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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 34  |  Issue : 4  |  Page : 1392-1398

Role of gray-scale and color Doppler ultrasound in women with chronic pelvic pain


1 Radiodiagnosis Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Radiodiagnosis Department ,Ministry of Health, Shebin Elkom, Menoufia, Egypt

Date of Submission01-Aug-2020
Date of Decision10-Oct-2020
Date of Acceptance20-Oct-2020
Date of Web Publication24-Dec-2021

Correspondence Address:
Mai A Ghobashy
MBBCH, Shebin El-kom, Menoufia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_281_20

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  Abstract 


Objectives
To assess the role of the gray-scale and Doppler ultrasound in the evaluation of women with chronic pelvic pain (CPP).
Background
CPP is a major cause of morbidity among women of different ages.
Patients and methods
We included in this study 200 female patients. They were referred to the Radiodiagnosis Department at Shebin Elkom Teaching Hospital complaining of CPP. Ultrasonographic scanning of the pelvis was requested to evaluate the cause.
Results
This study included 200 female patients with clinical signs and symptoms suggestive of CPP. The age of the patients ranged from 19 to 77 years, with a mean age±SD of 34.3±12.2 years. The sensitivity and specificity of ultrasonography in the diagnosis of gynecological causes of CPP in this study were 93.28 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of urological causes of CPP in this study were 94 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of gastrointestinal causes of CPP in this study were 88.88 and 100%, respectively.
Conclusion
Ultrasonography is the modality of choice for imaging evaluation of CPP in females.

Keywords: chronic pelvic pain, diagnosis, ultrasonography


How to cite this article:
Abdullah MS, Mousa WA, Ghobashy MA. Role of gray-scale and color Doppler ultrasound in women with chronic pelvic pain. Menoufia Med J 2021;34:1392-8

How to cite this URL:
Abdullah MS, Mousa WA, Ghobashy MA. Role of gray-scale and color Doppler ultrasound in women with chronic pelvic pain. Menoufia Med J [serial online] 2021 [cited 2024 Mar 28];34:1392-8. Available from: http://www.mmj.eg.net/text.asp?2021/34/4/1392/333233




  Introduction Top


Chronic pelvic pain (CPP) in women is defined as persistent, noncyclic pain perceived to be in structures related to the pelvis and lasting more than 6 months [1].

CPP may include dysmenorrhea, dyspareunia, dysuria, and dyschezia but can occur without any of these symptoms [2].

CPP is a common disorder affecting up to one in six of the adult female population [3].

CPP is a complex ailment rather than a single disease. In most of the patients, the etiology of CPP is multifactorial and not a single cause. This explains the need for a multidisciplinary approach for managing CPP [4].

Common gynecological pathologies that can present with CPP include endometriosis, ovarian cysts, pelvic congestion syndrome, and adenomyosis. Gastrointestinal conditions like inflammatory bowel disease or irritable bowel syndrome may cause the pelvic pain symptom complex [5].

The history is of utmost importance. Patients should be asked about the characteristics of the pain as well as their medical and surgical history. Particular attention should be given to obtaining a complete gynecological history, including pregnancy, delivery complications, dyspareunia, and trauma. A detailed review of systems should focus on the gynecological, gastrointestinal, musculoskeletal, urological, and neuropsychiatric systems [6].

Pelvic ultrasonography should be the first-line imaging examination to search for causative conditions that include endometrioma, adenomyosis, pelvic varices, and chronic infection. MRI is useful for making a positive diagnosis and assessing the spread of endometriosis. Color Doppler ultrasonography and magnetic resonance angiography are the best imaging techniques for the diagnosis of pelvic congestion syndrome [7].

Transvaginal ultrasonography is helpful to identify pelvic lesions. It is particularly useful for detecting pelvic masses less than 4 cm in diameter, which frequently cannot be palpated on bimanual examination. Ultrasonography is also useful for the detection of hydrosalpinx, an indicator of pelvic inflammatory disease. Follow-up MRI may be useful to define an abnormality detected on ultrasonography. Referral for the diagnostic evaluation of endometriosis by laparoscopy is usually indicated in severe cases [1].

This study aims to assess the role of the gray-scale and Doppler ultrasound in the evaluation of female CPP.


  Patients and methods Top


After approval of the ethical committee and obtaining written consent from the patients to participate in our study, this prospective study was carried on 200 female patients. Their ages ranged from 19 to 77 years, with a mean age ± SD of 34.3 ± 12.2 years. They were referred to the Radiodiagnosis Department at Shebin Elkom Teaching Hospital complaining of CPP from August 1, 2018 to July 31, 2019. Acute cases were excluded. Ultrasonographic scanning of the pelvis was requested to evaluate the cause. All the study participants were randomly selected from people coming for seeking medical advice (randomized clinical trial).

Inclusion criteria were as follows: all female married patients, above 18 years, and complaining of CPP.

Exclusion criteria were as follows: virgin patients, less than 18 years, and complaining of acute pelvic pain.

The patients of our study were subjected to careful history taking regarding onset, course, duration, what increase and what decrease pain, location, radiation of pain, and the relation to the menstrual cycle. The clinical presentations of the 200 patients were variable. All patients had CPP, 10 patients had vomiting, 15 patients had dysuria, 14 patients had hematuria, 29 patients had vaginal bleeding, five patients had fever, and 35 patients had infertility.

All patients underwent general examination, local examination of the abdomen and pelvis, and laboratory examination including complete blood count and urine analysis.

Then all patients had gray-scale and color Doppler ultrasonographic examination of the abdomen and pelvis using a color Doppler machine (GE Voluson S6, General Electric Medical Ultrasound, London, United Kingdom) and using a convex multifrequency transabdominal probe (3.5–5 MHz) and a transvaginal probe with a frequency 6.5 MHz. A transabdominal evaluation was always performed before considering vaginal scanning.

For a pelvic sonogram, performed transabdominally, the patient's urinary bladder should be distended to allow a better survey by serving as an acoustic window. The patient drank two to three glasses of water 30 min before the examination and had a full bladder. The patient was examined in a supine position. Coupling gel was applied to the patient skin. The patient was asked first to localize the area of maximal pain to facilitate the identification of the cause.

Transvaginal sonography scanning was done to detect abnormality in uterus, ovaries, and adnexa. No preparation was necessary. The patient was asked to empty her bladder before the examination being performed. The patient was asked to sign a consent form before having the examination. The patient was asked to lie on an examination couch. A sheet was provided to cover her. She was asked to bend her legs, and the transducer was inserted into the vagina with the patient in the lithotomy position. In transvaginal scanning, we covered the transducer with a condom. We put gel inside the condom with the removal of all air bubbles, and then we used a lubricant on the outside of the condom before insertion into the vagina for ease of insertion. The transducer was gently moved around and images of the pelvis were obtained.

Statistical analysis

The data collected were tabulated and statistically analyzed using statistical package for social science, version 17.0 on IBM compatible computer (SPSS Inc., Chicago, Illinois, USA). Two types of statistics were done.

Descriptive statistics

Percentage, mean, and SD. The sample size was calculated by the Epi info program at power 80% and a confidence level of 95%.

Analytic statistics

χ2 test was used to study the association between two qualitative variables.


  Results Top


The studied 200 patients were classified into three different groups according to the system affected:

Group 1: gynecological-related diseases were detected in 149 (74.5%) patients.

Group 2: urological-related diseases were detected in 33 (16.5%) patients.

Group 3: gastrointestinal-related diseases were detected in 18 (9%) patients.

Group 1 (Gynecological-related diseases) included 149 (74.5%) of the 200 patients. A total of 139 (93.29%) patients of this group were diagnosed by ultrasound examination to have the gynecological disease. MRI, hysterosalpingography, and endometrial biopsy were performed in 69 patients to confirm the diagnosis. Surgery was performed in 48 patients. A total of 32 patients were confirmed by clinical assessment and follow-up.

This group was subdivided by the final diagnosis into two groups: the first group (patients with adnexal lesions) [Figure 1] included 121 (60.5%) patients, and the second group (patients with uterine lesions) included 28 (14%) patients.
Figure 1: (a) Gray-scale transvaginal ultrasound examination shows well-defined cystic lesion at the right ovary with low-level internal echoes inside it (long arrow) showing posterior acoustic enhancement (short arrow) and measures 9 cm×6.5 cm. (b) Color Doppler transvaginal ultrasound examination shows no internal vascularity inside the lesion.

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The sensitivity and specificity of ultrasonography in the diagnosis of gynecological causes of CPP in this study were 93.28 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of endometrioma were 96.4 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of simple ovarian cyst were 100 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of hemorrhagic ovarian cyst were 100 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of dermoid cyst were 84.61 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of malignant ovarian cyst were 100 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of pelvic congestion syndrome were 92.59 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of pelvic inflammatory disease were 87.5 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of fibroid were 95 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of adenomyosis were 66.66 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of endometrial carcinoma were 67 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of endometrial polyp were 100 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of chronic endometritis were 87.5 and 100%, respectively [Table 1].
Table 1: Sensitivity and specificity of Doppler ultrasound in diagnosis of gynecological causes of chronic pelvic pain among studied group (n=200)

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Group 2 (urological-related diseases) [Figure 2] included 33 (16.5%) patients from 200 patients. A total of 31 (94%) patients of this group were diagnosed by the clinical and ultrasound examination to have the urological disease. Radiograph and histopathology were performed in 15 patients to reach the diagnosis. Laboratory investigations were performed in 18 patients to reach the diagnosis.
Figure 2: a) Gray-scale transabdominal ultrasound examination shows well-defined oval solid mass arising from the base of the urinary bladder more at the right side measuring 3.3 cm×2.9 cm×3.3 cm (arrow). (b, c) Color Doppler ultrasound examination shows vascularity inside the lesion and shows low resistance with pulsed wave doppler.

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The sensitivity and specificity of ultrasonography in the diagnosis of urological causes of CPP in this study were 94 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of cystitis were 100 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of urolithiasis were 90 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of bladder tumor were 80 and 100%, respectively [Table 2].
Table 2: Sensitivity and specificity of Doppler ultrasound in diagnosis of urological causes of chronic pelvic pain among studied group (n=200)

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Group 3 (gastrointestinal-related diseases) included 18 (9%) patients from the 200 patients. A total of 15 patients of this group were diagnosed by clinical and ultrasound examination to have the gastrointestinal disease. Barium study and computed tomography were performed in nine patients to reach the diagnosis. Surgery was performed in nine patients to reach the diagnosis.

The sensitivity and specificity of ultrasonography in the diagnosis of gynecological causes of CPP in this study were 88.88 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of chronic appendicitis were 100 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of inflammatory bowel disease were 87.5 and 100%, respectively. The sensitivity and specificity of ultrasonography in the diagnosis of cancer colon were 66.66 and 100%, respectively [Table 3].
Table 3: Sensitivity and specificity of Doppler ultrasound in diagnosis of gastrointestinal causes of chronic pelvic pain among studied group

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  Discussion Top


This study included 200 female patients with clinical signs and symptoms suggestive of CPP. The mean age of the patients was 34.3 ± 12.2 years. This is similar to a study done by Godoi et al. [8], where the mean age of the participants complaining of CPP was 39.40 ± 9.21 years.

In the current study, ovarian cysts were the most common disease in CPP. It accounted for 78 (39%) patients from 200 patients with CPP. Among the ovarian masses detected by ultrasound, 97.5% were benign and 2.5% were malignant. This is similar to a study done by Shrestha et al. [9], where among the ovarian masses detected by ultrasound, 88% were benign and 12% were malignant.

In our study, a simple cyst on ultrasound appeared as an oval or rounded anechoic thin-walled cyst without any irregularity in the internal wall. This is similar to a study done by Alcazar et al. [10], where the presence of any wall irregularity or echogenic cyst content should not be considered as a simple cyst.

In our study, the sensitivity of ultrasonography in the diagnosis of simple ovarian cysts was 100% and the specificity was 100%. This is similar to a study done by Sayasneh et al. [11], where the sensitivity of ultrasound achieved in the diagnosis of simple cysts was 100% and specificity was 95%.

The most common sonographic pattern for hemorrhagic ovarian cysts observed in our cases was the lace-like reticular echoes, and it was considered the most important pattern of hemorrhagic ovarian cysts on ultrasound. These results are complying with those of the study done by Abbas et al. [12], where a sponge-like pattern was considered the strongest predictor pattern of hemorrhagic ovarian cysts on ultrasound.

In our study, the sensitivity of ultrasonography in the diagnosis of hemorrhagic cysts was 100% and the specificity was 100%. This is similar to a study done by Sayasneh et al. [11] where the sensitivity of ultrasound achieved in the diagnosis of hemorrhagic cysts was 93% and the specificity was 99%.

In our study, ovarian endometrioma was typically diagnosed by ultrasound with its classic homogenous ground-glass appearance that appeared as diffuse homogenously low-level echoes within a well-marginated thin-walled cyst. No solid parts were detected. This is similar to a study done by Sayasneh et al. [11] to assess the accuracy of ultrasonography in the diagnosis of adnexal masses, where many endometriomas had a 'typical' unilocular appearance with ground-glass contents.

In our study, the sensitivity of Doppler ultrasonography in the diagnosis of endometrioma was 96.4% and the specificity was 100%. This is similar to a study done by Sayasneh et al. [11], where the sensitivity of ultrasound achieved in the diagnosis of endometriomas was 95% and the specificity was 99%.

In our study, there were various sonographic features suggestive of dermoid cysts; seven (3.5%) cases showed echogenic shadowing (calcification) in a cystic mass (tip of iceberg sign) and seven (3.5%) cases showed fat content. Moreover, nine (4.5%) cases had hyperechoic echogenicity and two (1%) cases had isoechoic echogenicity.

This is similar to a study done by Salem et al. [13], where cases with dermoid cysts had a densely echogenic mural tubercle with posterior acoustic shadow within a cystic component.

In our study, 13 (6.5%) patients were diagnosed as having dermoid cyst of 149 patients complaining of gynecological-related disease; the sensitivity of ultrasonography in the diagnosis of the dermoid ovarian cyst was 84.61% and the specificity was 100%. This is similar to a study done by Sayasneh et al. [11], where the sensitivity of ultrasound achieved in the diagnosis of the dermoid cyst was 88% and the specificity was 95%.

In our study, malignant ovarian cysts showed as complex masses (cystic lesion with mural nodule inside) with internal vascularity, which is similar to a study done by Salem et al. [13], where most ovarian tumors showed as complex lesions with internal vascularity.

In our study, ultrasonography had a sensitivity of 100% and specificity of 100% in the diagnosis of ovarian tumors. This is similar to a study done by Zhou et al. [14] where ultrasonography had a sensitivity of 89.47% and specificity of 83.64% in the diagnosis of ovarian tumors.

In our study, pelvic congestion syndrome appeared as dilated varicosities found within the pelvis, demonstrating reversal of blood flow and an increase in diameter during a Valsalva maneuver, with a vessel diameter of greater than 4 mm. This is similar to a study done by Steenbeek et al. [15], where pelvic congestion syndrome appeared as dilated varicosities found within the pelvis with a vessel diameter of greater than 4 mm.

In our study, 27 (13.5%) patients were diagnosed as pelvic congestion syndrome out of 149 patients complaining of gynecological-related disease. The sensitivity of ultrasonography in the diagnosis of pelvic congestion syndrome was 92.59% and the specificity was 100%. This is similar to a study done by Steenbeek et al. [15], where ultrasonography had a sensitivity of 100% and specificity of 100% in the diagnosis of pelvic congestion syndrome.

In our study, ultrasonography had a sensitivity of 87.5% and specificity of 100% in the diagnosis of pelvic inflammatory disease. This is similar to a study done by Sayasneh et al. [11], where the sensitivity of ultrasound achieved in the diagnosis of pelvic inflammatory disease was 100% and specificity was 100%.

In our study, the fibroid was the most common cause of uterine causes of CPP. A total of 16 (8%) cases of fibroids showed scanty internal vascularity, three (1.5%) cases with no internal vascularity, two (1%) cases with an area of cystic degeneration, two (1%) cases with isoechoic echogenicity, and 17 (8.5%) cases with hypoechogenicity. That is similar to a study done by Sharma et al. [16], where it was found that peripheral vascularity was seen in most cases, presence of cystic area, and variable echogenicity in some cases.

In our study, 20 patients were diagnosed as fibroid of 149 patients complaining of gynecological-related disease, and ultrasonography had a sensitivity of 95% and a specificity of 100% in the diagnosis of fibroid. This is similar to a study done by Maria et al. [17], which reported a sensitivity of 90–99% of detecting uterine fibroid when using a transvaginal ultrasound.

In our study, we found that uterine enlargement, heterogeneous myometrium, and ill-defined endometrial-myometrial interface were the sonographic features of adenomyosis, which are similar to the study done by Exacoustos et al. [18], where the most sensitive and specific ultrasound findings of adenomyosis were irregular or interrupted junctional zone, heterogeneous myometrial area, and asymmetrical thickening of uterine walls.

In our study, we found that adenomyosis showed internal vascularity, and the areas of increased vascularity reflected the distribution of adenomyosis. Ultrasonography had a sensitivity of 66.66% and specificity of 100% in the diagnosis of adenomyosis. This is similar to a study done by Andres et al. [19], where the sensitivity and specificity of transvaginal ultrasound for the diagnosis of adenomyosis were 83.8% and 63.9%, respectively.

In our study, endometrial polyp appeared as well-defined hyperechoic endometrial lesion with a single-vessel sign, which is similar to a study done by Kamaya et al. [20], where the most common sonographic feature was the pedicle vessel sign.

In our study, ultrasonography had a sensitivity of 100% and specificity of 100% in the diagnosis of endometrial polyps. This is similar to a study done by Zhu et al. [21], where the sensitivity and specificity of transvaginal ultrasound in the detection of endometrial polyps were 67 and 96%, respectively.

In our study, endometritis on ultrasound appeared as a fluid and gas-filled endometrial cavity. Gas in the endometrial cavity appeared as foci of increased echogenicity with associated posterior acoustic shadowing.

Kozyreva et al. [22] reported that patients with endometritis may not exhibit any sonographic imaging findings. A fluid-filled endometrial cavity is suggestive in the clinical setting of fever, vaginal discharge, and uterine tenderness on physical examination. Gas in the endometrial cavity will appear on ultrasound imaging as foci of increased echogenicity with associated posterior acoustic shadowing.

The sensitivity of the ultrasonography in the diagnosis of chronic endometritis was 78.1%, and its specificity was 82.5% [22].

In our study, ultrasonography had a sensitivity of 100% and a specificity of 100% in the diagnosis of chronic endometritis.

In our study, one patient was diagnosed by ultrasound as having endometrial carcinoma, having endometrial thickness of 10 mm, and underwent an endometrial biopsy, which confirmed the diagnosis.

In our study, ultrasonography had a sensitivity of 67% and specificity of 100% in the diagnosis of endometrial carcinoma. This is similar to a study done by Geng and Tang [23] where the sensitivity of ultrasound in the diagnosis of endometrial carcinoma was 84% and the specificity was 90%.

In our study, 18 patients with chronic cystitis presented increased bladder wall thickness above 3 mm with turbid fluid. This is similar to a study done by Huang et al. [24], where the most important criterion of cystitis in ultrasound was increased bladder wall thickness above 3 mm.

In our study, 18 patients were diagnosed as having chronic cystitis of 33 patients complaining of urological-related disease, and ultrasonography had a sensitivity of 100% and a specificity of 100% in the diagnosis of chronic cystitis in the current study. This is similar to a study done by Huang et al. [24], where the sensitivity and specificity of ultrasonography for diagnosing chronic cystitis were 71.4 and 92.8%, respectively.

In our study, two cases from seven cases of urolithiasis showed hydronephrosis. Ultrasonography had a sensitivity of 90% and a specificity of 100% in the diagnosis of urolithiasis. This is similar to a study done by Liu et al. [25] where ultrasound had a sensitivity of 96.39% and a specificity of 80.77%.

In our study, three cases of bladder tumors appeared as hypoechoic masses with internal vascularity, one case appeared as an isoechoic mass with internal vascularity, and two cases showed increased wall thickness measuring 4 mm. This is similar to a study done by Gharibvand et al. [26], where the most common finding of bladder tumor was the presence of a papillary mass in the bladder with internal vascularity.

Ultrasonography had a sensitivity of 80% and a specificity of 100% in the diagnosis of bladder tumors in the current study. This is similar to a study done by Gharibvand et al. [26], where the ultrasound had a sensitivity of 93.24% and specificity of 100% in the diagnosis of bladder tumor.

In our study, ultrasonography had a sensitivity of 100% and specificity of 100% in the diagnosis of chronic appendicitis. This is similar to a study done by Alegbeleye [27], where the sensitivity of ultrasound as the gold standard was 90.2% and the specificity was 85.6%.

In our study, inflammatory bowel disease appeared as increased bowel wall thickness (in small bowel measured above 3 mm and in large bowel measured above 5 mm) with narrowing of the bowel lumen, increased bowel wall vascularity, the involvement of peri-enteric fatty tissue, and mesenteric lymphadenopathy. This is similar to a study done by Kucharzik et al. [28], where the most prominent and most important parameter that indicated inflammatory activity in inflammatory bowel disease was an increase in bowel wall thickness. Another characteristic feature of intestinal inflammation was the increased vascularization, which may be visualized using color Doppler. Mesenteric lymph nodes were another sign of intestinal inflammation, which may be seen during chronic intestinal inflammation.

In our study, ultrasonography had a sensitivity of 87.5% and specificity of 100% in the diagnosis of inflammatory bowel disease. This is similar to a study done by Allocca et al. [29] where sensitivity and specificity of bowel ultrasound were 88 and 96%, respectively.

In our study, colon cancer appeared as increased bowel wall thickness measuring above 5 mm with narrowing of bowel lumen and mesenteric lymphadenopathy. This is similar to a study done by Debnath et al. [30], which showed the same picture.

In our study, ultrasonography had a sensitivity of 66.66%, the specificity of 100%, and positive predictive value of 100% in the diagnosis of colon cancer. This is similar to a study done by Debnath et al. [30] where the sensitivity of ultrasound to identify colon cancer was 86.48% and its specificity was 84%.


  Conclusion Top


CPP in women is common. Gynecological causes are the most common cause of CPP.

Ultrasonography is a rapid, inexpensive modality to rule out CPP. Ultrasonographic scanning of the pelvis is a highly recommended and reliable method together with clinical data in all cases of CPP.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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