Al-Kandari L, Masoomi MA, El-Gargani AA, Hamza MA, Agha RM. Rationalizing whole-body computed tomography in trauma: A national audit on resource utilization and strategies to minimize radiation exposure. World J Radiol 2026; 18(1): 113747 [DOI: 10.4329/wjr.v18.i1.113747]
Corresponding Author of This Article
Michael A Masoomi, PhD, MRCP, Visiting Professor, Department of Medical Imaging, ADAN Hospital, Ministry of Health, Moseley Street, Hadiya 46020, Kuwait. masoomim@sky.com
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Radiology, Nuclear Medicine & Medical Imaging
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Retrospective Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Jan 28, 2026 (publication date) through Jan 28, 2026
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World Journal of Radiology
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1949-8470
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Al-Kandari L, Masoomi MA, El-Gargani AA, Hamza MA, Agha RM. Rationalizing whole-body computed tomography in trauma: A national audit on resource utilization and strategies to minimize radiation exposure. World J Radiol 2026; 18(1): 113747 [DOI: 10.4329/wjr.v18.i1.113747]
Co-first authors: Latifah Al-Kandari and Michael A Masoomi.
Author contributions: Al-Kandari L contributed to conceptualization, methodology, overall setup, and joint funding acquisition; Masoomi MA contributed to data curation, editorial work, funding acquisition, project administration, original draft writing, review and editing, and communication; El-Gargani AA was responsible for visualization, investigation, and data collection supervision; Hamza MA handled visualization, resources, and data curation; Agha RM contributed to data curation and validation; All authors read and approved the published version of the manuscript. Al-Kandari L and Masoomi MA contributed equally to this article and are the co-first authors of this manuscript.
Supported by the Kuwait Foundation for the Advancement of Sciences, No. PN22-13MM-1695.
Institutional review board statement: This study was approved by the Medical Ethics Committee of the ADAN Hospital, Ministry of Health Institutional Review Board, Approval No. 2023-141.
Informed consent statement: In this retrospective study, all patients provided written consent for clinical imaging as part of the institution’s routine procedures.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: The original anonymized dataset is available from the corresponding author upon reasonable request (masoomim@sky.com).
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Michael A Masoomi, PhD, MRCP, Visiting Professor, Department of Medical Imaging, ADAN Hospital, Ministry of Health, Moseley Street, Hadiya 46020, Kuwait. masoomim@sky.com
Received: September 4, 2025 Revised: October 13, 2025 Accepted: December 11, 2025 Published online: January 28, 2026 Processing time: 144 Days and 14.8 Hours
Abstract
BACKGROUND
Major trauma is the sixth leading cause of death worldwide and the leading cause of death and disability in the population aged 5 years to 45 years. The assessment is typically guided by strict protocols to quickly identify life-threatening conditions before conducting a comprehensive evaluation of other injuries. Whole-body computed tomography (WBCT) is often indiscriminately used in trauma cases.
AIM
To assess the effective use of WBCT in patients with trauma across radiology departments in State of Kuwait, evaluate the true incidence of critical injuries, and minimize unnecessary radiation exposure.
METHODS
This multicenter, retrospective study across seven radiology departments included 1367 patients with trauma who underwent WBCT between 2022 and 2023, according to the American College of Radiology guidelines. Data on age, sex, injury mechanism, clinical indications, dose-length product, and WBCT findings were collected and analyzed using IBM SPSS version 25.
RESULTS
Of 1367 referrals, 578 (42.3%) had no significant findings, while 789 (57.7%) showed positive trauma-related results. Among the positive findings, 530 patients (38.8%) had major injuries, including solid organ and vertebral column injuries. The most common causes of WBCT referrals were road traffic accidents (911 patients, 66.6%), falls from height (182 patients, 13%), falls of heavy objects (112 patients, 8%), head trauma (82 patients, 6%), buggy accidents (28 patients, 2%) and others. Negative WBCT findings had a mean effective dose of 19.98 ± 10.26 mSv.
CONCLUSION
This national audit demonstrates that a substantial proportion of WBCT scans in patients with trauma are negative (42.3%), underscoring the need to rationalize imaging practices. The findings highlight the importance of evidence-based stewardship to enhance trauma care delivery in State of Kuwait.
Core Tip: Rationalizing the use of whole-body computed tomography in patients with trauma is essential to achieve timely diagnosis while safeguarding against unnecessary radiation exposure and optimizing radiology resources. Findings from this national audit highlight practice patterns across State of Kuwait and emphasize protocol optimization as a strategy to balance clinical benefit with patient safety. This initiative represents a pivotal step toward enhancing trauma care management and promoting evidence-based utilization of imaging resources.
Citation: Al-Kandari L, Masoomi MA, El-Gargani AA, Hamza MA, Agha RM. Rationalizing whole-body computed tomography in trauma: A national audit on resource utilization and strategies to minimize radiation exposure. World J Radiol 2026; 18(1): 113747
Major trauma is the sixth leading cause of death worldwide and the leading cause of death and disability in the population aged 5 years to 45 years[1]. The assessment is typically guided by strict protocols to quickly identify life-threatening conditions before conducting a comprehensive evaluation of other injuries. These protocols often prioritize the use of plain film radiography, ultrasonography and laboratory testing over comprehensive history and physical examination. Common initial imaging strategies include chest and pelvic radiographs and extended focused assessment with sonography for trauma (FAST), which are cost-effective and easy to perform but offer limited diagnostic accuracy. Several studies have shown that a thorough clinical examination, including the use of FAST, chest X-rays, and pelvic X-rays, can effectively exclude injuries, potentially avoiding unnecessary whole-body computed tomography (WBCT) scans. By contrast, WBCT is often used as the primary assessment tool in trauma centers due to its high sensitivity and speed in detecting traumatic injuries[2]. In severely injured patients, WBCT provides accurate details about the extent of injuries and is also used to identify occult injuries in high-energy patients with trauma who may not show obvious signs of injury[3-6]. Studies support the routine use of WBCT because without it, there is a high risk of missing significant injuries in patients with trauma. However, the routine use of WBCT in patients with major trauma, even when no injury is clinically suspected, remains controversial, particularly from a radiation protection standpoint[3].
Studies have indicated that 1%-3% of cancers globally are attributed to medical sources of radiation. On average, WBCT exposes each patient to more than 20 mSv of effective radiation, which increases the risk of cancer mortality[7-9]. For a 35-year-old male, the risk of cancer mortality is estimated at 1 in 900 with a radiation dose of 24 mSv, whereas for an average 45-year-old adult, the risk is 1 in 1250 with a radiation dose ranging from 10-20 mSv[7,10-12].
While WBCT use in the State of Kuwait is aligned with the country’s broader healthcare objectives under State of Kuwait Vision 2035[13], which aims to modernize the healthcare system and improve patient outcomes, optimizing WBCT use is critical to achieving these goals without overburdening healthcare resources or exposing patients to unnecessary radiation risks. WBCT is widely available in government hospitals under the Ministry of Health. Its use is common in trauma cases, particularly for road traffic accidents (RTAs), which are a major public health issue in State of Kuwait[14]. Recently, there has been a shift from indiscriminate referrals for WBCT in patients with trauma, particularly those with high-energy trauma, toward a more risk-benefit-oriented approach. This approach incorporates clinical prediction rules to safely exclude WBCT in selected cases[15]. The aim of this study was to estimate the true incidence of clinically significant injuries among patients with trauma referred to emergency departments at radiology centers in the State of Kuwait. We hypothesized that such an estimation could lead to more effective utilization of radiology resources, which are currently strained by the high volume of referrals, and could contribute to the optimization of radiology healthcare services.
MATERIALS AND METHODS
This multicentric retrospective study included all seven radiology departments in Kuwait, examining 1367 patients with trauma from 2022 to 2023 who referred from emergency departments of the collaborative hospitals. All patients with trauma were initially managed and proceed to WBCT in accordance with the American College of Radiology guidelines for Major Blunt Trauma[16].
Inclusion and exclusion criteria
All patients with major traumatic event (blunt or penetrating injury resulting from high-energy mechanisms and activation of the trauma team or equivalent emergency protocol), hemodynamic stability (systolic blood pressure ≥ 90 mmHg and heart rate ≤ 120 bpm at initial assessment or after primary resuscitation) and altered consciousness (Glasgow Coma Scale score ≤ 13 on arrival or within the first 15 minutes of emergency department evaluation) who were admitted to the emergency department were included in this study and underwent WBCT. Any other causes were excluded from this assessment.
Data collection
The proposed study received approval from the Ethics Committee of the relevant institution (Ministry of Health-KEC 1298). Data were collected from patients with trauma admitted to the emergency departments of collaborative radiology centers. Consent was obtained as part of the standard clinical study. Three of the seven departments were equipped with GE CT-128, GE CT-256, and Siemens CT-128 scanners, while the remainder had Siemens CT-256 scanners. Patients received intravenous contrast-medium for the chest and abdomen. Post-imaging, all patient data were archived using Picture Archiving and Communication System, with four departments utilizing Centricity, two using Agfa, and one using Siemens.
Age, sex, mechanism of injury, clinical requests, clinical findings, and WBCT findings in the cervical spine, thoracolumbar spine, chest, abdomen, pelvis, and appendicular skeleton were recorded based on institutional reporting. Radiological results were initially classified into negative and positive findings. Positive findings were then categorized as major or minor injuries based on impact of energy, physiological disturbances, potential for life-threatening conditions and anatomical regions involved. The process of referral, classification, and radiological assessment is summarized in Figure 1. The specification of WBCT scan acquisition parameters, dose-length product (DLP) values from the scanner-generated dose reports and a conversion factor that is, the region-specific normalized effective dose (ED) per DLP (mSv × mGy-1 × cm-1)[17] were used to calculate the ED. The ED was estimated as the product of the DLP and the corresponding conversion factor (k): ED (mSv) ≈ k × DLP. For the whole-body scan, we used a k value (k = 0.0093 mSv × mGy-1 × cm-1)[18,19]. Computed tomography (CT) automatic exposure control that modulates radiation exposure automatically and is widely used for optimization of radiation dose in CT were used by the departments[20,21]. The Sante Digital Imaging and Communications in Medicine viewer was utilized to retrieve all the relevant parameters.
Figure 1 Flowchart of whole-body computed tomography use in trauma patients: Clinical decision pathway and radiological outcomes.
ED: Effective dose; ER: Emergency room; WBCT: Whole-body computed tomography.
Statistical analysis
A power calculation with a 10% margin of error and 95% confidence level indicated a minimum of 96 datasets per center. However, 200 WBCT datasets for patients with trauma were collected from each center for a more robust analysis. Pre-test clinical requests, including clinical signs, symptoms, injury mechanisms, and clinical queries, were compared with WBCT findings. Data analysis was conducted using IBM SPSS version 25.0 (IBM Inc., Armonk, NY, USA). The Kolmogorov-Smirnov test assessed normality. Statistical significance was set at the 5% level, χ2, Student’s t-test, and Mann-Whitney tests were used to compare categorical and quantitative datasets.
RESULTS
A total number of 1367 cases were included and assessed in this study. The mean age of patients referred to all cohort departments was 33.54 ± 16.09 years, where 1074 (78.6%) were males and 293 (21.4%) were females, and male to female ratio was 3.7:1. Out of 1367 patients scan, 578 (42.3%) were reported as normal (negative finding), whereas 789 patients (57.7%) had positive trauma related radiological finding of which 530 patients were found to have a major injury (38.8%) including solid organ and vertebral column injuries (Table 1). According to CT indication, 911 patients had been referred due to RTA (66.6%), 182 patients due to falls from height (13%), 112 patients due to a fall of a heavy object (8%), 82 patients due to head trauma (6%), while 28 patients had injuries due to buggy accident (2%), and 24 patients had an injury due to assault (1.8%). The RTA, with a 66.6 % score was the most common indication for WBCT referral (Table 2), (Figure 2). Anatomical body regions that were affected according to the WBCT scan results were head (48.7%), chest (31.1%), abdominal (10.2%), pelvis (7.6%), others (2.4%) (Figure 3).
Description of WBCT scan finding and classification is given in Table 3, where the most common (top 5) finding injuries across all the collaborative radiology departments were reported to be: Head hemorrhage/edema/hematoma 293 (21.4%), fracture spine 242 (17.7%), fracture ribs/clavicle/scapula 191 (14.0%), fracture skull/face 173 (12.7%) and lung contusions 162 (11.9%). For the positive case category, the mean values for CT dose index volume, scan length, and DLP were recorded as 89.01 ± 59.80 mGy, 43.53 ± 30.13 cm, and 2410.52 ± 1112.07 mGy × cm, respectively. The ED was calculated, yielding a mean ED of 22.41 ± 10.35 mSv. In comparison, for patients with negative CT findings, the mean ED was 19.98 ± 10.26 mSv, which significantly overlapped the range of positive CT cases (22.41 ± 10.35 mSv), considering the standard deviations of ± 10.26 and ± 10.35 (Table 4). Box plot comparisons of WBCT ED data across departments, showing overall consistency in dose distribution, with one department exhibiting greater variability in individual patient data, is illustrated in Figure 4. The limited availability of data may have influenced the variability.
WBCT plays a crucial role in detecting injuries and assessing their severity for treatment planning. According to a study by Kalra et al[22], up to 22% of injuries may be missed without WBCT; however, these findings are often derived from studies conducted in major trauma centers in the United States, which typically deal with a combination of blunt and penetrating trauma and a higher volume of severe cases[23]. Furthermore, there is no conclusive evidence that WBCT reduces trauma mortality[24]. To the best of our knowledge, this is the first large-scale multicenter study in the State of Kuwait to evaluate the use of WBCT in patients with trauma within emergency departments.
The occurrence of incidental findings, or “incidentalomas”, on CT scans has been reported in multiple studies, with some indicating an incidence rate exceeding 50%[25,26]. A recent analysis from the New York trauma registry[27] reported that 40% of trauma CTs included incidental findings, with 63% classified as class 2, which did not require immediate intervention but were not considered normal variants, thus warranting further evaluation. While incidental findings can potentially facilitate early detection of significant underlying conditions[28,29], their clinical impact was not specifically assessed in this study, and no analysis of associated costs, follow-up investigations, or patient outcomes was performed. Fear of missing significant pathology resulting in serious complications or outcomes and the worry of medicolegal ramifications are legitimate concerns[30].
A study by Caputo et al[31] comparing the severity of injury, found that those undergoing WBCT had significantly higher Injury Severity Score greater than 15 compared with those receiving selective scanning (29.72 vs 26.46, n = 23172; P < 0.001). This might be misinterpreted as patients with more significant injuries being more likely to receive a WBCT scan, suggesting potential selection bias. However, both groups had Injury Severity Score greater than 15, indicating that they were comparably severely injured.
Meta-analyses of retrospective observational studies have reported that WBCT improves time to diagnosis and treatment, and reduces mortality in patients with trauma, although these studies were heterogeneous and carried a high risk of bias[32,33]. WBCT for trauma has demonstrated a sensitivity of 95% and a specificity of 56% for detecting significant injuries[34].
The Randomized Study of Early Assessment by CT Scanning (REACT-2) is the only multicenter randomized controlled trial examining the use of WBCT in trauma. The trial included 1403 patients with severe trauma, randomized to either immediate WBCT or initial assessment with history, examination, chest X-ray, and FAST, followed by selective CT based on identified injuries. The study found no significant difference in mortality in 24 hours or 30 days. Subgroup analysis of patients with polytrauma also showed no difference in mortality. However, REACT-2 demonstrated a reduction in time to diagnosis or treatment by 7 minutes overall, and 11 minutes in patients with polytrauma. Despite some criticism, REACT-2 remains the highest quality evidence (level 2) for WBCT use in trauma[35]. Davies et al[36] proposed a clinical scoring system considering multiple factors such as trauma to various body regions, Glasgow Coma Scale, hemodynamic and respiratory abnormalities, and injury mechanism. Several studies suggest using clinical prediction rules to safely omit unnecessary WBCTs, reducing radiation exposure and costs[28,37,38]. While WBCT is beneficial for severe polytrauma, high rates of WBCT in patients with trauma with no acute findings raise concerns about overuse, unnecessary radiation exposure, and incidental findings requiring follow-up[39].
In recent retrospective studies of hemodynamically stable patients after high-risk motor vehicle collision, low rates of injury requiring treatment or follow-up were found in body regions without clinically suspected injury, suggesting that CT should perhaps be selected based on physical findings[40]. An example of this can be found in the study by Huber-Wagner et al[37], where 3924 patients with trauma underwent computed tomography as part of their initial evaluation. Of these, 2430 patients received organ-selective CT, whereas 1494 underwent WBCT. The study found that the predicted mortality rate was significantly higher in the WBCT group (23.2% vs 17.3%; P < 0.001) compared to the organ-selective CT group (17.1% vs 17.5%; P = 0.66)[34]. These findings were further explored in a follow-up study conducted by the same authors in 2013, which included a total of 16719 patients (9233 in the WBCT group and 7486 in the organ-selective CT group). The study revealed that the absolute mortality rate in the WBCT group was significantly lower than in the organ-selective CT group (17.4% vs 21.4%; P < 0.001)[37]. Several meta-analyses have supported these results, reinforcing the idea that WBCT is a safe, effective, and efficient tool for surgical triage[31,33,34,41]. The inclusion of a WBCT protocol in the management of severely injured patients with trauma has been shown to reduce time to a definitive diagnosis, improve the accuracy of patient selection for operative vs non-operative management, and lower overall radiation exposure.
In our study, RTAs were the leading cause of injury among male patients (1074, 78.6%) and female patients (293, 21.4%) referred to emergency room departments. The overall rate of positive WBCT findings was 57.7%, with major cases at 38.8% and minor cases at 18.9%. While these findings provide valuable insights, they may lead to unnecessary follow-up investigations, increasing healthcare costs, though no follow-up investigations or analysis of associated costs was performed in this study. A more selective approach would optimize resource use and allow for better allocation of funds to critical services. In countries like the United Kingdom, Germany, and Denmark, WBCT is applied more selectively, guided by clinical justification and reducing unnecessary radiation exposure[20].
In the Middle East, the use of WBCT in patients with trauma demonstrates considerable variability in diagnostic yield, although the study populations are relatively small. In Saudi Arabia, 531 patients with trauma underwent WBCT, with 43% showing positive findings and 57% negative[42]. In Egypt, among the 186 WBCTs in patients with trauma, 79.6% had positive findings and 20.4% negative[43].
In this study, we found that 42.3% of all WBCT findings were negative, which raising concerns about the unnecessary use of WBCT in radiology departments in State of Kuwait. This overuse can place significant strain on the 24/7 availability of skilled personnel and clinical services. In contrast, European countries such as the United Kingdom and Germany have reported lower percentages of negative findings (< 20%)[44]. Additionally, we found that 73.9% of negative CT findings were associated with male patients, while 26.1% were associated with female patients. This discrepancy can be attributed to demographic and occupational factors and cultural norms. In Kuwait and similar Gulf states, males are more frequently involved in high-risk activities such as driving and manual labor, which increases their exposure to trauma events requiring WBCT[45]. Conversely, cultural norms may expose fewer females to such risks, thereby reducing their need for WBCT and contributing to the lower percentage of negative findings among them.
Although no large-scale epidemiologic studies of cancer risk have been reported in association with CT scans, experts state that up to 2% of cancers in the United States may be attributed to radiation exposure from CT scans. The stochastic risk of radiation-induced carcinogenesis is believed to follow a linear relationship between dose and biological effect, with no safe threshold[46]. In our study, the related ED among the participated radiology departments were in the range of 11.92 mSv to 28.9 mSv that are influenced by including the type of CT scanner, acquisition parameters, and the protocol in use. Patients with negative CT findings, with a mean ED of 19.98 ± 10.26, are exposed to radiation levels within the same range as those with positive CT findings (mean ED of 22.41 ± 10.35). Similar standard deviations (± 10.26 and ± 10.35) indicate that both groups receive comparable radiation doses highlighting potential issues with unnecessary exposure.
The systematic review and analysis by Healy et al[47] found no difference in radiation mortality when comparing WBCT vs selective scanning of n = 8180 and n = 5470 trauma cases. To avoid unnecessary exposure and minimize the effect, adherence to the national diagnostic reference level which is set for CT diagnostic imaging based on the current facilities and practice in State of Kuwait is recommended. In view of further optimization and improving dose management, use of “Dose Watch” software solution that is a comprehensive, proactive radiation management program is recommended which can report the radiation dose delivered to patients during an examination and presents this data in an organized manner.
State of Kuwait’s national healthcare goals, as outlined in Vision 2035[13], focus on improving healthcare services and maximizing resource efficiency. Our study findings therefore highlight the importance of rationalizing WBCT in trauma care. Rationalization requires the adoption of structured clinical decision tools and selective imaging strategies that can reduce unnecessary scans, minimize radiation exposure, and optimize the use of radiology services[36,38]. Within State of Kuwait, this focus on rationalization also supports national healthcare priorities for efficient and sustainable resource utilization[14]. A national trauma registry is recommended to be used in each trauma center to enable the centers to contribute to a national database. Furthermore, it can help shape public health strategies, particularly in addressing high-risk factors like RTAs, a major trauma cause in State of Kuwait.
Limitations
Some limitations of our study include its retrospective design and the lack of standardized consideration for injury severity. However, the impact of injury severity on the findings is likely minimal, as the two primary parameters - CT scan duration and image quality - are generally unaffected by the patient’s condition. Furthermore, variability in CT scanner models and acquisition protocols across participating centers may have introduced inconsistencies in radiation dose measurements. The study also did not assess the cost-effectiveness of WBCT utilization or quantify the economic implications of potentially unnecessary scans - an important aspect of imaging stewardship that warrants investigation in a dedicated, large-scale analysis. Finally, although incidental findings are discussed, they were not systematically documented or analyzed, limiting the ability to evaluate their clinical relevance or downstream consequences.
CONCLUSION
WBCT remains a cornerstone in the thorough assessment of patients with trauma; however, its use requires careful rationalization to balance diagnostic benefit against radiation risk and radiology resource utilization. This national audit demonstrates a substantial proportion of negative scans, reinforcing the need for protocol optimization and integration of clinical decision tools to support more selective imaging strategies. Rationalizing WBCT in trauma care not only enhances patient safety but also contributes to more sustainable stewardship of healthcare resources, in alignment with national and international priorities for high-value trauma care.
ACKNOWLEDGEMENTS
The authors would like to acknowledge Hany Elrahman from the Medical Imaging Department at ADAN Hospital for his invaluable contribution in providing technical, computational services, and expertise. Furthermore, the authors express their appreciation to the following emergency and radiology departments in the State of Kuwait for their participation in providing data on patients with trauma (listed alphabetically): Al Adan Hospital - Ahmadi Health District; Farwaniya Hospital - Farwaniya Health District; Al-Jahra Hospital - Al Jahra Health District; Sabah Hospital - Al Sabah Specialized MED Center; Mubarak Al Kabeer Hospital - Hawally Health District; Amiri Hospital - Capital District; and Jaber Hospital - Capital District.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Radiology, nuclear medicine and medical imaging
Country of origin: Kuwait
Peer-review report’s classification
Scientific Quality: Grade A, Grade C
Novelty: Grade A, Grade C
Creativity or Innovation: Grade A, Grade D
Scientific Significance: Grade A, Grade C
P-Reviewer: Hajalamin M, MD, Chief Physician, Research Fellow, Researcher, Ireland; Wan HJ, Chief Nurse, Dean, Deputy Director, Professor, Research Fellow, China S-Editor: Bai Y L-Editor: Filipodia P-Editor: Zheng XM
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