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Vega EA, Salehi O, Panettieri E, Salirrosas O, Brauner E, Mellado S, Dvir K, Perepletchikov A, Kozyreva O, Conrad C. Subsegmental approaches to S7: anatomic laparoscopic transdiaphragmatic and nonanatomic robotic transthoracic. Surg Endosc 2023; 37:8154-8155. [PMID: 37644157 DOI: 10.1007/s00464-023-10310-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 07/12/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Minimally invasive liver surgery of postero-superior segments (S4a, S7, S8) remains a challenge. The caudal view, an increased distance between trocars and the operative field, and the liver fulcrum limiting the view, contribute to the difficulty [1, 2]. We and other groups have previously reported the use of intercostal trocars to access subdiaphragmatic tumors (transdiaphragmatic approach) [3-5], only few reports on a laparoscopic total transthoracic approach, none (to our knowledge) dynamic manuscripts of a total transthoracic robotic approach, and none (to our knowledge) that use preoperative port site and anatomic modelling exist. Further, we developed a total transthoracic (thoracoscopic) approach to avoid a hostile abdomen, while bringing viewing axis and instruments close to the target [6-10]. In this context, this report details the advantages of a laparoscopic vs. robotic transthoracic approach. According to institutional protocol, reports of individual cases in print or video format do not require institutional review board approval. PATIENT A 68-year-old male on peritoneal dialysis with left colon adenocarcinoma and a single synchronous liver metastasis in S6-7 close to the root of the right hepatic vein underwent a laparoscopic transdiaphragmatic metastasectomy. Two years later, the patient developed a recurrent 1.5 cm liver metastasis in S7, which lend itself to a robotic transthoracic approach. TECHNIQUE Following 3-D modelling and virtual port placement planning, the first metastasectomy was performed laparoscopically using a transdiaphragmatic approach. The recurrence was managed transthoracically due to more apical, subdiaphragmatic location. For this operation, a robotic approach was optimal as robotic wrist articulation facilitates manipulation via the limited intercostal space. This was particularly helpful during the diaphragmatic reconstruction. CONCLUSIONS Total transthoracic liver surgery is certainly an advanced procedure requiring superior MIS liver skills. Recommendations for starting with a total transthoracic approach are not unlike from starting a standard, none-transthoracic liver surgery. Early on in the experience we recommend advanced liver MIS skills, and single, small, subdiaphragmatic tumors away from major vessels. Nonetheless, when these recommendations are followed a total transthoracic approach may be safer and result in less access trauma, than traversing a hostile abdomen to reach the posterior-superior liver. Both laparoscopic and robotic transthoracic approaches can facilitate the resection of subdiaphragmatic tumors, especially in patients with hostile abdomens. While the laparoscopic approach has advantages due to a broader spectrum of available surgical tools (flexible tip camera, parenchymal dissection, and energy devices), the robotic wrist articulation facilitates manipulation via the restricted intercostal space.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Eran Brauner
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | | | - Kathrin Dvir
- Department of Oncology, Dana Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, MA, USA
| | - Aleksandr Perepletchikov
- Department of Pathology, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Department of Oncology, Dana Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
- General Surgery and Surgical Oncology, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA.
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Fortuna GMG, Rios P, Rivero A, Zuniga G, Dvir K, Pagacz MM, Manzano A. Papillary Thyroid Carcinoma With Cystic Changes in a Patient With Prior History of Toxic Nodule. J Investig Med High Impact Case Rep 2021; 8:2324709620942672. [PMID: 32666838 PMCID: PMC7364832 DOI: 10.1177/2324709620942672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Thyroid nodules are palpable on up to 7% of asymptomatic patients. Cancer is present in 8% to 16% of those patients with previously identified thyroid nodules. Papillary thyroid carcinoma (PTC) is the most common type of thyroid cancer, accounting for approximately 85% of thyroid cancers. Although most appear as solid nodules on ultrasound imaging, a subset of 2.5% to 6% has cystic components. The presence of cystic changes within thyroid nodules decreases the accuracy of fine needle aspiration (FNA) in the diagnosis of thyroid cancer, given the difficulty of obtaining appropriate cellular content. This becomes a diagnostic and therapeutic challenge. We present a case of a 31-year-old female with a 1-month history of palpitations, fatigue, and night sweats, who underwent evaluation, and was diagnosed with subclinical hyperthyroidism. She presented 4 years later with compressive symptoms leading to repeat FNA, showing Bethesda III-atypia of undetermined significance and negative molecular testing. Thyroid lobectomy revealed PTC with cystic changes. This case is a reminder that patients with hyperfunctioning thyroid nodule should have closer follow-up. It poses the diagnostic dilemma of how much is good enough in the evaluation and management of a thyroid nodule. Early detection and action should be the standard of care.
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Affiliation(s)
| | - Paola Rios
- Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Ailyn Rivero
- Mount Sinai Medical Center, Miami Beach, FL, USA
| | | | - Kathrin Dvir
- Mount Sinai Medical Center, Miami Beach, FL, USA
| | | | - Alex Manzano
- Mount Sinai Medical Center, Miami Beach, FL, USA
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Dvir K, Galarza-Fortuna GM, Haines JM, Gines P, Ruiz AL, Rodriguez E. Real-World Data on Liquid Biopsy Use in Non-Small Cell Lung Cancer in the Community Setting. J Immunother Precis Oncol 2021; 4:1-5. [PMID: 35664822 PMCID: PMC9161665 DOI: 10.36401/jipo-20-26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/17/2020] [Indexed: 06/15/2023]
Abstract
INTRODUCTION The yield of adding plasma-based next-generation sequencing (NGS) to tissue NGS for the detection of actionable aberrations (AAs) has been reported; however, additional studies are needed to determine utility in the clinical setting. In this retrospective data review, we present our real world data on the utilization of liquid biopsies in the routine management of NCSLC patients, in a community setting. METHODS We conducted a retrospective review of 279 consecutive patients with non-small cell lung cancer (NSCLC) in the community setting, who had liquid biopsies performed between the years 2014 and 2019 as part of routine clinical management. RESULTS Over a period of 5 years, 337 liquid biopsy samples, taken from 279 patients were sent for plasma NGS testing. The median age at diagnosis was 73 years (range 36-93 y, SD 10.4 y), 141, (51%) were men and 138 (49%) were women. The majority were White or Caucasian (80% versus 8% Black or African American versus 12% Multiracial or unknown race) and had a history of smoking (79%). Excluding synonymous mutations and variants of unknown significance, 254 AAs were detected in 106 patients. Commonly detected AAs were EGFR (n = 127, 50%), KRAS (n = 61, 24%), BRAF (n = 24, 9.5%), and MET (n = 23, 9%). Tissue NGS detected AAs in 45 patients, with EGFR (n = 28, 57%) and KRAS (n = 10, 20%) being the most common AAs. Concordance agreement between plasma and tissue NGS modalities was detected in 39 of 45, 87% patients and was demonstrated most commonly in EGFR (n = 25) and KRAS (n = 11). In 44 of 106 (42%) of patients, for whom tissue NGS was not performed, additional precision treatment was guided by the AA detected through liquid biopsy. CONCLUSIONS Integration of liquid biopsy into the routine management of patients with non-small cell lung cancer demonstrated AA detection in 44 additional patients, which comprise a 42% increase in AA detection rate, when tissue NGS was not performed.
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Affiliation(s)
- Kathrin Dvir
- Department of Medicine, Mount Sinai Medical Center, Miami Beach, FL, USA
| | | | - Joel M. Haines
- Department of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Paulina Gines
- Department of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Ana L. Ruiz
- The Mount Sinai Comprehensive Cancer Center, Mount Sinai Medical Center, Miami Beach, FL, USA
| | - Estelamari Rodriguez
- The Mount Sinai Comprehensive Cancer Center, Mount Sinai Medical Center, Miami Beach, FL, USA
- Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
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Galarza Fortuna GM, Dvir K. Circulating tumor DNA: Where are we now? A mini review of the literature. World J Clin Oncol 2020; 11:723-731. [PMID: 33033694 PMCID: PMC7522544 DOI: 10.5306/wjco.v11.i9.723] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/31/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023] Open
Abstract
For many years tissue biopsy has been the primary procedure to establish cancer diagnosis and determine further treatment and prognosis. However, this method has multiple drawbacks, including, to mention some, being an invasive procedure carrying significant risk for fragile patients and allowing only for a "snapshot" of the tumor biology in time. The process of liquid biopsy allows for a minimally invasive procedure that provides molecular information about underlying cancer by analyzing circulating tumor DNA (ctDNA) via next-generation sequencing technology and circulating tumor cells. This paper focuses on describing the basis of ctDNA and its current utilities.
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Affiliation(s)
| | - Kathrin Dvir
- Internal Medicine, Mount Sinai Medical Center, Miami Beach, FL 33140, United States
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Cortez N, Berzosa M, Mahfouz M, Dvir K, Galarza Fortuna GM, Ben-David K. Diagnosis and Treatment of Metastatic Disease to the Pancreas. J Laparoendosc Adv Surg Tech A 2020; 30:1008-1012. [PMID: 32614661 DOI: 10.1089/lap.2020.0219] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Metastatic disease to the pancreas is a rare entity from all malignant pancreatic masses. Its diagnosis is very challenging, but with the introduction of endoscopic ultrasound (EUS)-fine needle aspiration (FNA), now there is a feasible way to make an accurate histopathological and definitive diagnosis. Materials and Methods: This is a retrospective review of 11 patients with metastasis to the pancreas diagnosed with EUS-FNA in a tertiary referral center over a period of 3 years. We describe our institutional experience in diagnosing metastatic disease to the pancreas through EUS-FNA. Results: Between January 2015 and June 2018, 115 patients were diagnosed with pancreatic malignancy by EUS-FNA and only 11 (10%) with metastatic disease to the pancreas. Most common primary malignancy was renal cell carcinoma, followed by colon carcinoma, squamous/small cell carcinoma of the lung, and urothelial carcinoma. Five of 11 patients presented as a solitary pancreatic mass on initial imaging without any evidence of primary or metastatic disease elsewhere. Conclusions: In our experience, metastatic disease to the pancreas can represent up to 10% of solid pancreatic masses, which is lower compared to the reported incidence in previous literature. Our findings reveal that early identification and diagnosis help patient management and limit surgical morbidity and mortality.
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Affiliation(s)
- Nathaly Cortez
- Department of Internal Medicine, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Manuel Berzosa
- Department of Gastroenterology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Mahmoud Mahfouz
- Department of Gastroenterology, University of Miami, Miami, Florida, USA
| | - Kathrin Dvir
- Department of Internal Medicine, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | | | - Kfir Ben-David
- Department of Surgery, Mount Sinai Medical Center, Comprehensive Cancer Center, Miami Beach, Florida, USA
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Dvir K, Galarza Fortuna G, Haines JM, Drusbosky L, Febres-Aldana C, Gines P, Rodriguez E. Real-world data on liquid biopsies utilization in lung cancer patients in the community setting: The Mount Sinai experience. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e21502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e21502 Background: Liquid biopsy describes the extraction of circulating tumor DNA (ctDNA) from peripheral blood via next-generation-sequencing (NGS). The yield of adding plasma-based NGS to tissue NGS for the detection of Actionable Mutations (AM) have been reported scarcely and additional “real world” data is needed. Methods: In this retrospective data review, we included patients with non-small cell lung cancer (NSCLC) who had plasma NGS genomic testing ordered between Nov 2014 and July 2019, as part of routine management. Plasma testing was performed using Guardant360 commercial platform and was analyzed for therapeutically AM in: EGFR, ALK, MET, BRCA1, BRCA2, KRAS, ROS1, RET, ERBB2, BRAF, and NTRK2. Results: Over a period of 5 years, 337 samples taken from 279 patients were sent for ctDNA NGS testing. The median age at diagnosis was 73 years [range 36-93, SD:10.4], 51% (N=141) were males and 49% (N=138) were females. Excluding synonymous mutations and variants of unknown significance, 239 samples (71%) and 201 patients (72%) had 705 somatic mutations. Of them, 36% (N=254) were therapeutically actionable and were detected in 139 samples (58%), taken from 106 patients (53%). Commonly detected AM were EGFR (N=127; 50%), KRAS (N=61; 24%), BRAF (N=24; 9.5%), MET (N=23; 9%), RET (N=5; 1.9%), BRCA1 (N=5; 1.9%), BRCA2 (N=4; 1.6%), ERBB2 (N=4; 1.6%) and ALK (N=1, 0.4%). None of the samples had mutations in ROS1, NTRK2. One patient had Microsatellite instability (MSI). Common co-occurring mutations were EGFR and BRAF (N=14), EGFR and MET (N=13) and MET and BRAF (N=10) (p<0.001). Common mutually exclusive mutations were KRAS and EGFR (p<0.001). Tissue NGS analysis was performed in 62/106 patients (58%), with AM found in 45 patients (72%). Concordance agreement in AM between plasma and tissue NGS modalities was detected in 39/45 patients (87%) and was demonstrated in EGFR (N=25), KRAS (N=11), BRAF (N=2) and MET (N=1). In the reminder 6 patients (13%), tissue NGS was discordant from their plasma NGS results. In 44/106 patients, for whom tissue sampling was not performed, utilizing plasma NGS increased AM detection yield by 41%. Conclusions: Integration of plasma NGS testing into the routine management of NSCLC patients demonstrated substantial yield of therapeutically targetable mutations detection rate, when tissue NGS was not available.
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Affiliation(s)
- Kathrin Dvir
- Mount Sinai Medical Center of Florida Department of Internal Medicine, Miami Beach, FL
| | | | - Joel M. Haines
- Mount Sinai Medical Center of Florida Department of Internal Medicine, Miami Beach, FL
| | | | | | - Paulina Gines
- Comprehensive Cancer Center, Mount Sinai Medical Center of Florida, Miami Beach, FL
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Dvir K, Fortuna GMG, Schwartz M. Delayed Presentation of Thymoma-Related Aplastic Anemia: An Unusual Presentation of a Rare Complication. J Hematol 2020; 8:160-164. [PMID: 32300464 PMCID: PMC7155810 DOI: 10.14740/jh557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 10/07/2019] [Indexed: 11/17/2022] Open
Abstract
A 68-year-old Caucasian man presented with gross hematuria and oral mucosal bleeding. The patient was known to have an anterior mediastinal mass, highly suspicious for thymoma, which was incidentally identified on imaging, 8 years prior. The patient then declined treatment and was lost to follow-up. On presentation, imaging re-demonstrated the anterior mediastinal mass and the patient was found to have profound pancytopenia. Bone marrow biopsy confirmed the diagnosis of aplastic anemia (AA). Despite optimal treatment, the patient expired on day 9 of admission. In this case we report an unusual presentation of thymoma-related AA (TR-AA), a rare complication of thymoma, presenting years after initial diagnosis in a patient with long standing thymoma that was left untreated as per the patient’s wishes. To our best knowledge, this is the first published report where TR-AA presented 8 years after initial diagnosis in a patient with unresected and untreated thymoma.
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Affiliation(s)
- Kathrin Dvir
- Department of Internal Medicine at Mount Sinai Medical Center, Miami Beach, FL, USA
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Galarza Fortuna GM, Dvir K, Febres-Aldana C, Schwartz M, Medina AM. Primary Central Nervous System Lymphoma in an Immunocompetent Patient Presenting as Multiple Cerebellar Lesions: A Case Report and Review of Literature. J Investig Med High Impact Case Rep 2019; 7:2324709619893548. [PMID: 31818145 PMCID: PMC6904776 DOI: 10.1177/2324709619893548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Primary central nervous system (CNS) lymphoma (PCNSL) is an uncommon extranodal
non-Hodgkin lymphoma often presenting as a single brain lesion within the CNS.
On histopathological evaluation of PCNSL a positive CD10, which is frequently
observed in systemic diffuse large B-cell lymphoma, is present in approximately
10% of PCNSL. We describe a case of CD10-positive PCNSL presenting with multiple
posterior fossa enhancing lesions in an immunocompetent older woman with a
history of breast cancer successfully treated by the RTOG 0227 protocol
consisting of pre-irradiation chemotherapy with high-dose methotrexate,
rituximab, and temozolomide for 6 cycles, followed by low-dose whole-brain
radiation and post-irradiation temozolomide.
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Affiliation(s)
| | - Kathrin Dvir
- Mount Sinai Medical Center, Miami Beach, FL, USA
| | | | | | - Ana Maria Medina
- Mount Sinai Medical Center, Miami Beach, FL, USA.,Florida International University, Miami, FL, USA
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Tur-Sinai A, Kolobov T, Tesler R, Baron-Epel O, Dvir K, Harel-Fisch Y. Direct and the Indirect Determinants of Weight-Control Behaviours among Adolescents. Eur J Public Health 2019. [DOI: 10.1093/eurpub/ckz186.134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Economic determinants such as socioeconomic inequalities and parents’ employment have a profound impact on the health of adolescents in terms of unhealthy weight-control behaviours (UWCB). In addition, various family factors may play a role in adolescents’ weight-control behaviours (WCB). This study examines the association among socioeconomic status, perceived family wealth, and number of employed parents and Israeli adolescents’ WCB and asks whether family variables (parental communication, monitoring, support, and family meals) mediate WCB.
Methods
Data from the cross-sectional questionnaire of the 2014 Israeli Health Behaviour in School-Aged Children study are analysed using structural equation modelling. The research population includes approximately 7,000 Israeli schoolchildren in grades 6, 8, and 10. The association among socioeconomic status (SES) factors (SES measures, parental employment), sociodemographic factors, and weight-control behaviours among adolescents is calculated.
Results
High family affluence and high perceived family wealth are negatively associated with unhealthy weight-control behaviour. Having two employed parents leads to lower levels of UWCB. Family-related variables like family communication and support and parental monitoring are found to mitigate unhealthy weight-control behaviours. Family meals have a significantly positive effect on healthy weight-control behaviour and a significantly negative impact on unhealthy weight-control activities.
Conclusions
The findings suggest that economic factors such as SES and number of employed parents are necessary strategies for long-term weight-control practice. The combination of WCB and family meals is the most effective method for adolescents’ healthy weight-control behaviour.
Key messages
The study highlights the importance of considering the quality of family communication and support as a health asset that may contribute to WCB among young people. Family affluence and perceived family wealth, which were two separate measurements, were perceived differently by adolescents.
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Affiliation(s)
- A Tur-Sinai
- Health Systems Management, The Max Stern Yezreel Valley College, Yezreel Valley, Israel
| | - T Kolobov
- School of Education, Bar-Ilan University, Ramat Gan, Israel
| | - R Tesler
- Health System Management, Ariel University, Ariel, Israel
| | - O Baron-Epel
- School of Public Health, University of Haifa, Haifa, Israel
| | - K Dvir
- Research, Henrietta Szold Institute, Jerusalem, Israel
| | - Y Harel-Fisch
- School of Education, Bar-Ilan University, Ramat Gan, Israel
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