Imperial College London

Dr George Garas PhD DIC FRCS FEBORL-HNS

Faculty of MedicineDepartment of Surgery & Cancer

Honorary Clinical Research Fellow
 
 
 
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Contact

 

g.garas

 
 
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Location

 

Queen Elizabeth the Queen Mother Wing (QEQM)St Mary's Campus

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Summary

 

Publications

Publication Type
Year
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77 results found

COVIDSurg Collaborative, GlobalSurg Collaborative, Shalhoub J, 2021, Effects of pre-operative isolation on postoperative pulmonary complications after elective surgery: an international prospective cohort study, Anaesthesia, ISSN: 0003-2409

Journal article

COVIDSurg Collaborative, GlobalSurg Collaborative, 2021, Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study, Anaesthesia, Vol: 76, Pages: 748-758, ISSN: 0003-2409

Peri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery within 0–2 weeks, 3–4 weeks and 5–6 weeks of the diagnosis (odds ratio (95%CI) 4.1% (3.3–4.8), 3.9% (2.6–5.1) and 3.6% (2.0–5.2), respectively). Surgery performed ≥ 7 weeks after SARS‐CoV‐2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5% (0.9–2.1%)). After a ≥ 7 week delay in undertaking surgery following SARS‐CoV‐2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2–8.7) vs. 2.4% (95%CI 1.4–3.4) vs. 1.3% (95%CI 0.6–2.0%), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS‐CoV‐2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

Journal article

COVIDSurg Collaborative, GlobalSurg Collaborative, 2021, SARS-CoV-2 vaccination modelling for safe surgery to save lives: data from an international prospective cohort study., British Journal of Surgery, ISSN: 0007-1323

Journal article

Garas G, Darzi A, Athanasiou T, Lancaster Jet al., 2021, Stapler closure versus manual closure in total laryngectomy for laryngeal cancer: A systematic review and meta-analysis, CLINICAL OTOLARYNGOLOGY, Vol: 46, Pages: 918-918, ISSN: 1749-4478

Journal article

Patel VM, Haunschild R, Bornmann L, Garas Get al., 2021, A call for governments to pause Twitter censorship: using Twitter data as social-spatial sensors of COVID-19/SARS-CoV-2 research diffusion, SCIENTOMETRICS, Vol: 126, Pages: 3193-3207, ISSN: 0138-9130

Journal article

Bonduelle Q, Garas G, Ramakrishnan Y, 2021, A rare cause of diplopia: Solitary extramedullary plasmacytoma of the skull base, ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, Vol: 103, Pages: E38-E41, ISSN: 0035-8843

Journal article

Ellis M, Garas G, Hardman J, Khan M, Mehanna H, Smith ME, Tikka T, Ubayasiri K, Williams Ret al., 2020, Post-Treatment Head and Neck Cancer Care: National Audit and Analysis of Current Practice in the United Kingdom, CLINICAL OTOLARYNGOLOGY, Vol: 46, Pages: 284-294, ISSN: 1749-4478

Journal article

Garas G, Mallick AS, O'Donoghue G, 2020, Comment on "Tracheotomy in Ventilated Patients with COVID-19"., Ann Surg

Journal article

Kumar N, Garas G, Swift AC, O'Donoghue GMet al., 2020, Recognizing and Mitigating the Threat Posed by COVID-19 to Otolaryngologists: A UK Perspective, LARYNGOSCOPE, Vol: 130, Pages: E524-E524, ISSN: 0023-852X

Journal article

Stubington TJ, Mallick AS, Garas G, Stubington E, Reddy C, Mansuri MSet al., 2020, Tracheotomy in COVID-19 patients: Optimizing patient selection and identifying prognostic indicators, HEAD AND NECK-JOURNAL FOR THE SCIENCES AND SPECIALTIES OF THE HEAD AND NECK, Vol: 42, Pages: 1386-1391, ISSN: 1043-3074

Journal article

Garas G, Cingolani I, Patel V, Panzarasa P, Alderson D, Darzi A, Athanasiou Tet al., 2020, Surgical innovation in the era of global surgery: a network analysis, Annals of Surgery, Vol: 271, Pages: 868-874, ISSN: 0003-4932

OBJECTIVE: To present a novel network-based framework for the study of collaboration in surgery and demonstrate how this can be used in practice to help build and nurture collaborations that foster innovation. BACKGROUND: Surgical innovation is a social process that originates from complex interactions among diverse participants. This has led to the emergence of numerous surgical collaboration networks. What is still needed is a rigorous investigation of these networks and of the relative benefits of various collaboration structures for research and innovation. METHODS: Network analysis of the real-world innovation network in robotic surgery. Hierarchical mixed-effect models were estimated to assess associations between network measures, research impact and innovation, controlling for the geographical diversity of collaborators, institutional categories, and whether collaborators belonged to industry or academia. RESULTS: The network comprised of 1700 organizations and 6000 links. The ability to reach many others along few steps in the network (closeness centrality), forging a geographically diverse international profile (network entropy), and collaboration with industry were all shown to be positively associated with research impact and innovation. Closed structures (clustering coefficient), in which collaborators also collaborate with each other, were found to have a negative association with innovation (P < 0.05 for all associations). CONCLUSIONS: In the era of global surgery and increasing complexity of surgical innovation, this study highlights the importance of establishing open networks spanning geographical boundaries. Network analysis offers a valuable framework for assisting surgeons in their efforts to forge and sustain collaborations with the highest potential of maximizing innovation and patient care.

Journal article

Rocke J, Mclaren O, Hardman J, Garas G, Smith ME, Ishii H, Constable J, Tikka T, Wie Liu Z, Williams R, Rocke J, Mclaren O, Hardman J, Garas G, Smith ME, Ishii H, Constable J, Tikka T, Liu ZW, Williams Ret al., 2020, The role of allied healthcare professionals in head and neck cancer surveillance: A systematic review, CLINICAL OTOLARYNGOLOGY, Vol: 45, Pages: 83-98, ISSN: 1749-4478

Journal article

Garas G, Darzi A, Athanasiou T, 2019, Comment on: Relationship between surgeons and industry, British Journal of Surgery, Vol: 106, Pages: 1560-1560, ISSN: 0007-1323

Journal article

Garas G, Cingolani I, Patel V, Panzarasa P, Darzi A, Athanasiou Tet al., 2019, Evaluating the implications of Brexit for research collaboration and policy: A network analysis and simulation study, BMJ Open, Vol: 9, Pages: 1-11, ISSN: 2044-6055

Objective To evaluate the role of the European Union (EU) as a research collaborator in the United Kingdom (UK)’s success as a global leader in healthcare research and innovation and quantify the impact that Brexit may have. Design Network and regression analysis of scientific collaboration, followed by simulation models based on alternative scenarios. Setting International real world collaboration network among all countries involved in robotic surgical research and innovation.Participants 772 organisations from industry and academia nested within 56 countries and connected through 2,397 collaboration links.Main outcome measures Research impact measured through citations, innovation value measured through the innovation index, and an array of attributes of social networks to measure brokerage and geographical entropy at national and international levels.Results Globally, the UK ranks third in robotic surgical innovation, and the EU constitutes its prime collaborator. Brokerage opportunities and collaborators’ geographical diversity are associated with a country’s research impact (c=211.320 and 244.527, respectively;p-value<0·01) and innovation (c=18.819 and 30.850, respectively;p-value<0·01). Replacing EU collaborators with United States (US)’ ones is the only strategy that could benefit the UK, but on the condition that US collaborators are chosen among the top-performing ones, which is likely to be very difficult and costly, at least in the short term. Conclusions This study suggests what has long been argued, namely that the UK-EU research partnership has been mutually beneficial and that its continuation represents the best possible outcome for both negotiating parties. However, the uncertainties raised by Brexit necessitate looking beyond the EU for potential research partners. In the short-term, the UK’s best strategy might be to try and maintain its academic links with the EU. In the longer-term, strategic r

Journal article

Mallick AS, Garas G, McGlashan J, 2019, Presbylaryngis: a state-of-the-art review, CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY, Vol: 27, Pages: 168-177, ISSN: 1068-9508

Journal article

Garas G, Cingolani I, Panzarasa P, Darzi A, Athanasiou Tet al., 2019, Correction: Beyond IDEAL: the importance of surgical innovation metrics, The Lancet, Vol: 393, Pages: 746-746, ISSN: 0140-6736

Garas G, Cingolani I, Panzarasa P, Darzi A, Athanasiou T. Beyond IDEAL: the importance of surgical innovation metrics. Lancet 2019; 393: 315—In this Correspondence, the affiliations should read “Department of Surgery and Cancer, St Mary's Hospital (GG, AD, TA), and Centre for Health Policy (IC), Imperial College London, London W2 1NY, UK; and School of Business and Management, Queen Mary University of London, London, UK (PP)”. This correction has been made as of Feb 21, 2019.

Journal article

Garas G, Cingolani I, Panzarasa P, Darzi A, Athanasiou Tet al., 2019, Beyond IDEAL: the importance of surgical innovation metrics, Lancet, Vol: 393, Pages: 315-315, ISSN: 0140-6736

Journal article

Vauterin T, Garas G, Arora A, 2018, Transoral robotic surgery for obstructive sleep apnoea-hypopnoea syndrome, ORL, Vol: 80, Pages: 134-147, ISSN: 0301-1569

Obstructive sleep apnoea-hypopnoea (OSAH) syndrome constitutes a major health care problem. Surgical modalities for the treatment of OSAH are regaining momentum in view of the increasing prevalence of OSAH and the low compliance rates associated with continuous positive airway pressure. There are several investigations to complement clinical examination in accurately determining the level of airway collapse to ensure correct patient selection and a targeted surgical approach. The most commonly employed include drug-induced sleep endoscopy and imaging with the tongue base and epiglottis often revealed as the major sites of airway narrowing during sleep. In the continuing search for the optimal approach to address these areas, transoral robotic surgery (TORS) has been successfully used for tongue base reduction and epiglottoplasty. With sufficient experience, this technique is safe and well tolerated. Meticulous work-up and careful patient selection are crucial. Multiple studies have demonstrated very good short-term results of TORS for OSAH, with significant reduction in both the Apnoea-Hypopnea Index (AHI) and Epworth Sleepiness Score (ESS). With the appropriate infrastructure, proctoring, and access to robotic surgical technology, it is possible for these results to be reproduced more widely. Further prospective long-term clinical evaluation will ultimately determine the exact role of TORS in the treatment of OSAH.

Journal article

Garas G, Arora A, 2018, Robotic head and neck surgery: history, technical evolution and the future, ORL, Vol: 80, Pages: 117-124, ISSN: 0301-1569

The first application of robotic technology in surgery was described in 1985 when a robot was used to define the trajectory for a stereotactic brain biopsy. Following its successful application in a variety of surgical operations, the da Vinci® robot, the most widely used surgical robot at present, made its clinical debut in otorhinolaryngology and head and neck surgery in 2005 when the first transoral robotic surgery (TORS) resections of base of tongue neoplasms were reported. Subsequently, the indications for TORS rapidly expanded, and they now include tumours of the oropharynx, hypopharynx, parapharyngeal space, and supraglottic larynx, as well as obstructive sleep apnoea (OSA). The da Vinci® robot has also been successfully used for scarless-in-the-neck thyroidectomy and parathyroidectomy. At present, the main barrier to the wider uptake of robotic surgery is the prohibitive cost of the da Vinci® robotic system. Several novel, flexible surgical robots are currently being developed that are likely to not only enhance patient safety and expand current indications but also drive down costs, thus making this innovation more widely available. Future directions relate to overlay technology through augmented reality/AR that allows real-time image-guidance, miniaturisation (nanorobots), and the development of autonomous robots.

Journal article

Aidan P, Arora A, Lorincz B, Tolley N, Garas Get al., 2018, Robotic thyroid surgery: current perspectives and future considerations, ORL-Journal for Oto-Rhino-Laryngology Head and Neck Surgery, Vol: 80, Pages: 186-194, ISSN: 0301-1569

Robotic transaxillary thyroidectomy, pioneered in South Korea, is firmly established throughout the Far East but remains controversial in Western practice. This relates to important population differences (anthropometry and culture) compounded by the smaller mean size of thyroid nodules operated on in South Korea due to a national thyroid cancer screening programme. There is now level 2 evidence (including from Western World centres) to support the safety, feasibility, and equivalence of the robotic approach to its open counterpart in terms of recurrent laryngeal nerve injury, hypoparathyroidism, haemorrhage, and oncological outcomes for differentiated thyroid cancer. Moreover, robotic thyroidectomy has been shown to be superior to open surgery for certain patient-reported outcome measures, namely scar cosmesis and pain. Downsides include its high cost, longer operative time, and risk of complications not encountered in open thyroidectomy (brachial plexus neurapraxia). Careful patient selection is paramount as this procedure is not for every patient, surgeon, or hospital. It should only be undertaken by high-volume surgeons operating as part of a multidisciplinary robotic team in specialised centres. Novel robotic approaches utilising the retroauricular and transoral routes for thyroidectomy have recently been described but further studies are required to establish their respective role in modern thyroid surgery.

Journal article

Arora A, Garas G, Tolley N, 2018, Robotic parathyroid surgery: current perspectives and future considerations, ORL; journal for oto-rhino-laryngology and its related specialties, Vol: 80, Pages: 195-203, ISSN: 0301-1569

Robotic parathyroidectomy represents a novel surgical approach in the treatment of primary hyperparathyroidism when the parathyroid adenoma has been pre-operatively localised. It represents the "fourth generation" in the evolution of parathyroid surgery following a process of surgical evolution from cervicotomy and 4-gland exploration to a variety of minimally invasive, open and endoscopic, targeted approaches. The existing evidence (levels 2-3) supports it as a feasible and safe technique with equivalent results to targeted open parathyroidectomy for primary hyperparathyroidism in carefully selected patients. However, it takes longer to perform and is more costly than conventional parathyroidectomy. It offers superior cosmesis by completely avoiding a neck scar making it a valid option for those patients who for biological and/or cultural reasons may wish to avoid a neck scar. Robotic parathyroidectomy is not for every patient, surgeon, or hospital. Its application should be confined to high-volume centres and experienced surgeons. Intensive training and proctorship are required for its safe implementation combined with careful patient selection. This particularly relates to the patient's body habitus (BMI < 30 kg/m2) and concordance among the different imaging modalities used pre-operatively. With robotic market competition driving down costs, its role may change. For now, robotic parathyroidectomy occupies a niche role and can only be justified in a select subset of patients.

Journal article

Garas G, 2018, ASO Author Reflections: Induced Bias Due to Crossover Within Randomized Controlled Trials in Surgical Oncology., Annals of Surgical Oncology, Vol: 25, Pages: 3889-3890, ISSN: 1068-9265

Journal article

Garas G, Tolley N, 2018, Robotics in otorhinolaryngology - head and neck surgery A look at the past, present and future, ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, Vol: 100, Pages: 34-+, ISSN: 0035-8843

Journal article

Sepehripour AH, Garas G, Athanasiou T, Casula Ret al., 2018, Robotics in cardiac surgery A summary of its uses in mitral valve surgery and coronary artery revascularisation, ANNALS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND, Vol: 100, Pages: 22-+, ISSN: 0035-8843

Journal article

Garas G, Markar SR, Malietzis G, Ashrafian H, Hanna GB, Zacharakis E, Jiao LR, Argiris A, Darzi A, Athanasiou Tet al., 2017, Induced Bias Due to Crossover Within Randomized Controlled Trials in Surgical Oncology: A Meta-regression Analysis of Minimally Invasive versus Open Surgery for the Treatment of Gastrointestinal Cancer., Annals of Surgical Oncology, Vol: 25, Pages: 221-230, ISSN: 1068-9265

BACKGROUND: Randomized controlled trials (RCTs) inform clinical practice and have provided the evidence base for introducing minimally invasive surgery (MIS) in surgical oncology. Crossover (unplanned intraoperative conversion of MIS to open surgery) may affect clinical outcomes and the effect size generated from RCTs with homogenization of randomized groups. OBJECTIVES: Our aims were to identify modifiable factors associated with crossover and assess the impact of crossover on clinical endpoints. METHODS: A systematic review was performed to identify all RCTs comparing MIS with open surgery for gastrointestinal cancer (1990-2017). Meta-regression analysis was performed to analyze factors associated with crossover and the influence of crossover on endpoints, including 30-day mortality, anastomotic leak rate, and early complications. RESULTS: Forty RCTs were included, reporting on 11,625 patients from 320 centers. Crossover was shown to affect one in eight patients (mean 12.6%, range 0-45%) and increased with American Society of Anesthesiologists score (β = + 0.895; p = 0.050). Pretrial surgeon volume (β = - 2.344; p = 0.037), composite RCT quality score (β = - 7.594; p = 0.014), and site of tumor (β = - 12.031; p = 0.021, favoring lower over upper gastrointestinal tumors) showed an inverse relationship with crossover. Importantly, multivariate weighted linear regression revealed a statistically significant positive correlation between crossover and 30-day mortality (β = + 0.125; p = 0.033), anastomotic leak rate (β = + 0.550; p = 0.004), and early complications (β = + 1.255; p = 0.001), based on intention-to-treat analysis. CONCLUSIONS: Crossover in trials was associated with an increase in 30-day mortality, anastomotic leak rate, and early complications within the MIS group based on intention-

Journal article

Garas G, Cingolani I, Panzarasa P, Darzi A, Athanasiou Tet al., 2017, Network analysis of surgical innovation: Measuring value and the virality of diffusion in robotic surgery., PLoS ONE, Vol: 12, ISSN: 1932-6203

BACKGROUND: Existing surgical innovation frameworks suffer from a unifying limitation, their qualitative nature. A rigorous approach to measuring surgical innovation is needed that extends beyond detecting simply publication, citation, and patent counts and instead uncovers an implementation-based value from the structure of the entire adoption cascades produced over time by diffusion processes. Based on the principles of evidence-based medicine and existing surgical regulatory frameworks, the surgical innovation funnel is described. This illustrates the different stages through which innovation in surgery typically progresses. The aim is to propose a novel and quantitative network-based framework that will permit modeling and visualizing innovation diffusion cascades in surgery and measuring virality and value of innovations. MATERIALS AND METHODS: Network analysis of constructed citation networks of all articles concerned with robotic surgery (n = 13,240, Scopus®) was performed (1974-2014). The virality of each cascade was measured as was innovation value (measured by the innovation index) derived from the evidence-based stage occupied by the corresponding seed article in the surgical innovation funnel. The network-based surgical innovation metrics were also validated against real world big data (National Inpatient Sample-NIS®). RESULTS: Rankings of surgical innovation across specialties by cascade size and structural virality (structural depth and width) were found to correlate closely with the ranking by innovation value (Spearman's rank correlation coefficient = 0.758 (p = 0.01), 0.782 (p = 0.008), 0.624 (p = 0.05), respectively) which in turn matches the ranking based on real world big data from the NIS® (Spearman's coefficient = 0.673;p = 0.033). CONCLUSION: Network analysis offers unique new opportunities for understanding, modeling and measuring surgical innovation, and ultimately for assessing and comparing generative value between different sp

Journal article

Garas G, Markar S, Malietzis G, Darzi A, Athanasiou Tet al., 2017, Induced bias due to crossover in randomised controlled trials in surgical oncology, International Congress of the Association-of-Surgeons-of-Great-Britain-and-Ireland, Publisher: WILEY, Pages: 36-37, ISSN: 0007-1323

Conference paper

Garas G, Cingolani I, Panzarasa P, Darzi A, Athanasiou Tet al., 2017, 0527 - Networks of surgical innovation: measuring value and the virality of diffusion the example of robotic surgery, International Congress of the Association-of-Surgeons-of-Great-Britain-and-Ireland, Publisher: Wiley, Pages: 229-229, ISSN: 1365-2168

Conference paper

Garas G, Kythreotou A, Georgalas C, Arora A, Kotecha B, Holsinger FC, Grant DG, Tolley Net al., 2017, Is transoral robotic surgery a safe and effective multilevel treatment for obstructive sleep apnoea in obese patients following failure of conventional treatment(s)?, Annals of Medicine and Surgery, Vol: 19, Pages: 55-61, ISSN: 2049-0801

A best evidence topic was written according to a structured protocol. The question addressed waswhether TransOral Robotic Surgery (TORS) is a safe and effective multilevel treatment for ObstructiveSleep Apnoea (OSA) in obese patients following failure of conventional treatment(s). A total of 39 paperswere identified using the reported searches of which 5 represented the best evidence to answer theclinical question. The authors, date, journal, study type, population, main outcome measures and resultsare tabulated. Existing treatments for OSA - primarily CPAP - though highly effective are poorly toleratedresulting in an adherence often lower than 50%. As such, surgery is regaining momentum, especially inthose patients failing non-surgical treatment (CPAP or oral appliances). TORS represents the latestaddition to the armamentarium of Otorhinolaryngologists - Head and Neck Surgeons for the manage-ment of OSA. The superior visualisation and ergonomics render TORS ideal for the multilevel treatmentof OSA. However, not all patients are suitable candidates for TORS and its suitability is questionable inobese patients. In view of the global obesity pandemic, this is an important question that requiresaddressing promptly. Despite the drop in success rates with increasing BMI, the success rate of TORS innon-morbidly obese patients (BMI¼30-35kgm-2) exceeds 50%. A 50% success rate may atfirst seem low,but it is important to realize that this is a patient cohort suffering from a life-threatening disease and nooption left other than a tracheostomy. As such, TORS represents an important treatment in non-morbidlyobese OSA patients following failure of conventional treatment(s)

Journal article

Pinto C, Garas G, Harling L, Darzi A, Casula R, Athanasiou Tet al., 2017, Is endovascular treatment with multilayer flow modulator stent insertion a safe alternative to open surgery for high-risk patients with thoracoabdominal aortic aneurysm?, Annals of Medicine and Surgery, Vol: 15, Pages: 1-8, ISSN: 2049-0801

A best evidence topic in cardiothoracic and vascular surgery was written according to a structured protocol. The question addressed was whether endovascular treatment with multilayer flow modulator stents (MFMS) can be considered a safe alternative to open surgery for high-risk patients with thoracoabdominal aortic aneurysm (TAAA). Altogether 27 papers were identified using the reported search, of which 11 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study limitations are tabulated. The outcomes of interest were all-cause survival, aneurysm-related survival, branch vessel patency and major adverse events. Aneurysm-related survival exceeded 78% in almost all studies, with the exception of one where the MFMS was inserted outside the instructions for use. In that study the aneurysm-related survival was 28.9%. The branch vessel patency was higher than 95% in 10 studies and not reported in one. At 12-month follow-up, several studies showed a low incidence of major adverse events, including stroke, paraplegia and aneurysm rupture. We conclude that MFMS represent a suitable and safe treatment for high-risk patients with TAAA maintaining branch vessel patency when used within their instructions for use. However, a number of limitations must be considered when interpreting this evidence, particularly the complete lack of randomised controlled trials (RCTs), short follow-up in all studies, and heterogeneity of the pathologies among the different populations studied. Further innovative developments are needed to improve MFMS safety, expand their instructions for use, and enhance their efficacy.

Journal article

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