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Engrand N, Sene T, Caputo G, Sabben C, Gregoire C, Blanc R, Aldea S, Chauvet D, Vo-Thanh S, Teissier S, Versace N, Rohou L, Piotin M, Gueguen A. Ethical Management of COVID-19 Pandemic at a Neurological Hospital: The Ethicovid Report. J Neurosurg Anesthesiol 2023; 35:417-422. [PMID: 35543619 DOI: 10.1097/ana.0000000000000849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 03/30/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND During the first wave of the coronavirus disease-2019 (COVID-19) pandemic, it was necessary to prepare for the possibility of triaging patients who could benefit from access to an intensive care unit (ICU). In our neuroscience institution, the challenge was to continue to manage usual neurological emergencies as well as the influx of COVID-19 patients. METHODS We report the experience of an ethical consulting unit to support care clinical decisions during the first wave of the pandemic (March 16 to April 30, 2020). Three objective evaluation criteria were defined: 2 of these criteria, patient's factors and general disease severity (Simplified Acute Physiology Score II), were common to all patients, and the third was the specific severity of the disease (neurological for brain injury, respiratory for COVID-19). Given our scarce resources, we used a high probability of a 3-month modified Rankin Scale ≤3 as the criterion for further resuscitation and management. RESULTS A total of 295 patients were admitted during the first pandemic wave; 111 with COVID-19 and 184 with neurological emergencies. The ethical unit's expertise was sought for 75 clinical situations in 56 patients (35 COVID-19 and 21 neurological). Decisions were as follows: 11% no limitation on care, 5% expectant care with reassessment (maximum therapy to assess possible progress pending decision), 67% partial limitation (no intensification of care or no transfer to ICU), and 17% limitation of curative care. At no time did a lack of availability of ICU beds require the ethical unit to advise against admission to the ICU. CONCLUSIONS Our ethical consulting unit allowed for collegial ethical decision-making in line with international recommendations. This model could be easily transferred to other triage situations, provided it is adapted to the local context.
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Affiliation(s)
- Nicolas Engrand
- Intensive Care Unit-Anesthesiology/Mobile Palliative Care Team
| | | | | | | | | | | | - Sorin Aldea
- Neurosurgery, Rothschild Foundation Hospital
| | | | - Sophie Vo-Thanh
- Intensive Care Unit-Anesthesiology/Mobile Palliative Care Team
| | | | - Nathalie Versace
- Department of Neuroscience, Rothschild Foundation Hospital, Paris, France
| | - Léa Rohou
- Intensive Care Unit-Anesthesiology/Mobile Palliative Care Team
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Aljaberi MA, Al-Sharafi MA, Uzir MUH, Sabah A, Ali AM, Lee KH, Alsalahi A, Noman S, Lin CY. Psychological Toll of the COVID-19 Pandemic: An In-Depth Exploration of Anxiety, Depression, and Insomnia and the Influence of Quarantine Measures on Daily Life. Healthcare (Basel) 2023; 11:2418. [PMID: 37685451 PMCID: PMC10487588 DOI: 10.3390/healthcare11172418] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
The COVID-19 pandemic, on a global scale, has prompted multifaceted challenges, including a notable psychological toll on the general population. This study uses mixed-method approach for a nuanced exploration of these experiences. Using a phenomenological strategy, qualitative responses from 999 participants were analyzed regarding their pandemic-induced anxiety and the influence of quarantine measures on their lives. Quantitative measures, including the revised Impact of Event Scale (IES-R), patient health questionnaire-9 (PHQ-9), the seven-item generalized anxiety disorder assessment (GAD-7), and Insomnia Severity Index (ISI), were used to quantify trauma, depression, anxiety, and insomnia attributed to COVID-19. Partial least squares structural equation modeling (PLS-SEM) was utilized for quantitative data analysis. The anxiety-related responses were mainly clustered into four themes: life threats, support shortage, economic consequences, and disruptions to family and social life. Subthemes that addressed the perceived effects encapsulated disruptions to academic and professional lives, familial and social relationships, psychopathological stress, and movement limitations. The findings from quantitative analysis revealed the significant associations between COVID-19-related trauma and symptoms of anxiety, depression, and insomnia, as indicated by coefficients exceeding 0.10 (all z-values > 1.96; p-values < 0.05). In conclusion, the findings underscore COVID-19's role in escalating anxiety, influenced by various factors, and its disruptive effects on daily life due to quarantine measures. The strong associations between the pandemic and the symptoms of depression, anxiety, and insomnia underscore the urgency of comprehensive psychological and public health interventions to alleviate these impacts.
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Affiliation(s)
- Musheer A. Aljaberi
- Faculty of Medicine and Health Sciences, Taiz University, Taiz 6803, Yemen
- Faculty of Nursing and Applied Sciences, Lincoln University College, Petaling Jaya 47301, Malaysia
- Department of Community Health, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Serdang 43300, Malaysia;
| | - Mohammed A. Al-Sharafi
- Institute of Informatics and Computing in Energy, Universiti Tenaga Nasional, Putrajaya Campus, Kajang 43000, Malaysia;
| | - Md. Uzir Hossain Uzir
- Faculty of Business and Accountancy, Lincoln University College, Petaling Jaya 47301, Malaysia;
| | - Aiche Sabah
- Faculty of Human and Social Sciences, Hassiba Benbouali University of Chlef, Chlef 02076, Algeria;
| | - Amira Mohammed Ali
- Department of Psychiatric Nursing and Mental Health, Faculty of Nursing, Alexandria University, Smouha, Alexandria 21527, Egypt;
| | - Kuo-Hsin Lee
- Department of Emergency Medicine, E-Da Dachang Hospital, I-Shou University, Kaohsiung City 824, Taiwan
- School of Medicine, College of Medicine, I-Shou University, No. 8, Yi-Da Road, Jiao-Su Village, Yan-Chao District, Kaohsiung City 824, Taiwan
| | - Abdulsamad Alsalahi
- Department of Pharmacology, Faculty of Pharmacy, Sana’a University, Sana’a 1247, Yemen;
| | - Sarah Noman
- Department of Community Health, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, Serdang 43300, Malaysia;
| | - Chung-Ying Lin
- Institute of Allied Health Sciences, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
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Abma IL, Olthuis GJ, Maassen ITHM, Knippenberg ML, Moviat M, Hasker AJ, Buenen AG, Fikkers BG, Oerlemans AJM. Putting ICU triage guidelines into practice: A simulation study using observations and interviews. PLoS One 2023; 18:e0286978. [PMID: 37616248 PMCID: PMC10449194 DOI: 10.1371/journal.pone.0286978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 05/29/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has prompted many countries to formulate guidelines on how to deal with a worst-case scenario in which the number of patients needing intensive care unit (ICU) care exceeds the number of available beds. This study aims to explore the experiences of triage teams when triaging fictitious patients with the Dutch triage guidelines. It provides an overview of the factors that influence decision-making when performing ICU triage with triage guidelines. METHODS Eight triage teams from four hospitals were given files of fictitious patients needing intensive care and instructed to triage these patients. Sessions were observed and audio-recorded. Four focus group interviews with triage team members were held to reflect on the sessions and the Dutch guidelines. The results were analyzed by inductive content analysis. RESULTS The Dutch triage guidelines were the main basis for making triage decisions. However, some teams also allowed their own considerations (outside of the guidelines) to play a role when making triage decisions, for example to help avoid using non-medical criteria such as prioritization based on age group. Group processes also played a role in decision-making: triage choices can be influenced by the triagists' opinion on the guidelines and the carefulness with which they are applied. Intensivists, being most experienced in prognostication of critical illness, often had the most decisive role during triage sessions. CONCLUSIONS Using the Dutch triage guidelines is feasible, but there were some inconsistencies in prioritization between teams that may be undesirable. ICU triage guideline writers should consider which aspects of their criteria might, when applied in practice, lead to inconsistencies or ethically questionable prioritization of patients. Practical training of triage team members in applying the guidelines, including explanation of the rationale underlying the triage criteria, might improve the willingness and ability of triage teams to follow the guidelines closely.
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Affiliation(s)
- Inger L. Abma
- IQ healthcare, section Ethics of healthcare, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert J. Olthuis
- IQ healthcare, section Ethics of healthcare, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Irma T. H. M. Maassen
- IQ healthcare, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marjan L. Knippenberg
- IQ healthcare, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Miriam Moviat
- Department of Intensive Care Medicine, Jeroen Bosch Hospital, ’s-Hertogenbosch, The Netherlands
| | | | - A. G. Buenen
- Department of Emergency Medicine, Bernhoven Hospital, Uden, The Netherlands
| | - Bernard G. Fikkers
- Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anke J. M. Oerlemans
- IQ healthcare, section Ethics of healthcare, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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Gherman MA, Arhiri L, Holman AC. Ageism and moral distress in nurses caring for older patients. ETHICS & BEHAVIOR 2022. [DOI: 10.1080/10508422.2022.2072845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
| | - Laura Arhiri
- Department of Psychology and Educational Sciences, “Alexandru Ioan Cuza” University
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Butler CR, Webster LB, Diekema DS, Gray MM, Sakata VL, Tonelli MR, Vranas KC. Perspectives of Triage Team Members Participating in Statewide Triage Simulations for Scarce Resource Allocation During the COVID-19 Pandemic in Washington State. JAMA Netw Open 2022; 5:e227639. [PMID: 35435971 PMCID: PMC9016492 DOI: 10.1001/jamanetworkopen.2022.7639] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE The COVID-19 pandemic prompted health care institutions worldwide to develop plans for allocation of scarce resources in crisis capacity settings. These plans frequently rely on rapid deployment of institutional triage teams that would be responsible for prioritizing patients to receive scarce resources; however, little is known about how these teams function or how to support team members participating in this unique task. OBJECTIVE To identify themes illuminating triage team members' perspectives and experiences pertaining to the triage process. DESIGN, SETTING, AND PARTICIPANTS This qualitative study was conducted using inductive thematic analysis of observations of Washington state triage team simulations and semistructured interviews with participants during the COVID-19 pandemic from December 2020 to February 2021. Participants included clinician and ethicist triage team members. Data were analyzed from December 2020 through November 2021. MAIN OUTCOMES AND MEASURES Emergent themes describing the triage process and experience of triage team members. RESULTS Among 41 triage team members (mean [SD] age, 50.3 [11.4] years; 21 [51.2%] women) who participated in 12 simulations and 21 follow-up interviews, there were 5 Asian individuals (12.2%) and 35 White individuals (85.4%); most participants worked in urban hospital settings (32 individuals [78.0%]). Three interrelated themes emerged from qualitative analysis: (1) understanding the broader approach to resource allocation: participants strove to understand operational and ethical foundations of the triage process, which was necessary to appreciate their team's specific role; (2) contending with uncertainty: team members could find it difficult or feel irresponsible making consequential decisions based on limited clinical and contextual patient information, and they grappled with ethically ambiguous features of individual cases and of the triage process as a whole; and (3) transforming mindset: participants struggled to disentangle narrow determinations about patients' likelihood of survival to discharge from implicit biases and other ethically relevant factors, such as quality of life. They cited the team's open deliberative process, as well as practice and personal experience with triage as important in helping to reshape their usual cognitive approach to align with this unique task. CONCLUSIONS AND RELEVANCE This study found that there were challenges in adapting clinical intuition and training to a distinctive role in the process of scarce resource allocation. These findings suggest that clinical experience, education in ethical and operational foundations of triage, and experiential training, such as triage simulations, may help prepare clinicians for this difficult role.
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Affiliation(s)
- Catherine R. Butler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle
- Veterans Affairs Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
| | - Laura B. Webster
- Bioethics Program, Virginia Mason Medical Center, Seattle, Washington
- Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle
| | - Douglas S. Diekema
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Trueman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington
| | - Megan M. Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Vicki L. Sakata
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Northwest Healthcare Response Network, Seattle, Washington
| | - Mark R. Tonelli
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Kelly C. Vranas
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland
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Tian YJA. The Ethical Unjustifications of COVID-19 Triage Committees. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:621-628. [PMID: 34964927 PMCID: PMC8715149 DOI: 10.1007/s11673-021-10132-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 07/05/2021] [Indexed: 06/14/2023]
Abstract
The ever-debated question of triage and allocating the life-saving ventilator during the COVID-19 pandemic has been repeatedly raised and challenged within the ethical community after shortages propelled doctors before life and death decisions (Anderson-Shaw and Zar 2020; Huxtable 2020; Jongepier 2020; Peterson, Largent, and Karlawish 2020). The British Medical Association's ethical guidance highlighted the possibility of an initial surge of patients that would outstrip the health system's ability to deliver care "to existing standards," where utilitarian measures have to be applied, and triage decisions need to maximize "overall benefit" (British Medical Association 2020, 3) In these emergency circumstances, triage that "grades according to their needs and the probable outcomes of intervention" will prioritize or eliminate patients for treatment, and health professionals may be faced with obligations to withhold or withdraw treatments to some patients in favour of others (British Medical Association 2020, 4). This piece is a response and extension to articles published on the manner of involvement for ethics and ethicists in pandemic triage decisions, particularly examining the ability and necessity of establishing triage committees to ameliorate scarce allocation decisions for physicians.
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Affiliation(s)
- Yi Jiao Angelina Tian
- Institute for Biomedical Ethics, University of Basel, Bernouillistrasse 28, CH-4056, Basel, Switzerland.
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Gessler F, Lehmann F, Bösel J, Fuhrer H, Neugebauer H, Wartenberg KE, Wolf S, Bernstock JD, Niesen WD, Schuss P. Triage and Allocation of Neurocritical Care Resources During the COVID 19 Pandemic - A National Survey. Front Neurol 2021; 11:609227. [PMID: 33584507 PMCID: PMC7874200 DOI: 10.3389/fneur.2020.609227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/08/2020] [Indexed: 11/16/2022] Open
Abstract
Objective: In light of the ongoing COVID-19 pandemic and the associated hospitalization of an overwhelming number of ventilator-dependent patients, medical and/or ethical patient triage paradigms have become essential. While guidelines on the allocation of scarce resources do exist, such work within the subdisciplines of intensive care (e.g., neurocritical care) remains limited. Methods: A 16-item questionnaire was developed that sought to explore/quantify the expert opinions of German neurointensivists with regard to triage decisions. The anonymous survey was conducted via a web-based platform and in total, 96 members of the Initiative of German Neurointensive Trial Engagement (IGNITE)-study group were contacted via e-mail. The IGNITE consortium consists of an interdisciplinary panel of specialists with expertise in neuro-critical care (i.e., anesthetists, neurologists and neurosurgeons). Results: Fifty members of the IGNITE consortium responded to the questionnaire; in total the respondents were in charge of more than 500 Neuro ICU beds throughout Germany. Common determinants reported which affected triage decisions included known patient wishes (98%), the state of health before admission (96%), SOFA-score (85%) and patient age (69%). Interestingly, other principles of allocation, such as a treatment of “youngest first” (61%) and members of the healthcare sector (50%) were also noted. While these were the most accepted parameters affecting the triage of patients, a “first-come, first-served” principle appeared to be more accepted than a lottery for the allocation of ICU beds which contradicts much of what has been reported within the literature. The respondents also felt that at least one neurointensivist should serve on any interdisciplinary triage team. Conclusions: The data gathered in the context of this survey reveal the estimation/perception of triage algorithms among neurointensive care specialists facing COVID-19. Further, it is apparent that German neurointensivists strongly feel that they should be involved in any triage decisions at an institutional level given the unique resources needed to treat patients within the Neuro ICU.
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Affiliation(s)
- Florian Gessler
- Department of Neurosurgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Felix Lehmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Julian Bösel
- Department of Neurology, Kassel General Hospital, Kassel, Germany
| | - Hannah Fuhrer
- Department of Neurology, University Hospital Freiburg, Freiburg, Germany
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | | | - Stefan Wolf
- Department of Neurosurgery, Charité University Hospital Berlin, Berlin, Germany
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, United States.,Harvard Medical School, Harvard University, Boston, MA, United States
| | - Wolf-Dirk Niesen
- Department of Neurology, University Hospital Freiburg, Freiburg, Germany
| | - Patrick Schuss
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
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Sprung CL, Joynt GM, Christian MD, Truog RD, Rello J, Nates JL. Crisis Level ICU Triage Is About Saving Lives. Crit Care Med 2021; 49:e102-e103. [PMID: 33337749 DOI: 10.1097/ccm.0000000000004671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Charles L Sprung
- Department of Anesthesiology, Critical Care Medicine and Pain, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | | | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Jordi Rello
- Department of Anesthesiology, Critical Care Medicine and Pain, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
- London's Air Ambulance, Barts Health NHS Trust, London, United Kingdom
- Center for Bioethics, Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Clinical Research/Epidemiology in Pneumonia and Sepsis, Vall d'Hebron Institute of Research (VHIR), Barcelona, Spain
- Centro de Investigacion Biomedica en Red en Efermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Barcelona, Spain
- Clinical Research, CHU Nîmes, NÎmes, France
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joseph L Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX
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The Triage Stalemate During the Coronavirus Disease 2019 Pandemic: Losing Fairness to Ethical Paralysis. Crit Care Med 2020; 48:e1380-e1381. [PMID: 32826433 PMCID: PMC7467035 DOI: 10.1097/ccm.0000000000004567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Coronavirus Disease 2019: Withdrawing Mechanical Ventilation to Reallocate Life Support Under Crisis Standards of Care-Nonequivalence of the Equivalence Thesis. Crit Care Med 2020; 48:e994-e996. [PMID: 32541569 PMCID: PMC7314343 DOI: 10.1097/ccm.0000000000004475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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