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  • Gruen, Russell L.  (14)
  • General Surgery
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  • 1
    In: Journal of Evaluation in Clinical Practice, August 2011, Vol.17(4), pp.819-826
    Description: This qualitative study identifies cultural factors that influence the effective implementation of evidence‐based medicine (EBM) in surgical practice among Australian surgeons. In‐depth interviews ( = 22) were conducted with surgeons from a variety of specialties within a large hospital system in Victoria, Australia. The interviews explored the surgeons' understanding of EBM; and challenges to the adoption of EBM. The canons and procedures of the Miles and Huberman's Matrix Analyses approach to qualitative research guided the coding and organization of the data derived from the semi‐structured interviews. Surgeons had a good understanding of EBM, but viewed it as little more than a system of evidence, which was often divorced from actual clinical practice. The data also suggested that surgical culture(s) and typologies of surgical style were important variables in the implementation of EBM. The results suggest that the ideal method of EBM implementation is workplace instruction led by surgeons, who exhibit scientist and/or clinician styles of surgical practice; EBM training should occur early in the surgeons' careers; and EBM practice should be role modelled in the presence of trainees by surgeons who exhibit either a scientist and/or clinician style of surgical practice. The study findings suggest that using pre‐existing surgical culture(s) and styles is an important component in the implementation of EBM in surgery. The effective use of the scientist and/or clinician surgeon within the apprenticeship model and the context‐specific collegial networks of the surgical profession appear to be key elements in ensuring the successful implementation of EBM in surgery.
    Keywords: Ebm Training ; Epistemic Culture ; Implementation ; Hidden Curriculum ; Surgery
    ISSN: 1356-1294
    E-ISSN: 1365-2753
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  • 2
    In: Medical Journal of Australia, July 2002, Vol.177(2), pp.111-115
    Description: To determine the effect of proximity of surgical specialists on general practitioners' (GPs') rates of referral of surgical problems to specialist care (ie, are surgical referral rates of GPs in rural or remote areas similar to those of GPs in urban centres?). A cross‐sectional survey of GP–patient encounters. The Bettering the Evaluation and Care of Health (BEACH) program, which involves all active registered GPs in Australia. A random sample of 3030 GPs, each providing details of 100 consecutive patient encounters. Proportion of surgical problems (including ophthalmological and obstetric and gynaecological) referred to surgical specialists (surgeons' rooms, hospital outpatient departments or hospital emergency departments). Absence of a local specialist did not significantly influence the proportion of surgical problems referred by GPs overall, but the proportion referred was significantly lower for obstetric (odds ratio [OR], 0.56; 95% CI, 0.44–0.70) and ophthalmological (OR, 0.60; 95% CI, 0.49–0.73) problems. Other factors independently associated with referral of a lower proportion of problems included male GPs, female and younger patients, holders of a Health Care Card, injury‐related and non‐cancer‐related problems, follow‐up presentations, and more than one problem managed at an encounter. Our findings confirm that rural and remote GPs undertake much of their patients' antenatal care, and are less likely to use specialists when managing ophthalmological problems. Absence of local specialists in other surgical specialties is not a barrier to referral of patients with surgical disorders.
    Keywords: General Medicine ; General Medicine ; Surgical Procedures ; Operative
    ISSN: 0025-729X
    E-ISSN: 1326-5377
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  • 3
    In: Journal of Evaluation in Clinical Practice, August 2011, Vol.17(4), pp.678-683
    Description: Rural and remote surgical practice presents unique barriers to the uptake of the evidence‐based medicine (EBM) paradigm. As medical and education institutions around Australia develop practices and support for EBM, there are growing questions about how EBM is situated in the rural and remote context. The Monash University Department of Surgery at Monash Medical Centre implemented a study to explore the current understandings, attitudes and practices of rural surgeons towards the EBM paradigm. Descriptive survey of rural surgeons based in a tertiary care environment. The overall results of the survey demonstrate that: (1) rural surgeons have a good understanding of EBM; (2) EBM evidence is somewhat useful but not very important to clinical decision making; and (3) while rural surgeons are relatively confident in most sources listed, they are most confident in their own judgment and clinical practice guidelines, and least confident in telephone contact with colleagues. Rural surgeons’ understanding, usage and confidence in EBM purports that rural surgeons have contradictory, ambivalent and complex views of the EBM paradigm and its place in rural surgical practice. Professional isolation and context specificity are important to consider when extending the EBM paradigm to rural surgical practice and understanding the EBM uptake in the rural surgery context.
    Keywords: Attitudes And Training ; Evidence‐Based Medicine ; Rural ; Surgical Practice
    ISSN: 1356-1294
    E-ISSN: 1365-2753
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  • 4
    Language: English
    In: World Journal of Surgery, 2012, Vol.36(8), pp.1978-1992
    Description: Byline: Henry Thomas Stelfox (1), Manjul Joshipura (2), Witaya Chadbunchachai (3), Ranjith N. Ellawala (4), Gerard O'Reilly (5), Thai Son Nguyen (6), Russell L. Gruen (7) Abstract: Background Quality Improvement (QI) programs have been shown to be a valuable tool to strengthen care of severely injured patients, but little is known about them in low and middle income countries (LMIC). We sought to explore opportunities to improve trauma QI activities in LMIC, focusing on the Asia--Pacific region. Methods We performed a mixed methods research study using both inductive thematic analysis of a meeting convened at the Royal Australasian College of Surgeons, Melbourne, Australia, November 21--22, 2010 and a pre-meeting survey to explore experiences with trauma QI activities in LMIC. Purposive sampling was employed to invite participants with demonstrated leadership in trauma care to provide diverse representation of organizations and countries within Asia--Pacific. Results A total of 22 experts participated in the meeting and reported that trauma QI activities varied between countries and organizations: morbidity and mortality conferences (56 %), monitoring complications (31 %), preventable death studies (25 %), audit filters (19 %), and statistical methods for analyzing morbidity and mortality (6 %). Participants identified QI gaps to include paucity of reliable/valid injury data, lack of integrated trauma QI activities, absence of standards of care, lack of training in QI methods, and varying cultures of quality and safety. The group highlighted barriers to QI: limited engagement of leaders, organizational diversity, limited resources, heavy clinical workload, and medico-legal concerns. Participants proposed establishing the Asia--Pacific Trauma Quality Improvement Network (APTQIN) as a tool to facilitate training and dissemination of QI methods, injury data management, development of pilot QI projects, and advocacy for quality trauma care. Conclusions Our study provides the first description of trauma QI practices, gaps in existing practices, and barriers to QI in LMIC of the Asia--Pacific region. In this study we identified opportunities for addressing these challenges, and that work will be supported by APTQIN. Author Affiliation: (1) Department of Critical Care Medicine, Medicine and Community Health Sciences, Institute for Public Health, University of Calgary, Teaching Research & Wellness Building, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada (2) Academy of Traumatology, Ahmedabad, India (3) Khon Kaen Hospital, Khon Kaen, Thailand (4) College of Surgeons, Colombo, Sri Lanka (5) Emergency and Trauma Centre, The Alfred Hospital, Monash University, Melbourne, Australia (6) Duc Giang Hospital, Hanoi, Vietnam (7) The National Trauma Research Institute, The Alfred Hospital, Monash University, Melbourne, Australia Article History: Registration Date: 23/03/2012 Online Date: 13/04/2012
    Keywords: Information Management -- Analysis ; Information Management -- Methods ; Information Management -- Health Aspects ; Universities And Colleges -- Analysis ; Universities And Colleges -- Methods ; Universities And Colleges -- Health Aspects ; Safety Regulations -- Analysis ; Safety Regulations -- Methods ; Safety Regulations -- Health Aspects ; Medical Societies -- Analysis ; Medical Societies -- Methods ; Medical Societies -- Health Aspects ; Public Health -- Analysis ; Public Health -- Methods ; Public Health -- Health Aspects ; Quality Control -- Analysis ; Quality Control -- Methods ; Quality Control -- Health Aspects;
    ISSN: 0364-2313
    E-ISSN: 1432-2323
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  • 5
    In: The New England Journal of Medicine, 2007, Vol.356(17), pp.1742-1750
    Description: Background Relationships between physicians and pharmaceutical, medical device, and other medically related industries have received considerable attention in recent years. We surveyed physicians to collect information about their financial associations with industry and the factors that predict those associations. Methods We conducted a national survey of 3167 physicians in six specialties (anesthesiology, cardiology, family practice, general surgery, internal medicine, and pediatrics) in late 2003 and early 2004. The raw response rate for this probability sample was 52%, and the weighted response rate was 58%. Results Most physicians (94%) reported some type of relationship with the pharmaceutical industry, and most of these relationships involved receiving food in the workplace (83%) or receiving drug samples (78%). More than one third of the respondents (35%) received reimbursement for costs associated with professional meetings or continuing medical education, and more than one quarter (28%) received payments for consulting, giving lectures, or enrolling patients in trials. Cardiologists were more than twice as likely as family practitioners to receive payments. Family practitioners met more frequently with industry representatives than did physicians in other specialties, and physicians in solo, two-person, or group practices met more frequently with industry representatives than did physicians practicing in hospitals and clinics. Conclusions The results of this national survey indicate that relationships between physicians and industry are common and underscore the variation among such relationships according to specialty, practice type, and professional activities. In this national survey of 3167 physicians, 83% reported receiving food or beverages paid for by a company that makes drugs or other medical products, 78% drug samples, 35% reimbursement for professional meetings, and 28% payments for consulting, speaking, or enrolling patients in clinical trials. Family practitioners met most frequently with industry representatives, and cardiologists were most likely to receive payments. In this national survey of physicians, 83% reported receiving food or beverages paid for by a company that makes drugs or other medical products, 78% drug samples, 35% reimbursement for professional meetings, and 28% payments for consulting, speaking, or enrolling patients in clinical trials. In the past 20 years, physician–industry relationships have received considerable attention.1–12 In 2000, Wazana reviewed 16 studies published between 1982 and 1997 and estimated that, on average, physicians met with industry representatives four times per month and residents accepted six gifts per year from industry representatives.13 A 2001 survey showed that 92% of physicians received drug samples, 61% received meals, tickets to events, or free travel, 13% received financial or other kinds of benefits, and 12% received incentives for participation in clinical trials.14 Many of these previous studies are now somewhat dated or focused on particular specialties or geographic . . .
    Keywords: Anesthesiology–Statistics & Numerical Data ; Cardiology–Statistics & Numerical Data ; Data Collection–Statistics & Numerical Data ; Drug Industry–Statistics & Numerical Data ; Equipment & Supplies–Statistics & Numerical Data ; Family Practice–Statistics & Numerical Data ; Female–Statistics & Numerical Data ; General Surgery–Statistics & Numerical Data ; Gift Giving–Statistics & Numerical Data ; Humans–Statistics & Numerical Data ; Industry–Statistics & Numerical Data ; Internal Medicine–Statistics & Numerical Data ; Interprofessional Relations–Statistics & Numerical Data ; Logistic Models–Statistics & Numerical Data ; Male–Statistics & Numerical Data ; Marketing–Statistics & Numerical Data ; Multivariate Analysis–Statistics & Numerical Data ; Pediatrics–Statistics & Numerical Data ; Physicians–Statistics & Numerical Data ; United States–Statistics & Numerical Data ; United States–Us ; Acquisitions & Mergers ; Meetings ; Health Facilities ; American Medical Association ; Pharmaceutical Research & Manufacturers of America;
    ISSN: 0028-4793
    E-ISSN: 1533-4406
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  • 6
    Language: English
    In: World Journal of Surgery, 2016, Vol.40(11), pp.2611-2619
    Description: To access, purchase, authenticate, or subscribe to the full-text of this article, please visit this link: http://dx.doi.org/10.1007/s00268-016-3614-y Byline: Kathleen M. O'Neill (1,2), Sarah L. M. Greenberg (1,3), Meena Cherian (4), Rowan D. Gillies (5), Kimberly M. Daniels (1,6), Nobhojit Roy (7,8), Nakul P. Raykar (1,9), Johanna N. Riesel (1,10), David Spiegel (11), David A. Watters (12,13), Russell L. Gruen (14,15) Abstract: Background Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care. Methods We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures--which we term "bellwether procedures"--was associated with performing a full range of essential surgical procedures. Findings The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p 〈 0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures. Interpretation Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team. Author Affiliation: (1) Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA (2) Department of Surgery, Yale New Haven Hospital, 1245 Chapel Street Apt 503, New Haven, CT, 06510, USA (3) Department of Surgery, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI, 53226, USA (4) WHO Emergency and Essential Surgical Care Programme, The World Health Organization, Headquarters, Geneva, Switzerland (5) Royal North Shore Hospital, Plastic, Reconstructive and Burns, Reserve Rd, St Leonards, NSW, 2065, Australia (6) Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA (7) Department of Surgery, Bhabha Atomic Research Center (BARC) Hospital, Mumbai, 94, India (8) Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden (9) Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA (10) The Harvard Program in Plastic Surgery, Boston, MA, 02114, USA (11) Department of Orthopedics, Children's Hospital of Philadelphia, Philadelphia, PA, USA (12) Royal Australasian College of Surgeons, East Melbourne, VIC, Australia (13) School of Medicine, Faculty of Health, Barwon Health, Deakin University, Geelong, VIC, Australia (14) The Alfred Hospital and Monash University, Melbourne, VIC, 3051, Australia (15) Nanyang Technological University, 50 Nanyang Drive, Research Techno Plaza, Level 4 X-Frontiers Block, Singapore, 637553, Singapore Article History: Registration Date: 11/06/2016 Online Date: 28/06/2016 Article note: Disclaimer: The authors include WHO staff. The views expressed in this publication reflect their views and not necessarily that of WHO.
    Keywords: Delivery (Childbirth) -- Analysis ; Laparotomy -- Analysis;
    ISSN: 0364-2313
    E-ISSN: 1432-2323
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  • 7
    In: ANZ Journal of Surgery, October 2006, Vol.76(10), pp.871-872
    Description: The author outlines key features of the Papua New Guinea surgical programme and the principles for support from developed countries. (non- author abstract)
    Keywords: Surgery, Education ; Developing Countries ; Papua New Guinea;
    ISSN: 1445-1433
    E-ISSN: 1445-2197
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  • 8
    In: ANZ Journal of Surgery, May 2008, Vol.78(5), pp.360-360
    Description: Academic surgery in Australia and New Zealand is at risk if sustainability is not addressed so that surgeons like Joe Tjandra can join with others and channel their energies into a lively and productive department. (non-author abstract)
    Keywords: Education, Medical ; Patient Care ; Research ; Surgery, Organization And Administration ; Australia ; Clinical Competence ; Faculty, Medical, Organization And Administration ; Humans ; Leadership ; New Zealand ; Professional Practice ; Surgery, Education ; Surgery, Trends ; Time Factors;
    ISSN: 1445-1433
    E-ISSN: 1445-2197
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  • 9
    In: Journal of Continuing Education in the Health Professions, 2009, Vol.29(3), pp.185-189
    Description: : In recent years increasing attention has been paid to issues of professionalism in surgery and the content and structure of continuing professional development for surgeons; however, little attention has been paid to interprofessional education (IPE) in surgical training. Imagining the form(s) of IPE and/or continuing interprofessional education (CIPE) programs within surgical training requires serious attention to 2 fundamental issues—the discourses of professionalism in surgery and the professional culture of surgery, as shaped and expressed within the clinical setting. We explore the possibility that concepts of professionalism within surgery may be in conflict with the tenets of interprofessionalism held by other health and medical professionals. We believe that if any rapprochement is to occur between the concept of professionalism in surgical training (and within the everyday clinical culture of surgical subspecialties groups and their professional institutions) and broader discourses of interprofessionalism circulating within health care institutions, there is a pressing need to understand and deconstruct this conflict from the point of view of surgery.
    Keywords: Interdisciplinary Communication ; Professional Competence ; Education, Medical, Continuing -- Methods ; General Surgery -- Education;
    ISSN: 0894-1912
    E-ISSN: 1554558X
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  • 10
    Language: English
    In: World Journal of Surgery, April, 2017, Vol.41(4), p.954(9)
    Description: To access, purchase, authenticate, or subscribe to the full-text of this article, please visit this link: http://dx.doi.org/10.1007/s00268-016-3759-8 Byline: Angela Lashoher (1), Eric B. Schneider (2,3), Catherine Juillard (4), Kent Stevens (5), Elizabeth Colantuoni (6), William R. Berry (7), Christina Bloem (8), Witaya Chadbunchachai (9), Satish Dharap (10), Sydney M. Dy (11), Gerald Dziekan (12), Russell L. Gruen (13), Jaymie A. Henry (14), Christina Huwer (15), Manjul Joshipura (16), Edward Kelley (17), Etienne Krug (18), Vineet Kumar (19), Patrick Kyamanywa (20), Alain Chichom Mefire (21), Marcos Musafir (22), Avery B. Nathens (23), Edouard Ngendahayo (24), Thai Son Nguyen (25), Nobhojit Roy (26), Peter J. Pronovost (27), Irum Qumar Khan (28), Junaid Abdul Razzak (29,30), Andres M. Rubiano (31), James A. Turner (32), Mathew Varghese (33), Rimma Zakirova (34), Charles Mock (35) Abstract: Background Trauma contributes more than ten percent of the global burden of disease. Initial assessment and resuscitation of trauma patients often requires rapid diagnosis and management of multiple concurrent complex conditions, and errors are common. We investigated whether implementing a trauma care checklist would improve care for injured patients in low-, middle-, and high-income countries. Methods From 2010 to 2012, the impact of the World Health Organization (WHO) Trauma Care Checklist program was assessed in 11 hospitals using a stepped wedge pre- and post-intervention comparison with randomly assigned intervention start dates. Study sites represented nine countries with diverse economic and geographic contexts. Primary end points were adherence to process of care measures secondary data on morbidity and mortality were also collected. Multilevel logistic regression models examined differences in measures pre- versus post-intervention, accounting for patient age, gender, injury severity, and center-specific variability. Results Data were collected on 1641 patients before and 1781 after program implementation. Patient age (mean 34 [+ or -] 18 vs. 34 [+ or -] 18), sex (21 vs. 22 % female), and the proportion of patients with injury severity scores (ISS) a[yen] 25 (10 vs. 10 %) were similar before and after checklist implementation (p 〉 0.05). Improvement was found for 18 of 19 process measures, including greater odds of having abdominal examination (OR 3.26), chest auscultation (OR 2.68), and distal pulse examination (OR 2.33) (all p 〈 0.05). These changes were robust to several sensitivity analyses. Conclusions Implementation of the WHO Trauma Care Checklist was associated with substantial improvements in patient care process measures among a cohort of patients in diverse settings. Author Affiliation: (1) 14 Chemin de Contamine, 01420, Chanay, France (2) Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Suite 4-020, Boston, MA, 02120, USA (3) Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins School of Medicine, Baltimore, MD, USA (4) Department of Surgery, Center for Global Surgical Studies, University of California, San Francisco, 1001 Potrero Ave, 3A, San Francisco, CA, 94110, USA (5) The Johns Hopkins School of Medicine, 1800 Orleans Street, Suite 6107E, Baltimore, MD, 21287, USA (6) Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, 615 N Wolfe Street, Baltimore, MD, 21205, USA (7) Department of Health Policy and Management, Harvard School of Public Health, 401 Park Drive, Boston, MA, 02215, USA (8) Department of Emergency Medicine, SUNY Downstate Medical Center, 450 Clarkson Ave, Box 1228, Brooklyn, NY, 11203, USA (9) WHO Collaborating Center for Injury Prevention and Safety Promotion, Khon Kaen Hospital, Khon Kaen, 40000, Thailand (10) Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, 400022, India (11) Johns Hopkins Bloomberg School of Public Health, Rm 609, 624 N Broadway, Baltimore, MD, 21205, USA (12) World Self-Medication Industry, Rue de Cossonay 5, Case Postale 124, 1023, Crissier, Switzerland (13) Lee Kong Chian School of Medicine, Nanyang Technological University, Research Techno Plaza, 02-07, 50 Nanyang Drive, Singapore, 637553, Singapore (14) Department of Surgery, The University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA (15) Clinic for Trauma Surgery and Orthopedics, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany (16) Academy of Traumatology, 504, Sangita Complex, Parimal Garden, Ahmadabad, 380015, India (17) Service Delivery and Safety Department, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland (18) Department for the Management of NCDs, Disability, Violence and Injury Prevention, World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland (19) Department of Surgery, Lokmanya Tilak Municipal Medical College and General Hospital, College Building, First Floor, Sion, Mumbai, 400022, India (20) School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Nyarugenge Campus, P.O. Box. 3286, Kigali, Rwanda (21) Faculty of Health Sciences, University of Buea and Regional Hospital Limbe, P.O. Box 25526, Yaounde, Cameroon (22) Federal University of Rio de Janeiro, Rua Voluntarios da Patria, 445 SL 201, Botafogo, Rio de Janeiro, CEP: 22270-005, Brazil (23) Department of Surgery, University of Toronto and Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D5 74, Toronto, Ontario, M4N 3M5, Canada (24) University Teaching Hospital of Kigali, P.O. Box 2534, Kigali, Rwanda (25) Duc Giang General Hospital, 54 Truong Lam, Long Bien, Hanoi, Vietnam (26) Department of Surgery, BARC hospital (Govt of India), HBNI University, Anushaktinagar, Mumbai, 400094, India (27) Johns Hopkins Medicine, 600 N Wolfe Street, CMSC 131, Baltimore, MD, 21287, USA (28) Department of Emergency Medicine, Aga Khan University, 1st floor, Stadium Road, P.O. Box 3500, Karachi, 74800, Pakistan (29) Johns Hopkins University School of Medicine, 5801 Smith Ave, Ste 220, Baltimore, MD, 21219, USA (30) Aga Khan University, Karachi, Pakistan (31) MEDITECH Foundation, Neiva University Hospital, Calle 5 11-19, Huila, Neiva, Colombia (32) Department of Paedeatric Orthopedics, Sick Kids Hospital, 555 University Ave, Toronto, ON, M5G 1X8, Canada (33) Department of Orthopaedics, St Stephen's Hospital, Tis Hazari, Delhi, 110054, India (34) St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada (35) Department of Surgery, Harborview Medical Center, HIPRC, University of Washington, 325 Ninth Avenue, Box 359960, Seattle, WA, 98104, USA Article History: Registration Date: 04/10/2016 Online Date: 31/10/2016
    Keywords: Public Health -- Economic Aspects
    ISSN: 0364-2313
    E-ISSN: 14322323
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