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Digital Rectal Exam in the Acute Hospital Setting: Bridging Patient Experience and the Physician Perspective. J Community Hosp Intern Med Perspect 2023; 12:64-68. [PMID: 36816164 PMCID: PMC9924647 DOI: 10.55729/2000-9666.1119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 11/11/2022] Open
Abstract
The digital rectal examination is one of the key physical examination tools used in the assessment of gastrointestinal bleed, different rectal diseases and prostate disease. It is an invasive diagnostic test that has a significant level of patient anxiety and discomfort involved. Despite its many diagnostic utilities this exam has been vastly underutilised due to many limiting factors including lack of physician confidence with this bedside physical maneuver. This review includes patient's point of view and providers perspective on digital rectal examination in the inpatient hospital setting. Some of the contributors to negative patient experience include opposite gender of the physician performing the procedure, lack of procedural awareness and expectations and repeat examinations due to improper electronic health care record charting. A better understanding of the limitations and constraints involved from both the patient and physician perspective can help improve patient experience and overall clinical outcomes.
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Digital Rectal Examination Is a Valuable Bedside Tool for Detecting Dyssynergic Defecation: A Diagnostic Study and a Meta-Analysis. Can J Gastroenterol Hepatol 2021; 2021:5685610. [PMID: 34746041 PMCID: PMC8568520 DOI: 10.1155/2021/5685610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/20/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Accurate dyssynergic defecation (DD) diagnosis depends on anorectal physiological tests that are not widely available. AIM The purpose of this study is to evaluate the diagnostic yield of digital rectal examination (DRE) compared with anorectal physiological tests in diagnosing DD in patients with constipation. METHODS A total of 218 chronic constipation patients who fulfilled the Rome IV diagnostic criteria for functional constipation (FC) and underwent a standardized DRE and high-resolution anorectal manometry (HRAM) test were enrolled in this study. The diagnostic accuracy of DRE compared with HRAM was evaluated, and the agreement between DRE and HRAM was calculated. Furthermore, a comprehensive literature search on PubMed, Web of Science, Cochrane Library, and Embase database was conducted to further elucidate the pooled diagnostic accuracy of DRE in DD patients. RESULTS A total of 101 patients (46.33%) had a DD pattern using HRAM, while 117 patients (53.67%) were diagnosed without DD. The sensitivity of DRE in diagnosing dyssynergia was 71.3%, and the specificity was 76.1%. There was a moderate agreement between DRE and HRAM for diagnosing DD (κ-coefficient = 0.474, P < 0.001). Meanwhile, six studies (including our study) comprising 964 constipated patients were included in our meta-analysis. The outcomes demonstrated that the AUC was 0.85 (95% CI 0.82-0.88) with 77% summary sensitivity (95% CI 65-86) and 80% summary specificity (95% CI 71-86) to diagnose DD. CONCLUSIONS DRE could be a valuable tool for screening DD. Our study revealed acceptable sensitivity and specificity of DRE in detecting dyssynergia compared with the physiological tests. Meanwhile, our study highlights that DRE remains an important tool in clinical practice.
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Hopkins H, Weaks C, Webster T, Elcin M. The association of standardized patient educators (ASPE) gynecological teaching associate (GTA) and male urogenital teaching associate (MUTA) standards of best practice. Adv Simul (Lond) 2021; 6:23. [PMID: 34154661 PMCID: PMC8215835 DOI: 10.1186/s41077-021-00162-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/17/2021] [Indexed: 11/10/2022] Open
Abstract
Gynecological Teaching Associates (GTAs) and Male Urogenital Teaching Associates (MUTAs) instruct healthcare professional learners to perform accurate and respectful breast, speculum, bimanual vaginal, rectal, urogenital, and prostate examinations. During such sessions, the GTA/MUTA uses their own body to instruct while providing real-time feedback. While GTAs/MUTAs fall under the broader umbrella of Standardized Patient methodology, the specificity of their role indicates need for establishment of Standards of Best Practice (SOBP) for GTA/MUTA programs. On behalf of the Association of Standardized Patient Educators (ASPE), the Delphi process was utilized to reach international consensus identifying the Practices that comprise the ASPE GTA/MUTA SOBP. The original ASPE SOBP was used as the foundation for the iterative series of three surveys. Results were presented at the ASPE 2019 conference for additional feedback. Fifteen participants from four countries completed the Delphi process. Four of the original ASPE SOBP Domains were validated for GTA/MUTA programs: Safe Work Environment, Instructional Session Development, Training GTAs/MUTAs, and Program Management. Principles and Practices were shaped, and in some instances created, to best fit the distinct needs of GTA/MUTA programs. The ASPE GTA/MUTA SOBP apply to programs that engage GTAs/MUTAs in formative instructional sessions with learners. Programs that incorporate GTAs/MUTAs in simulation roles or in summative assessment are encouraged to reference the ASPE SOBP in conjunction with this document. The SOBP are aspirational and should be used to shape Practices within the program's local context. The ASPE GTA/MUTA SOBP will continue to evolve as our knowledge-base and practice develop.
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Affiliation(s)
- Holly Hopkins
- Eastern Michigan University School of Nursing, 311 Marshall Building, Ypsilanti, MI 48197 USA
| | - Chelsea Weaks
- Eastern Virginia Medical School Sentara Center for Simulation and Immersive Learning, 651 Colley Avenue, Norfolk, VA 23501 USA
| | - Tim Webster
- University of Manitoba Rady Faculty of Health Sciences, 250 Brodie Centre, 727 McDermot Avenue, Winnipeg, Manitoba R3E 3P5 Canada
| | - Melih Elcin
- Department of Medical Education and Informatics, Hacettepe University Faculty of Medicine, Sihhiye Campus, 06100 Ankara, Turkey
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Hopkins H, Weaks C, Napier E. Implementation and utilization of gynecological teaching associate and male urogenital teaching associate programs: a scoping review. Adv Simul (Lond) 2021; 6:19. [PMID: 34016185 PMCID: PMC8138924 DOI: 10.1186/s41077-021-00172-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 05/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Gynecological Teaching Associates (GTAs) and Male Urogenital Teaching Associates (MUTAs) are individuals trained to instruct health professional learners with their own body to conduct accurate, patient-centered breast, pelvic, urogenital, rectal, and/or prostate examinations. Evidence indicates that this results in improvements in technical competence and communication skills, but there is wide variability to how such programs are implemented and engaged within the curriculum. In this scoping review, we mapped evidence regarding (1) how GTA/MUTA programs are utilized with health professional learners, (2) how GTA/MUTA programs are implemented using the Association of Standardized Patient Educators (ASPE) Standards of Best Practice (SOBP) as a framework, and (3) what broad outcomes are addressed in publications. METHODS PubMed, ERIC, PsychINFO, CINAHL, and Sociological Abstracts were searched for all publications addressing instruction of physical examinations with a GTA/MUTA and/or administration of GTA/MUTA programs. Studies were charted in tandem until consensus was identified and then charted individually, using an iterative process. The scoping review protocol was registered prospectively. RESULTS One hundred and one articles were identified, and nearly all highlighted positive results regarding GTA/MUTA programs. Most studies addressed medical students within the USA and Europe. During instructional sessions, three (SD=1.4) learners worked with each GTA/MUTA and an average of 32 min (SD=17) was allocated per learner. GTAs/MUTA instructed both independently (n=33) and in pairs (n=51). Thirty-eight articles provided detailed information consistent with one or more of the Domains of the ASPE SOBP, with six providing specific information regarding safe work environments. CONCLUSIONS While studies demonstrate consistently positive outcomes for learners, there is wide variability in implementation patterns. This variability may impact learning outcomes and impact both physical and psychological safety for GTAs/MUTAs and learners. Terminology used to refer to GTAs/MUTAs is inconsistent and may obscure relevant publications. Additional research is indicated to explore the pedagogical variables that result in positive learning outcomes and examine methods to ensure physical and psychological safety of GTAs/MUTAs and learners. TRIAL REGISTRATION https://osf.io/x9w2u/ .
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Affiliation(s)
- Holly Hopkins
- Eastern Michigan University School of Nursing, 311 Marshall Building, Ypsilanti, MI 48197 USA
| | - Chelsea Weaks
- Standardized Patient Educator, GTA Program, Eastern Virginia Medical School Sentara Center for Simulation and Immersive Learning, 651 Colley Avenue, PO Box 1980, Norfolk, VA 23501-1980 USA
| | - Elise Napier
- Ferris State University, 1201 S. State Street, Big Rapids, MI 49307 USA
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Pinto RA, Corrêa Neto IJF, Nahas SC, Froehner Junior I, Soares DFM, Cecconello I. IS THE PHYSICIAN EXPERTISE IN DIGITAL RECTAL EXAMINATION OF VALUE IN DETECTING ANAL TONE IN COMPARISON TO ANORECTAL MANOMETRY? ARQUIVOS DE GASTROENTEROLOGIA 2019; 56:79-83. [PMID: 31141075 DOI: 10.1590/s0004-2803.201900000-04] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 01/23/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Digital rectal examination (DRE) is part of the physical examination, is also essential for the colorectal surgeon evaluation. A good DRE offers precious information related to the patient's complaints, which will help in decision making. It is simple, quick and minimally invasive. In many centers around the world, the DRE is still the only method to evaluate the anal sphincter prior to patient's management. On the other hand, anorectal manometry (ARM) is the main method for objective functional evaluation of anal sphincter pressures. The discrepancy of DRE depending on the examiner to determine sphincter tonus in comparison to ARM motivated this study. OBJECTIVE To compare the DRE performed by proficient and non-experienced examiners to sphincter pressure parameters obtained at ARM, depending on examiners expertise. METHODS Thirty-six consecutive patients with complaints of fecal incontinence or chronic constipation, from the anorectal physiology clinic of the University of São Paulo School of Medicine, were prospectively included. Each patient underwent ARM and DRE performed by two senior colorectal surgeons and one junior colorectal surgeon prior to the ARM. Patient's history was blinded for the examiner's knowledge, also the impressions of each examiner were blinded from the others. For the DRE rest and squeeze pressures were classified by an objective scale (DRE scoring system) that was compared to the parameters of the ARM for the analysis. The results obtained at the ARM were compared to the DRE performed by the seniors and the junior colorectal surgeons. STATISTICAL ANALYSIS Descriptive analysis was performed for all parameters. For the rest and squeeze pressures the Gamma index was used for the comparison between the DRE and ARM, which varied from 0 to 1. The closer to 1 the better was the agreement. RESULTS The mean age was 48 years old and 55.5% of patients were female. The agreement of rest anal pressures between the ARM and the DRE performed by the senior proficient examiners was 0.7 (CI 95%; 0.32-1.0), while for the junior non-experienced examiner was 0.52 (CI 95%; 0.09-0.96). The agreement of squeeze pressures was 0.96 (CI 95%; 0.87-1.0) for the seniors and 0.52 (CI 95%; 0.16-0.89) for the junior examiner. CONCLUSION More experienced colorectal surgeons used to DRE had a more significant agreement with the ARM, thereafter would have more appropriate therapeutic management to patients with sphincter functional problems. ARM, therefore, persists as an important exam to objectively evaluate the sphincter complex, justifying its utility in the clinical practice.
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Affiliation(s)
- Rodrigo Ambar Pinto
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil
| | | | - Sérgio Carlos Nahas
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil
| | - Ilario Froehner Junior
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil
| | | | - Ivan Cecconello
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil
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International Anal Neoplasia Society Guidelines for the Practice of Digital Anal Rectal Examination. J Low Genit Tract Dis 2019; 23:138-146. [DOI: 10.1097/lgt.0000000000000458] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Guo J, Chen Y, Liu Z, Guan Y, Wang W, Sun X, Li W, Xu D. The Diagnostic and Prognostic Value of Digital Rectal Examination in Gastric Cancer Patients with Peritoneal Metastasis. J Cancer 2019; 10:1489-1495. [PMID: 31031858 PMCID: PMC6485225 DOI: 10.7150/jca.29814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/09/2019] [Indexed: 12/27/2022] Open
Abstract
Background: Peritoneal metastasis (PM) is the most common cause of death in gastric cancer (GC) patients. However, diagnosis of PM is still difficult in clinical practice. This study aimed to explore the diagnostic and prognostic value of digital rectal examination (DRE) in GC. Methods: 247 GC patients with PM confirmed by operation were included. The diagnostic yield of DRE compared with computed tomography (CT) was calculated. In another group of 1330 cases receiving radical gastrectomy, 38 cases with DRE (+) postoperatively were analyzed to identify risk factors. A nomogram was constructed to predict postoperative DRE (+). Results: The specificity, positive predictive value and positive likelihood ratio of DRE in diagnosis of PM was 99.8%, 91.2% and 58.4, higher than CT (97.6%, 64.9% and 10.4). Though the sensitivity of DRE (12.6%) was lower than CT (24.7%), 17 of 31 patients with DRE (+) could not be found by CT. Moreover, the overall survival of confirmed PM patients with DRE (+) (PM-DRE (+)) was much lower than PM-DRE (-) patients (P<0.001). In addition, the nomogram to predict postoperative DRE (+) had a bootstrap-corrected concordance index of 0.73 and was well calibrated. Conclusions: GC patients with DRE (+) could be regarded as a special subtype of stage IV ones with poorer prognosis. Supply of palliative care and chemotherapy rather than unnecessary operation might be a better alternative for these patients. DRE was an effective supplement for CT and should be generally recommended for GC patients.
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Affiliation(s)
- Jing Guo
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yongming Chen
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Zhimin Liu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Yuanxiang Guan
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Wei Wang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiaowei Sun
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Wei Li
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Dazhi Xu
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou, China
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, Guangzhou, China
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Krautter M, Diefenbacher K, Schultz JH, Maatouk I, Herrmann-Werner A, Koehl-Hackert N, Herzog W, Nikendei C. Physical examination skills training: Faculty staff vs. patient instructor feedback-A controlled trial. PLoS One 2017; 12:e0180308. [PMID: 28692703 PMCID: PMC5503248 DOI: 10.1371/journal.pone.0180308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 06/13/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Standardized patients are widely used in training of medical students, both in teaching and assessment. They also frequently lead complete training sessions delivering physical examination skills without the aid of faculty teaching staff-acting as "patient instructors" (PIs). An important part of this training is their ability to provide detailed structured feedback to students which has a strong impact on their learning success. Yet, to date no study has assessed the quality of physical examination related feedback by PIs. Therefore, we conducted a randomized controlled study comparing feedback of PIs and faculty staff following a physical examination assessed by students and video assessors. METHODS 14 PIs and 14 different faculty staff physicians both delivered feedback to 40 medical students that had performed a physical examination on the respective PI while the physicians observed the performance. The physical examination was rated by two independent video assessors to provide an objective performance standard (gold standard). Feedback of PI and physicians was content analyzed by two different independent video assessors based on a provided checklist and compared to the performance standard. Feedback of PIs and physicians was also rated by medical students and video assessors using a questionnaire consisting of 12 items. RESULTS There was no statistical significant difference concerning overall matching of physician or PI feedback with gold standard ratings by video assessment (p = .219). There was also no statistical difference when focusing only on items that were classified as major key steps (p = .802), mistakes or parts that were left out during physical examination (p = .219) or mistakes in communication items (p = .517). The feedback of physicians was significantly better rated than PI feedback both by students (p = .043) as well as by video assessors (p = .034). CONCLUSIONS In summary, our study demonstrates that trained PIs are able to provide feedback of equal quantitative value to that of faculty staff physicians with regard to a physical examination performed on them. However, both the students and the video raters judged the quality of the feedback given by the physicians to be significantly better than that of the PIs.
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Affiliation(s)
- Markus Krautter
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Katja Diefenbacher
- Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Medical Centre, Heidelberg, Germany
| | - Jobst-Hendrik Schultz
- Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Medical Centre, Heidelberg, Germany
| | - Imad Maatouk
- Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Medical Centre, Heidelberg, Germany
| | - Anne Herrmann-Werner
- Department of Psychosomatic Medicine and Psychotherapy, University of Tübingen, Tübingen, Germany
| | - Nadja Koehl-Hackert
- Department of General Practice and Health Services Research, University of Heidelberg, Heidelberg, Germany
| | - Wolfgang Herzog
- Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Medical Centre, Heidelberg, Germany
| | - Christoph Nikendei
- Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Medical Centre, Heidelberg, Germany
- * E-mail:
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Kailavasan M, Abdul-Rahman A, Hanchanale V, Rajpal S, Rogawski K, Palit V, Myatt A, Jain S, Biyani CS. The Validation of the Clinical Male Pelvic Trainer Mk 2-Advanced Models for Scrotal Examination Simulation. JOURNAL OF SURGICAL EDUCATION 2017; 74:423-430. [PMID: 27825660 DOI: 10.1016/j.jsurg.2016.10.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/24/2016] [Accepted: 10/10/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To validate the use of a novel physical model, the "Clinical Male Pelvic Trainer (CMPT) Mk 2-Advanced," for scrotal examination simulation and evaluate its use for surgical education. MATERIALS AND METHODS A total of 7 CMPT Mk 2-Advanced scrotal models were used for teaching: normal, varicocele, testicular tumor, epididymal cyst, hydrocele, epididymo-orchitis, and indirect inguinoscrotal hernia. At 4 surgical courses in the West Yorkshire Foundation Deanery, UK, between 2015 and 2016, trainees were asked to assess their clinical experience, confidence levels in diagnosing scrotal pathology and simulation properties of the scrotal models on a 5-point Likert Scale. Expert responses were used to validate these findings. RESULTS In total, 65 trainees and 12 experts (including 3 senior residents) participated in the study (n = 77). There was a positive-tailed distribution in responses from experts for realistic simulation of scrotal contents and pathology; only 1.5% and 14.4% of all responses by experts were scored as a "1" (strongly disagree) or "2" (disagree). The intraclass coefficient (κ) was 0.86 among experts. No significant differences between experts and trainees in assessment of simulation were observed. Following use of the models, there was a significant increase in confidence scores matched by trainee (p < 0.001). Approximately 92.9% and 100% of trainees and experts were in favor of using the models for assessment and future training respectively. CONCLUSIONS Our study demonstrates that the CMPT MK 2-Advanced models have high "face validity" and may be a valuable tool for surgical education. The use of these models should be explored for use in the curriculum at medical school.
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Affiliation(s)
- Mithun Kailavasan
- St James's University Hospital, Leeds Teaching Hospital Trust, Leeds, United Kingdom
| | - Ahmad Abdul-Rahman
- St James's University Hospital, Leeds Teaching Hospital Trust, Leeds, United Kingdom
| | - Vishwanath Hanchanale
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom
| | - Sanjay Rajpal
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - Karol Rogawski
- Huddersfield Royal Infirmary, Huddersfield, United Kingdom
| | - Victor Palit
- North Tees and Hartlepool NHS Trust, Stockton-on-Tees, United Kingdom
| | - Andy Myatt
- Hull & East Yorkshire NHS Trust, Hull, United Kingdom
| | - Sunjay Jain
- St James's University Hospital, Leeds Teaching Hospital Trust, Leeds, United Kingdom
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