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Psychological, sociodemographic, and clinicopathological predictors of breast cancer patients' decision to undergo breast reconstruction after mastectomy.

Breast cancer is the most commonly occurring cancer among females, and it affects 2.1 million women worldwide each year. (1) Among Saudi women, it is the most common cancer. (2) The incidence of breast cancer in the United States (US) is 124 per 100000 women. (3) In many cases of breast cancer, a mastectomy is indicated. Mastectomy significantly deprives women of their sense of femininity and makes them feel less attractive, and this in turn adversely influences their quality of life (QOL). (4-7) Postmastectomy breast reconstruction (BR) improves QOL. (8,9) There are primarily 2 types of BR, namely, implant and autologous (flap) reconstruction, and each of these can be implemented through various approaches. For example, implants include saline and silicone. A flap of the latissimus dorsi or transverse rectus abdominis (TRAM) is used for autologous BR. The latissimus dorsi flap is swung from the back. It provides less fullness than TRAM, thus an implant or a fat graft is often used coupled with it. (10) A TRAM flap is performed by rotating the rectus abdominis muscle or by removing a smaller part of the muscle with its skin (free flap). Free TRAM flaps provide more flexibility and lower risk of tissue necrosis when compared to pedicle TRAM flaps. (11) It has been shown that autologous BR yields superior outcomes, when compared to implant BR. (12-14) Nowadays, most BRs involve implants; in the late twentieth century, autologous implants were more popular. (15) This change is partially attributable to surgeons' efforts to provide the option of reconstruction to the high-risk postmastectomy population (namely, patients with other comorbidities and/or those older than 60 years). (16)

Breast cancer patients experience psychological morbidities, primarily mood disorders, after receiving and when living with the diagnosis. The untreated anxiety and depression are important factors that render the QOL of these patients low, not merely the physical aspect of the patients' presentation. (17,18) These morbidities in women with breast cancer are often overlooked and left untreated because they can have unclear presentations. (17)

According to the findings of a Polish study, deciding to undergo BR after breast removal is correlated with personality traits among women. Specifically, introverts rarely opted to undergo BR. (19) Another important personality type is the narcissistic personality. Specifically, narcissists tend to demand perfectionism as it is a sentinel feature of their personality type; hence, they seek to have an extremely attractive body. (20-22)

Despite recommendations to undergo BR, the rates at which the procedure is performed are low, ranging from 11% to less than 40% (in some tertiary care centers in the US). (23,24) The decision to undergo BR is complicated by a variety of procedures. (12) Women are asked to choose from an array of procedures, and the problem has become more strenuous with the development of the perforator flap technique, which minimizes the risk of hernia albeit requires longer operation time. (12) Additionally, the burden that the surgical procedure places on the patient and her relatives makes the decision-making process even more difficult. (25) Two studies that were conducted in Europe found that the patient's age influences her decision to undergo BR and the possession of information about the procedure. (26,27)

Only a small proportion of treated breast cancer patients decide to undergo BR. (15,28) Therefore, it is important to examine which mood states and social aspects influence this decision-making process. In this study, we aimed to examine the influence of socioeconomic factors, anxiety, depression, and personality traits on the decision to undergo BR after a mastectomy in one center in Jeddah, Saudi Arabia.

Methods. This cross-sectional study was conducted between March and July 2019, using an interview-based questionnaire. This interview was conducted among female patients who were diagnosed with breast cancer at King Abdulaziz University Hospital (KAUH), Jeddah, Saudi Arabia.

Women aged 18 years and older who had undergone mastectomy for breast cancer between January 2017 and 2019 were included. The exclusion criteria were as follows: a) undergone bilateral mastectomy, contralateral mastectomy for prophylactic purposes, or a reoperation and b) breast cancer recurrence. All contributors were knowledgeable before participation, and those who agreed to contribute were registered. Approximately 400 randomly chosen patients were identified from the hospital records, and 241 of them who met the study's inclusion criteria were contacted; only 196 patients agreed to participate (Figure 1). Patients were divided into 2 subgroups: Group A, which consisted of women who had opted for BR and Group B, which consisted of women who chose to not undergo BR.

Study variables. We reviewed the literature and developed a valid questionnaire based on the findings of several published studies. (19,29-32) The questionnaire consisted of 46 questions that were divided into 5 sections: demographic data, personality traits, (19) the Narcissism Index (NI), (29,30) and the Hospital Anxiety and Depression Scale (HADS). (31,32) The NI is a reliable tool for predicting the degree of narcissism. (29,30) The reliability and validity of HADS on similar populations (breast cancer patients) has been studied, and it has been shown to have a good predictive value. Furthermore, the Arabic translation used in this study has been shown to be both valid and reliable. (31-33) The study was conducted after ethical approval was granted by the Research Ethics Committee at the King Abdulaziz University Hospital. Patients participated in this study on an entirely voluntary basis.

Statistical analysis. Data were checked for completeness, and errors were corrected. The normality of the distributions of continuous variables were checked by conducting the Shapiro-Wilk and Kolmogorov Smirnov tests. Their results indicated that all variables were none normally distributed. The sociodemographic variables and clinicopathological features (namely, tumor size, lymph node involvement, and metastasisTNM) of the 2 participant groups were compared using the Chi-squared test. Respondents' scores on the NI and HADS were calculated by counting the responses. The mean scores of the 2 participant groups were compared using the Mann-Whitney U test. The relationship between TNM and anxiety and depression scores were examined using the Kruskal-Wallis test. The extroversion/introversion personality continuum of the 2 participant groups were compared using Chi-squared and fisher exact tests. Binary logistic regression analysis was conducted to identify the predictors of the decision to undergo BR. The results have been presented using tables and figures.

All analyses were conducted using the Statistical Package for Social Sciences version 23.0 (IBM, Armonk, NY, USA), and 95% confidence intervals were computed to interpret the results.

Results. A total of 196 patients were interviewed, and 118 (60.2%) of them had opted for BR; the remaining 78 (39.8%) patients had not opted for BR. The mean age of the participants was 48.44 ([+ or -] 9.87) years. Further, 86 (43.9%) patients were Saudi, the monthly income of 118 (60.2%) patients was <5000 Saudi Riyals (SR). One hundred and thirty (66.3%) patients were unemployed/housewives, 72 (36.7%) patients had chronic illnesses, and 76 (38.8%) patients had a family history of breast cancer (BC). Out of the 76 participants with a family history of BC, 71.1% had a relative who had BC and had undergone BR. The sociodemographic characteristics for each participant group are presented in Table 1.

The group of women who had opted for BR tended to have younger women (mean difference between the 2 groups was 7.53 years, p<0.001), fewer nonsmokers (p=0.015), and more women without chronic illnesses (p<0.001). Unemployed participants were less likely to have opted for BR (p=0.041). With regard to the TNM classification, a lymph node involvement was less prominent among those who had opted for BR (p=0.13) (Table 1).

Personality traits and mood status. The mean depression score for all participants was 5.78 ([+ or -] 4.65), anxiety score 7.72 ([+ or -] 4.88), and NI 4.17 ([+ or -] 2.81). Table 2 shows that anxiety (9.67 [+ or -] 5.07 versus 6.44 [+ or -] 4.31, p<0.001) and depression scores (7.74 [+ or -] 4.90 versus 4.49 [+ or -] 3.97, p<0.001) were significantly higher among participant who had opted to not undergo BR. However, scores on the NI were higher among those who had opted for BR (p=0.030) (Table 2).

The responses that the 2 participant groups provided to the extroversion/introversion personality questions (total: 5 questions) are summarized in Table 3. Group comparisons revealed that there was a statistically significant difference in the responses that were provided to questions 4 (p=0.0002) and 5 (p<0.001) (Table 3).

Disease stage and mood status. There was no statistically significant relationship between TNM classification and anxiety and depression scores (p>0.050).

Binary logistic regression. Binary logistic regression analysis was used to identify the predictors of the decision to undergo BR. Anxiety and depression scores, sociodemographic variables, TNM classification, and adjuvant treatment were included in the regression analysis. The results revealed that depression scores, age, and lymph node involvement were statistically significant predictors of BR decision. Other included variables were not statistically significant (p>0.050) (Table 4).

Discussion. Among breast cancer patients, undergoing mastectomy frequently has a negative impact on the QOL and psychological well-being. Undoubtedly, this body part entails important psychological implications. Consequently, patients who have undergone a mastectomy perceive a decline their sense of femininity and confidence levels. A mastectomy without BR can alter the mood and behaviors of patients in their workspaces. (34) Further, it can strongly impact their roles as a family member. Therefore, BR after breast removal can tremendously improve QOL and perceived body image. Accordingly, we aimed to examine the relationship that the decision to undergo BR shares with different personality traits, depression, anxiety and sociodemographic variables among breast cancer patients.

The existing literature suggests that age is a very important determinant on BR. (24,26,27) A similar result emerged in this study. This finding is attributable to surgeons' fear of postoperative complications, especially in a patient with other chronic illnesses. (27) There was a significant difference in BR status between Saudis and non-Saudis. This finding may be attributable to group differences in access to healthcare or the relatively higher mean depression (6.47 [+ or -] 4.96 versus 4.91 [+ or -] 4.04, p=0.035) and anxiety scores (8.93 [+ or -] 5.18 versus 6.19 [+ or -] 4.00, p<0.001) that non-Saudi participants obtained (the regression analysis presented in Table 4 yielded no significant predictor).

Another interesting finding was that the patients who were willing to undergo BR were healthier and did not have any chronic illnesses or comorbidities, when compared to the other group. Being healthy is closely related to happiness, and deciding to undergo such a procedure can tremendously improves a patient's QOL. (4-7,35) This is similar to the findings of 2 studies that were conducted in the US (36) and Australia, (37) whereby patients with fewer comorbidities were found to be more likely to undergo BR.

Past findings suggest that patients with early-stage BC are more likely to undergo BR. Similarly, in the present study, the percentage of node negative patients was higher in the BR group. It is noteworthy that many of these early stage BC patients do not require postmastectomy chemotherapy and radiotherapy. (24)

It is noteworthy that, in the present study, patients with a family member who had undergone BR were more likely to have opted for BR than their counterparts. This may be the case because BC survivors prefer to receive information about BR from their friends and peers. Further, they feel less isolated after they receive such information from patients who have undergone BR. (38)

In this study, the HADS was used to assess the affective states of the participants. The Center for Epidemiological Studies Depression (CES-D) Scale was not used owing to 2 primary reasons: a) it does not screen for anxiety and b) its performance and reliability has been examined primarily mostly on young population. (39,40) In comparison, the HADS is a simpler assessment, and its reliability has been examined across different contexts (including among BC patients and cancer patients in general) and age groups. (31-33) Our results suggest that women with depression and anxiety are not prepared to undergo another nonvital procedure as most of the focus is on monitoring BC recurrence with anxiety and depression being vaguely present. (17) Satisfactory doctor-patient communication regarding patient concerns and the provision of crucial information to the patient are important factors that can improve the detection of psychological problems and mitigate depressive symptoms and anxiety among BC patients. (18)

The responses that the 2 groups provided to the 5 personality questions, which were adapted from the assessment that was used in a Polish study, were compared using Chi-squared and fisher exact tests (Table 3). Interestingly, 2 questions for which significant group differences had emerged in the original study had also evidenced significant group differences in the current study. (19) In both the studies, patients who had opted for BR were more likely to be extroverted, as extrovert individuals are mainly outgoing and like to be with others. In the present study, the NI scores were higher among those who had opted for BR.

Study limitations. Although our sample size was moderate, and the study's objectives were addressed, the study has a few limitations. First, our article was cross-sectional in nature and covered a short time period. Therefore, the participants may not have been representative of the entire population of Saudi Arabia. Second, this study was conducted in a single center, thereby limiting the generalizability of the results. Third, the reliability of the 5 personality questions has not been studied. In the future, studies must include a larger number of hospitals that represent different regions within the country. This study offers insights into the prevalence of depression and anxiety among breast cancer patients after mastectomy. It also uncovers the variability in personality traits within this population. More importantly, it indicates that depression single handedly plays a significant role in the decision to not undergo BR, after potential confounds are controlled for. It is important to screen and detect undiagnosed depression and anxiety among patients who have undergone a mastectomy. This is necessary to effectively treat these conditions through prompt referral to a psychiatrist, improve their QOL, restore at least a moderate level of functioning, and provide assistance during this difficult postmastectomy decision-making period. Patients of all ages should receive counseling about BR after a mastectomy.

In conclusion, undergoing BR is a difficult, yet important decision for a woman who survived BC to make. Age and depression significantly influenced this decision among our study participants. Women who opted to undergo BR tend to be younger, report lower levels of depression, and were characterized by less nodal involvement. Certain personality traits can also influence the decision to undergo BR. Diagnosing and treating depressed patients is an important aspect of caring for BC patients. A patient's age should not deter physicians from counseling patients about BR.

Acknowledgment. The authors would like to thank Randa Abushanab and Renad Alnemari for their help in data collection. Also, we would like to acknowledge for English language editing.

Disclosure. Authors have no conflict of interests, and the work was not supported or funded by any drug company.


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[Please note: Some non-Latin characters were omitted from this article.]

doi: 10.15537/smj.2020.3.24946

Azmi Marouf, Medical Student, Hatan Mortada, MBBS, Mahmoud G. Fakiha, MD, DESC.

From the Faculty of Medicine (Marouf), King Abdulaziz University; from the Department of Plastic Surgery & Burn Unit (Mortada), King Saud Medical City; and from the Division of Plastic & Reconstructive Surgery (Fakiha), Department of Surgery, University of Jeddah, Jeddah, Kingdom of Saudi Arabia.

Received 1st November 2019. Accepted 16th January 2020.

Address correspondence and reprint request to: Dr. Hatan Mortada, Department of Plastic Surgery & Burn Unit, King Saud Medical City Riyadh, Kingdom of Saudi Arabia. E-mail: ORCID ID:

Caption: Figure 1--Flowchart depicting the inclusion and exclusion of the study participants.
Table 1--Sociodemographic characteristics and clinicopathological
features of the respondents split by participant group.

Characteristics   Attributes                (n=118)

Age (years)       Mean [+ or -] SD    45.44 [+ or -] 8.66
                  Median                      45.0
Nationality       Saudi                    62 (52.5)
                  Non-Saudi                56 (47.5)
Marital status    Single                    9 (7.6)
                  Married                  93 (78.8)
                  Divorced                  8 (6.8)
                  Widowed                   8 (6.8)
Educational       Below high school        29 (24.6)
level             High school              37 (31.4)
                  Bachelor's degree        41 (34.7)
                  Master                    6 (5.1)
                  PHD                       5 (4.2)
Monthly income    <5000                    68 (57.6)
(Saudi Riyals)    5000-10,000              18 (15.3)
                  10,000-20,000            24 (20.3)
                  >20,000                   8 (6.8)
Occupation        Works in Jeddah          26 (22.0)
                  Works outside            14 (11.9)
                  Unemployed               78 (66.1)
Smoking           No                       104 (88.1)
                  Yes                      14 (11.9)
Chronic illness   No                       88 (74.6)
                  Yes                      30 (25.4)
Family history    No                       70 (59.3)
of breast         Yes                      48 (40.7)
Family member     No                        4 (8.3)
underwent BR      Yes                       36 (75)
                  Don't know                8 (16.7)
Tumor size        Ductal carcinoma         27 (22.9)
                    in situ
                  Breast cancer            33 (28.0)
                    T1a-c ([less
                    than or equal
                    to] 2cm)
                  Breast cancer T2         34 (28.8)
                  Breast cancer T3          10 (8.5)
                  Breast cancer T4         14 (11.9)
Lymph node        N0                       56 (47.5)
involved          N1                       25 (21.1)
                  N2                       20 (16.8)
                  N3                       17 (14.4)
Distant           No                       110 (93.2)
metastasis        Yes                       8 (6.8)

Adjuvant          None                     29 (24.6)
therapy           Chemotherapy             54 (45.8)
                  Chemo + endocrine         6 (5.1)
                  Chemo + radio            16 (13.6)
                  Chemo + radio +          13 (11.0)

                                           No breast
Characteristics   Attributes                 (n=78)

Age (years)       Mean [+ or -] SD    52.97 [+ or -] 9.90
                  Median                      53.0
Nationality       Saudi                    24 (30.8)
                  Non-Saudi                54 (69.2)
Marital status    Single                    9 (11.5)
                  Married                  57 (73.1)
                  Divorced                  6 (7.7)
                  Widowed                   6 (7.7)
Educational       Below high school        19 (24.4)
level             High school              29 (37.2)
                  Bachelor's degree        25 (32.1)
                  Master                    4 (5.1)
                  PHD                       1 (1.3)
Monthly income    <5000                    50 (64.1)
(Saudi Riyals)    5000-10,000              14 (17.9)
                  10,000-20,000            10 (12.8)
                  >20,000                   4 (5.1)
Occupation        Works in Jeddah          24 (30.8)
                  Works outside             2 (2.6)
                  Unemployed               52 (66.7)
Smoking           No                       76 (97.4)
                  Yes                       2 (2.6)
Chronic illness   No                       36 (46.2)
                  Yes                      42 (53.8)
Family history    No                       50 (64.1)
of breast         Yes                      28 (35.9)
Family member     No                        8 (28.6)
underwent BR      Yes                      18 (64.3)
                  Don't know                2 (7.1)
Tumor size        Ductal carcinoma         10 (12.8)
                    in situ
                  Breast cancer            31 (39.7)
                    T1a-c ([less
                    than or equal
                    to] 2cm)
                  Breast cancer T2         23 (29.5)
                  Breast cancer T3          8 (10.3)
                  Breast cancer T4          6 (7.7)
Lymph node        N0                       35 (44.9)
involved          N1                       30 (38.5)
                  N2                       10 (12.8)
                  N3                        3 (3.8)
Distant           No                       70 (89.7)
metastasis        Yes                       8 (10.3)

Adjuvant          None                      7 (9.0)
therapy           Chemotherapy             47 (60.3)
                  Chemo + endocrine         8 (10.3)
                  Chemo + radio             8 (10.3)
                  Chemo + radio +           8 (10.3)

                                        Odds ratio
Characteristics   Attributes             (95% CI)      P-value

Age (years)       Mean [+ or -] SD                      <0.001
Nationality       Saudi                   2.491         0.003
                  Non-Saudi           (1.365-4.546)
Marital status    Single                                0.779
Educational       Below high school                     0.721
level             High school
                  Bachelor's degree
Monthly income    <5000                                 0.506
(Saudi Riyals)    5000-10,000
Occupation        Works in Jeddah                       0.041
                  Works outside
Smoking           No                      0.195         0.015
                  Yes                 (0.043-0.886)
Chronic illness   No                      3.422         <0.001
                  Yes                 (1.863-6.287)
Family history    No                      0.817         0.501
of breast         Yes                 (0.452-1.474)
Family member     No                                    0.046
underwent BR      Yes
                  Don't know
Tumor size        Ductal carcinoma                      0.241
                    in situ
                  Breast cancer
                    T1a-c ([less
                    than or equal
                    to] 2cm)
                  Breast cancer T2
                  Breast cancer T3
                  Breast cancer T4
Lymph node        N0                                    0.013
involved          N1
Distant           No                      0.636         0.430
metastasis        Yes                 (0.228-1.773)

Adjuvant          None                                  0.291
therapy           Chemotherapy
                  Chemo + endocrine
                  Chemo + radio
                  Chemo + radio +

* odds ratio were presented for dichotomous sociodemographic
variables. BR: breast reconstruction. 95% CI: 95% conference interval

Table 2--Distribution of respondents' mean NI score, anxiety score and
depression score split by participant group.

                         Breast              No breast
Scores               reconstruction        reconstruction      P-value
                         (n=118)               (n=78)

Narcissism Index   4.53 [+ or -] 2.84    3.64 [+ or -] 2.70     0.030
Anxiety score      6.44 [+ or -] 4.31    9.67 [+ or -] 5.07     <0.001
Depression score   4.49 [+ or -] 3.97    7.74 [+ or -] 4.90     <0.001

Values are presented as mean [+ or -] SD.

* Mann-Whitney U test was carried out

Table 3--Extroversion/introversion personality continuum in the 2
study groups.

                                 Breast        No breast
Personality questions/       reconstruction  reconstruction  P-value
answers                         (n=118)          (n=78)

1) Do you seek success                                        0.254
in life?                                                     ([double
  Definitely yes               100 (84.7)      68 (87.2)     dagger])
  Rather yes                   12 (10.2)        4 (5.1)
  Hard to say                   4 (3.4)         6 (7.7)
  Rather no                     2 (1.7)         0 (0.0)
  Definitely no                 0 (0.0)         0 (0.0)
2) Do you have the ability                                    0.216
to motivate other people?                                    ([double
  Definitely yes               80 (67.8)       50 (64.1)     dagger])
  Rather yes                   26 (22.0)       20 (25.6)
  Hard to say                   8 (6.8)         6 (7.7)
  Rather no                     4 (3.4)         0 (0.0)
  Definitely no                 0 (0.0)         2 (2.6)
3) Are you open to other                                      0.119
people?                                                      ([double
  Definitely yes               74 (62.7)       50 (64.1)     dagger])
  Rather yes                   30 (25.4)       12 (15.4)
  Hard to say                   10 (8.5)        8 (10.3)
  Rather no                     4 (3.4)         8 (10.3)
  Definitely no                 0 (0.0)         0 (0.0)
4) Does belonging to a                                       0.002 *
social group have an impact
of your feeling of safety?
  Definitely yes               52 (44.1)       40 (51.3)
  Rather yes                   22 (18.6)       16 (20.5)
  Hard to say                   4 (3.4)        14 (17.9)
  Rather no                    20 (16.9)        6 (7.7)
  Definitely no                20 (16.9)        2 (2.6)
5) Is the opinion of other                                   <0.001 *
people about you important
for you?
  Definitely yes               38 (32.2)       36 (46.2)
  Rather yes                   30 (25.4)       20 (25.6)
  Hard to say                   8 (6.8)         8 (10.3)
  Rather no                    12 (10.2)       12 (15.4)
  Definitely no                30 (25.4)        2 (2.6)

([double dagger]) Fisher-Freemen-Halton test. * Chi-square test

Table 4--Logistic regression of the predictors of the decision to
undergo breast reconstruction postmastectomy.

Variables                    Odds ratio         95% CI        P-value

Anxiety score                   0.897        0.786-1.024       0.108
Depression score                0.794        0.695-0.907       0.001
Age (years)                     0.870        0.813-0.930       0.001
  Saudi                         Ref.
  Non-Saudi                     2.082        0.722-6.005       0.175
  Unemployed                    Ref.
  Works outside Jeddah          0.006       0.000032-1.138     0.056
  Works in Jeddah               0.101      0.000435-23.453     0.410
Monthly income (SR)
  <5000                         Ref.
  5000-10000                    0.514        0.057-4.607       0.552
  10000-20000                   0.355        0.033-3.816       0.392
  >20000                        1.030        0.104-10.243      0.980
Educational level
  PHD                           Ref.
  Master                        0.643        0.076-5.491       0.687
  Bachelor degree               0.880        0.104-7.450       0.907
  High school                   1.567        0.044-55.619      0.805
  Below high school             0.520        0.058-4.676       0.560
Marital status
  Married                       Ref.
  Single                        0.731        0.068-7.903       0.797
  Divorced                      0.918        0.166-5.084       0.922
  Widowed                       0.349        0.041-2.929       0.332
  No                            Ref.
  Yes                           7.045       0.085-582.244      0.386
Chronic illness
  No                            Ref.
  Yes                           0.983        0.342-2.826       0.975
Tumor size
  Ductal carcinoma in situ      Ref.
  Breast cancer Tla-c           1.776        0.298-10.595      0.528
  Breast cancer T2              0.632        0.121-3.304       0.587
  Breast cancer T3              2.461        0.421-14.399      0.318
  Breast cancer T4              1.309        0.156-10.955      0.804
Lymph node involved
  N0                            Ref.
  N1                            0.217        0.021-2.255       0.201
  N2                            0.041        0.003-0.540       0.015
  N3                            0.090        0.007-1.156       0.064
Distal metastasis
  No                            Ref.
  Yes                           0.756        0.165-3.464       0.719
Adjuvant treatment
  None                          Ref.
  Chemotherapy                  2.475        0.221-27.750      0.462
  Chemo+endocrine therapy       0.657        0.086-5.008       0.685
  Chemo+radiotherapy            2.711        0.149-49.222      0.500
  Chemo+radio+endocrine         1.424        0.129-15.732      0.773
Family history of BR
  Yes                           Ref.                           0.063
  No                            0.194        0.034-1.095

Ref.: reference, SR: Saudi Riyals, BR: breast reconstruction
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Title Annotation:Original Article
Author:Marouf, Azmi; Mortada, Hatan; Fakiha, Mahmoud G.
Publication:Saudi Medical Journal
Geographic Code:7SAUD
Date:Mar 1, 2020
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