Publications by authors named "Tamara N Fitzgerald"

53 Publications

The Evolving Landscape of Global Surgery: A Qualitative Study of North American Surgeons' Perspectives on Faith-Based and Academic Initiatives.

J Relig Health 2021 Jul 23. Epub 2021 Jul 23.

Department of Surgery, Duke University School of Medicine, Durham, NC, USA.

Faith-based missions have played a large role in surgical care delivery in low- and middle-income countries (LMIC). As global surgery is now an academic discipline, this pilot study sought to understand how different faith ideologies influence surgeon motivations and subsequent culture of the global surgery landscape. Interviews were conducted with North American surgeons who pursue global surgery significantly in their career. Points of discussion included early influences, obstacles, motivations, philosophy and approach to global surgery work, and experiences with faith-based (FBO) and non-faith-based organizations (NFBO). Notes were transcribed and thematic analysis performed. Sixteen surgeons were interviewed (11 men, 5 women, ages 39-75 years-old). Surgeons had worked in 32 countries with FBO and NFBO in intermittent or long-term capacity. Religious upbringing and current affiliations included Atheism, Protestant Christianity, Catholicism, Hinduism, Judaism, Mormonism, Islam, and nonreligious spirituality. Early influences included international upbringing (n = 7), emphasis on service (n = 9), and exposure to the religious mission concept (n = 6). The most common core motivation among all participants was addressing disparities (n = 10). Some believed that FBO and NFBO have different goals (n = 4), and only surgeons identifying with Christianity believed the goals are similar (n = 3). Participants expressed that FBO are exclusive (n = 4) and focused on proselytization (n = 6) while NFBO are humanitarian (n = 3) but less integrated into the community (n = 4). Global surgeons have shared early influences, obstacles, and desire to address disparities. Perceptions of FBO and NFBO differed based on religious background. This pilot study will inform future studies regarding the collaborations of FBO and NFBO to improve global surgical care.
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http://dx.doi.org/10.1007/s10943-021-01337-zDOI Listing
July 2021

Dr. Sr. Mary Margaret Ajiko.

World J Surg 2021 Jul 15. Epub 2021 Jul 15.

Department of Surgery, Duke University, Durham, USA.

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http://dx.doi.org/10.1007/s00268-021-06243-9DOI Listing
July 2021

KeyLoop: Mechanical Retraction of the Abdominal Wall for Gasless Laparoscopy.

Surg Innov 2021 Jul 9:15533506211031084. Epub 2021 Jul 9.

Duke Global Health Institute, Durham, NC, USA.

Despite favorable outcomes of laparoscopic surgery in high-income countries, its implementation in low- and middle-income countries (LMICs) is challenging given a shortage of consumable supplies, high cost, and risk of power outages. To overcome these barriers, we designed a mechanical retractor that provides vertical tension on the anterior abdominal wall. The retractor design is anatomically and mathematically optimized to provide exposure similar to traditional gas-based insufflation methods. Anatomical data from computed tomography scans were used to define retractor size. The retractor is constructed of biocompatible stainless steel rods and paired with a table-mounted lifting system to provide 5 degrees of freedom. Structural integrity was assessed through finite element analysis (FEA) and load testing. Functional testing was performed in a laparotomy model. A user guide based on patient height and weight was created to customize retractor size, and 4 retractor sizes were constructed. FEA data using a 13.6 kg mass (15 mm Hg pneumoperitoneum) show a maximum of 30 mm displacement with no permanent deformation. Physical load testing with applied weight from 0 to 13.6 kg shows a maximum of 60 mm displacement, again without permanent deformation. Retraction achieved a 57% larger field of view compared to an unretracted state in a laparotomy model. The KeyLoop retractor maintains structural integrity, is easily sterilized, and can be readily manufactured, making it a viable alternative to traditional insufflation methods. For surgeons and patients in LMICs, the KeyLoop provides a means to increase access to laparoscopic surgery.
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http://dx.doi.org/10.1177/15533506211031084DOI Listing
July 2021

Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals.

Surgery 2021 Jun 12. Epub 2021 Jun 12.

Department of Surgery, University of California, San Francisco, CA. Electronic address:

Background: Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children's surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity.

Methods: Two years of a prospective clinical database of children's surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered.

Results: From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society.

Conclusion: This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.
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http://dx.doi.org/10.1016/j.surg.2021.05.007DOI Listing
June 2021

Invited Commentary: "Familial Non-Medullary Thyroid Carcinoma in Pediatric Age: Our Surgical Experience."

World J Surg 2021 Aug 6;45(8):2480-2481. Epub 2021 May 6.

Department of Surgery, Duke University, Box 3815, Durham, NC, 27710, USA.

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http://dx.doi.org/10.1007/s00268-021-06153-wDOI Listing
August 2021

Development of an Interactive Global Surgery Course for Interdisciplinary Learners.

Ann Glob Health 2021 03 31;87(1):33. Epub 2021 Mar 31.

Department of Surgery, Duke University, Durham, NC, USA.

Introduction: Global surgical care is increasingly recognized in the global health agenda and requires multidisciplinary engagement. Despite high interest among medical students, residents and other learners, many surgical faculty and health experts remain uniformed about global surgical care.

Methods: We have operated an interdisciplinary graduate-level course in Global Surgical Care based on didactics and interactive group learning. Students completed a pre- and post-course survey regarding their learning experiences and results were analyzed using the Wilcoxon signed-rank test.

Results: Fourteen students completed the pre-course survey, and 11 completed the post-course survey. Eleven students (79%) were enrolled in a Master's degree program in global health, with eight students (57%) planning to attend medical school. The median ranking of surgery on the global health agenda was fifth at the beginning of the course and third at the conclusion (p = 0.11). Non-infectious disease priorities tended to stay the same or increase in rank from pre- to post-course. Infectious disease priorities tended to decrease in rank (HIV/AIDS, p = 0.07; malaria, p = 0.02; neglected infectious disease, p = 0.3). Students reported that their understanding of global health (p = 0.03), global surgery (p = 0.001) and challenges faced by the underserved (p = 0.03) improved during the course. When asked if surgery was an indispensable part of healthcare, before the course 64% of students strongly agreed, while after the course 91% of students strongly agreed (p = 0.3). Students reported that the interactive nature of the course strengthened their skills in collaborative problem-solving.

Conclusions: We describe an interdisciplinary global surgery course that integrates didactics with team-based projects. Students appeared to learn core topics and held a different view of global surgery after the course. Similar courses in global surgery can educate clinicians and other stakeholders about strategies for building healthy surgical systems worldwide.
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http://dx.doi.org/10.5334/aogh.3178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8015709PMC
March 2021

The Evolving Landscape of Medical Device Regulation in East, Central, and Southern Africa.

Glob Health Sci Pract 2021 03 31;9(1):136-148. Epub 2021 Mar 31.

School of Medicine, Duke University, Durham, NC, USA.

Effective regulatory frameworks, harmonized to international standards, are critical to expanding access to quality medical devices in low- and middle-income countries. This review provides a summary of the state of medical device regulation in the 14 member countries of the College of Surgeons of East, Central, and Southern Africa (COSECSA) and South Africa. Countries were categorized according to level of regulatory establishment, which was found to be positively correlated to gross domestic product (GDP; r=0.90) and years of freedom from colonization (r=0.60), and less positively correlated to GDP per capita (r=0.40). Although most countries mandate medical device regulation in national legislation, few employ all the guidelines set forth by the World Health Organization. A streamlined regulatory process across African nations would simplify this process for innovators seeking to bring medical devices to the African market, thereby increasing patient access to safe medical devices.
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http://dx.doi.org/10.9745/GHSP-D-20-00578DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8087432PMC
March 2021

An Accessible Laparoscope for Surgery in Low- and Middle- Income Countries.

Ann Biomed Eng 2021 Jul 8;49(7):1657-1669. Epub 2021 Mar 8.

Duke Global Health Institute, Durham, NC, USA.

Laparoscopic surgery is the standard of care in high-income countries for many procedures in the chest and abdomen. It avoids large incisions by using a tiny camera and fine instruments manipulated through keyhole incisions, but it is generally unavailable in low- and middle-income countries (LMICs) due to the high cost of installment, lack of qualified maintenance personnel, unreliable electricity, and shortage of consumable items. Patients in LMICs would benefit from laparoscopic surgery, as advantages include decreased pain, improved recovery time, fewer wound infections, and shorter hospital stays. To address this need, we developed an accessible laparoscopic system, called the ReadyView laparoscope for use in LMICs. The device includes an integrated camera and LED light source that can be displayed on any monitor. The ReadyView laparoscope was evaluated with standard optical imaging targets to determine its performance against a state-of-the-art commercial laparoscope. The ReadyView laparoscope has a comparable resolving power, lens distortion, field of view, depth of field, and color reproduction accuracy to a commercially available endoscope, particularly at shorter, commonly-used working distances (3-5 cm). Additionally, the ReadyView has a cooler temperature profile, decreasing the risk for tissue injury and operating room fires. The ReadyView features a waterproof design, enabling sterilization by submersion, as commonly performed in LMICs. A custom desktop software was developed to view the video on a laptop computer with a frame rate greater than 30 frames per second and to white balance the image, which is critical for clinical use. The ReadyView laparoscope is capable of providing the image quality and overall performance needed for laparoscopic surgery. This portable low-cost system is well suited to increase access to laparoscopic surgery in LMICs.
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http://dx.doi.org/10.1007/s10439-020-02707-6DOI Listing
July 2021

Missions, Humanitarianism, and the Evolution of Modern Global Surgery.

Am Surg 2021 May 19;87(5):681-685. Epub 2020 Dec 19.

Department of Surgery, 160976Duke University, Durham, NC, USA.

Modern global surgery, which aims to provide improved and equitable surgical care worldwide, is a product of centuries of international care initiatives, some borne out of religious traditions, dating back to the first millennium. The first hospitals () were established in the 4th and 5th centuries CE by the early Christian church. Early "missions," a term introduced by Jesuit Christians in the 16th century to refer to the institutionalized expansion of faith, included medical care. Formalized Muslim humanitarian medical care was marked by organizations like the Aga Khan Foundation and the Islamic Association of North America in the 20th century. Secular medical humanitarian programs developed in the 19th century, notably with the creation of the International Committee of the Red Cross (1863) and the League of Nations Health Organization (1920) (which later became the World Health Organization [1946]). World War II catalyzed another proliferation of nongovernmental organizations, epitomized by the quintessential humanitarian health provider, Médecins Sans Frontières (1971). "Global health" as an academic endeavor encompassing education, service, and research began as an outgrowth of departments of tropical medicine and international health. The American College of Surgeons brought a surgical focus to global health beginning in the 1980s. Providing medical care in distant countries has a long tradition that parallels broad themes in history: faith, imperialism, humanitarianism, education, and service. Surgery as a focus of academic global health is a recent development that continues to gain traction.
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http://dx.doi.org/10.1177/0003134820979181DOI Listing
May 2021

Laparoscopic experience and attitudes toward a low-cost laparoscopic system among surgeons in East, Central, and Southern Africa: a survey study.

Surg Endosc 2020 Nov 17. Epub 2020 Nov 17.

Department of Surgery, DUMC, Duke University, Box 3815, Durham, NC, 27710, USA.

Background: Laparoscopic surgery has become standard of care in high-income countries but is rarely accessible in low- and middle-income countries (LMICs). This study assessed experience with laparoscopy and attitudes toward a low-cost laparoscopic system among surgeons in sub-Saharan Africa.

Methods: A survey assessing current laparoscopic practice and feedback on a low-cost laparoscopic system was administered to attendees of the College of Surgeons of East, Central, and Southern Africa (COSECSA) Scientific Conference between December 4 and December 6, 2019 in Kampala, Uganda.

Results: Fifty-six surgeons from 14 countries participated. A majority were male (n = 46, 82%) general surgeons (n = 37, 66%) from tertiary/teaching hospitals (n = 36, 64%). For those with training in laparoscopy (n = 33, 59%), 22 (67%) reported less than 1 year of training and over half (n = 17, 52%) reported 1 month or less. Overall, a minority (n = 21, 38%) used laparoscopy in current practice, with 57% (n = 12) of those performing laparoscopy less than once per week. The most common laparoscopic surgeries performed were cholecystectomy (n = 15), diagnostic laparoscopy (n = 14), and appendectomy (n = 12). Few surgeons were performing more complex cases (n = 5). Barriers to laparoscopy included poor access to training equipment (n = 34, 61%), mentors (n = 33, 59%), laparoscopic equipment (n = 31, 55%), equipment maintenance (n = 25, 45%), access to consumable supplies (n = 21, 38%), and cost (n = 31, 55%). Fifty-two participants (93%) were interested in increasing their use of laparoscopy; the majority felt that a low-cost laparoscope (n = 52, 93%) and lift retractor for gasless laparoscopy (n = 46, 82%) would serve an unmet need in their practice.

Conclusions: While the use of laparoscopy is currently limited in COSECSA countries, there is a significant interest among surgeons to increase implementation. A low-cost, durable laparoscopic system was viewed as a potential solution to the current barriers and could improve implementation in LMICs.
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http://dx.doi.org/10.1007/s00464-020-08151-wDOI Listing
November 2020

Social and financial barriers may contribute to a "hidden mortality" in Uganda for children with congenital anomalies.

Surgery 2021 02 21;169(2):311-317. Epub 2020 Oct 21.

Department Surgery, Duke University, Durham, NC; Duke Global Health Institute, Durham, NC. Electronic address:

Background: The true incidence of congenital anomalies in sub-Saharan Africa is unknown. Owing to complex challenges associated with congenital anomalies, many affected babies may never present to a health facility, resulting in an underestimation of disease burden.

Methods: Interviews were conducted with Ugandans between September 2018 and May 2019. Responses from community members versus families of children with congenital anomalies were compared.

Results: A total of 198 Ugandans were interviewed (91 family members, 80 community members). All participants (N = 198) believed that seeking surgical care would lead to poverty, 43% (n = 84) assumed fathers would abandon the child, and 26% (n = 45) thought a child with a congenital anomaly in their community had been left to die. Causes of anomalies were believed to be contraceptive methods (48%, n = 95), witchcraft (17%, n = 34), or drugs (10%, n = 19). Of family members, 25 (28%) were advised to allow the child to die. Families with affected children were more likely to have a lower income (P < .001), believe anomalies could be treated (P = .007), but thought that allowing the child to die was best for the family (32% vs 9%; P < .0001). Monthly household income <50,000 Uganda shillings ($13 United States dollars) was a significant predictor of the father leaving the family (P = .024), being advised to not pursue medical care (P = .046), and believing that God should decide the child's fate (P = .047).

Conclusion: Families face significant financial and social pressures when deciding to seek surgical care for a child with a congenital anomaly. Many children with anomalies may die and never reach a health facility to be counted, thus contributing to a hidden mortality.
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http://dx.doi.org/10.1016/j.surg.2020.09.018DOI Listing
February 2021

Ugandan Medical Student Career Choices Relate to Foreign Funding Priorities.

World J Surg 2020 Dec 20;44(12):3975-3985. Epub 2020 Sep 20.

Department of Surgery, Duke University School of Medicine, DUMC, Box 3815, Durham, NC, 27710, USA.

Introduction: The surgical workforce in sub-Saharan Africa is insufficient to meet population needs. Therefore, medical students should be encouraged to pursue surgical careers and "brain drain" must be minimized. It is unknown to what extent foreign aid priorities influence medical student career choices in Uganda.

Methods: Medical students in Uganda completed an online survey examining their career choices and attitudes regarding career opportunities and funding priorities. Data were analyzed using descriptive statistics, and responses among men and women were compared using Fisher's exact tests.

Results: Ninety-eight students participated. Students were most influenced by inspiring role models, employment opportunities and specialty fit with personal skills. Filling an underserved specialty was near the bottom of the influence scale. Women placed higher importance on advice from mentors (p = 0.049) and specialties with lower stress burden (p = 0.027). Men placed importance on opportunities in non-governmental organizations (p = 0.033) and academia (p = 0.050). Students expressed that the most supported specialties were infectious disease (n = 65, 66%), obstetrics (n = 15, 15%) and pediatrics (n = 7, 7%). Most students (n = 91, 93%) were planning a career in infectious disease. Fifty-three students (70%) indicated plans to leave Africa for residency. Female students were more likely to have a plan to leave (p = 0.027).

Conclusion: Medical students in Uganda acknowledge the career opportunities for physicians in specialties prioritized by the Sustainable Development Goals. In order to avoid "brain drain" and encourage students to pursue careers in surgery, career opportunities including surgical residencies must be prioritized and supported in sub-Saharan Africa.
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http://dx.doi.org/10.1007/s00268-020-05756-zDOI Listing
December 2020

The first six years of the APSA Travel Fellowship Program: Impact and lessons learned.

J Pediatr Surg 2021 May 28;56(5):862-867. Epub 2020 Jun 28.

Department of Surgery, Duke University, Durham, NC. Electronic address:

Introduction: The American Pediatric Surgical Association (APSA) travel fellowship was established in 2013 to allow pediatric surgeons from low- and middle-income countries to attend the APSA annual meeting. Travel fellows also participated in various clinical and didactic learning experiences during their stay in North America.

Methods: Previous travel fellows completed a survey regarding their motivations for participation in the program, its impact on their practice in their home countries, and suggestions for improvement of the fellowship.

Results: Eleven surgeons participated in the travel fellowship and attended the annual APSA meetings in 2013-2018. The response rate for survey completion was 100%. Fellows originated from 9 countries and 3 continents and most fellows worked in government practice (n=8, 73%). Nine fellows (82%) spent >3 weeks participating in additional learning activities such as courses and clinical observerships. The most common reasons for participation were networking (n=11, 100%), learning different ways of providing care (n=10, 90.9%), new procedural techniques (n=9, 81.8%), exposure to a different medical culture (n=10, 90.9%), and engaging in research (n=8, 72.7%). Most of the fellows participated in a structured course: colorectal (n= 6, 55%), laparoscopy (n=2, 18%), oncology (n=2, 18%), leadership skills (n=1, 9%), and safety and quality initiatives (n=1, 9%). Many fellows participated in focused clinical mentorships: general pediatric surgery (n=9, 82%), oncology (n=5, 45%), colorectal (n=3, 27%), neonatal care (n=2, 18%) and laparoscopy (n=2, 18%). Upon return to their countries, fellows reported that they were able to improve a system within their hospital (n=7, 63%), expand their research efforts (n=6, 54%), or implement a quality improvement initiative (n=6, 54%).

Conclusions: The APSA travel fellowship is a valuable resource for pediatric surgeons in low- and middle-income countries. After completion of these travel fellowships, the majority of these fellows have implemented important changes in their hospital's health systems, including research and quality initiatives, to improve pediatric surgical care in their home countries.

Level Of Evidence: This is not a clinical study. Therefore, the table that lists levels of evidence for "treatment study", "prognosis study", "study of diagnostic test" and "cost effectiveness study" does not apply to this paper.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.06.030DOI Listing
May 2021

Multidisciplinary Development of a Low-Cost Gastroschisis Silo for Use in Sub-Saharan Africa.

J Surg Res 2020 11 6;255:565-574. Epub 2020 Jul 6.

Department of Surgery, Duke University, Durham, North Carolina; Duke Global Health Institute, Duke University, Durham, North Carolina. Electronic address:

Background: Gastroschisis silos are often unavailable in sub-Saharan Africa (SSA), contributing to high mortality. We describe a collaboration between engineers and surgeons in the United States and Uganda to develop a silo from locally available materials.

Methods: Design criteria included the following: < $5 cost, 5 ± 0.25 cm opening diameter, deformability of the opening construct, ≥ 500 mL volume, ≥ 30 N tensile strength, no statistical difference in the leakage rate between the low-cost silo and preformed silo, ease of manufacturing, and reusability. Pugh scoring matrices were used to assess designs. Materials considered included the following: urine collection bags, intravenous bags, or zipper storage bags for the silo and female condom rings or O-rings for the silo opening construct. Silos were assembled with clothing irons and sewn with thread. Colleagues in Uganda, Malawi, Tanzania, and Kenya investigated material cost and availability.

Results: Urine collection bags and female condom rings were chosen as the most accessible materials. Silos were estimated to cost < $1 in SSA. Silos yielded a diameter of 5.01 ± 0.11 cm and a volume of 675 ± 7 mL. The iron + sewn seal, sewn seal, and ironed seal on the silos yielded tensile strengths of 31.1 ± 5.3 N, 30.1 ± 2.9 N, and 14.7 ± 2.4 N, respectively, compared with the seal of the current standard-of-care silo of 41.8 ± 6.1 N. The low-cost silos had comparable leakage rates along the opening and along the seal with the spring-loaded preformed silo. The silos were easily constructed by biomedical engineering students within 15 min. All silos were able to be sterilized by submersion.

Conclusions: A low-cost gastroschisis silo was constructed from materials locally available in SSA. Further in vivo and clinical studies are needed to determine if mortality can be improved with this design.
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http://dx.doi.org/10.1016/j.jss.2020.05.037DOI Listing
November 2020

Multidisciplinary Development of a Low-Cost Gastroschisis Silo for Use in Sub-Saharan Africa.

J Surg Res 2020 11 6;255:565-574. Epub 2020 Jul 6.

Department of Surgery, Duke University, Durham, North Carolina; Duke Global Health Institute, Duke University, Durham, North Carolina. Electronic address:

Background: Gastroschisis silos are often unavailable in sub-Saharan Africa (SSA), contributing to high mortality. We describe a collaboration between engineers and surgeons in the United States and Uganda to develop a silo from locally available materials.

Methods: Design criteria included the following: < $5 cost, 5 ± 0.25 cm opening diameter, deformability of the opening construct, ≥ 500 mL volume, ≥ 30 N tensile strength, no statistical difference in the leakage rate between the low-cost silo and preformed silo, ease of manufacturing, and reusability. Pugh scoring matrices were used to assess designs. Materials considered included the following: urine collection bags, intravenous bags, or zipper storage bags for the silo and female condom rings or O-rings for the silo opening construct. Silos were assembled with clothing irons and sewn with thread. Colleagues in Uganda, Malawi, Tanzania, and Kenya investigated material cost and availability.

Results: Urine collection bags and female condom rings were chosen as the most accessible materials. Silos were estimated to cost < $1 in SSA. Silos yielded a diameter of 5.01 ± 0.11 cm and a volume of 675 ± 7 mL. The iron + sewn seal, sewn seal, and ironed seal on the silos yielded tensile strengths of 31.1 ± 5.3 N, 30.1 ± 2.9 N, and 14.7 ± 2.4 N, respectively, compared with the seal of the current standard-of-care silo of 41.8 ± 6.1 N. The low-cost silos had comparable leakage rates along the opening and along the seal with the spring-loaded preformed silo. The silos were easily constructed by biomedical engineering students within 15 min. All silos were able to be sterilized by submersion.

Conclusions: A low-cost gastroschisis silo was constructed from materials locally available in SSA. Further in vivo and clinical studies are needed to determine if mortality can be improved with this design.
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http://dx.doi.org/10.1016/j.jss.2020.05.037DOI Listing
November 2020

Invited Commentary: Clinical Assessment of Pediatric Patients with Differentiated Thyroid Carcinoma: A 30-Year Experience at the Single Institution.

World J Surg 2020 10;44(10):3393-3394

Department of Surgery, Duke University School of Medicine, Durham, NC, USA.

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http://dx.doi.org/10.1007/s00268-020-05641-9DOI Listing
October 2020

Global Surgery Pro-Con Debate: A Pathway to Bilateral Academic Success or the Bold New Face of Colonialism?

J Surg Res 2020 08 10;252:272-280. Epub 2020 May 10.

Department of Surgery, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia.

Global surgery, especially academic global surgery, is of tremendous interest to many surgeons. Classically, it entails personnel from high-income countries going to low- and middle-income countries and engaging in educational activities as well as procedures. Academic medical personnel have included students, residents, and attendings. The pervasive notion is that this is a win-win situation for the volunteers and the hosts, that is, a pathway to bilateral academic success. However, a critical examination demonstrates that it can easily become the bold new face of colonialism of a low- and middle-income country by a high-income country.
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http://dx.doi.org/10.1016/j.jss.2020.01.032DOI Listing
August 2020

Comparison of Ugandan and North American Pediatric Surgery Fellows' Operative Experience: Opportunities for Global Training Exchange.

J Surg Educ 2020 May - Jun;77(3):606-614. Epub 2019 Dec 18.

Duke University Medical Center, Department of Surgery, Durham, North Carolina.

Objective: North American pediatric surgery training programs vary in exposure to index cases, while controversy exists regarding fellow participation in global surgery rotations. We aimed to compare the case logs of graduating North American pediatric surgery fellows with graduating Ugandan pediatric surgery fellows.

Design: The pediatric surgery training program at a regional Ugandan hospital hosts a collaboration between Ugandan and North American attending pediatric surgeons. Fellow case logs were compared to the Accreditation Council for Graduate Medical Education Pediatric Surgery Case Log 2018 to 19 National Data Report.

Setting: Mulago National Referral Hospital in Kampala, Uganda; and pediatric surgery training programs in the United States and Canada.

Results: Three Ugandan fellows completed training and submitted case logs between 2011 and 2019 with a mean of 782.3 index cases, compared to the mean 753 cases in North America. Ugandan fellows performed more procedures for biliary atresia (6.7 versus 4), Wilm's tumor (23.7 versus 5.7), anorectal malformation (45 versus 15.7), and inguinal hernia (158.7 versus 76.8). North American fellows performed more central line procedures (73.7 versus 30.7), cholecystectomies (27.3 versus 3), extracorporeal membrane oxygenation cannulations (16 versus 1), and congenital diaphragmatic hernia repairs (16.5 versus 5.3). All cases in Uganda were performed without laparoscopy.

Conclusions: Ugandan fellows have access to many index cases. In contrast, North American trainees have more training in laparoscopy and cases requiring critical care. Properly orchestrated exchange rotations may improve education for all trainees, and subsequently improve patient care.
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http://dx.doi.org/10.1016/j.jsurg.2019.12.001DOI Listing
June 2021

Burden and Outcomes of Neonatal Surgery in Uganda: Results of a Five-Year Prospective Study.

J Surg Res 2020 02 25;246:93-99. Epub 2019 Sep 25.

Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.

Background: Ninety-four percent of congenital anomalies occur in low- and middle-income countries. In Uganda, only three pediatric surgeons and three pediatric anesthesiologists serve more than 20 million children. This study estimates burden, outcomes, coverage, and economic benefit of neonatal surgical conditions in Uganda.

Methods: A prospectively collected database was reviewed for neonatal surgical admissions from January 1, 2012, to December 31, 2017, at the only two sites with specialist pediatric surgical coverage. Outcomes were compared with high-income countries. Met and unmet need were estimated using disability-adjusted life years. Economic benefit was estimated using a value of statistical life-year approach.

Results: For 1313 neonatal admissions, the median age of presentation was 3 d, overall mortality was 36%, and median distance traveled was 40 km. Anorectal malformations were most common (18%). Postoperative mortality was 24%. Mortality was significantly associated with surgical intervention (P < 0.0001). Met need was 4181 disability-adjusted life years per year, which corresponds to a $3.5 million net economic benefit to Uganda, with a potential additional benefit of $153 million if unmet need were fully addressed. Approximately 2% of the total need is met by the health care system.

Conclusions: Neonatal surgery is associated with improved survival for most conditions. Despite increases in workforce and infrastructure, a limited proportion of the need for neonatal surgery is currently being met. This is multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial.
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http://dx.doi.org/10.1016/j.jss.2019.08.015DOI Listing
February 2020

Burden of Surgical Infections in a Tertiary-Care Pediatric Surgery Service in Uganda.

Surg Infect (Larchmt) 2020 Mar 27;21(2):130-135. Epub 2019 Sep 27.

Department of Surgery, Duke University School of Medicine, Durham, North Carolina.

Delayed presentation of surgical disease often leads to infection in low- and middle-income countries (LMICs). In addition, many primary infections require surgical intervention. The burden of infection in children's surgery in LMICs is poorly defined and may tax the limited availability of surgical resources. A prospective surgical database was reviewed for all children presenting to a Ugandan tertiary referral hospital from January 2012 to August 2016. All patients presenting with infection were included and analyzed by operative intervention and survival. Of the 3,494 children admitted over the time period, 712 (20.4%) presented with infection. A total of 455 patients (64%) with an infection underwent an operation, with an in-hospital mortality rate of 12.5%. Operations involving infections represented 20% of the volume of the children's surgery department. Common conditions were abscesses (n = 308; 43.4%), typhoid intestinal perforations (n = 85; 12.0%), appendicitis (n = 78; 11.0%) and perforated bowel caused by ileocolic intussusception (n = 37; 5.2%). Patients with esophageal atresia presenting with aspiration pneumonia had an in-hospital mortality rate of 78.6%, those with abdominal sepsis a 67% mortality rate, and neonatal infants with necrotizing enterocolitis a 50% mortality rate. There is a high volume of infection in children requiring surgery, contributing to a high mortality rate. Resource allocation for children's surgical care in LMIC should be directed toward timely diagnosis and surgical intervention of these conditions.
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http://dx.doi.org/10.1089/sur.2019.045DOI Listing
March 2020

Investing in all of Our Children: Global Pediatric Surgery for the Twenty-First Century.

World J Surg 2019 06;43(6):1401-1403

Department of Surgery, Duke University School of Medicine, Box 3815, DUMC, Durham, NC, 27705, USA.

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http://dx.doi.org/10.1007/s00268-019-04973-5DOI Listing
June 2019

Unifying Children's Surgery and Anesthesia Stakeholders Across Institutions and Clinical Disciplines: Challenges and Solutions from Uganda.

World J Surg 2019 06;43(6):1435-1449

Department of Paediatrics and Child Health, Makerere University School of Medicine, Kampala, Uganda.

Background: There is a significant unmet need for children's surgical care in low- and middle-income countries (LMICs). Multidisciplinary collaboration is required to advance the surgical and anesthesia care of children's surgical conditions such as congenital conditions, cancer and injuries. Nonetheless, there are limited examples of this process from LMICs. We describe the development and 3-year outcomes following a 2015 stakeholders' meeting in Uganda to catalyze multidisciplinary and multi-institutional collaboration.

Methods: The stakeholders' meeting was a daylong conference held in Kampala with local, regional and international collaborators in attendance. Multiple clinical specialties including surgical subspecialists, pediatric anesthesia, perioperative nursing, pediatric oncology and neonatology were represented. Key thematic areas including infrastructure, training and workforce retention, service delivery, and research and advocacy were addressed, and short-term objectives were agreed upon. We reported the 3-year outcomes following the meeting by thematic area.

Results: The Pediatric Surgical Foundation was developed following the meeting to formalize coordination between institutions. Through international collaborations, operating room capacity has increased. A pediatric general surgery fellowship has expanded at Mulago and Mbarara hospitals supplemented by an international fellowship in multiple disciplines. Coordinated outreach camps have continued to assist with training and service delivery in rural regional hospitals.

Conclusion: Collaborations between disciplines, both within LMICs and with international partners, are required to advance children's surgery. The unification of stakeholders across clinical disciplines and institutional partnerships can facilitate increased children's surgical capacity. Such a process may prove useful in other LMICs with a wide range of children's surgery stakeholders.
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http://dx.doi.org/10.1007/s00268-018-04905-9DOI Listing
June 2019

Children with appendicitis on the US-Mexico border have socioeconomic challenges and are best served by a freestanding children's hospital.

Pediatr Surg Int 2018 Dec 28;34(12):1269-1280. Epub 2018 Sep 28.

Department of Surgery, Duke University School of Medicine, DUMC, Box 3815, Durham, NC, 27710, USA.

Introduction: The US-Mexico border is medically underserved. Recent political changes may render this population even more vulnerable. We hypothesized that children on the border present with high rates of perforated appendicitis due to socioeconomic barriers.

Methods: A prospective survey was administered to children presenting with appendicitis in El Paso, Texas. Primary outcomes were rate of perforation and reason for diagnostic delay. We evaluated the association between demographics, potential barriers to care, risk of perforation and risk of misdiagnosis using logistic regression. p < 0.05 was considered significant.

Results: 98 patients participated from October 2016 to February 2017. 96 patients (98%) were Hispanic and 81 (82%) had Medicaid or were uninsured. 11 patients (11%) resided in Mexico or Guatemala. Patients were less likely to receive a CT and more likely to receive an ultrasound if they presented to a freestanding children's hospital (p = 0.01). 37 patients (38%) presented with perforation, of which 19 (52%) were the result of practitioner misdiagnosis. Patients who presented to a freestanding children's hospital were less likely to be misdiagnosed than patients presenting to other facilities (p = 0.05). Children who underwent surgery in a freestanding children's hospital had the shortest length of stay after adjusting for perforation status and potential confounders (p < 0.01).

Conclusion: Children with low socioeconomic status did not have difficulty accessing care on the USA-Mexico border, but they were commonly misdiagnosed. Children were less likely to receive a CT, more likely to be correctly diagnosed and length of stay was shorter when patients presented to a freestanding children's hospital.
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http://dx.doi.org/10.1007/s00383-018-4353-yDOI Listing
December 2018

Penetrating trauma in children on the United States-Mexico border: Hispanic ethnicity is not a risk factor.

Injury 2018 Jul 17;49(7):1358-1364. Epub 2018 May 17.

Duke University, Department of Surgery, Durham, NC, United States. Electronic address:

Introduction: The United States-Mexico border is perceived as dangerous by the media and current political leaders. Hispanic ethnicity, low socioeconomic status, male gender and adolescent age have previously been identified as risk factors for penetrating trauma (PT).

Methods: A retrospective review of PT was performed in a border region. Children 0-17 years old, admitted to the region's only level I trauma center between 2001 and 2016 were included. Standardized morbidity ratio was used to compare observed to expected morbidity.

Results: There were 417 PT admissions. 197 (47%) were non-accidental, 34 (8%) suicide attempts and 186 (45%) accidental. There were 12 homicides, 7 suicides and no accidental deaths. The region contains over 280,000 children, thus yielding a homicide rate of 0.26 per 100,000. The U.S. pediatric homicide rate was 2.6-4.0 over this period. Adolescents 13-17 years old accounted for 237 (57%) admissions, 152 (78%) of non-accidental admissions and 12 (63%) deaths. Most admissions (N = 321, 77%) and 15 of the deaths (79%) were males. Non-accidental injuries were more frequent in ZIP codes associated with low incomes. Hispanic patients accounted for 173 (88%) of non-accidental trauma. However, 40 (20%) non-accidental injuries occurred in Mexico and 157 (80%) injuries occurred in an 82% Hispanic region. Therefore, the standardized morbidity ratio for Hispanic ethnicity was 1.048 (CL 0.8-1.2, P = 0.6).

Conclusion: On the United States-Mexico border, the pediatric homicide rate was less than 1/10 the national average. Male adolescents are at risk for non-accidental PT. In a Hispanic majority population, Hispanic ethnicity was not a risk factor for PT. It is possible that economic disparity, rather than race/ethnicity, is a risk factor for PT.
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http://dx.doi.org/10.1016/j.injury.2018.05.008DOI Listing
July 2018

Outcomes of laparoscopic resection of Meckel's diverticulum are equivalent to open laparotomy.

J Pediatr Surg 2019 Mar 15;54(3):507-510. Epub 2018 Mar 15.

Department of Surgery, Duke University Medical Center, Durham, NC, USA. Electronic address:

Purpose: Meckel's diverticulum (MD) is a common congenital anomaly caused by failure of involution of the omphalomesenteric duct. Enthusiasm for minimally invasive surgery (MIS) in children has burgeoned as technologies have advanced, but the outcomes of laparoscopic resection in comparison to open laparotomy for MD remain poorly defined. We queried a large national database to compare current practice patterns and clinical outcomes between surgical approaches for MD in the pediatric population.

Methods: The National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped) database was queried for patients undergoing surgical intervention for MD (2011-2014). Patients were stratified by surgical approach. Baseline characteristics, intraoperative variables, and perioperative complications were compared by univariate analysis using Pearson's χ test for categorical variables and Kruskall-Wallis test for continuous variables. Primary outcomes of interest were length of stay (LOS), rate of readmission, and 30-day mortality. Secondary outcomes included operative time, anesthesia time, postoperative complications, and rates of reoperation.

Results: A total of 148 cases of MD were identified, of which 73 (49.3%) were initially managed with a laparoscopic approach and 75 (50.7%) were managed with an open approach. We found a high rate of conversion from laparoscopy to an open approach (20/73 or 27.4%). The median age of the laparoscopic group was higher than the open group (8.3 vs. 2.5years, p<0.001). Operative and anesthesia time, LOS, 30-day mortality, post-operative complications, and rates of reoperation and readmission were similar between groups (all p>0.05).

Conclusion: Nearly half of all resections for MD in children are now approached laparoscopically. This approach has equivalent outcomes to traditional open laparotomy. More widespread use of a hybrid approach with laparoscopy and exteriorization of the small bowel through an extended port site may facilitate avoiding open laparotomy. Routine conversion to open for palpation of the MD or segmental small bowel resection should be avoided in the absence of compelling intra-operative findings or operative complications.

Level Of Evidence: Level III (retrospective comparative study).
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http://dx.doi.org/10.1016/j.jpedsurg.2018.03.010DOI Listing
March 2019

Factors Associated With Poor Child Motor Vehicle Restraint on the USA-Mexico Border.

J Trauma Nurs 2018 Mar/Apr;25(2):75-82

Paul L Foster School of Medicine, Texas Tech University, EI Paso (Drs Schrodt and Fitzgerald and Mr Huynh) and Duke University Medical Center, Durham, North Carolina (Dr Fitzgerald).

Motor vehicle collisions (MVCs) are a significant cause of pediatric morbidity, particularly in low- to middle-income countries. We describe car seat use in children on the USA-Mexico border. A retrospective review was conducted for children 0-9 years old, admitted to the region's only Level I trauma center. Simultaneously, data were obtained from the SAFE KIDS database, a program that encourages car seat use through city checkpoints. There were 250 MVC admissions and nine fatalities in children 0-9 years old from 2010 to 2015. Nine percent of MVCs occurred in Mexico and 49% in El Paso, TX. Comparing trauma admissions to SAFE KIDS, there was some correlation between the location of MVCs and screening checkpoints (r = .50). There was a weaker correlation between injured children's neighborhoods and screening locations (r = .32). Only 37% of parents knew the crash history of the car seat and 3% were using a car seat previously involved in an MVC. While 96% of inspected children were placed appropriately in the backseat, 80% of children were found to be inappropriately restrained. Younger children more likely to be restrained (p < .05). Children from New Mexico and Mexico had the lowest rates of proper restraint and the highest injury severity scores. Proper use of car seats is a public health concern on the USA-Mexico border, and children are not properly restrained. Screening may be improved by focusing where at-risk children live and where most accidents occur. Restraint education is needed, particularly in New Mexico and Mexico.
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http://dx.doi.org/10.1097/JTN.0000000000000347DOI Listing
September 2018

The socioeconomic impact of a pediatric ostomy in Uganda: a pilot study.

Pediatr Surg Int 2018 Apr 24;34(4):457-466. Epub 2018 Jan 24.

Department of Surgery, Duke University, Box 3815, DUMC, Durham, NC, USA.

Introduction: Multiple pediatric surgical conditions require ostomies in low-middle-income countries. Delayed presentations increase the numbers of ostomies. Patients may live with an ostomy for a prolonged time due to the high backlog of cases with insufficient surgical capacity. In caring for these patients in Uganda, we frequently witnessed substantial socioeconomic impact of their surgical conditions.

Methods: The operative log at the only pediatric surgery referral center in Uganda was reviewed to assess the numbers of children receiving ostomies over a 3-year period. Charts for patients with anorectal malformations (ARM) and Hirschsprung's disease (HD) were reviewed to assess delays in accessing care. Focus group discussions (FGD) were held with family members of children with ostomies based on themes from discussions with the surgical and nursing teams. A pilot survey was developed based on these themes and administered to a sample of patients in the outpatient clinic.

Results: During the period of January 2012-December 2014, there was one specialty-certified pediatric surgeon in the country. There were 493 ostomies placed for ARM (n = 234), HD (N = 114), gangrenous ileocolic intussusception (n = 95) and typhoid-induced intestinal perforation (n = 50). Primary themes covered in the FGD were: stoma care, impact on caregiver income, community integration of the child, impact on family unit, and resources to assist families. Many patients with HD and ARM did not present for colostomy until after 1 year of life. None had access to formal ostomy bags. 15 caregivers completed the survey. 13 (86%) were mothers and 2 (13%) were fathers. Almost half of the caregivers (n = 7, 47%) stated that their spouse had left the family. 14 (93%) caregivers had to leave jobs to care for the stoma. 14 respondents (93%) reported that receiving advice from other caregivers was beneficial.

Conclusion: The burden of pediatric surgical disease in sub-Saharan Africa is substantial with significant disparities compared to high-income countries. Significant socioeconomic complexity surrounds these conditions. While some solutions are being implemented, we are seeking resources to implement others. This data will inform the design of a more expansive survey of this patient population to better measure the socioeconomic impact of pediatric ostomies and guide more comprehensive advocacy and program development.
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http://dx.doi.org/10.1007/s00383-018-4230-8DOI Listing
April 2018

Surgical volunteerism as a collaborative teaching activity can benefit surgical residents in low-middle income countries.

Int J Surg 2017 Dec 7;48:34-37. Epub 2017 Oct 7.

Paul L Foster School of Medicine, Texas Tech University HSC, EI Paso, Texas, USA; Duke University Medical Center, Durham, NC, USA. Electronic address:

Surgical care is desperately needed in low-middle income countries (LMIC). Due to small numbers of faculty in local training programs, residents have limited exposure to subspecialists. We describe a teaching activity between visiting surgeons from the U.S. and a residency program in Malawi as an example for how surgeons in high income countries can meaningfully contribute. A short-term education activity was developed where residents participated in a pre-test on pediatric surgical management, lectures, intra-operative instruction, bedside rounds and a post-test. Five residents participated and all intend to practice in sub-Saharan Africa. All residents improved their scores from the pre-test to post-test (mean 44%-91%). The residency program performs approximately 1200 major surgical cases and 800 minor surgical procedures each year, representing a broad range of general surgery. Additionally, the residents encounter a broad range of pathology. Short-term mentorship activities in partnership with an established training program can enhance surgical resident education in LMIC, particularly for subspecialty care.
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http://dx.doi.org/10.1016/j.ijsu.2017.08.589DOI Listing
December 2017

Transition to Practice: A Global Surgery Approach.

J Surg Educ 2018 Mar - Apr;75(2):392-396. Epub 2017 Aug 9.

Department of Surgery, Malamulo Mission Hospital, Thyolo, Malawi; Department of Surgery, Loma Linda University Medical Center, Loma Linda, California.

Objective: To determine the feasibility of a global surgery setting for a transition to practice experience.

Setting: A rural hospital in Malawi, Africa.

Participants: A recent graduate of a U.S. general surgery residency program.

Results: Fellow performed 305 cases across the surgical disciplines with demonstrated improvements in operative ability.

Conclusion: The global surgery approach to transition to practice offers a unique opportunity to complement domestic training while providing critical assistance to communities with few surgical providers.
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http://dx.doi.org/10.1016/j.jsurg.2017.07.028DOI Listing
December 2018

Case report of migration of 2 ventriculoperitoneal shunt catheters to the scrotum: Use of an inguinal incision for retrieval, diagnostic laparoscopy and hernia repair.

Int J Surg Case Rep 2016 5;29:219-222. Epub 2016 Nov 5.

Department of Surgery, Paul L Foster School of Medicine, Texas Tech University, EI Paso, TX, USA. Electronic address:

Backgroud: Ventriculoperitoneal shunts are commonly used in the treatment of hydrocephalus, and catheter migration to various body sites has been reported. Pediatric and general surgeons are asked on occasion to assist with intraabdominal access for these shunts, particularly when there may be extensive adhesions or other complicating factors.

Methods: We describe a case in which an old shunt catheter was never removed from the abdomen, and it migrated through an inguinal hernia into the scrotum. The catheter became entangled and fibrosed to the testicle. A second and more recent shunt catheter was also in the scrotum. A single incision in the inguinal region was used to remove both shunt catheters, repair the inguinal hernia and perform diagnostic laparoscopy to assist in placing a new ventriculoperitoneal shunt.

Results: Prompt surgical removal is recommended for catheters remaining in the abdomen after ventriculoperitoneal shunt malfunction. These catheters may cause injury to the testicle, or possibly other intraabdominal organs. General or pediatric surgical consultation should be obtained for lost catheters or inguinal hernias.

Conclusion: In the case of an inguinal hernia containing a fractured shunt catheter, the hernia sac can be used to remove the catheter, repair the hernia and gain laparoscopic access to the abdomen to assist with shunt placement.
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http://dx.doi.org/10.1016/j.ijscr.2016.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5122702PMC
November 2016
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