SGS Papers ajog.

org

Effect of chair types on work-related musculoskeletal

discomfort during vaginal surgery
Ruchira Singh, MBBS; Daniel A. Carranza Leon, MD; Melissa M. Morrow, PhD; Tamara L. Vos-Draper, OT, ATP;
Michaela E. Mc Gree, BS; Amy L. Weaver, MS; Sandra M. Woolley, PhD; Susan Hallbeck, PhD; John B. Gebhart, MD

BACKGROUND: Evidence supports that surgeons are at high risk for
work-related musculoskeletal disorders.
OBJECTIVE: The objective of the study was to compare the effect of
different chairs on work-related musculoskeletal discomfort for surgeons
during vaginal operations.
STUDY DESIGN: This crossover study randomly assigned 4 surgeons
to 4 chair types using a 4
4 Latin square model: a conventional round
stool, a round stool with a backrest, a saddle chair with a backrest, and a
Capisco chair. Subjective assessments of surgeon discomfort were per-
formed with a validated body discomfort survey, and workload was
assessed with the surgical task load index. The objective postural load was
quantified with inertial measurement units of the modified rapid upper
limb assessment limits. Subjective and objective assessments of chair
comfort were performed with an 11 point scale and seat interface
pressureemapped distributions, respectively. The primary outcome was
the difference in body discomfort scores between pre- and postsurgery
measurements. Secondary outcomes were the differences in chair comfort
scores, postural load, and seating interface pressureemapped distribu-
tion. For each outcome, comparisons among the chair types were based
on fitting a linear mixed model that handled the surgeon as a random effect
and the chair type as a fixed effect.
RESULTS: Data were collected for 48 vaginal procedures performed for
pelvic organ prolapse. Mean (SD) duration of surgery was 122.3 (25.1)
minutes. Surgeons reported body discomfort during 31 procedures
(67.4%). Subjective increase in discomfort from the preoperative state was
noted most commonly in the lower back (n ¼ 14, 30.4%), followed by right
shoulder (n ¼ 12, 26.1%), upper back (n ¼ 8, 17.4%), hips and buttocks
(n ¼ 7, 15.2%), left shoulder (n ¼ 6, 13.0%), right or left thigh (n ¼ 6,
13.0%), and neck (n ¼ 6, 13.0%). Pre- and postsurgery body discomfort
scores did not differ with respect to chair type. Chair discomfort scores for
the round stool and the saddle chair were significantly higher than the
round stool with backrest and the Capisco chair (P < .001). Although the
average modified rapid upper limb assessment postural scores showed
moderate to high musculoskeletal risk of neck and shoulder discomfort
across the 4 surgeons; chair type did not affect postural scores. The saddle
chair had significantly reduced dispersion of seated pressure vs the round
stool with backrest (P  .001), depicted by the number of cells with
pressure values >5 mm Hg. An increased dispersion of pressure across
the chair surface was associated with increased comfort (Spearman
correlation, 0.40, P ¼ .006).
CONCLUSION: Musculoskeletal strain and associated discomfort for
surgeons are very high during vaginal operations. Chair type can affect
comfort, and chairs with more uniform distribution and fewer pressure
points are more comfortable. However, the chair type used in surgery did
not influence the musculoskeletal postural load findings.
Key words: chairs, ergonomics, musculoskeletal discomfort,
vaginal surgery

S urgeons work in a high-

performance environment that de-
mands both physical and mental
endurance.1 The increasing emphasis on
patient safety, along with the tremen-
dous cost of preventable adverse events
in health care, has made the job of the
surgeon further challenging.2 To adapt
to the new challenges, surgeons have
subjected themselves to work in poor
ergonomic conditions for long periods
in the operating room. The resulting
fatigue and discomfort may impair their
concentration and jeopardize their
Cite this article as: Singh R, Carranza Leon DA, Morrow
MM, et al. Effect of chair types on work-related muscu-
loskeletal discomfort during vaginal surgery. Am J Obstet
Gynecol 2016;215:648.e1-9.
0002-9378/$36.00
ª 2016 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajog.2016.06.016
performance and thereby affect patient
safety.3-5 A nonergonomic work envi-
ronment also may result in occupational
injuries to surgeons that may affect their
career longevity.
Evidence supports that surgeons are at
high risk for work-related musculoskel-
etal disorders. About 88% of surgeons
and gynecologists who perform mini-
mally invasive procedures have reported
discomfort or pain after performing an
operation.6,7
In a survey-based study, Matern and
Koneczny8 reported that 97% of sur-
geons expressed the need for ergonomic
improvements in the operating room.
With the prediction of a worsening
shortage of surgeons in the United
States, as well as an aging surgeon
workforce, surgeons may be required to
perform operations until older ages.9
These predictions further emphasize
the need for strategies to improve the
working environment for surgeons and
help minimize occupational injuries.
Despite the extensive prevalence of
musculoskeletal disorders among sur-
geons, the overall awareness of ergo-
nomic techniques in operating rooms
is low.6 The literature of evaluated
ergonomic issues in obstetrics and
gynecology is further limited.7,10-16 In
gynecological surgery, the vaginal route
is a traditional approach and involves
working in a constrained space and
in unfavorable postures for long
durations. A survey of gynecological
surgeons showed that 86.7% of surgeons
performing vaginal surgery experi-
enced work-related musculoskeletal
discomfort.14
In addition, performance of vaginal
operations was the leading cause of
backache among gynecologists.15 Zhu
et al10 objectively measured and quanti-
fied postural load of surgeons during

648.e1 American Journal of Obstetrics & Gynecology NOVEMBER 2016

ajog.org
FIGURE 1
The 4 different chair types used in the study
A, Round stool. B, Round stool with backrest. C, Saddle chair with backrest. D, Capisco chair.
Singh et al. Chair types during vaginal surgery. Am J Obstet Gynecol 2016.
vaginal procedures and reported it
to be great, especially during vaginal
hysterectomy.
We assessed the magnitude of
musculoskeletal disorders among gyne-
cologists who perform vaginal surgery
and compared the effect of different
chair types on work-related musculo-
skeletal discomfort and load during a
procedure.
Materials and Methods
This crossover study randomly assigned
4 gynecologists to use 4 chair types while
performing vaginal procedures for pelvic
organ prolapse. The chairs studied were
the round stool, the round stool with a
backrest, the saddle chair with a back-
rest,17 and the Capisco chair (Figure 1).
The 4 types were randomly assigned
to the surgeons using 3 separate 4
4
Latin squares. This strategy allowed us
to block on surgeon and chair order and
to have 3 replications per surgeon-chair
combination.
Measurements
Demographic data collected for the
participants included age, body mass
index, years of surgical experience,
handedness, previous injury or illness,
average number of surgical operations
performed per month, and percentage of
time spent performing vaginal or
abdominal procedures. The physical
activity of an individual surgeon was
assessed using the validated World
Health Organization Global Physical
Activity Questionnaire.18
Each surgeon completed a presurgery
questionnaire before procedure initia-
tion. This step included a validated tool,
the Cornell Musculoskeletal Discomfort
Questionnaire,19 to assess the baseline
discomfort status of the surgeon. Before
surgery, pressure mats with pressure
sensors were placed on the seat pan of
each chair. We recorded body postures
and movements in the operating room
using inertial measurement units (12M,
SXT version; APDM, Inc, Portland,
OR)20
Four inertial measurement units were
attached to each surgeon’s body at the
forehead, at the upper chest, and on
bilateral arms above the elbows. Imme-
diately after the procedures, the surgeons
were asked to complete the first post-
surgery questionnaire. The surgeons
completed the second postsurgery
questionnaire the day after the recorded
surgery.
The first postsurgery questionnaire
asked details of the surgery, including
procedure type, duration, an 11 point
visual analog scale assessment of comfort
NOVEMBER 2016 American Journal of Obstetrics & Gynecology
SGS Papers
of the chair and chair seat pan, the Sur-
gical Task Load Index21 (to measure the
surgical workload), and the modified
musculoskeletal discomfort question-
naire (Cornell Musculoskeletal Discom-
fort Questionnaire).19
The Surgical Task Load Index index21
is a validated tool that measures surgery-
specific workload. The second post-
surgery questionnaire included the
Cornell Musculoskeletal Discomfort
Questionnaire.19
When the surgeon performed >1
vaginal hysterectomy in a day, only the
first case was included in the study.
Similarly, when the surgeon performed a
vaginal procedure for prolapse on 2
consecutive days, the procedure per-
formed on the second day was not
included. This inclusion strategy allowed
for a washout period between the in-
terventions and increased the study’s
internal validity. When the surgeon
performed a vaginal procedure on 2
consecutive days, the surgeon was asked
to complete the postsurgery question-
naire early the second day before the
upcoming procedure.
The primary outcome was the differ-
ence between the pre- and postsurgery
Cornell Musculoskeletal Discomfort
Questionnaire ratings that provided
a subjective assessment of surgeon
648.e2
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analog scale; and seat interface distribu-

FIGURE 2
tions as assessed by pressure map-
The inertial measurement units (IMUs) used to measure postural load
ping26,27 (Figure 3).

Postural load using inertial

A, Surgeon wearing the IMUs. B, An IMU.
Singh et al. Chair types during vaginal surgery. Am J Obstet Gynecol 2016.
discomfort. Secondary outcomes were
postural load22,23 as measured by inertial
measurement units24 with modified
rapid upper limb assessment limits25
(Figure 2); difference in chair comfort
scores as assessed by the 11 point visual
measurement units
Musculoskeletal postural load was
objectively assessed and stratified into
risk categories by calculating modified
rapid upper limb assessment scores25 for
each body part, with the data collected
by the inertial measurement units
(Table 1). The body angles measured
with inertial measurement units were
neck flexion and extension, trunk flexion
and extension, and bilateral shoulder
elevation.
For each procedure, we calculated
the percentage of time spent in a spec-
ified range of risk categories for each
body part (Table 1). These percentages
of time were multiplied by the modified
rapid upper limb assessment risk score
for the specific category, and the
products were summed to reach an

FIGURE 3
Display of the pressure map interface

Singh et al. Chair types during vaginal surgery. Am J Obstet Gynecol 2016.

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combination was selected on the basis

TABLE 1
of the desired replications but without
Definition of risk category for each body part per modified rapid upper limb
overburdening the participants.
assessment
Risk Neck flexion and Trunk flexion and Statistical methods
category extension extension Shoulder elevation Statistical analysis was performed using a
software package (SAS statistical soft-
ware, version 9.3; SAS Institute Inc,
Cary, NC). For each outcome measure,
comparisons between chair types were
based on fitting a linear mixed model
that handled the individual surgeon as a
random effect and the individual chair
type as a fixed effect. A square root
1 (none) Flexion between 0 Flexion at 0 Elevation between 0 transformation was applied to the per-
and 10 and 20 centage of time spent in risk category 3
2 (mild) Flexion between 10 Flexion between 0 Elevation between 20 or 4 from the inertial measurement unit
and 20 and 20 and 45 measurements, before fitting the models.
3 (moderate) Flexion >20 Flexion between 20 Elevation between 45 P values were 2 sided, and values of
and 60 and 90 P < .05 were considered statistically
4 (high) Extension >0 Flexion >60 Elevation >90
significant. When the overall test for
differences among chair types was
Reproduced, with permission, from the Mayo Foundation for Medical Education and Research.
Singh et al. Chair types during vaginal surgery. Am J Obstet Gynecol 2016.
statistically significant, pairwise com-
parisons between chair types were eval-
uated without adjusting for multiple
comparisons.
overall risk score for each body part mapping session was 256 cells; the range
measured. of pressure at each cell was 5e200 mm Results
Hg. Data were extracted from 10 random The mean (SD) age of surgeon partici-
Seating interface pressures using frames of the final 10 minutes of the pants was 43.8 (4.8) years. The 4 sur-
pressure mapping pressure mapping. The following values geons were right-handed and, per the
The pressure map reading for each sur- were calculated for each pressure map: baseline questionnaire, usually operated
gical procedure was visually inspected by 2 or 3 days per week and for 5e8 hours
television for continuity or abnormal  Average pressure, defined as the on a typical surgery day. Two surgeons
readings. The resolution of each average pressure of all cells with >5 preferred the round stool when per-
mm Hg pressure. forming vaginal operations; the other 2
 Frequency of pressure, defined as the surgeons preferred the round stool with
FIGURE 4 total number of cells with pressure a backrest. Of the surgeons, 3 (75.0%)
Distribution of body discomfort values 200 mm Hg. devoted more than one-half of their total
before and immediately after  Surface area, defined as the total surgical time toward performing vaginal
the surgery
number of cells among 256 cells that procedures.
have values >5 mm Hg. This mea- The 4 surgeons responded with a
surement captures the dispersion of somewhat agree when asked whether
seated pressure across the chair seat they were exhausted when they got home
pan surface. from work, and they reported experi-
 Percentage frequency, defined as the encing work-related musculoskeletal
percentage of cells with values of discomfort previously. The body parts
200 mm Hg in 1 frame. most commonly involved were neck
(100%), lower back (100%), shoulders
The sample size for this project was (75.0%), upper back (75.0%), and fin-
chosen on the basis of feasibility. Given gers or thumb (75.0%).
Body part discomfort reported on the Cornell that 4 surgeons participated and the Factors contributing to the muscu-
Musculoskeletal Discomfort Questionnaire option of 4 or 5 chairs, we decided on 4 loskeletal discomfort were open
before and immediately after surgery. chairs to design the randomization abdominal operations, vaginal pro-
Singh et al. Chair types during vaginal surgery. Am J Obstet
Gynecol 2016.
using a 4
4 Latin square. The choice cedures, surgery duration >2 hours, and
of replications per surgeon-chair operating days >6 hours. Although the

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FIGURE 5
Change in discomfort scores for selected body parts by chair type

Change in Cornell Musculoskeletal Discomfort Questionnaire ratings for discomfort in selected body parts before and immediately after surgery by chair
type used is shown. For the change in discomfort rating before vs after surgery, 2 or 1 indicates less discomfort after surgery; þ2 or þ1 indicates
more discomfort after surgery.
Singh et al. Chair types during vaginal surgery. Am J Obstet Gynecol 2016.

surgeons denied having any medical
condition that may contribute to the
discomfort, they admitted seeking
medical help for the musculoskeletal
discomfort. As per the World Health
Organization Global Physical Activity
Questionnaire recommendations, the 4
surgeons reported engaging in physical
activity of moderate and vigorous in-
tensity for >600 metabolic equivalent
minutes per week.
Data were collected on 48 operations
performed by 4 surgeons. The mean
(SD) case duration was 122.3 (25.1)
minutes. The surgeries included vaginal
hysterectomy and modified McCall’s
culdoplasty (100%), along with anterior
colporrhaphy (93.8%), posterior col-
porrhaphy (83.3%), midurethral sling
(35.4%), and suprapubic catheter
placement (68.8%). For all dimensions,
the mean (SD) surgical task load index
score was 39.6 (13.7) on a scale of
0e100.
Surgeons reported experiencing body
discomfort (assessed by a modified
Cornell Musculoskeletal Discomfort
Questionnaire) while performing 31 of
the 46 surgeries. (67.4%) Body discom-
fort was present both before and
immediately after surgery (Figure 4). A
change in body discomfort score was
assessed by calculating the difference
between the reported body discomfort
ratings from the preoperative state and
from immediately after the procedure.
Overall, an increase in body discom-
fort immediately after the operation was
noted most commonly in the lower back

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TABLE 2
Comparison of the percentage of time during the vaginal procedure spent in risk category 3 or 4
Chair typea
Body part All types Round stool Round stool with backrest Saddle chair with backrest Capisco chair P value
Neck 58.4 (47.4, 77.8) 64.0 (55.0, 79.3) 51.7 (42.7, 62.4) 60.5 (55.1, 72.4) 50.6 (40.8, 83.0) .27
Trunk 2.0 (0.4, 12.7) 5.4 (0.3, 18.2) 0.8 (0.4, 12.6) 4.4 (0.4, 22.2) 2.0 (1.5, 11.8) .87
Right upper arm 27.9 (16.3, 52.9) 33.2 (15.7, 69.6) 19.4 (12.8, 34.5) 28.8 (27.6, 50.8) 29.0 (19.3, 59.8) .58
Left upper arm 22.2 (9.4, 38.1) 12.6 (2.6, 33.7) 13.8 (9.6, 36.0) 31.2 (13.9, 40.1) 34.8 (14.7, 57.2) .41
a
Values are presented as median and interquartile range.
Singh et al. Chair types during vaginal surgery. Am J Obstet Gynecol 2016.

(n ¼ 14, 30.4%), followed by right
shoulder (n ¼ 12, 26.1%), upper back
(n ¼ 8, 17.4%), hips and buttocks
(n ¼ 7, 15.2%), left shoulder (n ¼ 6,
13.0%), right or left thigh (n ¼ 6,
13.0%), and neck (n ¼ 6, 13.0%).
A tendency existed for surgeons to
have increased upper back discomfort
after using the round stool compared
with the Capisco chair and increased
lower back discomfort after using either
of the round stools compared with the
Capisco chair (Figure 5). However, these
comparisons, as well as all other chair
comparisons, did not reach statistical
significance.
When body discomfort scores were
assessed on the day after the surgical
procedure, surgeons noted increased
discomfort most commonly in the right
shoulder (n ¼ 11, 24.0%), followed by
neck (n ¼ 9, 19.6%), upper back (n ¼ 9,
19.6%), lower back (n ¼ 8, 17.4%), and
left shoulder (n ¼ 6, 13.0%). The neck
FIGURE 6
Distribution of chair comfort and chair seat pan comfort
and left shoulder discomfort was noted
to increase on the day after surgery as
compared with immediately after the
procedure (n ¼ 6, 13%). On the con-
trary, the discomfort in right shoulder
(n ¼ 6, 13%), upper back (n ¼ 8, 17%),
and lower back (n ¼ 13, 27.6%)
improved on the day after surgery.
Throughout a procedure, the sur-
geon’s neck spent a median of 11.1% of
the time flexed >20 (risk category 3)
and a median of 46.3% extended
>0 (risk category 4) (data not shown).
However, when compared across the
chair types, the median percentage of
time when the neck was in a position of
risk category 3 or 4 was not significantly
different (P ¼ .27) (Table 2). Similarly,
significant differences were not observed
among the chair types for percentage of
time spent with the trunk flexed >20 or
either shoulder elevated >45 .
The chair and chair seat pan discom-
fort scores (Figure 6) showed that both
the round stool and the saddle chair were
significantly more uncomfortable than
the round stool with a backrest and the
Capisco chair (each P < .05); all other
comparisons among chairs were not
statistically significant.
The mean (SD) seating pressure was
94.7 (27.0) mm Hg and did not differ
across the chairs or the surgeons
(Figure 7A). Similarly, no difference was
found in the frequency and the per-
centage frequency of the cells with
seating pressure >200 mm Hg across the
chairs (Figures 7, B and D). However, the
saddle chair was noted to have signifi-
cantly reduced dispersion of the seat
pressures (ie, surface area) compared
with the round stool with backrest
(P ¼.001), the round stool (P ¼.01), and
the Capisco chair (P ¼ .01) (Figure 7C).
An increased dispersion of seat pres-
sure across the chair surface (ie, surface
area) was significantly associated with
increased chair comfort (Spearman
correlation, 0.40, P ¼ .006). Such a cor-
relation was not observed between chair
comfort and the rest of the pressure
mapping variables (data not shown).

Comment
Our study showed that the surgeon
participants experienced discomfort
during 67.4% of vaginal procedures.
The reported discomfort was mostly
observed in the back, shoulders, and
neck, and these have been shown to be
the commonly affected body parts
among surgeons.7,11,14,15
The postural risk categories, calcu-
Distribution of chair comfort (A) and chair seat pan comfort (B) with 11 point visual analog scale.
Assessments are shown for comfort (0, very uncomfortable, to 10, very comfortable) by chair type. lated with the modified rapid upper limb
Singh et al. Chair types during vaginal surgery. Am J Obstet Gynecol 2016.
assessment, stayed in moderate or severe
risk (category 3 or 4) for the upper body

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FIGURE 7
Distribution of pressure map variables by chair type

A, The average pressure of all cells with >5 mm Hg pressure. B, Frequency, or the total number of cells with pressure values 200 mm Hg.
C, Surface area, or the total number of 256 cells that had values >5 mm Hg. D, Percentage frequency, or the frequency divided by area, of cells with
values of 200 mm Hg in 1 frame.
Singh et al. Chair types during vaginal surgery. Am J Obstet Gynecol 2016.

for a majority of time, which is a matter
of concern. Zhu et al10 assessed and
quantified the postural load during
vaginal procedures and all the surgeons
stood during the entire procedure.
Similar to our findings, the authors
noted that the neck was most affected
during vaginal surgery. However, the
percentage duration of time when the
neck was in nonergonomic posture
(deviation >30 ) was less when the
surgeons were standing (31e44% as
reported by Zhu et al) as compared
with the seated position (51e64%, as
reported in our study). In addition, Zhu
et al used Ergo PART for assessing
postural load, which visually assessed
posture by applying tape on the back of
the surgeon. This tool is less accurate for
measuring postural load than the inertial
measurement unit sensors used in our
study.
In view of serious physical strain
on surgeons noted during vaginal oper-
ations, it is imperative that strategies
be developed that are aimed toward
decreasing the risk of occupational
injuries among the surgeons. The sur-
geon participants reported that the round
stool with a backrest and the Capisco
chair were more comfortable than the
saddle chair and the round stool.
In addition, we noted that the saddle
chair had significantly reduced surface
(ie, dispersion) of seating pressure. In-
vestigators have demonstrated that chair
types with greater surface or dispersion
of seating interface pressure tend to be
preferred by surgeon study partici-
pants.27,28 However, we did not observe
a difference in the body part discomfort
scores or postural load with respect to
the chairs.
The unfavorable postural loads
observed across the 4 chairs underscore

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the need to adopt other interventions in
addition to using a comfortable chair to
further decrease postural load. Imple-
mentation of intraoperative breaks has
been shown to decrease physical and
mental fatigue among surgeons per-
forming abdominal and laparoscopic
procedures.29-31 The effect of intra-
operative breaks to decrease strain dur-
ing vaginal surgery is promising, but it
has not been explored.
The present study has several
strengths. It is a randomized prospective
study and uses such validated in-
struments as the Cornell Musculoskel-
etal Discomfort Questionnaire and the
surgical task load index. The comparison
of chairs during vaginal surgery is a novel
idea. Data were collected in real time
during the entire procedure instead
of in a simulation laboratory. Postural
load and chair comfort were evaluated
objectively using the inertial measure-
ment units and pressure map. Compared
with the other methods of measuring
the postural load, such as the original
observational rapid upper limb assess-
ment methodology,25 the use of inertial
measurement units is a relatively novel
technique and provides objective and
accurate data.32,33 Use of pressure map
parameters, such as peak pressure, mean
pressure, and pressure distribution, has
been shown to be a reliable means for
evaluating chair comfort.34,35 However,
a difference in chair design may affect the
seating interface pressures, which may be
a drawback of this technique.
Another limitation of this study is the
limited number of surgeon participants.
The study is subjected to bias because the
surgeons could not be blinded to the
chairs and the preferred chair for 2 sur-
geons prior to the study was a round
stool with a backrest.
Conclusion
Surgeons are prone to substantial
musculoskeletal strain while performing
vaginal procedures. The round stool
with a backrest and the Capisco chair
were reported to be more comfortable
than the saddle chair and the round
stool. Nonetheless, the chair type did not
influence musculoskeletal discomfort
and postural load. Hence, new strategies
need to be formulated to minimize
the musculoskeletal discomfort among
vaginal surgeons. n J Minim Invasive Gynecol 2013;20:648-55.
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Author and article information
From the Division of Gynecologic Surgery (Drs Singh,
Carranza Leon, and Gebhart), Division of Health Care
Policy and Research (Drs Morrow and Hallbeck),
Department of Physical Medicine and Rehabilitation (Ms
Vos-Draper), Division of Biomedical Statistics and
Informatics (Ms Mc Gree and Ms Weaver), and
Department of Safety (Dr Woolley), Mayo Clinic,
Rochester, MN.
Received Jan. 28, 2016; revised May 27, 2016;
accepted June 7, 2016.
ajog.org
The views expressed herein are those of the authors
and do not necessarily represent the official views of the
National Institutes of Health.
This study was supported by Clinical and Translational
Science Awards grant UL1 TR000135 from the National
Center for Advancing Translational Science. S.H. received a
research grant from Stryker Endoscopy, and J.B.G. serves
on the advisory board of Astora Women’s Health LLC and
receives royalties from UpToDate, Inc and Elsevier BV.
The authors report no conflict of interest.
Accepted for full oral presentation at the 42nd annual
scientific meeting of the Society of Gynecologic Surgeons,
April 10e13, 2016, Palm Springs, CA.
Corresponding author: Ruchira Singh, MBBS. singh.
ruchira@mayo.edu