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Alborzi S, Roman H, Askary E, Poordast T, Shahraki MH, Alborzi S, Hesam Abadi AK, Najar Kolaii EH. Colorectal endometriosis: Diagnosis, surgical strategies and post-operative complications. Front Surg 2022; 9:978326. [PMID: 36268216 PMCID: PMC9577108 DOI: 10.3389/fsurg.2022.978326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Abstract
Objective The present work aimed to investigate the feasibility, complications, recurrence rate, and infertility outcomes of the radical and conservative surgical methods for colorectal endometriosis in short- and long-term follow-ups. Methods In this prospective study, the patients with confirmed diagnosis of colorectal DIE were included from March 2015 to March 2021, who were referred to an Endometriosis Surgery Center affiliated with Shiraz University of Medical Sciences (SUMS). Information on demographics, surgical approaches, intra-operative, and post-operative findings as well as complications were collected and compared. Six- and 12-month interviews were conducted to evaluate the functional outcomes of all the procedures. Results Out of 3,111 patients who underwent endometriosis surgery, 837 (28.19%) with the average age of 34.2 ± 5.9 years and average ASRM score of 102.1 ± 36.8 had rectosigmoid endometriosis. Laparoscopic rectal shaving was performed in 263(30.0%) patients while 326 (37.2%) underwent segmental bowel resection, and 248 (28.30%) were treated with disc excision. Prophylactic ileostomy was performed in six (0.68%) patients and peritonitis was reported in four (0.45%). Five (0.58%) subjects developed rectovaginal fistula and one (0.11%) was diagnosed with bladder atonia. The recurrence rate was 3.8%, 1.2%, and 0.3% in rectal shaving, disc, and segmental bowel resection techniques, respectively. Dysmenorrhea, dyspareunia, and dyschezia were improved after surgery by 7.3, 9.4, and 12.5 times, respectively. We observed 25.2% of total pregnancy following the operation, the majority of which occurred in the first year after the surgery. Conclusion There were very few short-term or long-term complications in the three different techniques when the choice was correct.
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Affiliation(s)
- Saeed Alborzi
- Department of Obstetrics and Gynecology, School of Medicine, Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Horace Roman
- Department of Gynecology and Obstetrics, Clinique Gynécologique et Obstétrical, Rouen University Hospital, Rouen, France
| | - Elham Askary
- Department of Obstetrics and Gynecology, School of Medicine, Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran,Correspondence: Elham Askary
| | - Tahereh Poordast
- Department of Obstetrics and Gynecology, School of Medicine, Infertility Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Soroush Alborzi
- Cardiologist, Student Research Center, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alimohammad Keshtvarz Hesam Abadi
- Master of Biostatistics in Clinical Research Development Center of Nemazee Hospital, Department of Statistics, Shiraz University of Medical Sciences, Shiraz, Iran
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Popoutchi P, Marques Junior OW, Averbach P, Cardoso Filho CAM, Averbach M. SURGICAL TECHNIQUES FOR THE TREATMENT OF RECTAL ENDOMETRIOSIS: A SYSTEMATIC REVIEW OF RANDOMIZED CONTROLLED TRIALS AND OBSERVATIONAL STUDIES. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:548-559. [PMID: 34909864 DOI: 10.1590/s0004-2803.202100000-97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/18/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Endometriosis is a common disease in reproductive-age women and it is estimated to occur in up to 50% of those with infertility. Intestinal involvement is reported in up to a third of the cases. This condition is related to chronic pain and loss of quality of life, resulting in emotional, social and economic costs. Treatment consists of hormonal block and surgical resection, with variable side effects and efficacy. The best choice for surgical treatment for rectal endometriosis is a matter of discussion regarding the indication and the best technique to be employed. OBJECTIVE To summarize data on indications, results and complications of surgical techniques for the treatment of rectal endometriosis. METHODS This comprehensive systematic review is a compilation of the available literature and discussion, carried out by a team with experience in the surgical treatment of intestinal endometriosis. Data regarding indications, results and complications of conservative and radical techniques for the surgical treatment of rectal endometriosis was carefully reviewed. Searches of PubMed, EMBASE, and CENTRAL up to May 2021 were performed to identify randomized controlled trials (RCTs) and observational studies that compared at least two of the three surgical techniques of interest (i.e., shaving, discoid resection, segmental resection). RESULTS One RCT and nine case series studies with a total of 3,327 patients met the eligibility criteria. Participants ages ranged from a mean of 30.0 to 37.9 years old. Mean follow-up ranged from 1.2 to 42.76 months. With regards the methodological quality, overall the included studies presented a low risk of bias in the majority of the domains. Surgical treatment of rectal endometriosis is indicated for patients with obstructive symptoms and those with pain scores above 7/10. Patients with disease involving beyond muscularis propria of the rectum, documented in magnetic resonance imaging or transvaginal pelvic ultrasound with intestinal preparation, are candidates for discoid or segmental resection. The presence of multifocal disease, extension greater than 3 cm and infiltration greater than 50% of the loop circumference favor the radical technique. The distance from the lesion to the anal verge, age, symptoms and reproductive desire are other factors that influence the choice of the technique to be employed. The risk of complications and unfavorable functional results seems to be directly related to the complexity of the procedure. CONCLUSION The choice of surgical technique performed for the treatment of rectal endometriosis is a matter of discussion and depends not only on the preoperative staging, but also on the patient's expectations, risks and potential complications, recurrence rates and the expertise of the multidisciplinary team.
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Affiliation(s)
- Pedro Popoutchi
- Hospital Sírio-Libanês, Instituto de Ensino e Pesquisa, São Paulo, SP, Brasil
| | - Oswaldo Wiliam Marques Junior
- Hospital Sírio-Libanês, Instituto de Ensino e Pesquisa, São Paulo, SP, Brasil.,Fundação Antônio Prudente - A.C.Camargo Hospital, São Paulo, SP, Brasil
| | - Pedro Averbach
- Disciplina de Coloproctologia, Departamento de Gastroenterologia da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Celso Augusto Milani Cardoso Filho
- Hospital Sírio-Libanês, Instituto de Ensino e Pesquisa, São Paulo, SP, Brasil.,Fundação Antônio Prudente - A.C.Camargo Hospital, São Paulo, SP, Brasil
| | - Marcelo Averbach
- Hospital Sírio-Libanês, Instituto de Ensino e Pesquisa, São Paulo, SP, Brasil
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Marcello C, Roberto C, Adele ME, Katarzyna SA, Paola DM, Matteo C, Giacomo R, Francesco B, Lorenzo R, Daniela S. "The Sword in the Stone": radical excision of deep infiltrating endometriosis with bowel shaving-a single-centre experience on 703 consecutive patients. Surg Endosc 2021; 36:3418-3431. [PMID: 34312725 DOI: 10.1007/s00464-021-08663-z] [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: 02/14/2021] [Accepted: 07/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Laparoscopic segmental bowel resection, disc excision and rectal shaving are described as surgical options for the treatment of bowel endometriosis, but the gold standard has not yet established. The aim of the study is to investigate the efficacy of the laparoscopic bowel shaving technique in terms of pain symptomatology and to analyse early and late postoperative complications. METHODS Retrospective cohort study of a series of 703 consecutive patients treated between January 2014 and December 2019 in a tertiary care referral centre. All patients underwent laparoscopic bowel shaving with concomitant radical excision of DIE. RESULTS Bilateral posterolateral parametrectomy and ureterolysis were performed, respectively, in 314 (44.7%) and 318 cases (45.2%). A radical hysterectomy was performed in 107 cases (82.9%). Postoperative complications were infrequent: 17 patients required a reoperation (2.4%) and in this subgroup we registered 2 rectovaginal fistulas (0.3%), 4 patients received blood transfusion (0.6%), 12 patients (1.7%) experienced postoperative fever, 6 patients experienced impaired bladder voiding (0.9%) after 6 months. Median follow-up was 14 months. The study reported good clinical and surgical results, with a regression of symptoms (p < 0.0001) and an overall rate of recurrence of 6.5%. Clinical and instrumental criteria of bowel endometriosis relapse were exclusively detected in 5 patients (0.8%). Eleven patients (1.7%) with relapsed endometriosis were reoperated. CONCLUSIONS Bowel shaving is a feasible and valuable surgical procedure. It is only the last step of a complex surgery which is aimed to minimize the residual quote of infiltrating nodule and requires a multidisciplinary team to achieve optimal treatment preoperatively, intraoperatively and postoperatively.
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Affiliation(s)
- Ceccaroni Marcello
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy-IRCCS "Sacro Cuore-Don Calabria" Hospital, Via Don A. Sempreboni 5, 37024, Negrar, Verona, Italy.
| | - Clarizia Roberto
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy-IRCCS "Sacro Cuore-Don Calabria" Hospital, Via Don A. Sempreboni 5, 37024, Negrar, Verona, Italy
| | - Mussi Erica Adele
- Department of Obstetrics and Gynecology, "Maggiore della Carità" Hospital, "Università del Piemonte Orientale", Corso Mazzini 18, 28100, Novara, Italy
| | - Stepniewska Anna Katarzyna
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy-IRCCS "Sacro Cuore-Don Calabria" Hospital, Via Don A. Sempreboni 5, 37024, Negrar, Verona, Italy
| | - De Mitri Paola
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy-IRCCS "Sacro Cuore-Don Calabria" Hospital, Via Don A. Sempreboni 5, 37024, Negrar, Verona, Italy
| | - Ceccarello Matteo
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy-IRCCS "Sacro Cuore-Don Calabria" Hospital, Via Don A. Sempreboni 5, 37024, Negrar, Verona, Italy
| | - Ruffo Giacomo
- Department of General Surgery, IRCCS "Sacro Cuore-Don Calabria" Hospital, Via Don A. Sempreboni 5, 37024, Negrar, Verona, Italy
| | - Bruni Francesco
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy-IRCCS "Sacro Cuore-Don Calabria" Hospital, Via Don A. Sempreboni 5, 37024, Negrar, Verona, Italy
| | - Rettore Lorenzo
- Department of General Surgery, IRCCS "Sacro Cuore-Don Calabria" Hospital, Via Don A. Sempreboni 5, 37024, Negrar, Verona, Italy
| | - Surico Daniela
- Department of Obstetrics and Gynecology, "Maggiore della Carità" Hospital, "Università del Piemonte Orientale", Corso Mazzini 18, 28100, Novara, Italy
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Barra F, Alessandri F, Scala C, Ferrero S. Ultrasonographic 3D Evaluation in the Diagnosis of Bladder Endometriosis: A Prospective Comparative Diagnostic Accuracy Study. Gynecol Obstet Invest 2021; 86:299-306. [PMID: 34157713 DOI: 10.1159/000516634] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 04/19/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The use of three-dimensional (3D) transvaginal ultrasonography (TVS) has been investigated for the diagnosis of deep endometriosis (DE). This study aimed to evaluate if 3D reconstructions improve the performance of TVS) in assessing the presence and characteristics of bladder endometriosis (BE). DESIGN This was a single-center comparative diagnostic accuracy study. Participants/Materials, Setting, Methods: Patients referred to our institution (Piazza della Vittoria 14 Srl, Genova, Italy) with clinical suspicion of DE were included. In case of surgery, women underwent systematic preoperative ultrasonographic imaging; an experienced sonographer performed a conventional TVS; another experienced sonographer, blinded to results of the previous exam, performed TVS, with the addition of 3D modality. The presence and characteristics of BE nodules were described in accord with International DE Analysis group consensus. Ultrasound data were compared with surgical and histological results. RESULTS Overall, BE was intraoperatively found in 34 out of 194 women who underwent surgery for DE (17.5%; 95% confidence interval: 12.8-23.5%). TVS without and with 3D reconstructions were able to detect endometriotic BE in 82.2% (n = 28/34) and 85.3% (n = 29/34) of the cases (p = 0.125). Both the exams similarly estimated the largest diameter of BE (p = 0.652) and the distance between the endometriotic nodule and the closest ureteral meatus (p = 0.341). However, TVS with 3D reconstructions was more precise in estimating the volume of BE (p = 0.031). In one case (2.9%), TVS without and with 3D reconstructions detected the infiltration of the intramural ureter, which was confirmed at surgery and required laparoscopic ureterovesical reimplantation. LIMITATIONS The extensive experience of the gynecologists performing the ultrasonographic scans, the lack of prestudy power analysis, and the population selected, which may have been influenced by the position of the institution as a referral center specialized in the treatment of severe endometriosis, are limitations of the current study. CONCLUSION Our results demonstrated the high accuracy of ultrasound for diagnosing BE. The addition of 3D reconstructions does not improve the performance of TVS in diagnosing the presence and characteristics of BE. However, the volume of BE may be more precisely assessed by 3D ultrasound.
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Affiliation(s)
- Fabio Barra
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy.,Academic Unit of Obstetrics and Gynecology, IRRCS Ospedale Policlinico San Martino, Genova, Italy.,Piazza della Vittoria 14 SRL, Genova, Italy
| | - Franco Alessandri
- Unit of Obstetrics and Gynecology, IRRCS Ospedale Policlinico San Martino, Genova, Italy
| | - Carolina Scala
- Piazza della Vittoria 14 SRL, Genova, Italy.,Unit of Obstetrics and Gynecology, Gaslini Institute, Genova, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genova, Genova, Italy.,Academic Unit of Obstetrics and Gynecology, IRRCS Ospedale Policlinico San Martino, Genova, Italy.,Piazza della Vittoria 14 SRL, Genova, Italy
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Yela DA, Vitale SG, Vizotto MP, Benetti-Pinto CL. Risk factors for recurrence of deep infiltrating endometriosis after surgical treatment. J Obstet Gynaecol Res 2021; 47:2713-2719. [PMID: 33998109 DOI: 10.1111/jog.14837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/08/2021] [Accepted: 05/03/2021] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the frequency of complications and factors associated with the recurrence of endometriosis in women with deep infiltrating endometriosis (DIE) undergoing surgical treatment. METHODS A retrospective observational cohort study with 72 women who underwent surgery and followed up by DIE at the University of Campinas from 2007 to 2017. The variables analyzed were clinical characteristics, use and type of drug treatment before and after surgery, operative time and complications inherent to the procedure, as well as the recurrence of lesions on imaging. RESULTS The mean age of women was 39.7 ± 6.3 years and the mean follow-up was 4.56 ± 2.60 years. Complications were reported in 16.6% of surgeries and recurrence of lesions in 34.7%. The risk of intraoperative complications was higher in the presence of lesions of the bowel and in those who used intramuscular progestin before surgery. A higher risk of recurrence was observed among those who did not use hormonal treatment or used a levonorgestrel-releasing intrauterine device (LNG-IUD) in the postoperative period. CONCLUSION Women with DIE have a high rate of complications during surgical treatment and a higher risk of recurrence when they did not receive hormonal treatment or when treated with LNG-IUD after surgery.
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Affiliation(s)
- Daniela Angerame Yela
- School of Medical Sciences, Department of Obstetrics and Gynecology, University of Campinas (Unicamp), Campinas, Brazil
| | - Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | | | - Cristina Laguna Benetti-Pinto
- School of Medical Sciences, Department of Obstetrics and Gynecology, University of Campinas (Unicamp), Campinas, Brazil
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Nisolle M, Brichant G, Tebache L. A peroperative analysis of rectal vascularization after the shaving technique: an innovative method to avoid fistula? Fertil Steril 2020; 114:275-276. [PMID: 32741465 DOI: 10.1016/j.fertnstert.2020.04.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 04/28/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Michelle Nisolle
- Department of Obstetrics and Gynecology, University of Liège, CHR Liège, Liège, Belgium
| | - Géraldine Brichant
- Department of Obstetrics and Gynecology, University of Liège, CHR Liège, Liège, Belgium
| | - Linda Tebache
- Department of Obstetrics and Gynecology, University of Liège, CHR Liège, Liège, Belgium
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Biscaldi E, Barra F, Leone Roberti Maggiore U, Ferrero S. Other imaging techniques: Double-contrast barium enema, endoscopic ultrasonography, multidetector CT enema, and computed tomography colonoscopy. Best Pract Res Clin Obstet Gynaecol 2020; 71:64-77. [PMID: 32698994 DOI: 10.1016/j.bpobgyn.2020.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 02/07/2023]
Abstract
Double-contrast barium enema (DCBE), transrectal endoscopic ultrasonography (REU), multidetector computerized tomography enema (MDCT-e), and computed tomography colonoscopy (CTC) have been successfully used for the diagnosis of bowel endometriosis. DCBE provides a complete overview of the entire colon and allows detecting cecal nodules. The accuracy of DCBE is operator dependent and, thus, it may have low specificity. It does not allow identifying the cause of the mass effect. DCBE requires the administration of barium and exposure to radiation. REU precisely estimates the distance between the rectosigmoid nodule and the anal verge. However, it allows investigating only the distal part of rectosigmoid, it misses anterior pelvic lesions, and it has poor sensitivity for the diagnosis of endometriomas. MDCT-e is accurate and reproducible in diagnosing intestinal endometriosis and in assessing its characteristics: the largest diameter of the nodule, the distance between the distal part of the nodule and the anal verge, and depth of infiltration of endometriosis in the intestinal wall. MDCT-e requires the administration of iodinated contrast medium (CM) and the exposure to radiations. CTC has good performance in the diagnosis of rectosigmoid endometriosis. It allows estimating the degree of intestinal stenosis CTC, and the distance between the intestinal endometriotic nodule and the anal verge. It requires exposure to radiations, and it may require the administration of an iodinated CM.
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Affiliation(s)
- Ennio Biscaldi
- Department of Radiology, Galliera Hospital, via Mura delle Cappuccine 14, Genova, 16128, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy.
| | | | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Largo R. Benzi 10, 16132, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Italy
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Estes SJ, Soliman AM, Epstein AJ, Bond JC, Gordon K, Missmer SA. National trends in inpatient endometriosis admissions: Patients, procedures and outcomes, 2006-2015. PLoS One 2019; 14:e0222889. [PMID: 31536593 PMCID: PMC6752838 DOI: 10.1371/journal.pone.0222889] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/08/2019] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Despite guidance towards minimally invasive, outpatient procedures for endometriosis, many patients nonetheless receive inpatient care. Our objective was to assess trends in patient and hospital characteristics, surgical complications and hospital charges for women with an endometriosis-related inpatient admission in the United States. METHODS We conducted a pooled cross-sectional analysis of Healthcare Cost and Utilization Project Nationwide Inpatient Sample data. Visits were stratified into three time-period-defined cohorts (2006-2007, 2010-2011, and 2014 through the first three quarters of 2015). Visits were included if the patient was aged 18-49 years and the primary diagnosis code was for endometriosis (International Classification of Diseases, 9th Revision code 617.xx). We evaluated counts of inpatient admissions and rates of patient and hospital characteristics. RESULTS The number of inpatient admissions with a primary diagnosis code for endometriosis decreased by 72.8% from 2006 to 2015. At the same time, among those admitted for inpatient care for endometriosis, the proportions who had Medicaid insurance and multiple documented comorbidities increased. From 2006 to 2015, mean total hospital charges increased by 75% to $39,662 in 2015 US dollars, although average length of stay increased by <1 day. CONCLUSIONS The number of inpatient admissions with a primary diagnosis of endometriosis decreased over the past decade, while surgical complications and associated hospital charges increased. The share of patients with multiple comorbidities increased and an increasing proportion of inpatient endometriosis admissions were covered by Medicaid and occurred at urban teaching hospitals. These findings suggest a demographic shift in patients receiving inpatient care for endometriosis towards more complex, vulnerable patients.
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Affiliation(s)
- Stephanie J. Estes
- Department of Obstetrics and Gynecology, Penn State Health, Hershey, PA, United States of America
- * E-mail:
| | | | | | - Julia C. Bond
- Medicus Economics, Philadelphia, PA, United States of America
| | - Keith Gordon
- AbbVie Inc., North Chicago, IL, United States of America
| | - Stacey A. Missmer
- Department of Obstetrics, Gynecology and Reproductive Biology, Michigan State University, Grand Rapids, Michigan, United States of America
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
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