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Oslin SJ, Lu VM, Graffeo CS. Systematic reviews and meta-analyses in the cerebrovascular space: essential domains for readers. Neurosurg Rev 2024; 47:454. [PMID: 39168862 DOI: 10.1007/s10143-024-02690-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 07/30/2024] [Accepted: 08/11/2024] [Indexed: 08/23/2024]
Abstract
INTRODUCTION Systematic Review and Meta-Analysis (SRMAs) in neurosurgery have significantly increased. With approximately 1 million patients affected by cerebrovascular disease annually, interpreting SRMAs necessitates a systematic approach. The objective of this review is to identify and describe four essential domains for SRMA interpretation. METHODS This review outlines the necessities of reviewing existing literature and methodological frameworks essential for interpreting cerebrovascular neurosurgery SRMAs. Each domain is to accurately assess study design variations, heterogeneity assessment methods, outcome comparability strategies, and the impact of technological advancements and time bias on study outcomes. RESULTS Study design evaluation distinguishes between randomized controlled trials (RCTs) and non-randomized studies. RCTs provide high internal validity, but as seen in the ARUBA trial, can contain internal flaws that necessitate a deeper understanding before application to clinical practices. Non-randomized studies offer valuable real-world insights. A heterogeneity assessment involves readers and writers accurately using forest plots, Cochrane's Q test, Higgins I² statistics, subgroup analysis, and meta-regressions to understand a study's clinical findings. The expertise thresholds, as in the NASCET trial, significantly impact a study's external validity. Strategies such as the GRADE approach can assist in managing diverse outcome measures. Technological advancements, particularly in endovascular procedures and SRS, influence the accuracy of comparing studies across periods, and thus swiftly outdate older studies, lowering the applicability of SRMAs. CONCLUSION Effective interpretation of cerebrovascular neurosurgery SRMAs requires attention to study design, heterogeneity, outcome comparability, and technological advancements. These domains collectively enable evidence-based clinical decision-making and optimized patient care in a dynamic field.
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Affiliation(s)
- Spencer J Oslin
- Department of Neurosurgery, University of Oklahoma, 1000 N Lincoln Blvd, #4000, Oklahoma City, OKC, 73104, USA
| | - Victor M Lu
- Department of Neurosurgery, University of Miami, Jackson Memorial Hospital, Miami, FL, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, University of Oklahoma, 1000 N Lincoln Blvd, #4000, Oklahoma City, OKC, 73104, USA.
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Jha DK, Agrawal M, Gosal JS, Janu V, Agrawal DK, Sharma RK, Garg M, Ghatak S, Elhence P, Bhatia PK. Manual Instruments as an Alternative to Drilling for Bony Exposure in Skull Base Surgery: Concept and Technique. J Neurol Surg B Skull Base 2024; 85:212-220. [PMID: 38449585 PMCID: PMC10914465 DOI: 10.1055/a-2031-3647] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/05/2023] [Indexed: 02/12/2023] Open
Abstract
Background Drilling in neurosurgery is an integral part of surgical exposure, especially in skull base approaches and craniovertebral junction (CVJ) surgeries. Most of such drillings are done in close proximity to the neurovascular structures in skull base surgeries and cervical-medullary junction or facet/pedicle in CVJ surgeries. Reluctance to drilling among young neurosurgeons is due to less hands-on experience during training and also, in the early part of the career, due to fear of injury to neurovascular structures. Methods Five commonest bone removals for skull base region and CVJ surgeries that can be safely done using manual instruments were identified based on experiences of senior authors. The authors highlight key technical nuances to widen surgical corridors using manual instruments safely for skull base surgical approaches. Results Basic neuroanatomical concepts and basic physics help in using manual instruments safely for bone removals in various skull base surgical approaches. Conclusions Manual instruments may be used for bone removals in selected skull base surgical approaches, which help young neurosurgeons to perform these surgeries in limited-resource settings.
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Affiliation(s)
- Deepak K. Jha
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Mohit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Jaskaran Singh Gosal
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Vikas Janu
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Dhruv K. Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Raghvendra K. Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Mayank Garg
- Department of Neurosurgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Surajit Ghatak
- Department of Anatomy, All India Institute of Medical Sciences, Jodhpur, India
| | - Poonam Elhence
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Jodhpur, India
| | - Pradeep K. Bhatia
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Jodhpur, India
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Joshi S, Khan M, Jelen MB, Pandit AS. Current Attitudes Toward Neuroanatomy: A Comparative Cross-Sectional Survey of Neurosurgeons from the United Kingdom and Worldwide. World Neurosurg 2022; 166:e607-e623. [PMID: 35868505 DOI: 10.1016/j.wneu.2022.07.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE How attitudes toward neuroanatomy and preferences of studying resources vary among neurosurgeons is unknown. The impact of the coronavirus disease 2019 (COVID-19) pandemic on anatomy learning habits is also yet to be elucidated. In this study, we explore these objectives, to guide the development of future neurosurgeon-tailored anatomy education and resources. METHODS This was a 2-stage, cross-sectional study design comprising a local pilot survey followed by a structured 17-item questionnaire, distributed to both neurosurgical trainees and consultants. Grade and nationality differences in sentiment agreement were statistically compared. RESULTS A total of 365 responses were received from 32 countries (overall response rate, 23.2%). Neuroanatomy is highly regarded among most neurosurgeons and takes a central role in their professional identity. Yet, 69% of neurosurgeons wanted to spend more time learning. Common study prompts included perceived operative complexity, lack of familiarity and teaching. Financial barriers and motivation were obstacles limiting neuroanatomy learning, more so among trainee neurosurgeons, with personal commitment barriers significantly varying with geographic location. Surgical relevance, accessibility, and image quality were important factors when selecting anatomy resources, with cost and up-to-datedness being important for juniors. The COVID-19 pandemic saw a shift toward virtual resources, particularly affecting United Kingdom-based trainees. CONCLUSIONS Although neuroanatomy is well regarded, barriers exist that impede further neuroanatomy learning. Neurosurgical training programs should tailor anatomy education according to the seniority and background of their residents. Furthermore, resources that are surgically relevant and accessible and are of high image quality are more likely to be better used.
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Affiliation(s)
- Shivani Joshi
- University College London Medical School, University College London, London, United Kingdom
| | - Mehdi Khan
- University College London Medical School, University College London, London, United Kingdom
| | - Maria B Jelen
- Department of Psychology and Language Sciences, University College London, London, United Kingdom
| | - Anand S Pandit
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom.
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Ruiz-Garcia H, Middlebrooks EH, Trifiletti DM, Chaichana KL, Quinones-Hinojosa A, Sheehan JP. The Extent of Resection in Gliomas-Evidence-Based Recommendations on Methodological Aspects of Research Design. World Neurosurg 2022; 161:382-395.e3. [PMID: 35505558 DOI: 10.1016/j.wneu.2021.08.140] [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: 08/16/2021] [Accepted: 08/30/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Modern neurosurgery has established maximal safe resection as a cornerstone in the management of diffuse gliomas. Evaluation of the extent of resection (EOR), and its association with certain outcomes or interventions, heavily depends on an adequate methodology to draw strong conclusions. We aim to identify weaknesses and limitations that may threaten the internal validity and generalizability of studies involving the EOR in patients with glioma and to suggest methodological recommendations that may help mitigate these threats. METHODS A systematic search was performed by querying PubMed, Web of Science, and Scopus since inception to April 30, 2021 using PICOS/PRISMA guidelines. Articles were then screened to identify high-impact studies evaluating the EOR in patients diagnosed with diffuse gliomas in accordance with predefined criteria. We identify common weakness and limitations during the evaluation of the EOR in the selected studies and then delineate potential methodological recommendations for future endeavors dealing with the EOR. RESULTS We identified 31 high-impact studies and found several research design issues including inconsistencies regarding EOR terminology, measurement, data collection, analysis, and reporting. Although some of these issues were related to now outdated reporting standards, many were still present in recent publications and deserve attention in contemporary and future research. CONCLUSIONS There is a current need to focus more attention to the methodological aspects of glioma research. Methodological inconsistencies may introduce weaknesses into the internal validity of the studies and hamper comparative analysis of cohorts from different institutions. We hope our recommendations will eventually help develop stronger methodological designs in future research endeavors.
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Affiliation(s)
- Henry Ruiz-Garcia
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida, USA
| | - Erik H Middlebrooks
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Daniel M Trifiletti
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia, USA.
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Gigliotti MJ, Srikanth S, Cockroft KM. Patterns of prophylactic anticonvulsant use in spontaneous intracerebral and subarachnoid hemorrhage: results of a practitioner survey. Neurol Sci 2021; 43:1873-1877. [PMID: 34495437 DOI: 10.1007/s10072-021-05588-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/26/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The use of prophylactic anti-seizure medications (ASMs) in the management of patients with spontaneous intracerebral hemorrhage (sICH) and aneurysmal subarachnoid hemorrhage (aSAH) is controversial. OBJECTIVE The purpose of this survey was to better characterize the current state of prophylactic ASM use in sICH and aSAH in North America. METHODS US and Canadian neurosurgeons, neurologists, and interventional neuroradiologists with an interest in or expertise in the management of neurovascular disease were surveyed using an electronic survey tool. RESULTS Seven hundred ninety-four survey requests were sent; responses were received from 103 (13%). The majority of respondents were neurosurgeons (84%). Thirty-eight percent of respondents self-identified as vascular neurosurgeons and 10% self-identified as neurocritical care specialists. Seventy-two percent were in academic practice. When asked their preference for ASM prophylaxis (aSAH, sICH, or both), the most common response was to use prophylaxis in both aSAH and sICH (43, 45%). Twenty-one (22%) did not use routine prophylaxis, while 22 (23%) used prophylaxis only in aSAH and 9 (9%) only in sICH. The majority of practitioners (35, 67%) who answered that they used ASM prophylaxis in sICH, used ASMs selectively. For aSAH, the vast majority (53, 82%) used prophylaxis for all patients. Respondents felt that they were more likely to use ASMs for sICH patients if the sICH was in a cortical location, supratentorial location, or was related to a structural abnormality (e.g., tumor, arteriovenous malformation) Levetiracetam (Keppra) was the most commonly used ASM (73, 99%). When asked whether the statement "Current AHA/ASA Guidelines recommend against the use of prophylactic anticonvulsants in spontaneous ICH" was true or false, 78 (83%) responded correctly that the recommendation is true. Only 24 respondents answered the question as to whether they would be willing to randomize sICH and/or aSAH patients to management with or without ASM prophylaxis. Of these, 13 (54%) said they would be willing to randomize sICH patients, while only 6 (25%) were willing to randomize aSAH patients. There were no statistically significant differences in responses to survey questions when analyzed by practice type (academic versus non-academic) or physician specialty (critical care versus non-critical care, or vascular neurology/neurosurgery versus other). CONCLUSION The use of ASMs for seizure prophylaxis after sICH and aSAH remains widespread despite the lack of any specific evidence-based guideline to support the practice. A large-scale randomized controlled trial is needed to add clarity to the practice of prophylactic ASM use in patients with spontaneous intracranial hemorrhage.
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Affiliation(s)
- Michael J Gigliotti
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Health Milton S. Hershey Medical Center, 30 Hope Drive, EC110, Hershey, PA, 17033, USA
| | - Shwetha Srikanth
- Penn State Neuroscience Institute, Penn State M.S. Hershey Medical Center, Hershey, PA, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Health Milton S. Hershey Medical Center, 30 Hope Drive, EC110, Hershey, PA, 17033, USA. .,Penn State Neuroscience Institute, Penn State M.S. Hershey Medical Center, Hershey, PA, USA. .,Department of Radiology, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA. .,Department of Public Health Sciences, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.
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Scullen T, Mathkour M, Werner C, Nerva JD, Dumont AS. Commentary: Thrombolysis for Evacuation of Intracerebral and Intraventricular Hemorrhage: A Guide to Surgical Protocols With Practical Lessons Learned From the MISTIE and CLEAR Trials. Oper Neurosurg (Hagerstown) 2021; 20:E33-E34. [PMID: 33316811 DOI: 10.1093/ons/opaa311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Mansour Mathkour
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Cassidy Werner
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - John D Nerva
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
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Hoz SS, Aktham AA, Al-Sharshahi ZF, Esene IN, Mahoney D, Chaurasia B, Radwan SE, Dolachee AA, Abdulazeez MM, Ramadan AHA, Moscote-Salazar LR, Sadik H. The most recommended neuroanatomy resources for neurosurgeons: an international survey. Surg Neurol Int 2021; 12:11. [PMID: 33500826 PMCID: PMC7827437 DOI: 10.25259/sni_501_2020] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 11/27/2020] [Indexed: 11/11/2022] Open
Abstract
Background: Neuroanatomy is the core basis for neurosurgical excellence. The quantity of accessible neuroanatomy resources has witnessed exponential growth in recent years. Accumulating a list of popular sources and getting them ranked by neurosurgeons was the motivation behind this investigation. Methods: A list of neuroanatomy resources was compiled using Google search wherein multiple sets of variable combinations of keywords were used. A three-section, eleven-item questionnaire was designed by two neurosurgeons and revised by a third independent reviewer. Neurosurgeons from different parts of the world were invited to participate. The participants were asked to rank the neuroanatomy textbook and non-book online source that they would recommend to neurosurgeons and the features that make a textbook appealing to them. Results: A total of 250 neurosurgeons at different levels of training responded to our questionnaire. Overall, “Rhoton’s Cranial Anatomy and Surgical Approach: Albert L. Rhoton Jr., Doctor of Medicine” was the most commonly chosen textbook that the neurosurgeons would use to revise neuroanatomy (86.0%; n = 215), recommend for residents (80.8%; n = 202) and recommend for certified surgeons (Continuing Medical Education (59.8%; n = 150), where applicable. “Illustrations” was rated as the most important neuroanatomy textbook quality by 53% (n = 134). “Rhoton collection” was the most popular online source (65.7%; n = 164.25). Chi-square tests showed no association between years of experience and the textbooks neurosurgeons recommended. Conclusion: Based on our study Rhoton’s book and his online collection are the leading neuroanatomy resources, recommended by neurosurgeons for neurosurgeons worldwide. The other selected resources can be implemented as a complementary part of a comprehensive neuroanatomy teaching curriculum. Knowing the relevance of these assets from a neurosurgeon’s perspective is valuable in directing future educational plan updates and recommendations.
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Affiliation(s)
- Samer S Hoz
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq
| | - Awfa A Aktham
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq
| | | | - Ignatius N Esene
- Department of Neurosurgery, Faculty of Health Sciences, University of Bamenda, Cameroon
| | - Dominic Mahoney
- Medical Student, University of Bristol, Bristol, United Kingdom
| | | | - Sameh E Radwan
- Department of Neurosurgery, El-Matareya Educational Hospital, Cairo, Egypt
| | - Ali A Dolachee
- Department of Surgery, College of Medicine, University of Al-Qadisiyah, Diwaniyah, Iraq
| | | | - Abdullah H Al Ramadan
- Department of Neurosurgery, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | - Hatem Sadik
- Department of Intensive Care, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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Xia R, Hu X, Willcox M, Li X, Li Y, Wang J, Li X, Moore M, Liu J, Fei Y. How far do we still need to go? A survey on knowledge, attitudes, practice related to antimicrobial stewardship regulations among Chinese doctors in 2012 and 2016. BMJ Open 2019; 9:e027687. [PMID: 31171552 PMCID: PMC6561603 DOI: 10.1136/bmjopen-2018-027687] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 04/05/2019] [Accepted: 05/15/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To explore doctors' knowledge, willingness, concerns and the countermeasures to the most stringent antimicrobial stewardship regulations of China which implemented in August 2012. DESIGN Cross-sectional survey. A pretested 32-point structured questionnaire was distributed to doctors by sending a web link via the mobile phone application WeChat through snowball sampling methods and email groups of medical academic societies. SETTING China. PARTICIPANTS Doctors. PRIMARY AND SECONDARY OUTCOME MEASURES The questionnaire inquired about the doctors' experiences, knowledge, willingness, concerns and the countermeasures to the stewardship policies. RESULTS Total of persons in the groups was 19 791, among them 1194 submitted the answers, within them, 807 were doctors. Doctors had a mean age of 39.0 years. The majority (78.9% in 2012, 89.1% in 2016) reported that they were willing or very willing to accept the regulations. Almost all respondents (93.2%) felt the stewardship regulations had the potential to adversely affect the prognosis of patients who would have been prescribed antimicrobials before they were implemented, and >65% (65.7% in 2012, 66.9% in 2016) of doctors were often or always concerned about the prognosis of these patients. In 2012, 32% of doctors prescribed restricted antimicrobials or suggested patient self-medication with restricted antimicrobials to address doctors' concerns, and this number decreased to 22.6% in 2016. Although compulsory antimicrobial stewardship training was frequent, less than half of respondents (46.8%) responded correctly to all three knowledge questions. CONCLUSION Antimicrobial stewardship regulations had some positive effect on rational antimicrobial use. Willingness and practice of doctors towards the regulations improved from 2012 to 2016. Knowledge about rational antimicrobial use was still lacking. Doctors found ways of accessing restricted antibiotics to address their concerns about the prognosis of patients, which undermined the implementation of the stewardship regulations.
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Affiliation(s)
- Ruyu Xia
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoyang Hu
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Merlin Willcox
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Xinxue Li
- Department of International Liaison, World Federation of Chinese Medicine Societies, Beijing, China
| | - Yuxiu Li
- Department of endocrinology, South of Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jian Wang
- Department of Neurology, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, China
| | - Xun Li
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Michael Moore
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Jianping Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Yutong Fei
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
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