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Vasireddi N, Vasireddi N, Shah AK, Moyal AJ, Gausden EB, Mclawhorn AS, Poelstra KA, Gould HP, Voos JE, Calcei JG. High Prevalence of Work-related Musculoskeletal Disorders and Limited Evidence-based Ergonomics in Orthopaedic Surgery: A Systematic Review. Clin Orthop Relat Res 2024; 482:659-671. [PMID: 37987688 PMCID: PMC10936985 DOI: 10.1097/corr.0000000000002904] [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] [Received: 05/29/2023] [Accepted: 09/29/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND The Centers for Disease Control defines work-related musculoskeletal disorders as disorders of the nerves, muscles, tendons, joints, spinal discs, and cartilage that are caused or exacerbated by the environment or nature of work. Previous meta-analyses have characterized work-related musculoskeletal disorders among interventionists, general surgeons, and other surgical subspecialties, but prevalence estimates, prognosis, and ergonomic considerations vary by study and surgical specialty. QUESTIONS/PURPOSES (1) What is the career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons? (2) What is the treatment prevalence associated with work-related musculoskeletal disorders in orthopaedic surgeons? (3) What is the disability burden of work-related musculoskeletal disorders in orthopaedic surgeons? (4) What is the scope of orthopaedic surgical ergonomic assessments and interventions? METHODS A systematic review of English-language studies from PubMed, MEDLINE, Embase, and Scopus was performed in December 2022 and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that presented prevalence estimates of work-related musculoskeletal disorders or assessed surgical ergonomics in orthopaedic surgery were included. Reviews, case reports, gray literature (conference abstracts and preprints), and studies with mixed-surgeon (nonorthopaedic) populations were excluded. The search yielded 5603 abstracts; 24 survey-based studies with 4876 orthopaedic surgeons (mean age 48 years; 79% of surgeons were men) were included for an analysis of work-related musculoskeletal disorders, and 18 articles were included for a descriptive synthesis of ergonomic assessment. Quality assessment using the Joanna Briggs Institute Tool revealed that studies had a low to moderate risk of bias, largely because of self-reporting survey-based methodology. Because of considerable heterogeneity and risk of bias, prevalence outcomes were not pooled and instead are presented as ranges (mean I 2 = 91.3%). RESULTS The career prevalence of work-related musculoskeletal disorders in orthopaedic surgeons ranged from 37% to 97%. By anatomic location, the prevalence of work-related musculoskeletal disorders in the head and neck ranged from 4% to 74%; back ranged from 9% to 77%; forearm, wrist, and hand ranged from 12% to 54%; elbow ranged from 3% to 28%; shoulder ranged from 3% to 34%; hip and thigh ranged from 1% to 10%; knee and lower leg ranged from 1% to 31%; and foot and ankle ranged from 4% to 25%. Of orthopaedic surgeons reporting work-related musculoskeletal disorders, 9% to 33% had a leave of absence, practice restriction or modification, or early retirement, and 27% to 83% received some form of treatment. Orthopaedic surgeons experienced biomechanical, cardiovascular, neuromuscular, and metabolic stress during procedures. Interventions to improve orthopaedic surgical ergonomics have been limited, but have included robotic assistance, proper visualization aids, appropriate use of power tools, and safely minimizing lead apron use. In hip and knee arthroplasty, robotic assistance was the most effective in improving posture and reducing caloric expenditure. In spine surgery, proper use of surgical loupes was the most effective in improving posture. CONCLUSION Although the reported ranges of our main findings were wide, even on the low end of the reported ranges, work-related musculoskeletal disability among orthopaedic surgeons appears to be a substantial concern. We recommend that orthopaedic residency training programs incorporate surgical ergonomics or work injury lectures, workshops, and film review (alongside existing film review of surgical skills) into their curricula. We suggest hospitals engage in shared decision-making with surgeons through anonymous needs assessment surveys to implement wellness programs specific to surgeons' musculoskeletal needs. We urge institutions to assess surgeon ergonomics during routine quality assessment of novel surgical instruments and workflows. LEVEL OF EVIDENCE Level III, prognostic study.
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Affiliation(s)
- Nikhil Vasireddi
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Drusinsky Sports Medicine Institute, South Euclid, OH, USA
| | | | - Aakash K. Shah
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Andrew J. Moyal
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Drusinsky Sports Medicine Institute, South Euclid, OH, USA
| | | | | | - Kornelis A. Poelstra
- The Robotic Spine Institute of New Jersey, Jersey City, NJ, USA
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | | | - James E. Voos
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Drusinsky Sports Medicine Institute, South Euclid, OH, USA
| | - Jacob G. Calcei
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
- University Hospitals Drusinsky Sports Medicine Institute, South Euclid, OH, USA
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Ring D. CORR Insights®: High Prevalence of Work-related Musculoskeletal Disorders and Limited Evidence-based Ergonomics in Orthopaedic Surgery: A Systematic Review. Clin Orthop Relat Res 2024; 482:672-674. [PMID: 38019128 PMCID: PMC10936973 DOI: 10.1097/corr.0000000000002920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/16/2023] [Indexed: 11/30/2023]
Affiliation(s)
- David Ring
- Associate Dean for Comprehensive Care, Department of Surgery and Perioperative Care, Dell Medical School, Austin, TX, USA
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Xu AL, Covarrubias OG, Yakkanti RR, Sotsky RB, Aiyer AA. The Biomechanical Burden of Orthopaedic Procedures and Musculoskeletal Injuries Sustained by Orthopaedic Surgeons: A Systematic Review. JBJS Rev 2023; 11:01874474-202301000-00010. [PMID: 36722828 DOI: 10.2106/jbjs.rvw.22.00202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Orthopaedic surgeons are at high risk for experiencing work-related musculoskeletal (MSK) injuries and chronic pain due to repetitive large magnitude forces, altered posture from lead vests, and prolonged irregular body positions. We sought to synthesize available evidence regarding (1) the biomechanics of orthopaedic surgery and (2) MSK injuries sustained by orthopaedic surgeons with subsequent treatment and consequences. METHODS To conduct this systematic review, we queried 4 databases (PubMed, Embase, MEDLINE, and Web of Science) for original research studies presenting on the biomechanics of orthopaedic surgery or MSK injuries sustained by orthopaedic surgeons. Studies were excluded if they were not original research (i.e., reviews) or reported on non-MSK injuries and injuries in patients or nonorthopaedic specialists. The literature search yielded 3,202 publications, 34 of which were included in the final analysis. RESULTS Eight studies reported on the biomechanics of orthopaedic surgery. Surgeons spent an average 41.6% of operating time slouched. Head and whole spine angles were closest to natural standing position when using a microscope for visualization and with higher surgical field heights. Use of lead aprons resulted in a shifted weight distribution on the forefoot, gain in thoracic kyphosis, and increase in lateral deviation from postural loading. Twenty-six studies reported on MSK symptoms and injuries experienced by orthopaedic surgeons, with an overall prevalence from 44% to 97%. The most common body regions involved were lower back (15.2%-89.5%), hip/thigh (5.0%-86.6%), neck (2.4%-74%), hand/wrist (10.5%-54%), shoulder (7.1%-48.5%), elbow (3.1%-28.3%), knee/lower leg (7.9%-27.4%), and foot/ankle (7%-25.7%). Of surgeons with any reported MSK symptom or injury, 27% to 65.7% required nonoperative treatment, 3.2% to 34.3% surgery, and 4.5% to 31% time off work. Up to 59.3% of surgeons reported that their injuries would negatively influence their ability to perform surgical procedures in the future. CONCLUSIONS The orthopaedic surgeon population experiences a high prevalence of MSK symptoms and injuries, likely secondary to the biomechanical burdens of tasks required of them during strenuous operations. LEVEL OF EVIDENCE Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Amy L Xu
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Oscar G Covarrubias
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ramakanth R Yakkanti
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Rachel B Sotsky
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Amiethab A Aiyer
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Factors associated with pain intensity and magnitude of limitations among people with hip and knee arthritis. J Orthop 2021; 25:295-300. [PMID: 34140758 DOI: 10.1016/j.jor.2021.05.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/16/2021] [Indexed: 02/06/2023] Open
Abstract
Background The pain and limitations associated with osteoarthritis of the hip and knee have a notable variation that does not correspond directly with pathophysiology. The purpose of this study is to assess the influence of location of the arthritis on pain intensity and magnitude of limitations accounting for personal and psychological factors. Methods One hundred and fifty four patients with osteoarthritis of the hip (41 patients) or the knee (113 patients) were enrolled in this prospective cross sectional cohort study. Patients answered questionnaires which included demographics, site of arthritis (hip or knee), laterality (unilateral or bilateral), pain intensity, Patient-Reported Outcomes Measurement Information System Physical Function Computer Adaptive Test (PROMIS PF CAT), and psychologic questionnaires including the Tampa Scale of Kinesiophobia (TSK-4), Pain Catastrophizing Scale (PCS-4), Generalized Anxiety Disorder (GAD-2) and Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test (PROMIS Dep CAT). Kellgren-Lawrence classification was classified by the treating surgeon. Associations of these factors with pain and function were assessed using bivariate and multivariable regression models. Results In a multivariable model accounting for potential confounding, magnitude of limitations was independently associated with years of education, work status, time spent exercising, catastrophic thinking (PCS-4), and symptoms of depression. They accounted for 50% of variability in physical function, with the major contributor being catastrophic thinking. The model for pain intensity included time spent exercising and fear of painful movement (TSK-4). Anatomic site and radiographic severity of arthritis were not associated with either physical function or pain in our patient sample. Conclusions This study confirms that limitations and pain from osteoarthritis of the hip and knee are more closely related to personal and psychological factors, less effective cognitive coping strategies such as catastrophic thinking and kinesiophobia in particular, than to pathological and anatomical factors such as location and severity of arthritis. Care that incorporates incremental correction of common misconceptions that accompany the nociception from osteoarthritis have the potential to improve function and comfort in people with osteoarthritis. Level of Evidence Prognostic Level II.
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Abstract
OBJECTIVES Requests for opioid pain medication more than a few weeks after surgery are associated with greater symptoms of depression and cognitive biases regarding pain such as worst-case thinking and fear of painful movement. We sought factors associated with patient desire for more opioid medication and satisfaction with pain alleviation at suture removal after lower extremity surgery. DESIGN Cross sectional study. SETTING Enrollment occurred at 1 of 4 orthopaedic offices in an urban setting. PATIENTS/PARTICIPANTS At suture removal after lower extremity surgery, 134 patients completed questionnaires measuring catastrophic thinking, ability to reach goals and continue normal activities in spite of pain, symptoms of depression, and magnitude of physical limitations. MAIN OUTCOME MEASUREMENTS Psychological factors associated with questionnaire-reported patient desire for another opioid prescription, satisfaction with postoperative pain alleviation, and the self-reported number of pills remaining from original opioid prescription. RESULTS In logistic regression, smoking and greater catastrophic thinking were independently associated with desire for opioid refill (R2 = 0.20). Lower satisfaction with pain alleviation was associated with greater catastrophic thinking (R2 = 0.19). The size of surgery (large vs. medium/small procedure) was not associated with pain alleviation or satisfaction with pain alleviation. CONCLUSIONS The association between unhelpful cognitive bias regarding pain and request for more opioids reinforces the importance of diagnosing and addressing common misconceptions regarding pain in efforts to help people get comfortable. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Adverse Childhood Experiences Are Not Associated With Patient-reported Outcome Measures in Patients With Musculoskeletal Illness. Clin Orthop Relat Res 2019; 477:219-228. [PMID: 30586342 PMCID: PMC6345287 DOI: 10.1097/corr.0000000000000519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Adverse childhood experiences (ACEs) affect adult mental health and tend to contribute to greater symptoms of depression and more frequent suicide attempts. Given the relationship between symptoms of depression and patient-reported outcomes (PROs), adversity in childhood might be associated with PROs in patients seeking care for musculoskeletal problems, but it is not clear whether in fact there is such an association among patients seeking care in an outpatient, upper extremity orthopaedic practice. QUESTIONS/PURPOSES (1) Are ACE scores independently associated with variation in physical limitations measured among patients seen by an orthopaedic surgeon? (2) Are ACE scores independently associated with variations in pain intensity? (3) What factors are associated with ACE scores when treated as a continuous variable or as a categorical variable? METHODS We prospectively enrolled 143 adult patients visiting one of seven participating orthopaedic surgeons at three private and one academic orthopaedic surgery offices in a large urban area. We recorded their demographics and measured ACEs (using a validated 10-item binary questionnaire that measured physical, emotional, and sexual abuse in the first 18 years of life), magnitude of physical limitations, pain intensity, symptoms of depression, catastrophic thinking, and health anxiety. There were 143 patients with a mean age of 51 years, 62 (43%) of whom were men. In addition, 112 (78%) presented with a specific diagnosis and most (n = 79 [55%]) had upper extremity symptoms. We created one logistic and three linear regression models to test whether age, gender, race, marital status, having children, level of education, work status, insurance type, comorbidities, body mass index, smoking, site of symptoms, type of diagnosis, symptoms of depression, catastrophic thinking, and health anxiety were independently associated with (1) the magnitude of limitations; (2) pain intensity; (3) ACE scores on the continuum; and (4) ACE scores categorized (< 3 or ≥ 3). We calculated a priori that to detect a medium effect size with 90% statistical power and α set at 0.05, a sample of 136 patients was needed for a regression with five predictors if ACEs would account for ≥ 5% of the variability in physical function, and our complete model would account for 15% of the overall variability. To account for 5% incomplete responses, we enrolled 143 patients. RESULTS We found no association between ACE scores and the magnitude of physical limitations measured by Patient-Reported Outcomes Measurement Information System Physical Function (p = 0.67; adjusted R = 0.55). ACE scores were not independently associated with pain intensity (Pearson correlation [r] = 0.11; p = 0.18). Greater ACE scores were independently associated with diagnosed mental comorbidities both when analyzed on the continuum (regression coefficient [β] = 1.1; 95% confidence interval [CI], 0.32-1.9; standard error [SE] 0.41; p = 0.006) and categorized (odds ratio [OR], 3.3; 95% CI, 1.2-9.2; SE 1.7; p = 0.024), but not with greater levels of health anxiety (OR, 1.1; 95% CI, 0.90-1.3; SE 0.096; p = 0.44, C statistic = 0.71), symptoms of depression (ACE < 3 mean ± SD = 0.73 ± 1.4; ACE ≥ 3 = 1.0 ± 1.4; p = 0.29) or catastrophic thinking (ACE < 3 = 3.6 ± 3.5; ACE ≥ 3 = 4.9 ± 5.1; p = 0.88). CONCLUSIONS ACEs may not contribute to greater pain intensity or magnitude of physical limitations unless they are accompanied by greater health anxiety or less effective coping strategies. Adverse events can contribute to anxiety and depression, but perhaps they sometimes lead to development of resilience and effective coping strategies. Future research might address whether ACEs affect symptoms and limitations in younger adult patients and patients with more severe musculoskeletal pathology such as major traumatic injuries. LEVEL OF EVIDENCE Level II, prognostic study.
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Medina SH, Nadarajah V, Jauregui JJ, Smuda MP, Foster M, Meredith SJ, Packer JD, Henn RF. Orthopaedic surgery patients who use recreational marijuana have less pre-operative pain. INTERNATIONAL ORTHOPAEDICS 2018; 43:283-292. [PMID: 30135987 DOI: 10.1007/s00264-018-4101-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 08/08/2018] [Indexed: 01/26/2023]
Abstract
AIMS To determine the baseline clinical characteristics of recreational marijuana users undergoing outpatient orthopaedic surgery. We hypothesized that patients who report marijuana use would have worse pain, function, and general health status. PATIENTS AND METHODS Nine-hundred and thirty-seven patients undergoing outpatient orthopaedic surgery were asked to fill out patient-reported outcome (PRO) tools. These PROs included the Patient-Reported Outcomes Measurement Information Systems (PROMIS) computer adaptive tests and legacy PROs unique to each patients' surgical site. RESULTS Forty patients (4.2%) reported marijuana use. Marijuana use was associated with younger age (33 vs. 43 years, p < 0.001), having a history of fewer operations (1.8 vs. 3.2, p < 0.05), single marital status (68 vs. 38%, p < 0.01), and having a history of smoking cigarettes (63 vs. 31%, p < 0.0001). Marijuana use was found to be significantly associated with greater Marx lower extremity activity rating scale scores (8.5 points vs. 6.1 points, p < 0.05) and decreased pain intensity in the operative site (3.7 points vs. 5.0 points, p < 0.05). Multivariable analysis found that marijuana use was an independent factor associated with less pain intensity in the operative site (p < 0.05). CONCLUSION Our studies support other national studies that report increased marijuana use among younger patients and those who smoke cigarettes. The results do not support our hypothesis, as marijuana use was associated with less pain and better lower extremity activity rating scale scores when compared to non-users. Further research is warranted to analyze the effects of marijuana use on orthopaedic surgery patients. STUDY DESIGN Cross-sectional study.
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Affiliation(s)
- Shaun H Medina
- Department of Orthopaedics, University of Maryland School of Medicine, University of Maryland Rehabilitation and Orthopaedic Institute, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - Vidushan Nadarajah
- Department of Orthopaedics, University of Maryland School of Medicine, University of Maryland Rehabilitation and Orthopaedic Institute, 2200 Kernan Drive, Baltimore, MD, 21207, USA.,Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Julio J Jauregui
- Department of Orthopaedics, University of Maryland School of Medicine, University of Maryland Rehabilitation and Orthopaedic Institute, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - Michael P Smuda
- Department of Orthopaedics, University of Maryland School of Medicine, University of Maryland Rehabilitation and Orthopaedic Institute, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - Michael Foster
- Department of Orthopaedics, University of Maryland School of Medicine, University of Maryland Rehabilitation and Orthopaedic Institute, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - Sean J Meredith
- Department of Orthopaedics, University of Maryland School of Medicine, University of Maryland Rehabilitation and Orthopaedic Institute, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - Jonathan D Packer
- Department of Orthopaedics, University of Maryland School of Medicine, University of Maryland Rehabilitation and Orthopaedic Institute, 2200 Kernan Drive, Baltimore, MD, 21207, USA
| | - R Frank Henn
- Department of Orthopaedics, University of Maryland School of Medicine, University of Maryland Rehabilitation and Orthopaedic Institute, 2200 Kernan Drive, Baltimore, MD, 21207, USA.
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Dianat I, Bazazan A, Souraki Azad MA, Salimi SS. Work-related physical, psychosocial and individual factors associated with musculoskeletal symptoms among surgeons: Implications for ergonomic interventions. APPLIED ERGONOMICS 2018; 67:115-124. [PMID: 29122182 DOI: 10.1016/j.apergo.2017.09.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 09/14/2017] [Accepted: 09/18/2017] [Indexed: 06/07/2023]
Abstract
This study evaluated the effect of physical, psychosocial and individual factors on the presence of musculoskeletal symptoms (MSS) among surgeons (n = 312) in Iran. Data were collected using questionnaires and analysed by multivariate logistic regression. The prevalence of MSS, particularly in the knees (48.7%), neck (45.8%), low back (42.3%) and shoulders (40.1%) was relatively high. Work-related factors including time spent on surgeries each week (>25 h/week), number of hours working in standing position per day (>4 h/day), moderate to high levels of work-family conflict, duration of each surgery (>3 h), number of years worked as a surgeon (>10 years) and surgical specialty (particularly cardiothoracic and obstetric/gynecologic surgeries) were independently associated with the presence of MSS in different body regions. Individual factors including gender (being female) and little or no involvement in sport and physical activity were also independently associated with the occurrence of complaints. Implications of the findings for further research and development work for improving the working conditions and consequently reducing MSS among this working group are discussed.
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Affiliation(s)
- Iman Dianat
- Department of Occupational Health and Ergonomics, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Ahmad Bazazan
- Department of Occupational Health and Ergonomics, Faculty of Health, Tabriz University of Medical Sciences, Tabriz, Iran.
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