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Mullan PC, Levasseur KA, Bajaj L, Nypaver M, Chamberlain JM, Thull-Freedman J, Ostrow O, Jain S. Recommendations for Choosing Wisely in Pediatric Emergency Medicine: Five Opportunities to Improve Value. Ann Emerg Med 2024; 84:167-175. [PMID: 38349290 DOI: 10.1016/j.annemergmed.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/15/2023] [Accepted: 01/04/2024] [Indexed: 07/22/2024]
Abstract
Unnecessary diagnostic tests and treatments in children cared for in emergency departments (EDs) do not benefit patients, increase costs, and may result in harm. To address this low-value care, a taskforce of pediatric emergency medicine (PEM) physicians was formed to create the first PEM Choosing Wisely recommendations. Using a systematic, iterative process, the taskforce collected suggested items from an interprofessional group of 33 ED clinicians from 6 academic pediatric EDs. An initial review of 219 suggested items yielded 72 unique items. Taskforce members independently scored each item for its extent of overuse, strength of evidence, and potential for harm. The 25 highest-rated items were sent in an electronic survey to all 89 members of the American Academy of Pediatrics PEM Committee on Quality Transformation (AAP COQT) to select their top ten recommendations. The AAP COQT survey had a 63% response rate. The five most selected items were circulated to over 100 stakeholder and specialty groups (within the AAP, CW Canada, and CW USA organizations) for review, iterative feedback, and approval. The final 5 items were simultaneously published by Choosing Wisely United States and Choosing Wisely Canada on December 1, 2022. All recommendations focused on decreasing diagnostic testing related to respiratory conditions, medical clearance for psychiatric conditions, seizures, constipation, and viral respiratory tract infections. A multinational PEM taskforce developed the first Choosing Wisely recommendation list for pediatric patients in the ED setting. Future activities will include dissemination efforts and interventions to improve the quality and value of care specific to recommendations.
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Affiliation(s)
- Paul C Mullan
- Division of Emergency Medicine, Department of Pediatrics, Eastern Virginia Medical School, Children's Hospital of the King's Daughters, Norfolk, VA.
| | - Kelly A Levasseur
- Division of Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, MI
| | - Lalit Bajaj
- Department of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Michele Nypaver
- Departments of Emergency Medicine and Pediatrics, University of Michigan Medical School, and Michigan Emergency Department Improvement Collaborative (funded by BCBSM), Ann Arbor, MI
| | - James M Chamberlain
- Division of Emergency Medicine, Pediatrics and Emergency Medicine, George Washington University, Children's National Hospital, Washington, DC
| | - Jennifer Thull-Freedman
- Departments of Pediatrics and Emergency Medicine, University of Calgary, Alberta Children's Hospital, Calgary, AB, Canada
| | - Olivia Ostrow
- Division of Emergency Medicine, University of Toronto, the Hospital for Sick Children, Toronto, ON, Canada
| | - Shabnam Jain
- Pediatrics and Emergency Medicine, Emory University, Children's Healthcare of Atlanta, Atlanta, GA
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Harris B, Kern K, Benner C, Moses J, Artinian H. Quality Improvement Project Reducing Sputum Cultures for Pediatric Patients With a Tracheostomy. Hosp Pediatr 2024; 14:564-572. [PMID: 38916049 DOI: 10.1542/hpeds.2023-007125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND AND OBJECTIVES Current research implies overuse of diagnostic testing and overtreatment in children with tracheostomies. There are no guidelines for obtaining sputum cultures for these patients, yet they are commonly obtained without significantly affecting management or outcomes. The aim of our quality improvement project was to decrease rate of sputum cultures in this population by 50%, from 64% to 32%. METHODS This was a single-center quality improvement project conducted in a pediatric emergency department (ED). Key drivers included: Standardized decision-making, appropriate culture collection, knowledge regarding colonization versus clinically relevant growth, and viral versus bacterial infections in this population. The study team developed an algorithm, used modification to electronic medical records orders, and provided education to drive change. Six months of preintervention and 12 months postintervention data were collected. Run charts/statistical process charts were created for the rate of cultures, length of stay, and return to the ED. RESULTS There were 159 patient encounters and the rate of sputum cultures decreased from 64% at baseline to 25% without change in length of stay or increased rate at which patients returned to the ED, including during local coronavirus disease 2019 and respiratory syncytial virus surges. We observed nonrandom data patterns after introduction of algorithm resulting in centerline shifts. CONCLUSIONS The study team was able to introduce an algorithm coinciding with a reduction in number of sputum cultures obtained. Next steps would be determining safety and efficacy of such an algorithm over a larger population.
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Affiliation(s)
- Baila Harris
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - Kristina Kern
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan
| | - Christopher Benner
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - James Moses
- Quality, Safety, and Experience, Corewell Health, Grand Rapids, Michigan
| | - Hovig Artinian
- Department of Pediatrics, Helen DeVos Children's Hospital, Grand Rapids, Michigan
- Michigan State University College of Human Medicine, Grand Rapids, Michigan
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Nedzinskaite M, Karakaite D, Zubrickyte E, Jankauskaite L. Assessment of Medical Test Overuse and Its Impact on Pediatric Emergency Department Outcomes in Upper Respiratory Tract Infections in a University Hospital in Lithuania. Diagnostics (Basel) 2024; 14:970. [PMID: 38786268 PMCID: PMC11119093 DOI: 10.3390/diagnostics14100970] [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: 02/22/2024] [Revised: 03/23/2024] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
Medical overuse poses potential risks to patients and contributes to increasing healthcare costs, pediatric emergency departments (PED) in particular. Often, upper respiratory tract infection (URTI) cases are viral-induced and self-limiting, and they do not require specific investigations or treatment. We conducted a retrospective study from 1 December 2021 to 31 January 2022, thereby aiming to identify the common tests and factors influencing specific diagnostic and treatment decisions for URTI in PED. In total, 307 (74.9%) URTI cases underwent complete blood count (CBC) tests, 312 (76.1%) were subjected to C-reactive protein (CRP) tests, and 110 (26.8%) received urinalysis tests. Patients with a longer duration of fever and a physician's suspicion of bacterial infection were more likely to receive CBC, CRP, and/or urinalysis tests (p < 0.05). Moreover, 75.1% of the cases were classified as viral URTIs, 9.8% were bacterial URTIs, and 15.1% were unspecified. Notably, 86 (20.1%) children received antibiotics and antibiotic prescription correlated with age, tonsillitis diagnosis, CRP values higher than 30 mg/L, and a CBC of p < 0.05. Patients triaged in the second or third categories were three times more likely to be observed for 24 h compared to patients with URTI and the fourth triage category (p < 0.05). This study highlights the need for interventions to improve the appropriateness of emergency service utilization, thereby emphasizing the importance of judicious decision making in managing pediatric URTIs.
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Affiliation(s)
- Melita Nedzinskaite
- Department of Pediatrics, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania;
| | - Dagna Karakaite
- Faculty of Medicine, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (D.K.); (E.Z.)
| | - Erika Zubrickyte
- Faculty of Medicine, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania; (D.K.); (E.Z.)
| | - Lina Jankauskaite
- Department of Pediatrics, Lithuanian University of Health Sciences, 44307 Kaunas, Lithuania;
- Department of Pediatrics, Lithuanian University of Health Sciences Kaunas Clinics, 50103 Kaunas, Lithuania
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Jankauskaite L, Wyder C, Del Torso S, Mamenko M, Trapani S, Grossman Z, Hadjipanayis A, Geitmann K, Matsui H, Saitoh A, Isayama T, Karara N, Montemaggi A, Ud Din FS, Størdal K. Over-investigation and overtreatment in pediatrics: a survey from the European Academy of Paediatrics and Japan Pediatric Society. Front Pediatr 2024; 12:1333239. [PMID: 38455393 PMCID: PMC10917967 DOI: 10.3389/fped.2024.1333239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
Introduction Avoiding over-investigation and overtreatment in health care is a challenge for clinicians across the world, prompting the international Choosing Wisely campaign. Lists of recommendations regarding medical overactivity are helpful tools to guide clinicians and quality improvement initiatives. We aimed to identify the most frequent and important clinical challenges related to pediatric medical overactivity in Europe and Japan. Based on the results, we aim to establish a (European) list of Choosing Wisely recommendations. Methods In an online survey, clinicians responsible for child health care in Europe and Japan were invited to rate 18 predefined examples of medical overactivity. This list was compiled by a specific strategic advisory group belonging to the European Academy of Paediatrics (EAP). Participants were asked to rate on a Likert scale (5 as the most frequent/important) according to how frequent these examples were in their working environment, and how important they were considered for change in practice. Results Of 2,716 physicians who completed the survey, 93% (n = 2,524) came from 17 countries, Japan (n = 549) being the largest contributor. Pediatricians or pediatric residents comprised 89%, and 51% had 10-30 years of clinical experience. Cough and cold medicines, and inhaled drugs in bronchiolitis were ranked as the most frequent (3.18 and 3.07 on the Likert scale, respectively), followed by intravenous antibiotics for a predefined duration (3.01), antibiotics in uncomplicated acute otitis media (2.96) and in well-appearing newborns. Regarding importance, the above-mentioned five topics in addition to two other examples of antibiotic overtreatment were among the top 10. Also, IgE tests for food allergies without relevant medical history and acid blockers for infant GER were ranked high. Conclusion Overtreatment with antibiotics together with cough/cold medicines and inhaled drugs in bronchiolitis were rated as the most frequent and important examples of overtreatment across countries in Europe and Japan.
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Affiliation(s)
- Lina Jankauskaite
- Department of Paediatrics, Lithuanian University of Health Sciences, Kaunas, Lithuania
- Institute of Physiology and Pharmacology, Lithuanian University of Health Sciences, Kaunas, Lithuania
- European Academy of Paediatrics, Brussels, Belgium
| | - Corinne Wyder
- European Academy of Paediatrics, Brussels, Belgium
- Paediatric Praxis Kurwerk, Burgdorf, Switzerland
| | - Stefano Del Torso
- European Academy of Paediatrics, Brussels, Belgium
- ChildCare WorldWide, Padova, Italy
| | - Marina Mamenko
- European Academy of Paediatrics, Brussels, Belgium
- Shupyk National Healthcare University of Ukraine, Kiev, Ukraine
- Ukrainian Academy of Paediatric Specialties, Kyiv, Ukraine
| | - Sandra Trapani
- European Academy of Paediatrics, Brussels, Belgium
- Department of Health Sciences, University of Florence, Florence, Italy
- Paediatric Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Zachi Grossman
- European Academy of Paediatrics, Brussels, Belgium
- Adelson School of Medicine, Ariel University, Ariel, Israel
- Pediatric Clinic, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Adamos Hadjipanayis
- European Academy of Paediatrics, Brussels, Belgium
- Medical School, European University Cyprus, Nicosia, Cyprus
| | | | - Hikoro Matsui
- University of Tokyo and School of Medicine, Tokyo, Japan
- Japan Pediatric Society, Tokyo, Japan
| | - Akihiko Saitoh
- Japan Pediatric Society, Tokyo, Japan
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tetsuya Isayama
- Japan Pediatric Society, Tokyo, Japan
- Division of Neonatology, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Nora Karara
- European Academy of Paediatrics, Brussels, Belgium
- Paediatric Public Health Office, Berlin, Germany
| | | | - Farhan Saleem Ud Din
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Ketil Størdal
- European Academy of Paediatrics, Brussels, Belgium
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Department of Pediatric Research, Faculty of Medicine, University of Oslo, Oslo, Norway
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Ropers FG, Rietveld S, Rings EHHM, Bossuyt PMM, van Bodegom-Vos L, Hillen MA. Diagnostic testing in children: A qualitative study of pediatricians' considerations. J Eval Clin Pract 2023; 29:1326-1337. [PMID: 37221991 DOI: 10.1111/jep.13867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/25/2023]
Abstract
AIMS AND OBJECTIVES Studies in adult medicine have shown that physicians base testing decisions on the patient's clinical condition but also consider other factors, including local practice or patient expectations. In pediatrics, physicians and parents jointly decide on behalf of a (young) child. This might demand more explicit and more complex deliberations, with sometimes conflicting interests. We explored pediatricians' considerations in diagnostic test ordering and the factors that influence their deliberation. METHOD We performed in-depth, semistructured interviews with a purposively selected heterogeneous sample of 20 Dutch pediatricians. We analyzed transcribed interviews inductively using a constant comparative approach, and clustered data across interviews to derive common themes. RESULTS Pediatricians perceived test-related burden in children higher compared with adults, and reported that avoiding an unjustified burden causes them to be more restrictive and deliberate in test ordering. They felt conflicted when parents desired testing or when guidelines recommended diagnostic tests pediatricians perceived as unnecessary. When parents demanded testing, they would explore parental concern, educate parents about harms and alternative explanations of symptoms, and advocate watchful waiting. Yet they reported sometimes performing tests to appease parents or to comply with guidelines, because of feared personal consequences in the case of adverse outcomes. CONCLUSION We obtained an overview of the considerations that are weighed in pediatric test decisions. The comparatively strong focus on prevention of harm motivates pediatricians to critically appraise the added value of testing and drivers of low-value testing. Pediatricians' relatively restrictive approach to testing could provide an example for other disciplines. Improved guidelines and physician and patient education could help to withstand the perceived pressure to test.
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Affiliation(s)
- Fabienne G Ropers
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie Rietveld
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
| | - Edmond H H M Rings
- Department of Pediatrics, Willem-Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands
- Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Patrick M M Bossuyt
- Amsterdam University Medical Centers, University of Amsterdam, Epidemiology & Data Science, Amsterdam, The Netherlands
- Amsterdam Public Health, Methodology, Amsterdam, The Netherlands
| | - Leti van Bodegom-Vos
- Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Marij A Hillen
- Amsterdam University Medical Centers, location AMC, Amsterdam Public Health, Medical Psychology, Amsterdam, The Netherlands
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Benis A, Tamburis O. The Need for Green and Responsible Medical Informatics and Digital Health: Looking Forward with One Digital Health. Yearb Med Inform 2023; 32:7-9. [PMID: 37414027 PMCID: PMC10751118 DOI: 10.1055/s-0043-1768717] [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] [Indexed: 07/08/2023] Open
Abstract
One Health is an important initiative to view the world in a more integrative sense of our health and environment. Digital Health provides essential support to all of us as healthcare professionals and customers. One Digital Health (ODH) combines both One Health and Digital Health to provide a technologically integrative view. ODH gives an essential place to the environment and ecosystems. Thus, health technologies and digital health must be "green" and eco-friendly as much as possible. We suggest in this position paper examples of developing and implementing ODH-related concepts, systems, and products with a respectful consideration of the environment. For humans and animals, developing cutting-edge technologies to improve wellness and healthcare is critical. Nevertheless, we can learn from One Health that digitalization and so One Digital Health must be built to implement green, eco-friendly, and responsible thinking.
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Affiliation(s)
- Arriel Benis
- Department of Digital Medical Technologies, Holon Institute of Technology, Israel
| | - Oscar Tamburis
- Institute of Biostructures and Bioimaging, National Research Council, Naples, Italy
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Trapani S, Montemaggi A, Indolfi G. Choosing Wisely in pediatric healthcare: A narrative review. Front Pediatr 2023; 10:1071088. [PMID: 36704146 PMCID: PMC9871764 DOI: 10.3389/fped.2022.1071088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Background It has been estimated that 20% of the tests and therapies currently prescribed in North America are likely unnecessary, add no value, and may even cause harm. The Choosing Wisely (CW) campaign was launched in 2012 in the US and Canada to limit the overuse of medical procedures in adult and pediatric healthcare, to avoid overdiagnosis and overtreatment. Methods In this narrative review, we describe the birth and spread of the CW campaign all over the world, with emphasis on CW in pediatric healthcare. Results To date, CW has spread to more than 25 countries and 80 organizations, with 700 recommendations published. The awareness of medication overuse also made its way into pediatrics. One year after the launch of the CW campaign, the American Academy of Pediatrics and the pediatric section of the Society of Hospital Medicine provided the first recommendations specifically aimed at pediatricians. Thereafter, many European pediatric societies also became active in the CW campaign and published specific top-5 recommendations, although there is not yet a common set of CW recommendations in Europe. Discussion We reviewed the main pediatric CW recommendations in medical and surgical fields and discussed how the recommendations have been produced, published, and disseminated. We also analyzed whether and how the CW recommendations impacted pediatric medical practice. Furthermore, we highlighted the common obstacles in applying CW recommendations, such as pressure from patients and families, diagnostic uncertainty, and worries about legal problems. Finally, we highlighted the necessity to foster the CW culture, develop an implementation plan, and measure the results in terms of overuse decline.
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Affiliation(s)
- Sandra Trapani
- Pediatric Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Giuseppe Indolfi
- Pediatric Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department NEUROFARBA, University of Florence, Florence, Italy
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Shi H, Li T, Liu Z, Zhao J, Qi F. Early detection of gastric cancer via high-resolution terahertz imaging system. Front Bioeng Biotechnol 2022; 10:1052069. [PMID: 36588946 PMCID: PMC9794757 DOI: 10.3389/fbioe.2022.1052069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
Terahertz (THz) wave has demonstrated a good prospect in recent years, but the resolution is still one of the problems that restrict the application of THz technology in medical imaging. Paraffin-embedded samples are mostly used in THz medical imaging studies, which are thicker and significantly different from the current gold standard slice pathological examination in sample preparation. In addition, THz absorption in different layers of normal and cancerous tissues also remains to be further explored. In this study, we constructed a high-resolution THz imaging system to scan non-tumorous adjacent tissue slices and gastric cancer (GC) tissue slices. In this system, a THz quantum cascade laser emitted a pulsed 3 THz signal and the transmitted THz wave was received by a THz detector implemented in a 65 nm CMOS process. The slice thickness was only 20 μm, which was close to that of the medical pathology examination. We successfully found THz transmittance differences between different layers of normal gastric tissues based on THz images, and the resolution could reach 60 μm for the first time. The results indicated that submucosa had a lower THz transmittance than that of mucosa and muscular layer in non-tumorous adjacent tissue. However, in GC tissue, THz transmittance of mucosa and submucosa was similar, caused by the decreased transmittance of mucosa, where the cancer occurs. Therefore, we suppose that the similar terahertz transmittance between gastric mucosa and submucosa may indicate the appearance of cancerization. The images obtained from our THz imaging system were clearer than those observed with naked eyes, and can be directly compared with microscopic images. This is the first application of THz imaging technology to identify non-tumorous adjacent tissue and GC tissue based on the difference in THz wave absorption between different layers in the tissue. Our present work not only demonstrated the potential of THz imaging to promote early diagnosis of GC, but also suggested a new direction for the identification of normal and cancerous tissues by analyzing differences in THz transmittance between different layers of tissue.
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Affiliation(s)
- Han Shi
- Shenyang Institute of Automation, Chinese Academy of Sciences, Shenyang, China,Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, China,Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors (China Medical University), Ministry of Education, Shenyang, China
| | - Tenghui Li
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, China,Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors (China Medical University), Ministry of Education, Shenyang, China
| | - Zhaoyang Liu
- Shenyang Institute of Automation, Chinese Academy of Sciences, Shenyang, China,Key Laboratory of Terahertz Imaging and Sensing, Liaoning Province, Shenyang, China
| | - Junhua Zhao
- Department of Surgical Oncology and General Surgery, the First Hospital of China Medical University, Shenyang, China,Key Laboratory of Precision Diagnosis and Treatment of Gastrointestinal Tumors (China Medical University), Ministry of Education, Shenyang, China,*Correspondence: Feng Qi, ; Junhua Zhao,
| | - Feng Qi
- Shenyang Institute of Automation, Chinese Academy of Sciences, Shenyang, China,Key Laboratory of Terahertz Imaging and Sensing, Liaoning Province, Shenyang, China,*Correspondence: Feng Qi, ; Junhua Zhao,
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