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Veerareddy RR, Panton ZA, Zagaria AB, Lites CJ, Keeney BJ, Werth PM. The Impact of Preoperative Medical Evaluation in an Orthopaedic Perioperative Medical Clinic on Total Joint Arthroplasty Outcomes: An Observational Study. J Bone Joint Surg Am 2024; 106:782-792. [PMID: 38502740 DOI: 10.2106/jbjs.23.00465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND A preoperative medical evaluation (PME) in total joint arthroplasty (TJA) is routine despite considerable variation and uncertainty regarding its benefits. The orthopaedic department in our academic health system established a perioperative medical clinic (PMC) to standardize perioperative management and to study the effect of this intervention on total hip arthroplasty (THA) and total knee arthroplasty (TKA) outcomes. This observational study compared the impact of a PME within 30 days prior to surgery at the PMC (Periop30) versus elsewhere ("Usual Care") on postoperative length of stay (LOS), extended LOS (i.e., a stay of >3 days), and Patient-Reported Outcomes Measurement Information System-10 (PROMIS-10) Global Physical Health (GPH) score improvement in TJA. METHODS We stratified adult patients (≥18 years of age) who underwent primary TJA between January 2015 and December 2020 into Periop30 or Usual Care. We utilized univariate tests (a chi-square test for categorical variables and a t test for continuous variables) to assess for differences in patient characteristics. For both TKA and THA, LOS was assessed with use of multivariable negative binomial regression models; extended LOS, with use of binary logistic regression; and PROMIS-10 GPH score, with use of mixed-effects models with random intercept and slope. Interaction terms between the focal predictor (Periop30, yes or no) and year of surgery were included in all models. RESULTS Periop30 comprised 82.3% of TKAs (1,911 of 2,322 ) and 73.8% of THAs (1,876 of 2,541). For THA, the Periop30 group tended to be male (p = 0.005) and had a higher body mass index (p = 0.001) than the Usual Care group. The Periop30 group had a higher rate of staged bilateral THA (10.6% versus 7.5%; p = 0.028) and a lower rate of simultaneous bilateral TKA (5.1% versus 12.2%; p < 0.001) than the Usual Care group. Periop30 was associated with a lower mean LOS for both TKA (43.46 versus 54.15 hours; p < 0.001) and THA (41.07 versus 57.94 hours; p < 0.001). The rate of extended LOS was lower in the Periop30 group than in the Usual Care group for both TKA (15% versus 26.5%; p < 0.001) and THA (13.3% versus 27.4%; p < 0.001). There was no significant difference in GPH score improvement between Periop30 and Usual Care for either TKA or THA. CONCLUSIONS Periop30 decreased mean LOS and the rate of extended LOS for TJA without an adverse effect on PROMIS-10 GPH scores. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Rakesh R Veerareddy
- Department of Orthopaedics, Dartmouth Health, Lebanon, New Hampshire
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Zachary A Panton
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | | | | | - Benjamin J Keeney
- Berkley Medical Management Solutions, W.R. Berkley Corporation, Boston, Massachusetts
| | - Paul M Werth
- Department of Orthopaedics, Dartmouth Health, Lebanon, New Hampshire
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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Rehman Y, Bala M, Rehman N, Agarwal A, Koperny M, Crandon H, Abdullah R, Hull A, Makhdami N, Grodecki S, Wrzosek A, Lesniak W, Evaniew N, Ashoorion V, Wang L, Couban R, Drew B, Busse JW. Predictors of Recovery Following Lumbar Microdiscectomy for Sciatica: A Systematic Review and Meta-Analysis of Observational Studies. Cureus 2023; 15:e39664. [PMID: 37388594 PMCID: PMC10307033 DOI: 10.7759/cureus.39664] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 07/01/2023] Open
Abstract
Chronic post-surgical pain is reported by up to 40% of patients after lumbar microdiscectomy for sciatica, a complaint associated with disability and loss of productivity. We conducted a systematic review of observational studies to explore factors associated with persistent leg pain and impairments after microdiscectomy for sciatica. We searched eligible studies in MEDLINE, Embase, and CINAHL that explored, in an adjusted model, predictors of persistent leg pain, physical impairment, or failure to return to work after microdiscectomy for sciatica. When possible, we pooled estimates of association using random-effects models using the Grading of Recommendations Assessment, Development, and Evaluation approach. Moderate-certainty evidence showed that the female sex probably has a small association with persistent post-surgical leg pain (odds ratio (OR) = 1.15, 95% confidence interval (CI) = 0.63 to 2.08; absolute risk increase (ARI) = 1.8%, 95% CI = -4.7% to 11.3%), large association with failure to return to work (OR = 2.79, 95% CI = 1.27 to 6.17; ARI = 10.6%, 95% CI = 1.8% to 25.2%), and older age is probably associated with greater postoperative disability (β = 1.47 points on the 100-point Oswestry Disability Index for every 10-year increase from age (>/=18 years), 95% CI = -4.14 to 7.28). Among factors that were not possible to pool, two factors showed promise for future study, namely, legal representation and preoperative opioid use, which showed large associations with worse outcomes after surgery. The moderate-certainty evidence showed female sex is probably associated with persistent leg pain and failure to return to work and that older age is probably associated with greater post-surgical impairment after a microdiscectomy. Future research should explore the association between legal representation and preoperative opioid use with persistent pain and impairment after microdiscectomy for sciatica.
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Affiliation(s)
- Yasir Rehman
- Health Research Methodology, McMaster University, Hamilton, CAN
| | - Malgorzata Bala
- Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Krakow, POL
| | - Nadia Rehman
- Health Research Methods, Impact and Evidence, McMaster University, Hamilton, CAN
| | | | - Magdalena Koperny
- Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Krakow, POL
| | - Holly Crandon
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, CAN
| | - Ream Abdullah
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, CAN
| | - Alexandra Hull
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, CAN
| | | | | | - Anna Wrzosek
- Interdisciplinary Intensive Care, Jagiellonian University, Krakow, POL
| | | | | | - Vahid Ashoorion
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, CAN
| | - Li Wang
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, CAN
| | - Rachel Couban
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, CAN
| | - Brian Drew
- Neurosurgery, McMaster University, Hamilton, CAN
| | - Jason W Busse
- Health Research Methodology, McMaster University, Hamilton, CAN
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Psychiatric Hospital Ethics Committee Discussions Over a Span of Nearly Three Decades. HEC Forum 2023; 35:55-71. [PMID: 34050841 DOI: 10.1007/s10730-021-09454-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 10/21/2022]
Abstract
Various types of health settings use clinical ethics committees (CEC) to deal with the ethical issues that confront both healthcare providers and their patients. Although these committees are now more common than ever, changes in the content of ethical dilemmas through the years is still a relatively unexplored area of research. The current study examines the major topics brought to the CEC of a psychiatric hospital in Israel and explores whether there were changes in their frequency across nearly three decades. The present paper reports on a thematic analysis of the written verbatim transcripts from 466 ethical topics brought to the CEC between the years 1991 and 2016. The following major topics related to ethical dilemmas were identified: confidentiality (30%), patient autonomy (23%), health records (14%), dual relationship (12%), allocation of resources (11%), inappropriate professional and personal conduct (9%), and multicultural sensitivity (1%). Topics related to confidentiality increased significantly over the years, as did inappropriate professional and personal conduct. In addition, the analysis showed that the content of the ethical cases and the resolutions suggested by the CEC also varied over the years. In conclusion, although most ethical topics have remained relatively stable over time, the discourse around them has evolved, requiring a dynamic assessment and reflection by the mental health practitioners serving as members of a CEC.
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Davies J, Brockie A, Breeze J. Bioethics in humanitarian disaster relief operations: a military perspective. BMJ Mil Health 2022; 168:449-452. [PMID: 34266976 DOI: 10.1136/bmjmilitary-2021-001927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/22/2021] [Indexed: 11/03/2022]
Abstract
The ethical dilemmas faced every day by military personnel working within the NHS will potentially be very different to ones that will be faced in the wake of a humanitarian disaster. Allied to this the potentially differing objectives from military personnel when compared with other healthcare workers in these scenarios and a conflict of ethics could arise.Within this paper, the fundamentals of this conflict will be explored and how working within the military framework can affect clinical decisions. This is a paper commissioned as a part of the humanitarian and disaster relief operations special issue of BMJ Military Health.
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Affiliation(s)
- James Davies
- Department of Maxillofacial Surgery, University Hospitals Birmingham, Birmingham, UK
| | - A Brockie
- Headquarters Joint Hospital Group, Plymouth, UK
| | - J Breeze
- Department of Maxillofacial Surgery, University Hospitals Birmingham, Birmingham, UK
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Leeds IL, Drabo EF, Lehmann LS, Safar B, Johnston FM. On All Accounts: Cost-Effectiveness Analysis of Limited Preoperative Optimization Efforts Before Colon Cancer Surgery. Dis Colon Rectum 2021; 64:744-753. [PMID: 33955409 PMCID: PMC8835996 DOI: 10.1097/dcr.0000000000001926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Reports suggest that preoperative optimization of a patient's serious comorbidities is associated with a reduction in postoperative complications. OBJECTIVE The purpose of this study was to assess the cost and benefits of preoperative optimization, accounting for total costs associated with postoperative morbidity. DESIGN This study is a decision tree cost-effectiveness analysis with probabilistic sensitivity analysis (10,000 iterations). SETTING This is a hypothetical scenario of stage II colon cancer surgery. PATIENT The simulated 65-year-old patient has left-sided, stage II colon cancer. INTERVENTION Focused preoperative optimization targets high-risk comorbidities. OUTCOMES Total discounted (3%) economic costs (US $2018), effectiveness (quality-adjusted life-years), incremental cost-effectiveness ratio (incremental cost-effectiveness ratio, cost/quality-adjusted life-years gained), and net monetary benefit. RESULTS We calculated the per individual expected health care sector total cost of preoperative optimization and sequelae to be $12,395 versus $15,638 in those not optimized (net monetary benefit: $1.04 million versus $1.05 million). A nonoptimized patient attained an average 0.02 quality-adjusted life-years less than one optimized. Thus, preoperative optimization was the dominant strategy (lower total costs; higher quality-adjusted life-years). Probabilistic sensitivity analysis demonstrated 100% of simulations favoring preoperative optimization. The breakeven cost of optimization to remain cost-effective was $6421 per patient. LIMITATIONS Generalizability must account for the lack of standardization among existing preoperative optimization efforts, and decision analysis methodology provides guidance for the average patient or general population, and is not patient-specific. CONCLUSIONS Although currently not comprehensively reimbursed, focused preoperative optimization may reduce total costs of care while also reducing complications from colon cancer surgery. See Video Abstract at http://links.lww.com/DCR/B494. EN TODO CASO ANLISIS DE RENTABILIDAD DE LOS ESFUERZOS LIMITADOS DE OPTIMIZACIN PREOPERATORIA ANTES DE LA CIRUGA DE CNCER DE COLON ANTECEDENTES:Los informes sugieren que la optimización preoperatoria de las comorbilidades graves de un paciente se asocia con una reducción de las complicaciones postoperatorias.OBJETIVO:El propósito de este estudio fue evaluar el costo y los beneficios de la optimización preoperatoria, teniendo en cuenta los costos totales asociados con la morbilidad postoperatoria.DISEÑO:Análisis de costo-efectividad de árbol de decisión con análisis de sensibilidad probabilístico (10,000 iteraciones).AJUSTE ENTORNO CLINICO:Escenario hipotético Cirugía de cáncer de colon en estadio II.PACIENTE:Paciente simulado de 65 años con cáncer de colon en estadio II del lado izquierdo.INTERVENCIÓN:Optimización preoperatoria enfocada dirigida a comorbilidades de alto riesgo.RESULTADOS:Costos económicos totales descontados (3%) (US $ 2018), efectividad (años de vida ajustados por calidad [AVAC]), relación costo-efectividad incremental (ICER, costo / AVAC ganado) y beneficio monetario neto (NMB).RESULTADOS:Calculamos que el costo total esperado por sector de atención médica individual de la optimización preoperatoria y las secuelas es de $ 12,395 versus $ 15,638 en aquellos no optimizados (NMB: $ 1.04 millones versus $ 1.05 millones, respectivamente). Un paciente no optimizado alcanzó un promedio de 0.02 AVAC menos que uno optimizado. Por lo tanto, la optimización preoperatoria fue la estrategia dominante (menores costos totales; mayores AVAC). El análisis de sensibilidad probabilístico demostró que el 100% de las simulaciones favorecían la optimización preoperatoria. El costo de equilibrio de la optimización para seguir siendo rentable fue de $ 6,421 por paciente.LIMITACIONES:La generalización debe tener en cuenta la falta de estandarización entre los esfuerzos de optimización preoperatorios existentes y esa metodología de análisis de decisiones proporciona una guía para el paciente promedio o la población general, no específica del paciente.CONCLUSIONES:Si bien actualmente no se reembolsa de manera integral, la optimización preoperatoria enfocada puede reducir los costos totales de la atención y al mismo tiempo reducir las complicaciones de la cirugía de cáncer de colon. Consulte Video Resumen en http://links.lww.com/DCR/B494.
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Affiliation(s)
- Ira L. Leeds
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emmanuel F. Drabo
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lisa Soleymani Lehmann
- VA New England Healthcare System, Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Bashar Safar
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M. Johnston
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Wong SP, Zietlow KM, McDonald SR, Barbeito A, Colon-Emeric CS, Lagoo-Deenadayalan SA, Loyack N, Heflin MT. Delaying Elective Surgery in Geriatric Patients: An Opportunity for Preoperative Optimization. Anesth Analg 2020; 130:e14-e18. [PMID: 31335399 DOI: 10.1213/ane.0000000000004335] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Deciding whether to pursue elective surgery is a complex process for older adults. Comprehensive geriatric assessment (CGA) can help refine estimates of benefits and risks, at times leading to a delay of surgery to optimize surgical readiness. We describe a cohort of geriatric patients who were evaluated in anticipation of elective abdominal surgery and whose procedures were delayed for any reason. Themes behind the reasons for delay are described, and a holistic framework to guide preoperative discussion is suggested.
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Affiliation(s)
- Serena P Wong
- From the *Department of Medicine, Duke University Medical Center, Durham, North Carolina †Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, North Carolina Departments of ‡Anesthesia §Surgery, Duke University Medical Center, Durham VA Medical Center, Durham, North Carolina
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Perioperative Optimization of Senior Health (POSH): A Descriptive Analysis of Cancelled Surgery. World J Surg 2020; 45:109-115. [PMID: 32935140 DOI: 10.1007/s00268-020-05772-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Geriatric collaborative care models improve postoperative outcomes for older adults. However, there are limited data exploring how preoperative geriatric assessment may affect surgical cancellations. METHODS This is a single-center retrospective cohort analysis. Patients enrolled in the Perioperative Optimization of Senior Health (POSH) program from 2011 to 2016 were included. POSH is a collaborative care model between geriatrics, surgery, and anesthesiology. Baseline demographic and medical data were collected during the POSH pre-op appointment. Patients who attended a POSH pre-op visit but did not have surgery were identified, and a chart review was performed to identify reasons for surgical cancellation. Baseline characteristics of patients who did and did not undergo surgery were compared. RESULTS Of 449 eligible POSH referrals within the study period, 33 (7.3%) did not proceed to surgery; cancellation rates within the POSH program were lower than institutional cancellation rates for adults over age 65 who did not participate in POSH. Patients who did not have surgery were significantly older, more likely to have functional limitations, and had higher rates of several comorbidities compared with those who proceeded to surgery (P < 0.05). Reasons for surgical cancellations included a similar number of patient- and provider-driven causes. CONCLUSIONS Many reasons for surgical cancellation were related to potentially modifiable factors, such as changes in goals of care or concerns about rehabilitation, emphasizing the importance of shared decision-making in elective surgery for older adults. These results highlight the important role geriatric collaborative care can offer to older adults with complex needs.
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Anandanadesan R, Shah M, De Silva AC. Making every contact count: the role of the clinician in smoking cessation during the perioperative period. Clin Med (Lond) 2020; 20:e2. [PMID: 32188674 DOI: 10.7861/clinmed.let.20.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chou PY, Denadai R, Chen C, Pai BCJ, Hsu KH, Chang CT, Pascasio D, Lin JAJ, Chen YR, Lo LJ. Comparison of Orthognathic Surgery Outcomes Between Patients With and Without Underlying High-Risk Conditions: A Multidisciplinary Team-Based Approach and Practical Guidelines. J Clin Med 2019; 8:E1760. [PMID: 31652792 PMCID: PMC6912447 DOI: 10.3390/jcm8111760] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/16/2019] [Accepted: 10/22/2019] [Indexed: 02/05/2023] Open
Abstract
Orthognathic surgery (OGS) has been successfully adopted for managing a wide spectrum of skeletofacial deformities, but patients with underlying conditions have not been treated using OGS because of the relatively high risk of surgical anesthetic procedure-related complications. This study compared the OGS outcomes of patients with and without underlying high-risk conditions, which were managed using a comprehensive, multidisciplinary team-based OGS approach with condition-specific practical perioperative care guidelines. Data of surgical anesthetic outcomes (intraoperative blood loss, operative duration, need for prolonged intubation, reintubation, admission to an intensive care unit, length of hospital stay, and complications), facial esthetic outcomes (professional panel assessment), and patient-reported outcomes (FACE-Q social function, psychological well-being, and satisfaction with decision scales) of consecutive patients with underlying high-risk conditions (n = 30) treated between 2004 and 2017 were retrospectively collected. Patients without these underlying conditions (n = 30) treated during the same period were randomly selected for comparison. FACE-Q reports of 50 ethnicity-, sex-, and age-matched healthy individuals were obtained. The OGS-treated patients with and without underlying high-risk conditions differed significantly in their American Society of Anesthesiologists Physical Status (ASA-PS) classification (p < 0.05), Charlson comorbidity scores, and Elixhauser comorbidity scores. The two groups presented similar outcomes (all p > 0.05) for all assessed outcome parameters, except for intraoperative blood loss (p < 0.001; 974.3 ± 592.7 mL vs. 657.6 ± 355.0 mL). Comparisons with healthy individuals revealed no significant differences (p > 0.05). The patients with underlying high-risk conditions treated using a multidisciplinary team-based OGS approach and the patients without the conditions had similar OGS-related outcomes.
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Affiliation(s)
- Pang-Yun Chou
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan.
| | - Rafael Denadai
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan.
| | - Chit Chen
- Department of Anesthesia, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
| | - Betty Chien-Jung Pai
- Department of Craniofacial Orthodontics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
| | - Kai-Hsiang Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan, Chang Gung University, Taoyuan 333, Taiwan.
| | - Che-Tzu Chang
- Division of Rheumatology, Allergy, and Immunology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan.
| | - Dax Pascasio
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan.
| | - Jennifer Ann-Jou Lin
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan.
| | - Yu-Ray Chen
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan.
| | - Lun-Jou Lo
- Department of Plastic and Reconstructive Surgery and Craniofacial Research Center, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 333, Taiwan.
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