Staff Profile
Ajay Malviya
Honorary Clinical Senior Lecturer
- Email: ajay.malviya@ncl.ac.uk
- Personal Website: https://nehipclinic.com
- Address: Northumbria Healthcare NHS Trust,
Trauma and Orthopaedics,
Wansbeck General Hospital,
Washington,
NE63 9JJ
I am a Consultant Orthopaedic Surgeon at Northumbria Healthcare NHS Foundation Trust, with a particular interest in young adult hip pathology, and an Honorary Consultant at Newcastle upon Tyne Hospitals NHS Foundation Trust. Trained in the North East, with fellowships in joint preservation surgery in Cambridge, London and Switzerland, I now run a national tertiary referral practice for young adult hip disorders, performing the highest volume of hip preservation surgery in the North East, around 150-200 cases a year, including hip arthroscopy for femoroacetabular impingement and sporting injuries, and minimally invasive periacetabular osteotomy for hip dysplasia. In 2016 I was awarded the British Orthopaedic Association's prestigious ABC (America-Britain-Canada) Fellowship, visiting leading centres across the USA and Canada.
My research interests centre on hip arthroscopy, the subject of a PhD on improving quality of life, and my work has an h-index of 37 with over 4,500 citations. I supervise research fellows through PhDs, MRes and other higher degrees, and have led or co-led national and international studies including the NIHR-funded FASHIoN trial, published in The Lancet, the HipHOP and HiPPO trials, and grant-funded platforms such as openOutcomes and openPredictor. I chair the Research Academy at SICOT and the Research Committee at ISHA, directing their international research strategy and collaboration.
Teaching is a regular part of my work: I run national and international hip preservation courses, mentor consultants setting up similar services in their own trusts, and examine for the FRCS (Trauma & Orthopaedics).
I am Vice President of the British Hip Society, a Council Member of the British Orthopaedic Association and Vice Chair of its Education and Careers Committee, and Vice Chair of ESSKA Hip. Having chaired the UK Non-Arthroplasty Hip Registry from 2020 to 2023, I remain a Trustee, and continue as Deputy Editor of the Journal of Hip Preservation Surgery (Oxford University Press), an Editorial Board member of the American Journal of Sports Medicine, and Associate Editor of the Journal of Orthopaedics.
My research interests are -
- Femoroacetabular impingement and Hip dysplasia - Principal Investigator in Northumbria for FASHiON trial which compares hip arthroscopy and non-operative treatment for FAI; Chief Investigator for HiPPO trial looking at the role of PRP for GTPS
- Outcomes after hip preservation surgery - periacetabular osteotomy and hip arthroscopy
- Machine learning (AI) in predicting outcomes after surgery
- Use of Patient-Reported Outcomes in Orthopaedic Surgery
- Improving outcome after hip and knee replacement - the role of Anaemia screening and MSSA decolonisation
- Enhanced recovery in hip and knee replacement
Local and Regional roles
- Orthopaedic registrar and foundation doctor training in Northumbria
- Orthopaedic training programme teaching in the North East
- Cadaver teaching of orthopaedic trainees
- In training clinical assessment of Orthopaedic registrars
- Physiotherapy teaching
National roles
- MCh Dundee teaching
- Faculty in Cadaver hip arthroscopy course - nationally and internationally
- Faculty in Early intervention in hip surgery - ORUK - London
- Faculty in Annual British Hip Society meetings - Young adult hip sessions
- FRCS T&O examiner
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Articles
- van Duren BH, Pursun Y, Andrade AJ, Bankes MJK, Khanduja V, Malviya A. Patients With Increased Anxiety and Depression Scores Are at Greater Risk of Not Achieving a Meaningful Improvement in Patient-Reported Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome. Arthroscopy 2026, 42(2), 455-464.
- van Duren BH, Amer MH, Stewart J, Malviya A. Increased Risk of Stress Fractures Following Second-Side Periacetabular Osteotomy: A Retrospective Cohort Study. Journal of Arthroplasty 2026, 41(3), 654-658.
- Ekhtiari S, Yoshitani J, Green J, Malviya A, Khanduja V. Floor and ceiling effects of the international hip outcome tool-12 in patients undergoing hip preservation surgery: A national registry study. International Orthopaedics 2026, 50, 777-786.
- Atchia I, Ali M, Oderuth E, Holleyman R, Malviya A. Efficacy of Platelet-Rich Plasma Versus Placebo for the Treatment of Greater Trochanteric Pain Syndrome A Double-Blinded Randomized Controlled Trial. Journal of Bone and Joint Surgery 2025, 107(5), 444-451.
- Holleyman RJ, Smith C, Baig K, Bankes M, Witt J, Judge A, Khanduja V, Malviya A. Change in Early Patient-Reported Sexual Function After Periacetabular Osteotomy: A Study Utilizing the UK Non-Arthroplasty Hip Registry. Orthopaedic Journal of Sports Medicine 2025, 13(6).
- Sunil Kumar KH, Bhargava K, Stamp G, Malviya A. Functional and radiological outcomes of periacetabular osteotomy for hip dysplasia in patients under fifty years using a minimally invasive approach—a single surgeon series with a minimum follow up of two years. International Orthopaedics 2024, 48, 1225-1231.
- Pettit MH, Hickman SHM, Malviya A, Khanduja V. Development of Machine-Learning Algorithms to Predict Attainment of Minimal Clinically Important Difference After Hip Arthroscopy for Femoroacetabular Impingement Yield Fair Performance and Limited Clinical Utility. Arthroscopy: The Journal of Arthroscopic and Related Surgery 2024, 40(4), 1153-1163.e2.
- Sohatee MA, Malviya A. Osteonecrosis of the Femoral Head - Vascularised and Non-vascularised Grafting Techniques. Biologic Orthopedics Journal 2023, 3(SP1), e35-e56.
- Holleyman R, Sohatee MA, Lyman S, Malviya A, Khanduja V, Bankes MJK, Andrade T, Board T, Conroy J, Wilson M, McBryde C. Hip arthroscopy for femoroacetabular impingement is associated with significant improvement in early patient reported outcomes: analysis of 4963 cases from the UK non-arthroplasty registry (NAHR) dataset. Knee Surgery, Sports Traumatology, Arthroscopy 2023, 31, 58-69.
- Smith C, Nero L, Holleyman R, Khanduja V, Malviya A. Hip Arthroscopy for Femoroacetabular Impingement Is Associated With Improved Sexual Function And Quality of Life. Arthroscopy: The Journal of Arthroscopic and Related Surgery 2023, 40(8), 204-2212.
- Scrimshire AB, Booth A, Fairhurst C, Coleman E, Malviya A, Kotze A, Tiplady C, Tate D, Laverty A, Davis G, Tadd W, Corbacho B, Torgerson DJ, McDaid C, Reed M. Scaling up Quality Improvement for Surgical Teams (QIST)—avoiding surgical site infection and anaemia at the time of surgery: a cluster randomised controlled trial of the effectiveness of quality improvement collaboratives to introduce change in the NHS. Implementation Science 2022, 17, 22.
- Allport J, Choudhury R, Bruce-Wootton P, Reed M, Tate D, Malviya A. Efficacy of mupirocin, neomycin and octenidine for nasal Staphylococcus aureus decolonisation: a retrospective cohort study. Antimicrobial Resistance & Infection Control 2022, 11, 5.
- Holleyman RJ, Lyman S, Bankes MJK, Board TN, Conroy JL, McBryde CW, Andrade AJ, Malviya A, Khanduja V. Comparison of early outcomes of arthroscopic labral repair or debridement A STUDY USING THE UK NON-ARTHROPLASTY HIP REGISTRY DATASET. Bone and Joint Open 2022, 3(4), 291-301.
- Bhargava K, Bhandari F, Board T, Andrade T, McBryde C, Conroy J, Bankes M, Khanduja V, Malviya A. Effect of COVID-19 pandemic on hip preservation surgery—a prospective surveillance from the UK Non-Arthroplasty Hip Registry. Journal of Hip Preservation Surgery 2021, 8(3), 225-32.
- Holleyman RJ, Critchley RJ, Mason JM, Jameson SS, Reed MR, Malviya A. Ceramic Bearings Are Associated With a Significantly Reduced Revision Rate in Primary Hip Arthroplasty: An Analysis From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man. Journal of Arthroplasty 2021, 36(10), 3498-3506.
- Holleyman R, Sohatee MA, Witt J, Bankes MJK, Andrade TJ, Board T, Lee Conroy J, Wilson M, McBryde C, Khanduja V, Malviya A. Periacetabular Osteotomy for Developmental Dysplasia of the Hip and Femoroacetabular Impingement: A Study Using the U.K. Non-Arthroplasty Hip Registry (NAHR) Data Set. The Journal of Bone and Joint Surgery 2020, 102(15), 1312-1320.
- Audenaert EA, Khanduja V, Claes P, Malviya A, Steenackers G. Mechanics of Psoas Tendon Snapping. A Virtual Population Study. Frontiers in Bioengineering and Biotechnology 2020, 8, 264.
- Kuroda Y, Saito M, Kumar S, Malviya A, Khanduja V. Hip Arthroscopy and Borderline Developmental Dysplasia of the Hip: A Systematic Review. Arthroscopy: The Journal of Arthroscopic & Related Surgery 2020, 36(9), 2550-2567.e1.
- Ali M, Benjamin B, Jain N, Malviya A. Does Platelet-rich Plasma Augmentation Following Hip Arthroscopy Improve Outcomes: A Systematic Review. Hip & Pelvis 2020, 32(2), 70-77.
- Sohatee M, Ali M, Khanduja V, Malviya A. Does hip preservation surgery prevent arthroplasty? Quantifying the rate of conversion to arthroplasty following hip preservation surgery. Journal of Hip Preservation Surgery 2020, 7(2), 168–182.
- Malviya A. What the papers say?. Journal of Hip Preservation Surgery 2018, 5(1), 100-102.
- Malviya A. What the papers say. Journal of Hip Preservation Surgery 2018, 5(2), 174-177.
- Jeans E, Holleyman R, Tate D, Reed M, Malviya A. Methicillin sensitive staphylococcus aureus screening and decolonisation in elective hip and knee arthroplasty. Journal of Infection 2018, 77(5), 405-409.
- Griffin DR, Dickenson EJ, Wall PDH, Achana F, Donovan JL, Griffin J, Hobson R, Hutchinson CE, Jepson M, Parsons NR, Petrou S, Realpe A, Smith J, Foster NE, FASHIoN StudyGroup. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet 2018, 391(10136), 2225-2235.
- Sims AL, Parsons N, Achten J, Griffin XL, Costa ML, Reed MR, CORNET traineecollaborative. A randomized controlled trial comparing the Thompson hemiarthroplasty with the Exeter polished tapered stem and Unitrax modular head in the treatment of displaced intracapsular fractures of the hip. Bone & Joint Journal 2018, 100(3), 352-360.
- Oderuth E, Ali M, Atchia I, Malviya A. A double blind randomised control trial investigating the efficacy of platelet rich plasma versus placebo for the treatment of greater trochanteric pain syndrome (the HIPPO trial): a protocol for a randomised clinical trial. Trials 2018, 19, 517.
- Malviya A. What the papers say?. Journal of Hip Preservation Surgery 2017, 4(4), 341-344.
- Malviya A. What the papers say. Journal of Hip Preservation Surgery 2017, 4(3), 262-265.
- Malviya A. What the papers say. Journal of Hip Preservation Surgery 2017, 4(2), 194-197.
- Malviya A. What the papers say. Journal of Hip Preservation Surgery 2017, 4(1), 115-118.
- Malviya A, Abdul N, Khanduja V. Outcomes Following Total Hip Arthroplasty: A Review of the Registry Data. Indian Journal of Orthopaedics 2017, 51(4), 405-413.
- Khan OA, Malviya A, Subramanian P, Agolley D, Witt JD. Minimally invasive periacetabular osteotomy using a modified Smith-Petersen approach, technique and early outcomes. Bone and Joint Journal 2017, 99-B(1), 22-28.
- Malviya A. What the papers say?. Journal of Hip Preservation Surgery 2016, 3(4), 368-371.
- Malviya A. What the papers say. Journal of Hip Preservation Surgery 2016, 3(3), 240-242.
- Malviya A. What the papers say. Journal of Hip Preservation Surgery 2016, 3(2), 165-167.
- Malviya A. What the papers say. Journal of Hip Preservation Surgery 2016, 3(1), 79-81.
- Malviya A. What the papers say. Journal of Hip Preservation Surgery 2016, 2(4), 439-442.
- Bardgett M, Lally J, Malviya AJ, Deehan D. Return to work after knee replacement: A qualitative study of patient experiences. BMJ Open 2016, 6(2), e007912.
- Malviya A, Raza A, Witt JD. Reliability in the diagnosis of femoroacetabular impingement and dysplasia among hip surgeons: role of surgeon volume and experience. Hip International 2016, 26(3), 284-9.
- Bardgett M, Lally J, Malviya A, Kleim B, Deehan D. Patient-reported factors influencing return to work after joint replacement. Occupational Medicine 2016, 66(3), 215-221.
- Bardgett M, Lally J, Malviya AJ, Kleim B, Deehan DJ. Patient reported factors influencing return to work after joint replacement – A Qualitative Analysis. Occupational Medicine 2016, 66(3), 215-221.
- Malviya A. What the papers say. The Journal of Hip Preservation Surgery 2015, 2(3), 318-320.
- Kleim BD, Malviya A, Rushton S, Bardgett M, Deehan DJ. Understanding the patient-reported factors determining time taken to return to work after hip and knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy 2015, 23(12), 3646-3652.
- Malviya A, Dandachli W, Beech Z, Bankes MJ, Witt JD. The incidence of stress fracture following peri-acetabular osteotomy: an under-reported complication. Bone & Joint Journal 2015, 97-B(1), 24-28.
- Malviya A, Raza A, Jameson S, James P, Reed MR, Partington PF. Complications and survival analyses of hip arthroscopies performed in the national health service in England: a review of 6,395 cases. Arthroscopy 2015, 31(5), 836-842.
- Khan SK, Malviya A, Muller SD, Carluke I, Partington PF, Emmerson KP, Reed MR. Reduced short-term complications and mortality following Enhanced Recovery primary hip and knee arthroplasty: results from 6,000 consecutive procedures. Acta Orthopaedica 2014, 85(1), 26-31.
- Raza A, Kailash K, Malviya A. Rare cause of hip pain in a young girl. BMJ Case Reports 2014.
- Malviya A, Wilson G, Kleim B, Kurtz SM, Deehan D. Factors influencing return to work after hip and knee replacement. Occupational Medicine 2014, 64(6), 402-409.
- Deehan DJ, Gangadharan R, Malviya A, Sutherland A, Holland JP. Anterior Knee Symptoms after S-ROM Hinge Implantation. Bulletin of the Hospital for Joint Disease 2014, 72(2), 167-172.
- Savaridas T, Serrano-Pedraza I, Khan SK, Martin K, Malviya A, Reed MR. Reduced medium-term mortality following primary total hip and knee arthroplasty with an enhanced recovery program:A study of 4,500 consecutive procedures. Acta Orthopaedica 2013, 84(1), 40-43.
- Malviya A, Ng L, Hashmi M, Rawlings D, Holland JP. Patterns of Changes in Femoral Bone Mineral Density Up To Five Years After Hip Resurfacing. Journal of Arthroplasty 2013, 28(6), 1025-1030.
- Malviya A, Paliobeis CP, Villar RN. Do Professional Athletes Perform Better Than Recreational Athletes After Arthroscopy for Femoroacetabular Impingement?. Clinical Orthopaedics and Related Research 2013, 471(8), 2477-2483.
- Malviya A, Bettinson K, Kurtz SM, Deehan DJ. When Do Patient-reported Assessments Peak after Revision Knee Arthroplasty?. Clinical Orthopaedics and Related Research 2012, 470(6), 1728-1734.
- Malviya A, Rushton SP, Foster HE, Ferris CM, Hanson H, Muthumayandi K, Deehan DJ. The relationships between adult juvenile idiopathic arthritis and employment. Arthritis & Rheumatism 2012, 64(9), 3016-3024.
- Malviya A, Stafford GH, Villar RN. Is hip arthroscopy for femoroacetabular impingement only for athletes?. British Journal of Sports Medicine 2012, 46(14), 1016-1018.
- Malviya A, Stafford GH, Villar RN. Impact of arthroscopy of the hip for femoroacetabular impingement on quality of life at a mean follow-up of 3.2 years. Bone & Joint Journal 2012, 94(4), 466-470.
- Malviya A, Stafford GH, Villar RJ, Villar RN. Have the media influenced the use of hip resurfacing arthroplasty? A review of UK print media. Annals of the Royal College of Surgeons of England 2012, 94(6), 432-437.
- Malviya A, Brewster NT, Bettinson K, Holland JP, Weir DJ, Deehan DJ. Functional outcome following aseptic single-stage revision knee arthroplasty. Knee Surgery, Sports Traumatology, Arthroscopy 2012, 20(10), 1990-1997.
- Malviya A, Ramaskandhan JR, Bowman R, Hashmi M, Holland JP, Kometa S, Lingard E. What advantage is there to be gained using large modular metal-on-metal bearings in routine primary hip replacement? A preliminary report of a prospective randomised controlled trial. J Bone Joint Surg Br 2011, 93(12), 1602-9.
- Malviya A, Walker LC, Avery P, Osborne S, Weir DJ, Foster HE, Deehan DJ. The long-term outcome of hip replacement in adults with juvenile idiopathic arthritis: the influence of steroids and methotrexate. J Bone Joint Surg Br 2011, 93(4), 443-8.
- Stafford GH, Malviya A, Villar RN. Fluid extravasation during hip arthroscopy. Hip Int 2011, 21(6), 740-3.
- Malviya A, Martin K, Harper I, Muller SD, Emmerson KP, Partington PF, Reed MR. Enhanced recovery program for hip and knee replacement reduces death rate. Acta Orthop 2011, 82(5), 577-81.
- Malviya A, Reed MR, Partington PF. Acute primary total knee arthroplasty for peri-articular knee fractures in patients over 65 years of age. Injury 2011, 42(11), 1368-71.
- Jameson SS, Bottle A, Malviya A, Muller SD, Reed MR. The impact of national guidelines for the prophylaxis of venous thromboembolism on the complications of arthroplasty of the lower limb. J Bone Joint Surg Br 2010, 92(1), 123-9.
- Malviya A, Foster HE, Avery P, Weir DJ, Deehan DJ. Long term outcome following knee replacement in patients with juvenile idiopathic arthritis. Knee 2010, 17(5), 340-344.
- Malviya A, Lingard EA, Malik A, Bowman R, Holland JP. Hip Flexion After Birmingham Hip Resurfacing Role of Cup Anteversion, Anterior Femoral Head-Neck Offset, and Head-Neck Ratio. JOURNAL OF ARTHROPLASTY 2010, 25(3), 387-391.
- Malviya A, Kuiper JH, Makwana N, Laing P, Ashton B. The effect of newer anti-rheumatic drugs on osteogenic cell proliferation: an in-vitro study. J Orthop Surg Res 2009, 4, 17.
- Malviya A, Holland JP. Pseudotumours associated with metal-on-metal hip resurfacing: 10-year Newcastle experience. ACTA ORTHOPAEDICA BELGICA 2009, 75(4), 477-483.
- Malviya A, Lingard EA, Weir DJ, Deehan DJ. Predicting range of movement after knee replacement: the importance of posterior condylar offset and tibial slope. KNEE SURGERY SPORTS TRAUMATOLOGY ARTHROSCOPY 2009, 17(5), 491-498.
- Mahawar KK, Kejariwal D, Malviya A, Birla R, Viswanath YK. Peer review practices in biomedical literature: a time for change?. Asian J Surg. 2009 2009, 32(4), 240-6.
- Dodds T, Reed M, Malviya A. Modernising hip knee replacement surgery. British Journal of Clinical Pharmacy 2009, 1(11), 343-5.
- Malviya A, Johnson-Lynn S, Avery P, Deehan D, Foster H. Juvenile idiopathic arthritis in adulthood and orthopaedic intervention. Clinical Rheumatology 2009, 28(12), 1411-1417.
- Malviya A, Glithero PR. Foreign body in the hip joint - an unusual presentation in a child. Int Emerg Nurs 2009, 17(2), 128-9.
- Malviya A, Makwana N, Laing P. Scarf osteotomy for hallux valgus – Is an Akin osteotomy necessary?. Foot and Ankle Surgery 2007, 13(4), 177-181.
- Malviya A, Lobaz S, Holland J. Mechanism of failure eleven years following a Buechel Pappas hip resurfacing. Acta Orthop Belg 2007, 73(6), 791-4.
- Malviya A, Tsintzas D, Mahawar K, Bache CE, Glithero PR. Gap index: a good predictor of failure of plaster cast in distal third radius fractures. JOURNAL OF PEDIATRIC ORTHOPAEDICS-PART B 2007, 16(1), 48-52.
- Malviya A, Makwana N, Laing P. Correlation of the AOFAS scores with a generic health qualy score in foot and ankle surgery. FOOT & ANKLE INTERNATIONAL 2007, 28(4), 494-498.
- Mahawar KK, Malviya A, Kumar G. Who publishes in leading general surgical journals? The divide between the developed and developing worlds. ASIAN JOURNAL OF SURGERY 2006, 29(3), 138-144.
- Malviya A, Simmons D, Vallamshetla R, Bache CE. Pink pulseless hand following supra-condylar fractures: an audit of British practice. JOURNAL OF PEDIATRIC ORTHOPAEDICS-PART B 2006, 15(1), 62-64.
- Malviya A, Richards J, Jones RK, Udwadia A, Doyle J. Reproducibilty of partial weight bearing. Injury 2005, 36(4), 556-9.
- Malviya A. Segmental tibial fractures: an assessment of procedures in 27 cases. Injury 2004, 35(8), 834.
- Malviya A, Udwadia A, Doyle J. Pressfit ceramic arthroplasty of the first metatarsophalangeal joint: a short-term review. Acta Orthop Belg 2004, 70(5), 455-60.
- Lunawat SK, Taneja DK, Malviya A. 0 0 1 25 147 Home 1 1 171 14.0 96 800x600 Normal 0 false false false EN-GB JA X-NONE Correlation between MRI and intra-operative findings in Prolapse Intervertebral Disc. Indian Journal of Orthopaedics 2002, 36(3), 185-188.
- Rao GS, Malviya A. 0 0 1 18 106 Home 1 1 123 14.0 96 800x600 Normal 0 false false false EN-GB JA X-NONE Viscosupplementation in Degenerative Joint Disease. Indian Journal of Orthopaedics 2002, 36(3), 164-167.
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Book Chapters
- Malviya A, Hunter AR, Witt J. The Anatomy of Hip Disease. In: Fares S Haddad, ed. The Young Adult Hip in Sport. London, UK: Springer, 2014, pp.3-11.
- Malviya A, McCaskie AW. Minimally invasive hip replacement. In: Limb, D; Hay, SM, ed. Evidence for Orthopaedic Surgery. Shrewsbury, UK: TFM Publishing Ltd, 2007, pp.223-232.
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Conference Proceedings (inc. Abstract)
- Malviya A, Ferris CM, Rushton SP, Foster HE, Hanson H, Muthumayandi K, Deehan DJ. Exploring the relationships between adult juvenile idiopathic arthritis and employment. In: Annual Meeting of the British Society for Rheumatology. 2012, Glasgow, UK: Oxford University Press.
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Editorial
- McWilliams R, Malviya A, Khanduja V. From data to decisions: The evolution and impact of hip preservation registries. Journal of ISAKOS 2025, 12, 100911.
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Letter
- Malviya A. Re-displacement of paediatric forearm fractures: Role of plaster moulding and padding [Injury 2006;37(3): 259-68]. INJURY-INTERNATIONAL JOURNAL OF THE CARE OF THE INJURED 2007, 38(2), 256-257.
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Reviews
- Hotham WE, Malviya A. A systematic review of surgical methods to restore articular cartilage in the hip. Bone and Joint Research 2018, 7(5), 336-342.
- Malviya A, Gerrand C. Evidence for orthopaedic surgery in the treatment of metastatic bone disease of the extremities: A review article. Palliative Medicine 2012, 26(6), 788-796.
- Malviya A, Ramaskandhan J, Holland JP, Lingard EA. Metal-on-Metal Total Hip Arthroplasty. JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME 2010, 92A(7), 1675-1683.
- Malviya A, McCaskie A. Surgery for osteoarthritis. Medicine 2006, 34(9), 369-372.