ORIGINAL ARTICLE
The Repair of International Clefts in the Current Surgical Landscape Sarah Persing, MD, MPH, Anup Patel, MD, MBA, James E. Clune, MD, Derek M. Steinbacher, MD, and John A. Persing, MD Abstract: Cleft lip and palate (CLP) constitute a significant global disease burden. There are two general models that exist to deliver cleft care: surgical missions and comprehensive cleft centers (CCC). While surgical missions offer high quality surgical care to patients who would be unlikely to ever receive treatment, they may fail to provide sustainable solutions. The development of CCC is growing in popularity worldwide. CCC are permanent centers that offer a multidisciplinary team approach to the treatment of cleft lip and palate. Operation Smile has adopted the concept of specialized surgical care centers. These centers are shown to be safe, costeffective, and provide sustainable solutions for cleft care. The authors discuss some of the benefits and drawbacks of the classic mission-based model and highlight why there may be a paradigm shift towards CCC. Key Words: Cleft, global (J Craniofac Surg 2015;26: 1126–1128)
C
left lip and palate (CLP) constitute a significant global disease burden with an incidence of 1 in 500 to 1000 live births worldwide.1 Children born with CLP experience problems with speech, hearing, feeding, and impaired psychosocial development. The high prevalence of these congenital defects in developing countries has fueled numerous nonprofit organizations to address CLP.2,3 There are 2 general models that exist to deliver cleft care: surgical missions and comprehensive cleft centers (CCCs). The authors discuss some of the benefits and drawbacks of the classic mission-based model and highlight why there may be a paradigm shift toward CCC.
THE MISSION MODEL Short-term international mission trips are ubiquitous in humanitarian relief efforts and play an integral role in providing access to surgical care.4 Historically, in resource-constrained countries, medical missions assist in the surgical treatment of clefts by sending medical and surgical personnel from developed countries for an abbreviated period of time. Local hosts are identified, fund raising efforts are initiated, and equipment is shipped several months before the arrival of the team. Recruiters on the mission From the Yale New Haven Hospital, New Haven, CT. Received November 27, 2014. Accepted for publication January 31, 2015. Address correspondence and reprint requests to John A. Persing, MD, Section of Plastic and Reconstructive Surgery, Yale School of Medicine, 330 Cedar St, New Haven, CT 06520; E-mail: [email protected] The authors report no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001682
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team must find and screen patients to identify those who would be appropriate for surgery and postoperative management within the predetermined time frame.5,6 Short-term surgical missions aim to address the unmet surgical needs for cleft care in developing countries. They offer high-quality surgical care to patients who would be unlikely to ever receive treatment. Furthermore, it is a core philosophy of most mission trips to support the local physicians in teaching surgical techniques and sharing expertise. Although surgical missions benefit many patients in the short term, they may fail to provide sustainable solutions and possibly achieve poorer long-term outcomes. For example, it has been reported that complication rates of oronasal fistula after cleft palate repair may be 20-fold higher in surgical missions than in high-income countries, irrespective of surgeon experience.7 Mission trips are also shown to achieve poorer functional results in the repair of cleft palates.8 Although economic analyses find cleft repairs in international setting to be cost-effective,2,9,10 these results should be tempered given that some studies do not consider the long-term complications.11 Furthermore, because of the intrinsic nature of these short-term mission trips, sustainability is difficult to achieve when the mission infrastructure and resources are gone.
The Comprehensive Cleft Care Model The development of CCC is growing in popularity worldwide. These centers are comprised of local and international staff, who provide a broad range of services that are relevant to a specific condition. In general, surgical specialty hospitals provide a high volume of care and improved surgical outcomes that remain sustainable, cost-effective, and educational.11 Comprehensive cleft centers are permanent centers that offer a multidisciplinary team approach to the treatment of CLP. The centers offer children with cleft disorders and other facial deformities free continuous access to surgical and postoperative care. They also have access to related care, such as dental treatment, speech language pathologists, and nutritional support. The process involves first the recruitment team, who identify areas in need of cleft care. The cleft centers may be established de novo or within existing local infrastructure. There is then a screening process that consisting of a multidisciplinary team, including a plastic surgeon, anesthesiologist, pediatrician, dentist, and nutritionist on the patient’s first visit site to ensure that the patient would be an appropriate candidate for surgery. The team works together to repair the patient’s cleft, maximizing safety and minimizing complications. Perhaps, the greatest value derived from CCC arises from the ability to provide preoperative preparation, in a time frame that is not possible in the mission trip format, and longterm follow-up with the necessary surgical and medical interventions. The structure of such a setup fosters collaboration, international partnership, and continuity of care that optimizes results for patients. In addition, these centers remain subjected to rigorous standards, which now are routine in developed countries, facilitating the highest quality care delivered.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Repair of International Clefts
Operation Smile’s Guwahati Comprehensive Cleft Care Center Operation Smile has adopted the concept of specialized surgicalcare centers with more than 37 CCCs for CLP globally.12 Operation Smile’s Guwahati Comprehensive Cleft Care Center (GCCCC) in India illustrates the benefits of this model. Since May 2011, the GCCCC has provided free comprehensive and cost-effective care to more than 7000 patients with CLP.13 This center is the result of a public-private partnership between Operation Smile India and local government agencies. The GCCCC is based on a model of surgical care that expands on mission-based platforms by incorporating a local care delivery system, facilitating long-term follow-up and interventions. A major impetus from the center is to meticulously document, analyze, and critique all aspects of their clinical care to improve the quality of care provided and contribute to the fund of knowledge and practices of cleft care. Outcomes from this center demonstrate comparable results to those performed at institutions in developed countries, and this level of care has been demonstrated to be both sustainable and cost-effective.13 From mobilizing patients to multidisciplinary treatment preoperative preparation and postoperative follow-up care, this model has had positive impact on the delivery of surgical care in developing countries. The GCCCC via employment of rigorous patient mobilization strategies recruit and treat numerous cleft patients. For example, a dedicated patient recruitment team, consisting of staff members who establish relationships with community partners, identifies cleft patients in remote areas and demonstrate what treatment options exist (Fig. 1). This team works with health care agencies, educational and social service systems, and religious organizations to help mobilize patients to the center. The GCCCC provides housing, food, and transportation for patients and their families during their stay at the center, defraying costs and enabling treatment of clefts. The GCCCC provides high-volume, subspecialized care upholding safety and quality standards. Approximately, 250 to 300 cases are performed per month, without mortality or significant morbidity to date.13 For example, postoperative fistula rates after cleft palate repair at the cleft center are 3.9%, which is comparable to those in developed countries14 and significantly less than those seen in surgical mission trips.7 They use standardized postoperative protocols, quality assurance standards, and patient education programs in an effort to promote safe, consistent, and patient-centered
FIGURE 2. Local in-country personnel and visiting surgeons working together to repair a complex cleft.
surgical care. The GCCCC also addresses the significant challenges to patient follow-up with outreach programs, telephone reminders, and coverage of the costs of transportation for patients and families. As a result, patient follow-up at the center is significantly improved compared to short-term mission trips.15 The GCCCC augments the quality of surgical care provided to patients with CLP through its multidisciplinary team consisting of surgeons, otolaryngologists, nurses, dentists, speech therapists, and child life specialists. Successful long-term outcomes rely on the skills of individual members of a cleft team working together in an effective and coordinated manner. From evaluating patients preoperatively, to surgical repair of the cleft, to post-operative followup and care, this team uses specialized skills to provide comprehensive and quality care for patients. In addition, the cost of surgery at the cleft centers is 40% less than the costs of international missions; the GCCCC is further shown to be cost-effective reducing disability-adjusted life years in the region.13 The majority of the expenses at the GCCCC are also reinvested into the institution and community in the form of developing local infrastructure, salaries, and support of local businesses.16 In resource-constrained countries, the GCCCC is an affordable and valuable model for surgical care. The principle aim of the GCCCC is to develop sustainability. This is achieved through supporting local medical staff in leadership positions, establishing funding mechanisms largely from within India, increasing volume and efficiency, reducing costs, and educating and training local medical staff in cleft care.13 The GCCCC hosts visit professors from around the world to share their expertise in cleft care and uses telemedicine technology to further connect the center and enhance the exchange of cleft knowledge in-country (Fig. 2). These efforts promote sustainability and foster an environment of collaboration and intellectual interchange that positively affect cleft care delivery.
CONCLUSIONS
FIGURE 1. Members of the patient recruitment team educating the local population about clefts and treatment options provided by the comprehensive care center.
#
2015 Mutaz B. Habal, MD
The current data show that the greatest opportunity to impact cleft care is through CCC. Complication rates and costs are lower, whereas surgical volume and sustainability of quality outcomes are increased. Although short-term surgical mission groups help deliver surgical care to patients in need, they are unable to provide consistent solutions needed for improved access and continuity of care, including appropriate medical follow-up. Developing local capacity and sustainability are essential to reaching a larger population of patients with cleft deformities. Comprehensive cleft centers are effective means to achieving care continuity, improving
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Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Persing et al
surgical outcomes, and, ultimately, reducing the global burden of CLP.
REFERENCES 1. Magee WP Jr. Evolution of a sustainable surgical delivery model. J Craniofac Surg 2010;21:1321–1326 2. Alkire B, Hughes CD, Nash K, et al. Potential economic benefit of cleft lip and palate repair in sub-Saharan Africa. World J Surg 2011;35:1194– 1201 3. Campbell A, Sullivan M, Sherman R, et al. The medical mission and modern cultural competency training. J Am Coll Surg 2011;212:124– 129 4. Yeow VK, Lee ST, Lambrecht TJ, et al. International task force on volunteer cleft missions. J Craniofac Surg 2002;13:18–25 5. Avashia YJ, Thaller SR. Postearthquake plastic surgery mission trip to Port-au-Prince, Haiti: a medical student’s perspective. J Craniofac Surg 2011;22:1549–1551 6. Patel A, Pfaff M, Clune JE, et al. Disseminating surgery effectively and efficiently in Haiti. J Craniofac Surg 2013;24:1244–1247 7. Maine R, Hoffman W, Palacios-Martinez J, et al. Comparison of fistula rates after palatoplasty for international and local surgeons on surgical missions in Ecuador with rates at a craniofacial center in the United States. Plast Reconstr Surg 2012;129:319e–326e 8. Roessingh AdB, Dolci M, Zbinden-Trichet C, et al. Success and failure for children born with facial clefts in Africa: a 15-year follow-up. World J Surg 2012;36:1963–1969
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9. Magee W, Burg RV, Hatcher K. Cleft lip and palate as a cost-effective health care treatment in the developing world. World J Surg 2010;34:420–427 10. Hughes CD, Babigian A, McCormack S, et al. The clinical and economic impact of a sustained program in global plastic surgery: valuing cleft care in resource-poor settings. Plast Reconstr Surg 2012;130:87e–94e 11. Shrime M, Sleemi A, Ravilla T. Charitable platforms in global surgery: a systematic review of their effectiveness, cost-effectiveness, sustainability, and role training. World J Surg 2014;39:10–20 12. Operation Smile Comprehensive Care Centers. http://www. operationsmile.org/our_work/building-self-sufficiency/comprehensivecare-centers.html. Accessed November 26, 2014 13. Campbell A, Restrepo C, Mackay D, et al. Scalable, sustainable costeffective surgical care: a model for safety and quality in the developing world, part III: impact and sustainability. J Craniofac Surg 2014;25:1–5 14. Deshpande G, Campbell A, Jagtap R, et al. Early complications after cleft palate repair: a multivariate statistical analysis of 709 patients. J Craniofac Surg 2014;25:1614–1618 15. Jansen L, Leonardo C, Wendby L, et al. Improving patient follow-up in developing regions. J Craniofacial Surgery 2014;25: 1640–1644 16. Nagengast E, Caterson E, Magee W, et al. Providing more than health care: the dynamics of humanitarian surgery efforts on the local microeconomy. J Craniofac Surg 2014;25:1622–1625
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Repair of International Clefts in the Current Surgical Landscape Sarah Persing, MD, MPH, Anup Patel, MD, MBA, James E. Clune, MD, Derek M. Steinbacher, MD, and John A. Persing, MD Abstract: Cleft lip and palate (CLP) constitute a significant global disease burden. There are two general models that exist to deliver cleft care: surgical missions and comprehensive cleft centers (CCC). While surgical missions offer high quality surgical care to patients who would be unlikely to ever receive treatment, they may fail to provide sustainable solutions. The development of CCC is growing in popularity worldwide. CCC are permanent centers that offer a multidisciplinary team approach to the treatment of cleft lip and palate. Operation Smile has adopted the concept of specialized surgical care centers. These centers are shown to be safe, costeffective, and provide sustainable solutions for cleft care. The authors discuss some of the benefits and drawbacks of the classic mission-based model and highlight why there may be a paradigm shift towards CCC. Key Words: Cleft, global (J Craniofac Surg 2015;26: 1126–1128)
C
left lip and palate (CLP) constitute a significant global disease burden with an incidence of 1 in 500 to 1000 live births worldwide.1 Children born with CLP experience problems with speech, hearing, feeding, and impaired psychosocial development. The high prevalence of these congenital defects in developing countries has fueled numerous nonprofit organizations to address CLP.2,3 There are 2 general models that exist to deliver cleft care: surgical missions and comprehensive cleft centers (CCCs). The authors discuss some of the benefits and drawbacks of the classic mission-based model and highlight why there may be a paradigm shift toward CCC.
THE MISSION MODEL Short-term international mission trips are ubiquitous in humanitarian relief efforts and play an integral role in providing access to surgical care.4 Historically, in resource-constrained countries, medical missions assist in the surgical treatment of clefts by sending medical and surgical personnel from developed countries for an abbreviated period of time. Local hosts are identified, fund raising efforts are initiated, and equipment is shipped several months before the arrival of the team. Recruiters on the mission From the Yale New Haven Hospital, New Haven, CT. Received November 27, 2014. Accepted for publication January 31, 2015. Address correspondence and reprint requests to John A. Persing, MD, Section of Plastic and Reconstructive Surgery, Yale School of Medicine, 330 Cedar St, New Haven, CT 06520; E-mail: [email protected] The authors report no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001682
1126
team must find and screen patients to identify those who would be appropriate for surgery and postoperative management within the predetermined time frame.5,6 Short-term surgical missions aim to address the unmet surgical needs for cleft care in developing countries. They offer high-quality surgical care to patients who would be unlikely to ever receive treatment. Furthermore, it is a core philosophy of most mission trips to support the local physicians in teaching surgical techniques and sharing expertise. Although surgical missions benefit many patients in the short term, they may fail to provide sustainable solutions and possibly achieve poorer long-term outcomes. For example, it has been reported that complication rates of oronasal fistula after cleft palate repair may be 20-fold higher in surgical missions than in high-income countries, irrespective of surgeon experience.7 Mission trips are also shown to achieve poorer functional results in the repair of cleft palates.8 Although economic analyses find cleft repairs in international setting to be cost-effective,2,9,10 these results should be tempered given that some studies do not consider the long-term complications.11 Furthermore, because of the intrinsic nature of these short-term mission trips, sustainability is difficult to achieve when the mission infrastructure and resources are gone.
The Comprehensive Cleft Care Model The development of CCC is growing in popularity worldwide. These centers are comprised of local and international staff, who provide a broad range of services that are relevant to a specific condition. In general, surgical specialty hospitals provide a high volume of care and improved surgical outcomes that remain sustainable, cost-effective, and educational.11 Comprehensive cleft centers are permanent centers that offer a multidisciplinary team approach to the treatment of CLP. The centers offer children with cleft disorders and other facial deformities free continuous access to surgical and postoperative care. They also have access to related care, such as dental treatment, speech language pathologists, and nutritional support. The process involves first the recruitment team, who identify areas in need of cleft care. The cleft centers may be established de novo or within existing local infrastructure. There is then a screening process that consisting of a multidisciplinary team, including a plastic surgeon, anesthesiologist, pediatrician, dentist, and nutritionist on the patient’s first visit site to ensure that the patient would be an appropriate candidate for surgery. The team works together to repair the patient’s cleft, maximizing safety and minimizing complications. Perhaps, the greatest value derived from CCC arises from the ability to provide preoperative preparation, in a time frame that is not possible in the mission trip format, and longterm follow-up with the necessary surgical and medical interventions. The structure of such a setup fosters collaboration, international partnership, and continuity of care that optimizes results for patients. In addition, these centers remain subjected to rigorous standards, which now are routine in developed countries, facilitating the highest quality care delivered.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Repair of International Clefts
Operation Smile’s Guwahati Comprehensive Cleft Care Center Operation Smile has adopted the concept of specialized surgicalcare centers with more than 37 CCCs for CLP globally.12 Operation Smile’s Guwahati Comprehensive Cleft Care Center (GCCCC) in India illustrates the benefits of this model. Since May 2011, the GCCCC has provided free comprehensive and cost-effective care to more than 7000 patients with CLP.13 This center is the result of a public-private partnership between Operation Smile India and local government agencies. The GCCCC is based on a model of surgical care that expands on mission-based platforms by incorporating a local care delivery system, facilitating long-term follow-up and interventions. A major impetus from the center is to meticulously document, analyze, and critique all aspects of their clinical care to improve the quality of care provided and contribute to the fund of knowledge and practices of cleft care. Outcomes from this center demonstrate comparable results to those performed at institutions in developed countries, and this level of care has been demonstrated to be both sustainable and cost-effective.13 From mobilizing patients to multidisciplinary treatment preoperative preparation and postoperative follow-up care, this model has had positive impact on the delivery of surgical care in developing countries. The GCCCC via employment of rigorous patient mobilization strategies recruit and treat numerous cleft patients. For example, a dedicated patient recruitment team, consisting of staff members who establish relationships with community partners, identifies cleft patients in remote areas and demonstrate what treatment options exist (Fig. 1). This team works with health care agencies, educational and social service systems, and religious organizations to help mobilize patients to the center. The GCCCC provides housing, food, and transportation for patients and their families during their stay at the center, defraying costs and enabling treatment of clefts. The GCCCC provides high-volume, subspecialized care upholding safety and quality standards. Approximately, 250 to 300 cases are performed per month, without mortality or significant morbidity to date.13 For example, postoperative fistula rates after cleft palate repair at the cleft center are 3.9%, which is comparable to those in developed countries14 and significantly less than those seen in surgical mission trips.7 They use standardized postoperative protocols, quality assurance standards, and patient education programs in an effort to promote safe, consistent, and patient-centered
FIGURE 2. Local in-country personnel and visiting surgeons working together to repair a complex cleft.
surgical care. The GCCCC also addresses the significant challenges to patient follow-up with outreach programs, telephone reminders, and coverage of the costs of transportation for patients and families. As a result, patient follow-up at the center is significantly improved compared to short-term mission trips.15 The GCCCC augments the quality of surgical care provided to patients with CLP through its multidisciplinary team consisting of surgeons, otolaryngologists, nurses, dentists, speech therapists, and child life specialists. Successful long-term outcomes rely on the skills of individual members of a cleft team working together in an effective and coordinated manner. From evaluating patients preoperatively, to surgical repair of the cleft, to post-operative followup and care, this team uses specialized skills to provide comprehensive and quality care for patients. In addition, the cost of surgery at the cleft centers is 40% less than the costs of international missions; the GCCCC is further shown to be cost-effective reducing disability-adjusted life years in the region.13 The majority of the expenses at the GCCCC are also reinvested into the institution and community in the form of developing local infrastructure, salaries, and support of local businesses.16 In resource-constrained countries, the GCCCC is an affordable and valuable model for surgical care. The principle aim of the GCCCC is to develop sustainability. This is achieved through supporting local medical staff in leadership positions, establishing funding mechanisms largely from within India, increasing volume and efficiency, reducing costs, and educating and training local medical staff in cleft care.13 The GCCCC hosts visit professors from around the world to share their expertise in cleft care and uses telemedicine technology to further connect the center and enhance the exchange of cleft knowledge in-country (Fig. 2). These efforts promote sustainability and foster an environment of collaboration and intellectual interchange that positively affect cleft care delivery.
CONCLUSIONS
FIGURE 1. Members of the patient recruitment team educating the local population about clefts and treatment options provided by the comprehensive care center.
#
2015 Mutaz B. Habal, MD
The current data show that the greatest opportunity to impact cleft care is through CCC. Complication rates and costs are lower, whereas surgical volume and sustainability of quality outcomes are increased. Although short-term surgical mission groups help deliver surgical care to patients in need, they are unable to provide consistent solutions needed for improved access and continuity of care, including appropriate medical follow-up. Developing local capacity and sustainability are essential to reaching a larger population of patients with cleft deformities. Comprehensive cleft centers are effective means to achieving care continuity, improving
1127
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Persing et al
surgical outcomes, and, ultimately, reducing the global burden of CLP.
REFERENCES 1. Magee WP Jr. Evolution of a sustainable surgical delivery model. J Craniofac Surg 2010;21:1321–1326 2. Alkire B, Hughes CD, Nash K, et al. Potential economic benefit of cleft lip and palate repair in sub-Saharan Africa. World J Surg 2011;35:1194– 1201 3. Campbell A, Sullivan M, Sherman R, et al. The medical mission and modern cultural competency training. J Am Coll Surg 2011;212:124– 129 4. Yeow VK, Lee ST, Lambrecht TJ, et al. International task force on volunteer cleft missions. J Craniofac Surg 2002;13:18–25 5. Avashia YJ, Thaller SR. Postearthquake plastic surgery mission trip to Port-au-Prince, Haiti: a medical student’s perspective. J Craniofac Surg 2011;22:1549–1551 6. Patel A, Pfaff M, Clune JE, et al. Disseminating surgery effectively and efficiently in Haiti. J Craniofac Surg 2013;24:1244–1247 7. Maine R, Hoffman W, Palacios-Martinez J, et al. Comparison of fistula rates after palatoplasty for international and local surgeons on surgical missions in Ecuador with rates at a craniofacial center in the United States. Plast Reconstr Surg 2012;129:319e–326e 8. Roessingh AdB, Dolci M, Zbinden-Trichet C, et al. Success and failure for children born with facial clefts in Africa: a 15-year follow-up. World J Surg 2012;36:1963–1969
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9. Magee W, Burg RV, Hatcher K. Cleft lip and palate as a cost-effective health care treatment in the developing world. World J Surg 2010;34:420–427 10. Hughes CD, Babigian A, McCormack S, et al. The clinical and economic impact of a sustained program in global plastic surgery: valuing cleft care in resource-poor settings. Plast Reconstr Surg 2012;130:87e–94e 11. Shrime M, Sleemi A, Ravilla T. Charitable platforms in global surgery: a systematic review of their effectiveness, cost-effectiveness, sustainability, and role training. World J Surg 2014;39:10–20 12. Operation Smile Comprehensive Care Centers. http://www. operationsmile.org/our_work/building-self-sufficiency/comprehensivecare-centers.html. Accessed November 26, 2014 13. Campbell A, Restrepo C, Mackay D, et al. Scalable, sustainable costeffective surgical care: a model for safety and quality in the developing world, part III: impact and sustainability. J Craniofac Surg 2014;25:1–5 14. Deshpande G, Campbell A, Jagtap R, et al. Early complications after cleft palate repair: a multivariate statistical analysis of 709 patients. J Craniofac Surg 2014;25:1614–1618 15. Jansen L, Leonardo C, Wendby L, et al. Improving patient follow-up in developing regions. J Craniofacial Surgery 2014;25: 1640–1644 16. Nagengast E, Caterson E, Magee W, et al. Providing more than health care: the dynamics of humanitarian surgery efforts on the local microeconomy. J Craniofac Surg 2014;25:1622–1625
#
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
