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Olvera DJ, Lauria M, Norman J, Gothard MD, Gothard AD, Weir WB. Implementation of a Rapid Sequence Intubation Checklist Improves First-Pass Success and Reduces Peri-Intubation Hypoxia in Air Medical Transport. Air Med J 2024; 43:241-247. [PMID: 38821706 DOI: 10.1016/j.amj.2023.12.010] [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: 10/11/2023] [Revised: 12/13/2023] [Accepted: 12/26/2023] [Indexed: 06/02/2024]
Abstract
OBJECTIVE Rapid sequence intubation (RSI) is a critical skill commonly performed by air medical teams in the United States. To improve safety and reduce potential patient harm, checklists have been implemented by various institutions in intensive care units, emergency departments, and even prehospital air medical programs. However, the literature suggests that checklist use before RSI has not shown improvement in clinically important outcomes in the hospital. It is unclear if RSI checklist use by air medical crews in prehospital environments confers any clinically important benefit. METHODS This institutional review board-approved project is a before-and-after observational study conducted within a large helicopter ambulance company. The RSI checklist was used by flight crewmembers (flight paramedic/nurse) for over 3 years. Data were evaluated for 8 quarters before and 8 quarters after checklist implementation, spanning December 2014 to March 2019. Data were collected, including the self-reported use of the checklist during intubation attempts, the reason for intubation, and correlation with difficult airway predictors (HEAVEN [Hypoxemia, Extremes of size, Anatomic disruption, Vomit, Exsanguination, Neck mobility/Neurologic injury] criteria), and compared with airway management before the implementation of the checklist. The primary outcome was improved first-pass success (FPS) when compared among those who received RSI before the checklist versus those who received RSI with the checklist. The secondary outcome was a definitive airway sans hypoxia improvement noted on the first pass among adult patients as measured before and after RSI checklist implementation. Post-RSI outcome scenarios were recorded to analyze and validate the effectiveness of the checklist. RESULTS Ten thousand four hundred five intubations were attempted during the study. FPS was achieved in 90.9% of patients before RSI checklist implementation, and 93.3% achieved FPS postimplementation of the RSI checklist (P ≤ .001). In the preimplementation epoch, 36.2% of patients had no HEAVEN predictors versus 31.5% after RSI checklist implementation. These data showed that before RSI checklist implementation, airways were defined as less difficult than after implementation. CONCLUSION The implementation of a standardized RSI checklist provided a better identification of deterring factors, affording efficient and accurate actions promoting FPS. Our data suggest that when a difficult airway is identified, using the RSI checklist improves FPS, thereby reducing adverse events.
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Affiliation(s)
- David J Olvera
- University of Colorado Anschutz College of Medicine, Aurora, CO
| | - Michael Lauria
- Lifeguard Air Emergency Services, Albuquerque, NM; University of New Mexico School of Medicine, Albuquerque, NM
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Schweizer MA, Wampler D, Lu K, Oh AS, Rahm SJ, Studer NM, Cunningham CW. Prehospital Battlefield Casualty Intervention Decision Cognitive Study. Mil Med 2020; 185:274-278. [PMID: 32074373 DOI: 10.1093/milmed/usz226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Airway compromise is the third most common cause of preventable battlefield death. Surgical cricothyroidotomy (SC) is recommended by Tactical Combat Casualty Care (TCCC) guidelines when basic airway maneuvers fail. This is a descriptive analysis of the decision-making process of prehospital emergency providers to perform certain airway interventions. METHODS We conducted a scenario-based survey using two sequential video clips of an explosive injury event. The answers were used to conduct descriptive analyses and multivariable logistic regression models to estimate the association between the choice of intervention and training factors. RESULTS There were 254 respondents in the survey, 176 (69%) of them were civilians and 78 (31%) were military personnel. Military providers were more likely to complete TCCC certification (odds ratio [OR]: 13.1; confidence interval [CI]: 6.4-26.6; P-value < 0.001). The SC was the most frequently chosen intervention after each clip (29.92% and 22.10%, respectively). TCCC-certified providers were more likely to choose SC after viewing the two clips (OR: 1.9; CI: 1.2-3.2; P-value: 0.009), even after controlling for relevant factors (OR: 2.3; CI: 1.1-4.8; P-value: 0.033). CONCLUSIONS Military providers had a greater propensity to be certified in TCCC, which was found to increase their likelihood to choose the SC in early prehospital emergency airway management.
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Affiliation(s)
- Marc A Schweizer
- Department of Defense Joint Trauma System, 3698 Chambers Pass Bldg. 3611, Joint Base San Antonio Fort Sam Houston, TX 78234-6315
| | - David Wampler
- Department of Emergency Health Sciences, University of Texas Health San Antonio, 4201 Medical Dr. Suite 120, San Antonio, TX 78229
| | - Kevin Lu
- Emergency Department, Medical College of Georgia at Augusta University, 1465 Laney Walker Blvd., Augusta, GA 30912
| | - Andrew S Oh
- 1st Battalion, 1st Special Forces Group (Airborne), Okinawa, Japan
| | - Stephen J Rahm
- Centre for Emergency Health Sciences, 353 Rodeo Dr., Spring Branch, TX 78070
| | - Nicholas M Studer
- Department of Emergency Medicine, Brooke Army Medical Center, MCHE-ZSE-R, Joint Base San Antonio Fort Sam Houston, 3551 Roger Brooke Dr., San Antonio, TX 78234-4551
| | - Cord W Cunningham
- Department of Defense Joint Trauma System, 3698 Chambers Pass Bldg. 3611, Joint Base San Antonio Fort Sam Houston, TX 78234-6315
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C-MAC videolaryngoscope compared with direct laryngoscopy for rapid sequence intubation in an emergency department: A randomised clinical trial. Eur J Anaesthesiol 2018; 33:943-948. [PMID: 27533711 DOI: 10.1097/eja.0000000000000525] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Airway management in the emergency room can be challenging when patients suffer from life-threatening conditions. Mental stress, ignorance of the patient's medical history, potential cervical injury or immobilisation and the presence of vomit and/or blood may also contribute to a difficult airway. Videolaryngoscopes have been introduced into clinical practice to visualise the airway and ultimately increase the success rate of airway management. OBJECTIVE The aim of this study was to test the hypothesis that the C-MAC videolaryngoscope improves first-attempt intubation success rate compared with direct laryngoscopy in patients undergoing emergency rapid sequence intubation in the emergency room setting. DESIGN A randomised clinical trial. SETTING Emergency Department of the University Hospital, Zurich, Switzerland. PATIENTS With approval of the local ethics committee, we prospectively enrolled 150 patients between 18 and 99 years of age requiring emergency rapid sequence intubation in the emergency room of the University Hospital Zurich. Patients were randomised (1 : 1) to undergo tracheal intubation using the C-MAC videolaryngoscope or by direct laryngoscopy. INTERVENTIONS Owing to ethical considerations, patients who had sustained maxillo-facial trauma, immobilised cervical spine, known difficult airway or ongoing cardiopulmonary resuscitation were excluded from our study. All intubations were performed by one of three very experienced anaesthesia consultants. MAIN OUTCOME MEASURES First-attempt success rate served as our primary outcome parameter. Secondary outcome parameters were time to intubation; total number of intubation attempts; Cormack and Lehane score; inadvertent oesophageal intubation; ease of intubation; complications including violations of the teeth, injury/bleeding of the larynx/pharynx and aspiration/regurgitation of gastric contents; necessity of using further alternative airway devices for successful intubation; maximum decrease of oxygen saturation and technical problems with the device. RESULTS A total of 150 patients were enrolled, but three patients had to be excluded from the analysis, resulting in 74 patients in the C-MAC videolaryngoscopy group and 73 patients in the direct laryngoscopy group. Tracheal intubation was achieved successfully at the first attempt in 73 of 74 patients in the C-MAC group and all patients in the direct laryngoscopy group (P = 1.0). Time to intubation was similar (32 ± 11 vs. 31 ± 9 s, P = 0.51) in both groups. Visualisation of the vocal cords, represented as the Cormack and Lehane score, was significantly better using the C-MAC videolaryngoscope (P < 0.001). CONCLUSION Our study demonstrates that visualisation of the vocal cords was improved by using the C-MAC videolaryngoscope compared with direct laryngoscopy. Better visualisation did not improve first-attempt success rate, which in turn was probably based on the high level of experience of the participating anaesthesia consultants. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT02297113.
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Emergency Cricothyrotomy Performed by Surgical Airway-naive Medical Personnel: A Randomized Crossover Study in Cadavers Comparing Three Commonly Used Techniques. Anesthesiology 2017; 125:295-303. [PMID: 27275669 DOI: 10.1097/aln.0000000000001196] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND When conventional approaches to obtain effective ventilation and return of effective spontaneous breathing fail, surgical airway is the last rescue option. Most physicians have a limited lifetime experience with cricothyrotomy, and it is unclear what method should be taught for this lifesaving procedure. The aim of this study is to compare the performance of medical personnel, naive to surgical airway techniques, in establishing an emergency surgical airway in cadavers using three commonly used cricothyrotomy techniques. METHODS Twenty medical students, without previous knowledge of surgical airway techniques, were randomly selected from their class. After training, they performed cricothyrotomy by three techniques (surgical, Melker, and QuickTrach II) in a random order on 60 cadavers with comparable biometrics. The time to complete the procedure, rate of success, and number of complications were recorded. A success was defined as the correct placement of the cannula within the trachea in 3 min. RESULTS The success rates were 95, 55, and 50% for surgical cricothyrotomy, QuickTrach, and Melker, respectively (P = 0.025). The majority of failures were due to cannula misplacement (15 of 20). In successful procedures, the mean procedure time was 94 ± 35 s in the surgical group, 77 ± 34 in the QuickTrach II group, and 149 ± 24 in the Melker group (P < 0.001). Few significant complications were found in successful procedures. No cadaver biometric parameters were correlated with success of the procedure. CONCLUSION Surgical airway-naive medical personnel establish emergency cricothyrotomy more efficiently and safely with the surgical procedure than with the other two commonly used techniques.
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Advanced airway management in an anaesthesiologist-staffed Helicopter Emergency Medical Service (HEMS): A retrospective analysis of 1047 out-of-hospital intubations. Resuscitation 2016; 105:66-9. [DOI: 10.1016/j.resuscitation.2016.04.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/13/2016] [Accepted: 04/15/2016] [Indexed: 01/23/2023]
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Alfes CM, Steiner S, Rutherford-Hemming T. Challenges and Resources for New Critical Care Transport Crewmembers: A Descriptive Exploratory Study. Air Med J 2016; 35:212-215. [PMID: 27393756 DOI: 10.1016/j.amj.2016.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 04/07/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE The purpose of this study was to identify the challenges new crewmembers experience in the critical care transport (CCT) environment and to determine the most valuable resources when acclimating to the transport environment. To date, no study has focused on the unique challenges nor the resources most effective in CCT training. METHODS This descriptive exploratory study was conducted with a convenience survey sent to the 3 largest professional CCT organizations: the Association of Air Medical Services, the Air and Surface Transport Nurses Association, and the Association of Critical Care Transport. RESULTS The study survey responses revealed that more education and training are needed. Novice crewmembers identified areas in safety, communication, environment, and crew resource management as particularly challenging. Responses also validate the need for more simulation training, especially for CCT of low-volume/high-risk patient populations. CONCLUSION Results of this survey provide valuable insight for improving training effectiveness of health care professionals transitioning to the CCT environment. More information regarding best practice on the frequency and timing of CCT simulation training should be collected, particularly for simulations completed in the transport environment.
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Affiliation(s)
- Celeste M Alfes
- Learning Resource Skills and Simulation Center, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH.
| | - Stephanie Steiner
- Dorothy Ebersbach Academic Center for Flight Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH
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Hilton MT, Wayne M, Martin-Gill C. Impact of System-Wide King LT Airway Implementation on Orotracheal Intubation. PREHOSP EMERG CARE 2016; 20:570-7. [DOI: 10.3109/10903127.2016.1163446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kempema J, Trust MD, Ali S, Cabanas JG, Hinchey PR, Brown LH, Brown CVR. Prehospital endotracheal intubation vs extraglottic airway device in blunt trauma. Am J Emerg Med 2015; 33:1080-3. [PMID: 25963681 DOI: 10.1016/j.ajem.2015.04.046] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 04/13/2015] [Accepted: 04/23/2015] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The objective of the study is to compare outcomes in blunt trauma patients managed with prehospital insertion of an extraglottic airway device (EGD) vs endotracheal intubation (ETI). The null hypothesis was that there would be no difference in mortality for the 2 groups. METHODS This is a retrospective study of blunt trauma patients with Glasgow Coma Scale score less than or equal to 8 transported by ground emergency medical services directly from the scene of injury to a single urban level 1 trauma center. Patients managed with only noninvasive airway techniques were excluded, leaving patients undergoing either EGD placement or ETI. Outcomes included in-emergency department (ED) traumatic arrest and hospital mortality. Multivariable logistic regression was used to control for the potential confounding effects of demographic and clinical variables. For all analyses, P < .05 was used to establish statistical significance. RESULTS In bivariate analysis, patients managed with EGD were more likely than those managed with ETI to have an in-ED traumatic arrest (36.5% vs 17.1%; P = .005), but eventual hospital mortality did not significantly differ between the 2 groups (75.7% vs 67.1%; P = .228). After controlling for demographic and clinical characteristics, patients managed with EGD were no more likely than patients managed with ETI to experience traumatic arrest in the ED (adjusted odds ratio, 1.67; 95% confidence interval, 0.72-3.89), and there was also no difference in overall hospital mortality (adjusted odds ratio, 0.912; 95% confidence interval, 0.36-2.30). CONCLUSION In this preliminary, retrospective analysis, we found no difference in overall survival among trauma patients managed with prehospital EGD and those managed with prehospital ETI.
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Affiliation(s)
- James Kempema
- Emergency Medicine Residency Program, University of Texas-Austin and University Medical Center Brackenridge, Austin, TX 78701
| | - Marc D Trust
- Department of Surgery, University of Texas-Austin and University Medical Center Brackenridge, Austin, TX 78701
| | - Sadia Ali
- Department of Surgery, University of Texas-Austin and University Medical Center Brackenridge, Austin, TX 78701
| | - Jose G Cabanas
- Austin-Travis County Office of the Medical Director, Austin, TX 78741
| | - Paul R Hinchey
- Austin-Travis County Office of the Medical Director, Austin, TX 78741
| | - Lawrence H Brown
- Emergency Medicine Residency Program, University of Texas-Austin and University Medical Center Brackenridge, Austin, TX 78701; Mount Isa Centre for Rural & Remote Health, James Cook University, Townsville, QLD, Australia, 4811.
| | - Carlos V R Brown
- Department of Surgery, University of Texas-Austin and University Medical Center Brackenridge, Austin, TX 78701
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Sulser S, Ubmann D, Brueesch M, Goliasch G, Seifert B, Spahn DR, Ruetzler K. The C-MAC videolaryngoscope compared with conventional laryngoscopy for rapid sequence intubation at the emergency department: study protocol. Scand J Trauma Resusc Emerg Med 2015; 23:38. [PMID: 25903358 PMCID: PMC4407430 DOI: 10.1186/s13049-015-0119-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 03/25/2015] [Indexed: 11/10/2022] Open
Abstract
Background Especially in the emergency setting, rapid and successful airway management is of major importance. Conventional endotracheal intubation is challenging and requires high level of individual skills and experience. Videolaryngoscopes like the C-MAC are likely to offer better glottis visualization and serve as alternatives to conventional endotracheal intubation. The aim of this study is to compare clinical performance and feasibility of the C-MAC videolaryngoscope compared to conventional endotracheal intubation in the emergency setting. Methods/Design This study is designed as a prospective, patient-blinded, mono-center, randomized cohort study. This study will be performed at the Emergency Department of the University Hospital Zurich, Zurich, Switzerland. All patients transferred to the Emergency Department and requiring emergent endotracheal intubation will be screened. Successful intubation with first intubation attempt will serve as the primary outcome. Time to intubation, intubation attempts, Cormack & Lehane Score, ease of intubation, complications, necessity of using alternate intubation device, maximum drop of saturation, and potential technical problems serve as secondary outcomes. Discussion In the clinical setting, the ultimate success rate of endotracheal intubation ranges between 97% and 99%. Unexpected difficulties during laryngoscopy and poor glottis visualization occur in up to 9% of all cases. In these cases, videolaryngoscopes may increase success rate of initial intubation attempt and thereby patient safety. Trial registration www.clinicaltrials.gov (identifier NCT02297113).
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Affiliation(s)
- Simon Sulser
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland.
| | - Dirk Ubmann
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland.
| | - Martin Brueesch
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland.
| | - Georg Goliasch
- Department of Cardiology, Medical University Vienna, Vienna, Austria.
| | - Burkhardt Seifert
- Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics, University of Zurich, Zurich, Switzerland.
| | - Donat R Spahn
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland.
| | - Kurt Ruetzler
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland. .,Outcomes Research Consortium, Cleveland, Ohio, USA.
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Thoeni N, Piegeler T, Brueesch M, Sulser S, Haas T, Mueller SM, Seifert B, Spahn DR, Ruetzler K. Incidence of difficult airway situations during prehospital airway management by emergency physicians--a retrospective analysis of 692 consecutive patients. Resuscitation 2015; 90:42-5. [PMID: 25708959 DOI: 10.1016/j.resuscitation.2015.02.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/12/2015] [Accepted: 02/09/2015] [Indexed: 01/21/2023]
Abstract
INTRODUCTION In the prehospital setting, advanced airway management is challenging as it is frequently affected by facial trauma, pharyngeal obstruction or limited access to the patient and/or the patient's airway. Therefore, incidence of prehospital difficult airway management is likely to be higher compared to the in-hospital setting and success rates of advanced airway management range between 80 and 99%. METHODS 3961 patients treated by an emergency physician in Zurich, Switzerland were included in this retrospective analysis in order to determine the incidence of a difficult airway along with potential circumstantial risk factors like gender, necessity of CPR, NACA score, GCS, use and type of muscle relaxant and use of hypnotic drugs. RESULTS 692 patients underwent advanced prehospital airway management. Seven patients were excluded due to incomplete or incongruent documentation, resulting in 685 patients included in the statistical analysis. Difficult intubation was recorded in 22 patients, representing an incidence of a difficult airway of 3.2%. Of these 22 patients, 15 patients were intubated successfully, whereas seven patients (1%) had to be ventilated with a bag valve mask during the whole procedure. CONCLUSION In this physician-led service one out of five prehospital patients requires airway management. Incidence of advanced prehospital difficult airway management is 3.2% and eventual success rate is 99%, if performed by trained emergency physicians. A total of 1% of all prehospital intubation attempts failed and alternative airway device was necessary.
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Affiliation(s)
- Nils Thoeni
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Tobias Piegeler
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Martin Brueesch
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Simon Sulser
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Thorsten Haas
- Department of Anaesthesia, University Children's Hospital, Zurich, Switzerland
| | | | - Burkhardt Seifert
- Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics, University of Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Kurt Ruetzler
- Institute of Anaesthesiology, University and University Hospital Zurich, Zurich, Switzerland.
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Optimizing Emergent Surgical Cricothyrotomy for use in Austere Environments. Wilderness Environ Med 2013; 24:53-66. [DOI: 10.1016/j.wem.2012.07.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Revised: 06/23/2012] [Accepted: 07/03/2012] [Indexed: 11/23/2022]
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