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: '92a6ee1bb8a0fe0c',cH: '7.fCLYBryj7cUCTdCxlCSXePm4PqoQ6D69Rqy9pT95w-1743666154-1.2.1.1-PHnkBT5SGU123VjclZ_FMm6G3LoAGYqsJr3s6E0qzqfylZsxwsRS6dGcrlvziOPL',cUPMDTk: "\/?__cf_chl_tk=7Jvw0bt0Bi2cLRSGwgwdNoqIdoyYWyYmGbKD7h.w8vU-1743666154-1.0.1.1-Tk.4gozLQO9jYClJw80ajzH69t7KDj_AZ9Y6gFFYnjg",cFPWv: 'g',cITimeS: '1743666154',cTTimeMs: '1000',cMTimeMs: '390000',cTplC: 0,cTplV: 5,cTplB: 'cf',cK: "",fa: "\/?__cf_chl_f_tk=7Jvw0bt0Bi2cLRSGwgwdNoqIdoyYWyYmGbKD7h.w8vU-1743666154-1.0.1.1-Tk.4gozLQO9jYClJw80ajzH69t7KDj_AZ9Y6gFFYnjg",md: "x5ZUJ.hBgGO572u7J7Penr5fm1wURplThrsu23cxyz4-1743666154-1.2.1.1-vLI_hbeODQx0eYkeJC7PRLnmM35.Q8ac_wu0N_VUrrQJnP7bmTSFDwrajq8lkQjtSaXb5_qgeOXofsTqIYu82mybeN_5d0FRu5PZE.UfmJ1AEsWKbshG9a9mRXnceA5qyQ7sNo1OyHMtHLKdxLysISI_0cqoNl1l20qiBFbbMfqSM8439hbirTSy5PXs6c4mbzd.hS.OQYmYdJny_fDJ59sWYySQ5TawjpFQcEkYtjQKgt8AraXTih2TiuYlj1ocSIBhYHgjwZ0VqTcVaxlWrMQv5rsHVBP1OD7WUu6CbOL_fgu0UljtBV0lEF2gPtGvWDKCv.Rcy2mmKULsF916eSnIYIdXS8g4BF_XgjEHtapxq7iTtyOWUtCDJV0sQupbPqE8iTIQJ1x99TI8Co.7znbdXxcz3fg3aXb5BVTRGUqkUucz6WwOoTccQ.zCcsbtWObLpbCU4fYrlEXrRuv_jk5fiWp9TcT6aKyIS0G9iPtZ_cw0tmqCIZ.qyFgMhWZrekjh8yl4CQS54BKP3yY2H2ILcQp6dkQKDDT7uVda_L.BA4kN2wS7XSDNUc7Jumve7.2FH3oiFSHpGA8lUjOwlFInohPPwdbGZIwTf7OVlvC68RjMkUR8Dmbu5yLYLYaF8MB6aSeeKVPkKlNiC8_cmfWqdeJimTQue9Lrs6lScZ6nDcJo5AVQDCF4wAX6gFEnts1FCEB0BZVKg1rAGrPgmM7lwV9OUhj3pMnZt0icKsjGLo6rAbK36kQMDBc5.vok8QlRa3yAXBmQjuicqxyb2rlDp1ZVbutgHS1ySiGQecTB4F8ititO2uohHX2q5MBLFfGizDwkwa6nZkKPewS0ONQGyQ3SOm258lZjMU0psiS06PuDpxwsHWn_teEbkkCn7GX29dOtLbUUuMSwgDUPfBEppQWQnVliKNcIgP.pMh3_pGrws7nHZw07ot1zmSh6dBRZiSAtL2Sgt2GRXrAewp.abBLomgkzIZIX80mKlVmlBkDgAhE5oIDAJgbneh9kNcpmaykHoNES1YPft0J970KqzgGnt_LYgsBGD09M5hCN_FglbTWKQFo.06a7mc91mmpsCzu.J9JVe6kgM5mtQlasH1SdZ7T2kwT5JiLxAEq0HfFcblmXmeQxI7A7t1CuvdKwjbrQl5nphOHo0RsKmTOB98lLr5465hhLkiAZDM1GoJq1dDsVZwhJ.536MpBY",mdrd: "1KuxzN9GMfh_iE6lbtczH_Edz5g0sB07GV_49MXTiEg-1743666154-1.2.1.1-uhS6u.mX1D1HBv3HtSO9SLZ_b7P6Fz7MqrVZfvwtSK2OzTy.uVb45tygVJt00Qb_JY3J8P7JcJjI.Dn9rP57Pqh0ch5xqSjusdk_pgGACez6em90RE6ZjwoTHi0C5vmp42vCHST0jhnEpq0sLvI68GTgMq2Pj0PhW7nYQBVz8WfxF3sBf8ZI4n06HNfmO5Pz3BBDKz5HRYs8FMBuJlNW28AJ.f9Fd2Kk22H_iZTjU3yvhCntp9KyjrFng3sFdkwx5g8113oQhLG8I8g_CnzPLgLRaL3YedFJoIvA2XqAm33VgSOPS8V1IfWAd1p.mUZ6QHF0wZkYSIhV9t76IT76y5Jf7K99cMx3UuKT30VGhNMZHATtlexOPdujtr1S0W2W2BhT4WP7y4rI7ligV8aYGa5IkjbUt5TRNvw3vVH.uDDeR2gH.3ccbsa.O8ZsJv9wuqQi_FwLA1iZVtKMm2WQLUG0LWKGx_RzJVvDctQkxOuqDmyR2oCaAQtFuREIqHrpzJQGAv1XvT1RD5gF1u9mdSFnHVE_bO6dgGX8coccSvHHiIv93MZwgtM0ypEiZx9yh6EdO2oprdYxbYRKu58k.kURL47W6mTivuIk5307wYyWLzzOC4ynfb35ldqTccCyWuA0nn5qGjKN6hkItHY5qvVf7E2Hy_vkSgfvYqoaagszEdubwOc1Qmp679zeO68TyuCUhOGcje6uS4nHSzUa3JTEeb5oNp2j9Uyh1XKEDdWEcML4HUmyiDx7Waf07ZEmFizPstPCU7ajIb3jCmL1YW21Nad49XuL_Liro5.GtKgIH_iXAVwqHCbNdKa4WzWy1106t4knrKIsi2a7PlsExQfGdfuEfnvOPexoAB7F0sx8d2Xeaihk.s3.WxppoGGnqASqck4BeR6wiYvMXTPq1NF9ZD2Kkm104UkN5WCHV2Oy9pdKlsTSpU81GK34bTYjfSiwLaIwvsRL3dcZmb24pyQ5d8e_2d68tYiumxLptlbVzq8QBf91u5e1f495.n2FDEB8Rpw0WzRat3E_LivjxPWt0btf2GK4eTxvQNhQ9VYwBumvuvb_FiQNC7w1UZcsOy8d0.lvYXSrax0Ne2prs8zTwQddmBwJRu.7TNPPoncbJTxFvla.UUxTY8TOdcQRSNSHHCipnpduHRaEErykp5U9AzTeRwt9oTpI7jQAeE.HmvyQ4bPGal13m6YvnnhyVf_N3hxHPWVpUqY7UjHcePuVToK3AtOQhAqMH1uYsOnyLgA2aWF9GhjbTw6bih3ohCgwey7dJlyqBu12eK3O9MsQnvfB9niX6V.BrxPoXAuTVHMxQ2PFnGB0U0kxDmhe.w9UHG9BiKboTINRl3v5k1.3qiwcj92Miv1ymC92WeC9jnAZLKTLsDCrmm2tVg3yIs.mVvc1b0ZmdSUZobCWPe2uuBuDRFb_wUHGrNRv0XvNeJNlXL4vJnY6z_MaUK.__wbmsxhWjLGiT3GmDsysIdE9CmNDGCup_bUQaodpdCpbM99cohBIJLlkexZe3Z5fU_iv.vlo2VEcnr97RwrlpIEnDlwzaB6.VPBday5DgDrmIRZ1TO.SdLNRG9NYZ9VdvGTWjtqieJKQ7tyXc2AwRBas2B64Nxfs3puMa7ema0OKHxL7cqMk0w9Rg65qeeVEXNjkeZShTpfkaQboH6V3mnO8mehvrhqI3U.XwsmbgzUkzdU79vtDcsB8Z8MLne42ZQC7U_FIILGRtl3P9U9OE2CfXHfTSbvbpAwhAKvhJjuS3OrRRk3327w8voIRaTO9KtAgQQEBfHm0uDCOBkUXmGHSCfSwo49.trcELlQROetcVxwXm31STx42bihfrT9PCsD61FZtRXpt96YXqyGFcXLFFsY.e_nWTs2O7eYsTRyvjWAZ4N0HnKh3bG7Rt4fAz0E6A5bDeG7cwDl80q.xSvq.29Y4oQ97BIYJ1.tujaN6gOxPZXzqDkgnwrA0eBoBLfsTJQHeDFGpYPHf0jx5gfFrpbz0urigE7fESbPS8_ir4kloOZFDT3o7hHAJYARg02jFYlEzoy3KrJsk5_OFTQ"};var cpo = document.createElement('script');cpo.src = '/cdn-cgi/challenge-platform/h/g/orchestrate/chl_page/v1?ray=92a6ee1bb8a0fe0c';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=7Jvw0bt0Bi2cLRSGwgwdNoqIdoyYWyYmGbKD7h.w8vU-1743666154-1.0.1.1-Tk.4gozLQO9jYClJw80ajzH69t7KDj_AZ9Y6gFFYnjg" + window._cf_chl_opt.cOgUHash);cpo.onload = function() {history.replaceState(null, null, ogU);}}document.getElementsByTagName('head')[0].appendChild(cpo);}());</script></body></html>