')[0].appendChild(cpo);}());</script></body></html>