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Jacobs MA, Gao Y, Schmidt S, Shireman PK, Mader M, Duncan CA, Hausmann LRM, Stitzenberg KB, Kao LS, Vaughan Sarrazin M, Hall DE. Social Determinants of Health and Surgical Desirability of Outcome Ranking in Older Veterans. JAMA Surg 2024; 159:1158-1169. [PMID: 39083255 PMCID: PMC11292565 DOI: 10.1001/jamasurg.2024.2489] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/08/2024] [Indexed: 08/03/2024]
Abstract
Importance Evaluating how social determinants of health (SDOH) influence veteran outcomes is crucial, particularly for quality improvement. Objective To measure associations between SDOH, care fragmentation, and surgical outcomes using a Desirability of Outcome Ranking (DOOR). Design, Setting, And Participants This was a cohort study of US veterans using data from the Veterans Affairs (VA) Surgical Quality Improvement Program (VASQIP; 2013-2019) limited to patients aged 65 years or older with inpatient stays between 2 and 30 days, merged with multiple data sources, including Medicare. Race and ethnicity data were retrieved from VASQIP, Medicare and Medicaid beneficiary summary files, the Veterans Health Administration Corporate Data Warehouse, and the United States Veterans Eligibility Trends and Statistics file. Data were analyzed between September 2023 and February 2024. Exposure Living in a highly deprived neighborhood (Area Deprivation Index >85), race and ethnicity used as a social construct, rurality, and care fragmentation (percentage of non-VA care days). Main Outcomes and Measures DOOR is a composite, patient-centered ranking of 26 outcomes ranging from no complication (1, best) to 90-day mortality or near-death complications (6, worst). A series of proportional odds regressions was used to assess the impact of SDOH and care fragmentation adjusted for clinical risk factors, including presentation acuity (presenting with preoperative acute serious conditions and urgent or emergent surgical procedures). Results The cohort had 93 644 patients (mean [SD] age, 72.3 [6.2] years; 91 443 [97.6%] male; 74 624 [79.7%] White). Veterans who identified as Black (adjusted odds ratio [aOR], 1.06; 95% CI, 1.02-1.10; P = .048) vs White and veterans with higher care fragmentation (per 20% increase in VA care days relative to all care days: aOR, 1.01; 95% CI, 1.01-1.02; P < .001) were associated with worse (higher) DOOR scores until adjusting for presentation acuity. Living in rural geographic areas was associated with better DOOR scores than living in urban areas (aOR, 0.93; 95% CI, 0.91-0.96; P < .001), and rurality was associated with lower presentation acuity (preoperative acute serious conditions: aOR, 0.88; 95% CI, 0.81-0.95; P = .001). Presentation acuity was higher in veterans identifying as Black, living in deprived neighborhoods, and with increased care fragmentation. Conclusions and Relevance Veterans identifying as Black and veterans with greater proportions of non-VA care had worse surgical outcomes. VA programs should direct resources to reduce presentation acuity among Black veterans, incentivize veterans to receive care within the VA where possible, and better coordinate veterans' treatment and records between care sources.
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Affiliation(s)
- Michael A. Jacobs
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Yubo Gao
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health San Antonio, San Antonio
| | - Paula K. Shireman
- Department of Medical Physiology, College of Medicine, Texas A&M University, Bryan
- Department of Primary Care and Rural Medicine, College of Medicine, Texas A&M University, Bryan
| | | | - Carly A. Duncan
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Leslie R. M. Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Lillian S. Kao
- Department of Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston
| | - Mary Vaughan Sarrazin
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, Iowa
- Department of Internal Medicine, Carver College of Medicine, The University of Iowa, Iowa City
| | - Daniel E. Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Singhal R, Dickerson L, Sakran N, Pouwels S, Chiappetta S, Weiner S, Purkayastha S, Madhok B, Mahawar K. Safe Surgery During the COVID-19 Pandemic. Curr Obes Rep 2022; 11:203-214. [PMID: 34709586 PMCID: PMC8552630 DOI: 10.1007/s13679-021-00458-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 11/06/2022]
Abstract
PURPOSE OF REVIEW Coronavirus Disease-2019 (COVID-19) has had an enormous impact on all aspects of healthcare, but its effect on patients needing surgery and surgeons has been disproportionate. In this review, we aim to understand the impact of the pandemic on surgical patients and teams. We compiled the emerging data on pre-operative screening methods, vaccinations, safe-surgery pathways and surgical techniques and make recommendations for evidence-based safe-surgical pathways. We also present surgical outcomes for emergency, oncological and benign surgery in the context of the pandemic. Finally, we attempt to address the impact of the pandemic on patients, staff and surgical training and provide perspectives for the future. RECENT FINDINGS Surgical teams have developed consensus guidelines and established research priorities and safety precautions for surgery during the COVID-19 pandemic. Evidence supports that surgery in patients with a peri-operative SARS-CoV-2 infection carries substantial risks, but risk mitigation strategies are effective at reducing harm to staff and patients. Surgery has increased risk for patients and staff, but this can be mitigated effectively, especially for elective surgery. Elective surgery can be safely performed during the COVID-19 pandemic employing the strategies discussed in this review.
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Affiliation(s)
- Rishi Singhal
- Upper GI Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham Heartlands Hospital, Birmingham, UK.
| | - Luke Dickerson
- Department of General Surgery, Leighton Hospital, Crewe, UK
| | - Nasser Sakran
- Director Bariatric Centre, Department of Surgery, Emek Medical Centre, Afula, Israel
- The Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, the Netherlands
| | - Sonja Chiappetta
- Head Obesity and Metabolic Surgery, Ospedale Evangelico Betania, Naples, Italy
| | - Sylvia Weiner
- Department of Obesity and Metabolic Surgery, Krankenhaus Nordwest, Frankfurt am Main, Germany
| | | | | | - Kamal Mahawar
- Bariatric Unit, South Tyneside and Sunderland NHS Trust, Sunderland, UK
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Vaughan EM, Pearson R, Wohlgemut JM, Knight SR, Spiers H, Damaskos D, Cornish J, Parmar C, Mahawar K, Moug S, Baiocchi GL, Catena F, Tierney G, Wilson MSJ. Research priorities in emergency general surgery (EGS): a modified Delphi approach. World J Emerg Surg 2022; 17:33. [PMID: 35710497 PMCID: PMC9202984 DOI: 10.1186/s13017-022-00432-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergency general surgery (EGS) patients account for more than one-third of admissions to hospitals in the National Health Service (NHS) in England. The associated mortality of these patients has been quoted as approximately eight times higher than that of elective surgical admissions. This study used a modified Delphi approach to identify research priorities in EGS. The aim was to establish a research agenda using a formal consensus-based approach in an effort to identify questions relevant to EGS that could ultimately guide research to improve outcomes for this cohort. METHODS Three rounds were conducted using an electronic questionnaire and involved health care professionals, research personnel, patients and their relatives. In the first round, stakeholders were invited to submit clinical research questions that they felt were priorities for future research. In rounds two and three, participants were asked to score individual questions in order of priority using a 5-point Likert scale. Between rounds, an expert panel analysed results before forwarding questions to subsequent rounds. RESULTS Ninety-two EGS research questions were proposed in Phase 1. Following the first round of prioritisation, forty-seven questions progressed to the final phase. A final list of seventeen research questions were identified from the final round of prioritisation, categorised as condition-specific questions of high interest within general EGS, emergency colorectal surgery, non-technical and health services research. A broad range of research questions were identified including questions on peri-operative strategies, EGS outcomes in older patients, as well as non-technical and technical influences on EGS outcomes. CONCLUSIONS Our study provides a consensus delivered framework that should determine the research agenda for future EGS projects. It may also assist setting priorities for research funding and multi-centre collaborative strategies within the academic clinical interest of EGS.
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Affiliation(s)
| | - Robert Pearson
- Department of General Surgery, Elizabeth University Hospital, Glasgow, G51 4TF, Queen, UK
| | - Jared Mark Wohlgemut
- Blizard Institute of Cell and Molecular Science: Barts and The London School of Medicine and Dentistry Blizard Institute, Whitechapel, London, E1 2AT, UK
| | - Stephen Richard Knight
- The University of Edinburgh Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, EH16 4UX, UK
| | - Harry Spiers
- Department of General Surgery, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Dimitrios Damaskos
- Department of General Surgery, Royal Infirmary Edinburgh, Edinburgh, EH16 4SA, UK
| | - Julie Cornish
- Department of General Surgery, University Hospital Wales, Cardiff, CF14 4XW, UK
| | - Chetan Parmar
- Department of General Surgery, The Whittington Hospital NHS Trust, London, N19 5NF, UK
| | - Kamal Mahawar
- Department of General Surgery, Sunderland Royal Hospital, Sunderland, SR4 7TP, UK
- Department of General Surgery, Royal Alexandra Hospital, Paisley, PA2 9PJ, UK
- Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Susan Moug
- Department of General Surgery, Royal Alexandra Hospital, Paisley, PA2 9PJ, UK
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy.
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, University of Parma, Parma, Italy
| | - Gillian Tierney
- Department of General Surgery, Derby City General Hospital, Derby, DE22 3NE, UK
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Abstract
BACKGROUND This research prioritization aimed to identify major research gaps in maternal, newborn, child and adolescent health (MNCAH) to help mitigate the direct and indirect effects of the COVID-19 pandemic. METHODS We adapted the Child Health and Nutrition Research Initiative methodology. We defined scope, domains, themes and scoring criteria. We approached diverse global experts via email to submit their research ideas in MNCAH and MNCAH-related cross-cutting/health systems area. We curated the research ideas as research questions (RQs) and sent them to the consenting experts for scoring via the online link. For each RQ, the research priority score (RPS) was calculated as an average of individual criterion scores and ranked based on RPS in each area. RESULTS We identified top-ranked 10 RQs in each maternal, newborn, and child and adolescent health and 5 in the cross-cutting/health systems area. In maternal health, indirect effects on care, measures to improve care, health risks and outcomes, and preventing and managing SARS-CoV-2 infection/COVID-19 disease were priority RQs. In newborn health, clinical characterization and managing SARS-CoV-2 infection/COVID-19 disease, mode of transmission and interventions to prevent transmission were the focus. For child and adolescent health, top-ranked RQs were indirect effects on care, clinical status and outcomes, interventions to protect against SARS-CoV-2 infection/COVID-19 disease, and educational institute-related RQs. The cross-cutting RQs were the effects of the pandemic on availability, access, care-seeking and utilization of MNCAH services and potential solutions. CONCLUSIONS We call on partners, including governments, non-governmental organizations, research institutes, and donors, to address this urgent research agenda.
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Hardy N, Dalli J, Khan MF, Nolan K, Cahill RA. Aerosols, airflow, and airspace contamination during laparoscopy. Br J Surg 2021; 108:1022-1025. [PMID: 33829231 PMCID: PMC8083507 DOI: 10.1093/bjs/znab114] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/15/2021] [Accepted: 03/01/2021] [Indexed: 11/12/2022]
Abstract
Laparoscopic surgery has been undermined throughout the COVID-19 pandemic by concerns that it may generate an infectious risk to the operating team through aerosolization of peritoneal particles. There is anyway a need for increased awareness and understanding of the occupational hazard for surgical teams regarding unfiltered escape of pollutants generated by surgical smoke and other microbials. Here, the aerosol-generating nature of this access modality was confirmed through repeatable real-time methodology both qualitatively and quantitively to inform best practice and additional engineering solutions to optimize the operating room environment.
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Affiliation(s)
- N Hardy
- UCD Centre of Precision Surgery, School of Medicine, University College Dublin, Dublin, Ireland
| | - J Dalli
- UCD Centre of Precision Surgery, School of Medicine, University College Dublin, Dublin, Ireland
| | - M F Khan
- UCD Centre of Precision Surgery, School of Medicine, University College Dublin, Dublin, Ireland
| | - K Nolan
- School of Mechanical and Material Engineering, University College Dublin, Dublin, Ireland
| | - R A Cahill
- UCD Centre of Precision Surgery, School of Medicine, University College Dublin, Dublin, Ireland
- Department of Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
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Nasa P, Jain R, Juneja D. Delphi methodology in healthcare research: How to decide its appropriateness. World J Methodol 2021; 11:116-129. [PMID: 34322364 PMCID: PMC8299905 DOI: 10.5662/wjm.v11.i4.116] [Citation(s) in RCA: 657] [Impact Index Per Article: 164.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/26/2021] [Accepted: 05/19/2021] [Indexed: 02/06/2023] Open
Abstract
The Delphi technique is a systematic process of forecasting using the collective opinion of panel members. The structured method of developing consensus among panel members using Delphi methodology has gained acceptance in diverse fields of medicine. The Delphi methods assumed a pivotal role in the last few decades to develop best practice guidance using collective intelligence where research is limited, ethically/logistically difficult or evidence is conflicting. However, the attempts to assess the quality standard of Delphi studies have reported significant variance, and details of the process followed are usually unclear. We recommend systematic quality tools for evaluation of Delphi methodology; identification of problem area of research, selection of panel, anonymity of panelists, controlled feedback, iterative Delphi rounds, consensus criteria, analysis of consensus, closing criteria, and stability of the results. Based on these nine qualitative evaluation points, we assessed the quality of Delphi studies in the medical field related to coronavirus disease 2019. There was inconsistency in reporting vital elements of Delphi methods such as identification of panel members, defining consensus, closing criteria for rounds, and presenting the results. We propose our evaluation points for researchers, medical journal editorial boards, and reviewers to evaluate the quality of the Delphi methods in healthcare research.
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Affiliation(s)
- Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai 00000, United Arab Emirates
| | - Ravi Jain
- Critical Care Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur 302001, Rajasthan, India
| | - Deven Juneja
- Institute of Critical Care Medicine, Max Super Speciality Hospital, New Delhi 110017, India
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Delphi methodology in healthcare research: How to decide its appropriateness. World J Methodol 2021. [PMID: 34322364 DOI: 10.5662/wjm.v11.i4.116.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The Delphi technique is a systematic process of forecasting using the collective opinion of panel members. The structured method of developing consensus among panel members using Delphi methodology has gained acceptance in diverse fields of medicine. The Delphi methods assumed a pivotal role in the last few decades to develop best practice guidance using collective intelligence where research is limited, ethically/logistically difficult or evidence is conflicting. However, the attempts to assess the quality standard of Delphi studies have reported significant variance, and details of the process followed are usually unclear. We recommend systematic quality tools for evaluation of Delphi methodology; identification of problem area of research, selection of panel, anonymity of panelists, controlled feedback, iterative Delphi rounds, consensus criteria, analysis of consensus, closing criteria, and stability of the results. Based on these nine qualitative evaluation points, we assessed the quality of Delphi studies in the medical field related to coronavirus disease 2019. There was inconsistency in reporting vital elements of Delphi methods such as identification of panel members, defining consensus, closing criteria for rounds, and presenting the results. We propose our evaluation points for researchers, medical journal editorial boards, and reviewers to evaluate the quality of the Delphi methods in healthcare research.
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McElroy L, Robinson L, Battle C, Laidlaw L, Teager A, de Bernard L, McGillivray J, Tsang K, Bell S, Leech C, Marsden M, Carden R, Challen K, Peck G, Hancorn K, Davenport R, Brohi K, Wilson MSJ. Use of a modified Delphi process to develop research priorities in major trauma. Eur J Trauma Emerg Surg 2021; 48:1453-1461. [PMID: 34132821 PMCID: PMC8208060 DOI: 10.1007/s00068-021-01722-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/05/2021] [Indexed: 11/30/2022]
Abstract
Purpose The burden of major trauma within the UK is ever increasing. There is a need to establish research priorities within the field. Delphi methodology can be used to develop consensus opinion amongst a group of stakeholders. This can be used to prioritise clinically relevant, patient-centred research questions to guide future funding allocations. The aim of our study was to identify key future research priorities pertaining to the management of major trauma in the UK. Methods A three-phased modified Delphi process was undertaken. Phase 1 involved the submission of research questions by members of the trauma community using an online survey (Phase 1). Phases 2 and 3 involved two consecutive rounds of prioritisation after questions were subdivided into 6 subcategories: Brain Injury, Rehabilitation, Trauma in Older People, Pre-hospital, Interventional, and Miscellaneous (Phases 2 and 3). Cut-off points were agreed by consensus amongst the steering subcommittees. This established a final prioritised list of research questions. Results In phase 1, 201 questions were submitted by 65 stakeholders. After analysis and with consensus achieved, 186 questions were taken forward for prioritisation in phase 2 with 114 included in phase 3. 56 prioritised major trauma research questions across the 6 categories were identified with a clear focus on long-term patient outcomes. Research priorities across the patient pathway from roadside to rehabilitation were deemed of importance. Conclusions Consensus within the major trauma community has identified 56 key research questions across 6 categories. Dissemination of these questions to funding bodies to allow for the development of high-quality research is now required. There is a clear indication for targeted multi-centre multi-disciplinary research in major trauma.
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Affiliation(s)
- Luke McElroy
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, FK5 4WR, UK.
| | - Lisa Robinson
- Rehabilitation Department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle Upon Tyne, NE1 4LP, UK
| | - Ceri Battle
- Physiotherapy Department, Morriston Hospital, Swansea, SA6 6NL, UK
| | | | | | | | | | - Kevin Tsang
- Division of Surgery, St Mary's Hospital, Imperial College London, Paddington, London, W2 1NY, UK
| | - Steve Bell
- Medical Directorate, North West Ambulance Service NHS Trust, Bolton, BL1 5DD, UK
| | - Caroline Leech
- University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Walsgrave, Coventry, CV2 2DX, UK
| | - Max Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Richard Carden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Kirsty Challen
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, PR2 9HT, UK
| | - George Peck
- Division of Surgery, St Mary's Hospital, Imperial College London, Paddington, London, W2 1NY, UK
| | - Kate Hancorn
- Trauma Service, Barts Health NHS Trust, The Royal London Hospital, Whitechapel, London, E1 1FR, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Michael S J Wilson
- Department of General Surgery, Forth Valley Royal Hospital, Larbert, FK5 4WR, UK
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Faraz Khan M, Dalli J, Cahill RA. Dynamic near-infrared carbon dioxide leak visualization detection during surgery using the FLIR GF343 optical imaging system. Surg Endosc 2020; 34:5208-5210. [PMID: 33034773 PMCID: PMC7545813 DOI: 10.1007/s00464-020-08071-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/30/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Mohammad Faraz Khan
- UCD Centre for Precision Surgery, University College Dublin and Department of Surgery, Mater Misericordiae University Hospital, 47 Eccles Street, Dublin 7, Ireland
| | - Jeffrey Dalli
- UCD Centre for Precision Surgery, University College Dublin and Department of Surgery, Mater Misericordiae University Hospital, 47 Eccles Street, Dublin 7, Ireland
| | - Ronan A Cahill
- UCD Centre for Precision Surgery, University College Dublin and Department of Surgery, Mater Misericordiae University Hospital, 47 Eccles Street, Dublin 7, Ireland.
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