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Schoene D, Hartmann C, Winzer S, Moustafa H, Günther A, Puetz V, Barlinn K. [Postoperative management following decompressive hemicraniectomy for malignant middle cerebral artery infarction-A German nationwide survey study]. Nervenarzt 2023; 94:934-943. [PMID: 37140605 PMCID: PMC10157548 DOI: 10.1007/s00115-023-01486-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/26/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Malignant middle cerebral artery infarction is a potentially life-threatening disease. Decompressive hemicraniectomy constitutes an evidence-based treatment practice, especially in patients under 60 years of age; however, recommendations with respect to postoperative management and particularly duration of postoperative sedation lack standardization. OBJECTIVE This survey study aimed to analyze the current situation of patients with malignant middle cerebral artery infarction following hemicraniectomy in the neurointensive care setting. MATERIAL AND METHODS From 20 September 2021 to 31 October 2021, 43 members of the initiative of German neurointensive trial engagement (IGNITE) network were invited to participate in a standardized anonymous online survey. Descriptive data analysis was performed. RESULTS Out of 43 centers 29 (67.4%) participated in the survey, including 24 university hospitals. Of the hospitals 21 have their own neurological intensive care unit. While 23.1% favored a standardized approach regarding postoperative sedation, the majority utilized individual criteria (e.g., intracranial pressure increase, weaning parameters, complications) to assess the need and duration. The timing of targeted extubation varied widely between hospitals (≤ 24 h 19.2%, ≤ 3 days in 30.8%, ≤ 5 days in 19.2%, > 5 days in 15.4%). Early tracheotomy (≤ 7 days) is performed in 19.2% and 80.8% of the centers aim for tracheotomy within 14 days. Hyperosmolar treatment is used on a regular basis in 53.9% and 22 centers (84.6%) agreed to participate in a clinical trial addressing the duration of postoperative sedation and ventilation. CONCLUSION The results of this nationwide survey among neurointensive care units in Germany reflect a remarkable heterogeneity in the treatment practices of patients with malignant middle cerebral artery infarction undergoing hemicraniectomy, especially with respect to the duration of postoperative sedation and ventilation. A randomized trial in this matter seems warranted.
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Affiliation(s)
- D Schoene
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland.
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland.
| | - C Hartmann
- Institut und Poliklinik für Diagnostische und Interventionelle Neuroradiologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - S Winzer
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - H Moustafa
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - A Günther
- Klinik für Neurologie, Universitätsklinikum Jena, Jena, Deutschland
| | - V Puetz
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
| | - K Barlinn
- Klinik und Poliklinik für Neurologie, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland
- Dresdner Neurovaskuläres Centrum, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Deutschland
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Siepmann T, Sedghi A, Simon E, Winzer S, Barlinn J, de With K, Mirow L, Wolz M, Gruenewald T, Schroettner P, von Bonin S, Pallesen LP, Rosengarten B, Schubert J, Lohmann T, Machetanz J, Spieth P, Koch T, Bornstein S, Reichmann H, Puetz V, Barlinn K. Increased risk of acute stroke among patients with severe COVID-19: a multicenter study and meta-analysis. Eur J Neurol 2021; 28:238-247. [PMID: 32920964 DOI: 10.1111/ene.14535] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/31/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Recent observations linked coronavirus disease 2019 (COVID-19) to thromboembolic complications possibly mediated by increased blood coagulability and inflammatory endothelial impairment. We aimed to define the risk of acute stroke in patients with severe and non-severe COVID-19. METHODS We performed an observational, multicenter cohort study in four participating hospitals in Saxony, Germany to characterize consecutive patients with laboratory-confirmed COVID-19 who experienced acute stroke during hospitalization. Furthermore, we conducted a systematic review using PubMed/MEDLINE, Embase, Cochrane Library and bibliographies of identified papers following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines including data from observational studies of acute stroke in COVID-19 patients. Data were extracted by two independent reviewers and pooled with multicenter data to calculate risk ratios (RRs) and 95% confidence intervals (95% CIs) for acute stroke related to COVID-19 severity using a random-effects model. Between-study heterogeneity was assessed using Cochran's Q and I2 statistics. International Prospective Register of Systematic Reviews registration number: CRD42020187194. RESULTS Of 165 patients hospitalized for COVID-19 (49.1% males, median age = 67 years [57-79 years], 72.1% severe or critical) included in the multicenter study, overall stroke rate was 4.2% (95% CI: 1.9-8.7). Systematic literature search identified two observational studies involving 576 patients that were eligible for meta-analysis. Amongst 741 pooled COVID-19 patients, overall stroke rate was 2.9% (95% CI: 1.9-4.5). Risk of acute stroke was increased for patients with severe compared to non-severe COVID-19 (RR = 4.18, 95% CI: 1.7-10.25; P = 0.002) with no evidence of heterogeneity (I2 = 0%, P = 0.82). CONCLUSIONS Synthesized analysis of data from our multicenter study and previously published cohorts indicates that severity of COVID-19 is associated with an increased risk of acute stroke.
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Affiliation(s)
- T Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
| | - A Sedghi
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
| | - E Simon
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
| | - S Winzer
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
| | - J Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
| | - K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
| | - L Mirow
- Department of General and Visceral Surgery, Klinikum Chemnitz gGmbH, Chemnitz
| | - M Wolz
- Department of Neurology, Elblandklinikum Meissen, Meissen
| | - T Gruenewald
- Department of Infectious Diseases/Tropical Medicine, Klinikum Chemnitz gGmbH, Chemnitz
| | - P Schroettner
- Department of Virology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
| | - S von Bonin
- Department of Internal Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
| | - L-P Pallesen
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
| | - B Rosengarten
- Department of Neurology, Klinikum Chemnitz gGmbH, Chemnitz
| | - J Schubert
- Department of Hematology and Oncology, Elblandklinikum Riesa, Riesa
| | - T Lohmann
- Department of Internal Medicine, Städtisches Klinikum Dresden, Dresden
| | - J Machetanz
- Department of Neurology, Städtisches Klinikum Dresden, Dresden
| | - P Spieth
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - T Koch
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - S Bornstein
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
| | - H Reichmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
| | - V Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
| | - K Barlinn
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden
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Pallesen LP, Lambrou D, Eskandari A, Barlinn J, Barlinn K, Reichmann H, Dunet V, Maeder P, Puetz V, Michel P. Perfusion computed tomography in posterior circulation stroke: predictors and prognostic implications of focal hypoperfusion. Eur J Neurol 2018; 25:725-731. [PMID: 29350878 DOI: 10.1111/ene.13578] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 01/08/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE The aim was to determine the predictors of focal hypoperfusion on computed tomography (CT) perfusion (CTP) in patients with acute posterior circulation stroke and its association with long-term outcome. METHODS Patients with posterior circulation stroke were selected from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL) who underwent CTP within 24 h of stroke onset as part of the stroke imaging protocol. Hypoperfusion was defined as an area of visually well demarcated mean transit time prolongation corresponding to an arterial territory on standard reconstruction CTP imaging maps. Areas of hypoperfusion were assessed with the posterior circulation Acute Stroke Prognosis Early CT Score. Clinical and imaging associations with focal hypoperfusion were identified using multiple imputation analyses, and the adjusted functional outcome measured by the modified Rankin Scale at 3 and 12 months was determined. RESULTS Of the 3595 consecutive patients from the ASTRAL registry between 2003 and 2014, 1070 (29.7%) had a posterior circulation stroke and 436 of these (40.7%) patients had a good quality baseline CTP. 23.1% had early ischaemic changes and 37.4% had focal hypoperfusion. In multiple imputation analysis, visual field deficits, reduced level of consciousness, cardiac and multiple stroke mechanisms, significant vessel pathology and ischaemic changes visible on plain CT were associated with focal hypoperfusion. Focal hypoperfusion was independently associated with outcome at 12 months (odds ratio 2.04, 95% confidence interval 1.22-3.42, P < 0.01). CONCLUSIONS In posterior circulation stroke patients undergoing acute CTP, multiple clinical, aetiological and radiological variables were associated with focal hypoperfusion. Patients with focal hypoperfusion had a worse 12-month outcome.
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Affiliation(s)
- L-P Pallesen
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland.,Dresden University Stroke Center, Department of Neurology, Dresden Technical University, Dresden, Germany
| | - D Lambrou
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - A Eskandari
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - J Barlinn
- Dresden University Stroke Center, Department of Neurology, Dresden Technical University, Dresden, Germany
| | - K Barlinn
- Dresden University Stroke Center, Department of Neurology, Dresden Technical University, Dresden, Germany
| | - H Reichmann
- Dresden University Stroke Center, Department of Neurology, Dresden Technical University, Dresden, Germany
| | - V Dunet
- Diagnostic and Interventional Radiology Service, Department of Medical Imaging, Lausanne University Hospital, Lausanne, Switzerland
| | - P Maeder
- Diagnostic and Interventional Radiology Service, Department of Medical Imaging, Lausanne University Hospital, Lausanne, Switzerland
| | - V Puetz
- Dresden University Stroke Center, Department of Neurology, Dresden Technical University, Dresden, Germany
| | - P Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
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Barlinn K, Seibt J, Engellandt K, Gerber J, Puetz V, Kepplinger J, Wunderlich O, Pallesen LP, Bodechtel U, Koch R, von Kummer R, Dzialowski I. Multimodal Computed Tomography Based Definition of Cerebral Imaging Profiles for Acute Stroke Reperfusion Therapy (CT-DEFINE): Results of a Prospective Observational Study. Clin Neuroradiol 2014; 25:403-10. [PMID: 25150187 DOI: 10.1007/s00062-014-0320-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 06/17/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE To prospectively evaluate the prognostic impact of multimodal computed tomography-based imaging in ischemic stroke patients potentially eligible for reperfusion therapy. METHODS Anterior circulation stroke patients underwent non-contrast CT (NCCT), CT-angiography, and CT-perfusion within 12 h from symptom-onset. Patients could be treated with intravenous-tissue plasminogen activator (IV-tPA), endovascular or combined reperfusion therapies. Cerebral imaging profiles (IP) were NCCT-Alberta Stroke Program Early CT Score (ASPECTS) > 7 (IP1); NCCT-ASPECTS > 5 and proximal occlusion on CT-angiography (IP2); CT-perfusion mismatch between cerebral blood volume (CBV)-ASPECTS, and cerebral blood flow (CBF)-ASPECTS ≥ 2 (IP3). Favorable outcome was defined as modified Rankin Scale ≤ 2 at 3 months. RESULTS Of 102 included patients, 62 (61%) received any reperfusion therapy. In IP2 and IP3, favorable outcome was more frequent in patients with reperfusion therapy than in those without; however, this did not reach statistical significance (IP2: 39% vs 15%, p = 0.26; IP3: 50% vs 17 %; p = 0.31). No difference was seen in IP1 (58% vs 58%, p = 1.0). In IP2, patients with IV-tPA alone achieved better functional outcome (50% vs 11%, p = 0.03) and lower mortality (0% vs 28%, p = 0.045) than those without. CONCLUSIONS Our results suggest a benefit with imaging profile selection based upon the combination of a small-to-moderate-sized infarction and a visible intracranial occlusion in patients receiving IV-tPA. Reperfusion therapy may be futile in patients without proven vessel occlusion.
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Affiliation(s)
- K Barlinn
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - J Seibt
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - K Engellandt
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - J Gerber
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - V Puetz
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - J Kepplinger
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - O Wunderlich
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - L-P Pallesen
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - U Bodechtel
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - R Koch
- Institute for Medical Informatics and Biometry, University Hospital Dresden, Dresden, Germany
| | - R von Kummer
- Division of Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - I Dzialowski
- Department of Neurology, Dresden University Stroke Center, University Hospital Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
- Elblandklinikum Meissen, Department of Neurology, Academic Teaching Hospital of the University of Technology Dresden, Meissen, Germany
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Palazzo P, Balucani C, Barlinn K, Tsivgoulis G, Zhang Y, Zhao L, Dewolfe J, Toaldo B, Stamboulis E, Vernieri F, Rossini PM, Alexandrov AV. Association of reversed Robin Hood syndrome with risk of stroke recurrence. Neurology 2010; 75:2003-8. [PMID: 21115955 DOI: 10.1212/wnl.0b013e3181ffe4e4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Reversed Robin Hood syndrome (RRHS) has recently been identified as one of the mechanisms of early neurologic deterioration in acute ischemic stroke (AIS) patients related to arterial blood flow steal from ischemic to nonaffected brain. We sought to investigate the association of RRHS with risk of stroke recurrence in a single-center cohort study. METHODS Consecutive patients with AIS or TIA affecting the anterior circulation were prospectively evaluated with serial NIH Stroke Scale assessments and bilateral transcranial Doppler monitoring with breath-holding test. RRHS was defined according to previously validated criteria. RESULTS A total of 360 patients (51% women, mean age 62 ± 15 years) had an ischemic stroke (81%) or TIA (19%) in the anterior circulation, and 30 (8%) of them had RRHS. During a mean follow-up period of 6 months (range 1-24), a total of 16 (4%) recurrent strokes (15 ischemic and 1 hemorrhagic) were documented. The cumulative recurrence rate was higher in patients with RRHS (19%; 95% confidence interval [CI] 1-37) compared to the rest (15%; 95% CI 0-30; p = 0.022 by log-rank test). All recurrent strokes in patients with RRHS were cerebral infarcts that occurred in the ipsilateral to the index event anterior circulation vascular territory. After adjusting for demographic characteristics, vascular risk factors, and secondary prevention therapies, RRHS was independently associated with a higher stroke recurrence risk (hazard ratio 7.31; 95% CI 2.12-25.22; p = 0.002). CONCLUSIONS Patients with AIS and RRHS appear to have a higher risk of recurrent strokes that are of ischemic origin and occur in the same arterial territory distribution to the index event. Further independent validation of this association is required in a multicenter setting.
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Affiliation(s)
- P Palazzo
- Comprehensive Stroke Center/Neurology, The University of Alabama at Birmingham, RWUH M226, 619 19 St., South Birmingham, AL 35249-3280, USA
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Gahn G, Barlinn K, Dzialowski I, Puetz V, Kunz A, Hentschel H, Becker U. Combined thrombolysis with abciximab and rtPA in patients with middle cerebral artery occlusion. Acta Neurol Scand 2010; 121:63-6. [PMID: 20074286 DOI: 10.1111/j.1600-0404.2009.01241.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND In patients with acute middle cerebral artery (MCA) occlusion, recanalization rates with intravenous (IV) recombinant tissue plasminogen activator (rtPA) are limited. Aim- We evaluated the feasibility and safety of combined IV thrombolysis with abciximab and reduced dose rtPA in a 3- to 6-h time window. METHODS We prospectively (March 2002 to February 2005) studied patients with symptomatic MCA occlusion on computed tomography (CT) angiography and absence of major early ischemic changes (EIC) on non-contrast CT (NCCT) within 3-6 h from symptom onset. Patients were treated with IV abciximab and half-standard dose rtPA. Outcome parameters were symptomatic intracerebral hemorrhage (sICH), early clinical improvement and functional independence at discharge (modified Rankin Scale score < or = 2). RESULTS Of 13 patients, mean age was 62 +/- 11 years, onset-to-treatment time 4.8 +/- 0.9 h and median baseline National Institutes of Health Stroke Scale score 11 (interquartile range 6.5-13.5). sICH occurred in one patient (8%). We observed early clinical improvement in four patients (31%). Six patients (46%) were functionally independent at discharge. CONCLUSIONS In patients with acute symptomatic MCA occlusion and absence of major EIC on NCCT, combined IV thrombolysis with abciximab and half-standard dose rtPA was feasible and seemed to be safe if applied within 3-6 h from symptom onset.
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Affiliation(s)
- G Gahn
- Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, Germany.
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Disqué C, Barlinn K, Gahn G. Rekanalisationsrate und Outcome kardialer Embolien versus arterioarterieller Embolien nach Lyse. Akt Neurol 2005. [DOI: 10.1055/s-2005-919465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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