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van Eijk JA, Doeleman LC, Loer SA, Koster RW, van Schuppen H, Schober P. Ventilation during cardiopulmonary resuscitation: A narrative review. Resuscitation 2024; 203:110366. [PMID: 39181499 DOI: 10.1016/j.resuscitation.2024.110366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/12/2024] [Accepted: 08/15/2024] [Indexed: 08/27/2024]
Abstract
Ventilation during cardiopulmonary resuscitation is vital to achieve optimal oxygenation but continues to be a subject of ongoing debate. This narrative review aims to provide an overview of various components and challenges of ventilation during cardiopulmonary resuscitation, highlighting key areas of uncertainty in the current understanding of ventilation management. It addresses the pulmonary pathophysiology during cardiac arrest, the importance of adequate alveolar ventilation, recommendations concerning the maintenance of airway patency, tidal volumes and ventilation rates in both synchronous and asynchronous ventilation. Additionally, it discusses ventilation adjuncts such as the impedance threshold device, the role of positive end-expiratory pressure ventilation, and passive oxygenation. Finally, this review offers directions for future research.
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Affiliation(s)
- Jeroen A van Eijk
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands.
| | - Lotte C Doeleman
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
| | - Stephan A Loer
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
| | - Rudolph W Koster
- Amsterdam UMC location University of Amsterdam, Cardiology, Meibergdreef 9, Amsterdam, Netherlands
| | - Hans van Schuppen
- Amsterdam UMC location University of Amsterdam, Anesthesiology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
| | - Patrick Schober
- Amsterdam UMC location Vrije Universiteit Amsterdam, Anesthesiology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Quality of Care, Amsterdam, the Netherlands
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Rhue AL, VanDerveer B. Wilderness First Responder: Are Skills Soon Forgotten? Wilderness Environ Med 2018; 29:132-137. [PMID: 29361386 DOI: 10.1016/j.wem.2017.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 11/08/2017] [Accepted: 11/08/2017] [Indexed: 11/17/2022]
Abstract
Wilderness first responders are trained to provide competent medical care in wilderness settings or until evacuation for more advanced treatment can be obtained. In light of the isolated environments in which they are called upon to respond to illnesses and injuries, their ability to effectively apply their training is crucial. Despite the responsibility assigned to them, there is an absence of research assessing the skill and knowledge retention of wilderness first responders, creating a gap in understanding whether a deficit in their ability to perform exists between certifications. Without such research, it is important to review knowledge and skill retention in related responder groups. The literature over the past 4 decades documents the loss over time of skills and knowledge across an array of trained responders, both professional and laypeople. Although the findings reviewed suggest that WFRs will exhibit a similar pattern of increasing skill loss beginning shortly after certification and a slower, but concurrent, decrease in knowledge, research is needed to document or refute this assumption.
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Ewy GA. Cardiocerebral and cardiopulmonary resuscitation - 2017 update. Acute Med Surg 2017; 4:227-234. [PMID: 29123868 PMCID: PMC5674458 DOI: 10.1002/ams2.281] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/13/2017] [Indexed: 12/21/2022] Open
Abstract
Sudden cardiac arrest is a major public health problem in the industrialized nations of the world. Yet, in spite of recurrent updates of the guidelines for cardiopulmonary resuscitation and emergency cardiac care, many areas have suboptimal survival rates. Cardiocerebral resuscitation, a non‐guidelines approach to therapy of primary cardiac arrest based on our animal research, was instituted in Tucson (AZ, USA) in 2002 and subsequently adopted in other areas of the USA. Survival rates of patients with primary cardiac arrest and a shockable rhythm significantly improved wherever it was adopted. Cardiocerebral resuscitation has three components: the community, the pre‐hospital, and the hospital. The community component emphasizes bystander recognition and chest compression only resuscitation. Its pre‐hospital or emergency medical services component emphasizes: (i) urgent initiation of 200 uninterrupted chest compressions before and after each indicated single defibrillation shock, (ii) delayed endotracheal intubation in favor of passive delivery of oxygen by a non‐rebreather mask, (iii) early adrenaline administration. The hospital component was added later. The national and international guidelines for cardiopulmonary resuscitation and emergency medical services are still not optimal, for several reasons, including the fact that they continue to recommend the same approach for two entirely different etiologies of cardiac arrest: primary cardiac arrest, often caused by ventricular fibrillation, where the arterial blood oxygenation is little changed at the time of the arrest, and secondary cardiac arrest from severe respiratory insufficiency, where the arterial blood is severely desaturated at the time of cardiac arrest. These different etiologies need different approaches to therapy.
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Affiliation(s)
- Gordon A Ewy
- Department of Medicine (Cardiology) University of Arizona College of Medicine Tucson AZ USA
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Pearson DA, Darrell Nelson R, Monk L, Tyson C, Jollis JG, Granger CB, Corbett C, Garvey L, Runyon MS. Comparison of team-focused CPR vs standard CPR in resuscitation from out-of-hospital cardiac arrest: Results from a statewide quality improvement initiative. Resuscitation 2016; 105:165-72. [DOI: 10.1016/j.resuscitation.2016.04.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 03/29/2016] [Accepted: 04/11/2016] [Indexed: 10/21/2022]
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Abstract
PURPOSE OF REVIEW To describe an alternative approach for improving survival of patients with out-of-hospital cardiac arrest (OHCA). The survival of patients with OHCA has been poor and relatively unchanged for decades in spite of recurrent national and international guidelines. Although there are exceptions, many thought and continue to think that any change in the guidelines for cardiopulmonary resuscitation should be based on randomized controlled trials in humans. However, many factors, including the need for informed consent, the marked variability of patients, and the variability of the type and quality of bystander and advanced resuscitation efforts, all make such studies problematic. Thus, potentially life-saving procedures are often withheld for decades, resulting in unnecessary loss of life. RECENT FINDINGS Many improvements in public health conditions have been made using models of continuous quality improvement. When applied to resuscitation science, once baseline data are obtained, changes based on reliable experimental findings are instituted and outcomes measured. This approach has now been shown to result in significant improvement in neurologically intact survival of patients with OHCA. SUMMARY Following this model, we found significant improvement in survival of patients with a witnessed OHCA primary cardiac arrest.
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Nasiri E, Nasiri R. A comparison between over-the-head and lateral cardiopulmonary resuscitation with a single rescuer by bag-valve mask. Saudi J Anaesth 2014; 8:30-7. [PMID: 24665237 PMCID: PMC3950449 DOI: 10.4103/1658-354x.125923] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Context: mask fixation in the lateral position is difficult during CPR. Aim: the aim of this study is to compare the lateral CPR for the use of bag-valve mask by single paramedic rescuer as well as over-the-head CPR on the chest compression and ventilation on the manikin. Settings and Design: Mazandaran University of Medical Sciences. The design of this study was a randomized cross-over trial. Methods: participants learned a standardized theoretical introduction CPR according to the 2010 guidelines. The total number of chest compressions per two minutes was measured. Total number of correct and wrong ventilation per two minutes was evaluated. Statistical Analysis: we used Wilcoxon signed-rank test to analyze the non-normally distributed data in dependence groups A. P-value of more than 0.05 was considered to show statistical significance. Results: there were 100 participants (45 women and 55 men) who participated in the study from September to March, 2011. The compression and ventilation rate in lateral CPR was lower than OTH CPR. Around 51% of participants had correct chest compression rate more than 90 beats per minute in lateral CPR and 65% of them had equal or more than ten correct ventilations per minute. Conclusions: in conclusion, this study confirmed that in a simulated CPR model over-the-head position CPR led to a better BLS than the lateral position CPR by a single paramedic student with a BVM device. We also concluded that by this new BVM fixation method on the face of the patients in the lateral position CPR can be a good alternative over-the-head mask fixation by a single trained rescuer.
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Affiliation(s)
- Ebrahim Nasiri
- Department Anesthesiology and Emergency Medicine, Faculty Member, Traditional and Complementary Medicine Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | - Reza Nasiri
- Medical Student, Medical Student Research Committee, Ramsar, Mazandaran University of Medical Sciences, Iran
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Murugiah K, Chen SI, Dharmarajan K, Nuti SV, Wayda B, Shojaee A, Ranasinghe I, Dreyer RP. Most important outcomes research papers on cardiac arrest and cardiopulmonary resuscitation. Circ Cardiovasc Qual Outcomes 2014; 7:335-45. [PMID: 24619323 DOI: 10.1161/circoutcomes.114.000957] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Chalkias A, Vogiatzakis N, Tampakis K, Kalafati M, Papadimitriou L, Xanthos T. One-hand chest compression and hands-off time in single-lay rescuer CPR-a manikin study. Am J Emerg Med 2013; 31:1462-5. [PMID: 24035052 DOI: 10.1016/j.ajem.2013.07.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 07/22/2013] [Accepted: 07/24/2013] [Indexed: 10/26/2022] Open
Abstract
PURPOSE To evaluate the effect of one-hand chest compression while continuously maintaining an open airway (OCOA) on rescue breath-associated hands-off time (RAHO) during single-lay rescuer cardiopulmonary resuscitation (CPR). METHODS In this study, 193 CPR/automated external defibrillator certified lay rescuers were randomly allocated into 2 groups and were tested in a standard scenario using a mannequin. In control group (group A), the participants provided standard CPR. In group B, OCOA was performed by placing the heel of the strong hand in the center of the mannequin's chest while maintaining an open airway using the other hand. RESULTS Mean RAHO was statistically significantly different between the two groups (group A: 8.38 ± 1.97 vs group B: 7.71 ± 2.43, P = .008). Only 13 (13.5%) group A and 25 (25.8%) group B providers ventilated the manikin with tidal volumes of 500 to 600 mL, while most participants caused hyperventilation. Although there were no significant differences in mean tidal volume between the groups, stomach inflation was greater in group A (< .001). Chest compressions were deeper in group A (P < .001), while chest recoil was significantly better in group B. In group B, there was a positive correlation between body mass index and compression depth (group A, P = .423; group B, P < .001). CONCLUSIONS In our study, OCOA resulted in shorter RAHO and less stomach inflation. Our results indicate that the airway should be maintained open during chest compressions, regardless of the technique. Larger studies are needed for the full clarification of OCOA.
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Affiliation(s)
- Athanasios Chalkias
- National and Kapodistrian University of Athens, Medical School, MSc "Cardiopulmonary Resuscitation", 115 26 Athens, Greece.
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Beesems SG, Wijmans L, Tijssen JG, Koster RW. Duration of Ventilations During Cardiopulmonary Resuscitation by Lay Rescuers and First Responders. Circulation 2013; 127:1585-90. [DOI: 10.1161/circulationaha.112.000841] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The 2010 guidelines for cardiopulmonary resuscitation allow 5 seconds to give 2 breaths to deliver sufficient chest compressions and to keep perfusion pressure high. This study aims to determine whether the recommended short interruption for ventilations by trained lay rescuers and first responders can be achieved and to evaluate its consequence for chest compressions and survival.
Methods and Results—
From a prospective data collection of out-of-hospital cardiac arrest, we used automatic external defibrillator recordings of cardiopulmonary resuscitation by rescuers who had received a standard European Resuscitation Council basic life support and automatic external defibrillator course. Ventilation periods and total compressions delivered per minute during each 2 minutes of cardiopulmonary resuscitation cycle were measured, and the chest compression fraction was calculated. Neurological intact survival to discharge was studied in relation to these factors and covariates. We included 199 automatic external defibrillator recordings. The median interruption time for 2 ventilations was 7 seconds (25th–75th percentile, 6–9 seconds). Of all rescuers, 21% took <5 seconds and 83% took <10 seconds for a ventilation period; 97%, 88%, and 63% of rescuers were able to deliver >60, >70, and >80 chest compressions per minute, respectively. The median chest compression fraction was 65% (25th–75th percentile, 59%–71%). Survival was 25% (49 of 199), not associated with long or short ventilation pauses when controlled for covariates.
Conclusions—
The great majority of rescuers can give 2 rescue breaths in <10 seconds and deliver at least 70 compressions in a minute. Longer pauses for ventilations are not associated with worse outcome. Guidelines may allow longer pauses for ventilations with no detriment to survival.
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Affiliation(s)
- Stefanie G. Beesems
- From the Academic Medical Center, Department of Cardiology, Amsterdam, the Netherlands
| | - Lizzy Wijmans
- From the Academic Medical Center, Department of Cardiology, Amsterdam, the Netherlands
| | - Jan G.P. Tijssen
- From the Academic Medical Center, Department of Cardiology, Amsterdam, the Netherlands
| | - Rudolph W. Koster
- From the Academic Medical Center, Department of Cardiology, Amsterdam, the Netherlands
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Abstract
AbstractIntroductionImmediate resuscitation is necessary in order to achieve conscious survival for persons who have lost airways or pulses. However, current literature suggests that even in medically-trained personnel, CPR skills are forgotten shortly after certification.Hypothesis/ProblemThe purpose of this study was to determine the CPR skill and knowledge decay in those who are paid to respond to emergency situations within the workplace.MethodsUsing an unconscious victim scenario, the sequence and accuracy of CPR events were observed and recorded in 244 participants paid to act as first responders in large industrial or service industry settings.ResultsA significant negative correlation was observed between days since training and a pre-CPR safety check variable, periodic checks for breathing and positioning. Many of the knowledge-related assessment skills (e.g., scene safety, emergency medical system (EMS) activation) appeared to deteriorate with time, although they could be contaminated by the repetition of training in those who had recertified one or more times. Skill-based components such as landmarking for chest compressions and controlling the airway declined in a more predictable fashion.ConclusionThe results of this study suggest that repetition may be more important than days since last trained for skill and knowledge retention, and methods of “refreshing” skills should be examined. While skills deteriorate rapidly, changing frequency of certification is not necessarily the best way to increase retention of skill and knowledge.Anderson GS, Gaetz M, Statz C. CPR skill retention of first aid attendants within the workplace. Prehosp Disaster Med. 2012;27(4):1-7.
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Affiliation(s)
- David D Berg
- The Brigham and Women's Hospital and Harvard Medical School, Internal Medicine Residency Office, Boston, MA 02115, USA.
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Anderson GS, Gaetz M, Masse J. First aid skill retention of first responders within the workplace. Scand J Trauma Resusc Emerg Med 2011; 19:11. [PMID: 21303536 PMCID: PMC3044091 DOI: 10.1186/1757-7241-19-11] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 02/08/2011] [Indexed: 11/20/2022] Open
Abstract
Background Recent literature states that many necessary skills of CPR and first aid are forgotten shortly after certification. The purpose of this study was to determine the skill and knowledge decay in first aid in those who are paid to respond to emergency situations within a workplace. Methods Using a choking victim scenario, the sequence and accuracy of events were observed and recorded in 257 participants paid to act as first responders in large industrial or service industry settings. A multiple choice exam was also written to determine knowledge retention. Results First aid knowledge was higher in those who were trained at a higher level, and did not significantly decline over time. Those who had renewed their certificate one or more times performed better than those who had learned the information only once. During the choking scenario many skills were performed poorly, regardless of days since last training, such as hand placement and abdominal thrusts. Compressions following the victim becoming unconscious also showed classic signs of skill deterioration after 30 days. Conclusions As many skills deteriorate rapidly over the course of the first 90 days, changing frequency of certification is not necessarily the most obvious choice to increase retention of skill and knowledge. Alternatively, methods of regularly "refreshing" a skill should be explored that could be delivered at a high frequency - such as every 90 days.
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Affiliation(s)
- Gregory S Anderson
- Kinesiology and Physical Education, University of the Fraser Valley, Abbotsford, BC, Canada.
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Postconditioning in cardiopulmonary resuscitation: A better protocol for cardiopulmonary resuscitation. Med Hypotheses 2009; 73:321-3. [DOI: 10.1016/j.mehy.2009.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Revised: 02/22/2009] [Accepted: 03/04/2009] [Indexed: 11/20/2022]
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Siebers C, Müßig B, Huppertz T, Kanz KG. Atemwegsmanagement in der Initialphase der Reanimation. Notf Rett Med 2009. [DOI: 10.1007/s10049-009-1149-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sanders AB. Progress in improving neurologically intact survival from cardiac arrest. Ann Emerg Med 2008; 52:253-5. [PMID: 18490079 DOI: 10.1016/j.annemergmed.2008.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2008] [Revised: 04/06/2008] [Accepted: 04/16/2008] [Indexed: 10/22/2022]
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Fletcher D, Galloway R, Chamberlain D, Pateman J, Bryant G, Newcombe RG. Basics in advanced life support: a role for download audit and metronomes. Resuscitation 2008; 78:127-34. [PMID: 18486301 DOI: 10.1016/j.resuscitation.2008.03.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2007] [Revised: 01/03/2008] [Accepted: 03/10/2008] [Indexed: 10/22/2022]
Abstract
An intention in 2003 to undertake a multicentre trial in the United Kingdom of compressions before and after defibrillation could not be realized because of concerns at the time in relation to informed consent. Instead, the new protocol was introduced in one ambulance service, ahead of the 2005 Guidelines, with greater emphasis on compressions. The results were monitored by analysis of electronic ECG downloads. Deficiencies in the standard of basic life support were identified but were not unique to our service. The introduction of metronomes and the provision of feedback to crews led to major improvements in performance. Our experience has implications for the emergency pre-hospital care of cardiac arrest.
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Affiliation(s)
- David Fletcher
- South East Coast Ambulance Trust, 40-42 Friars Walk, Lewes BN7 2XW, East Sussex, United Kingdom
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Sayre MR, Berg RA, Cave DM, Page RL, Potts J, White RD. Hands-only (compression-only) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out-of-hospital sudden cardiac arrest: a science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee. Circulation 2008; 117:2162-7. [PMID: 18378619 DOI: 10.1161/circulationaha.107.189380] [Citation(s) in RCA: 273] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Educación en reanimación básica. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2008. [DOI: 10.1016/s0120-3347(08)61005-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Jäntti H, Kuisma M, Uusaro A. The effects of changes to the ERC resuscitation guidelines on no flow time and cardiopulmonary resuscitation quality: A randomised controlled study on manikins. Resuscitation 2007; 75:338-44. [PMID: 17628319 DOI: 10.1016/j.resuscitation.2007.05.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2007] [Revised: 04/30/2007] [Accepted: 05/02/2007] [Indexed: 11/30/2022]
Abstract
AIM OF THE STUDY The European Resuscitation Council (ERC) guidelines changed in 2005. We investigated the impact of these changes on no flow time and on the quality of cardiopulmonary resuscitation (CPR). MATERIALS AND METHODS Simulated cardiac arrest (CA) scenarios were managed randomly in manikins using ERC 2000 or 2005 guidelines. Pairs of paramedics/paramedic students treated 34 scenarios with 10min of continuous ventricular fibrillation. The rhythm was analysed and defibrillation shocks were delivered with a semi-automatic defibrillator, and breathing was assisted with a bag-valve-mask; no intravenous medication was given. Time factors related to human intervention and time factors related to device, rhythm analysis, charging and defibrillation were analysed for their contribution to no flow time (time without chest compression). Chest compression quality was also analysed. RESULTS No flow time (mean+/-S.D.) was 66+/-3% of CA time with ERC 2000 and 32+/-4% with ERC 2005 guidelines (P<0.001). Human factor interventions occupied 114+/-4s (ERC 2000) versus 107+/-4s (ERC 2005) during 600-s scenarios (P=0.237). Device factor interventions took longer using ERC 2000 guidelines: 290+/-19s versus 92+/-15s (P<0.001). The total number of chest compressions was higher with ERC 2005 guidelines (808+/-92s versus 458+/-90s, P<0.001), but the quality of CPR did not differ between the groups. CONCLUSIONS The use of a single shock sequence with guidelines 2005 has decreased the no flow time during CPR when compared with guidelines 2000 with multiple shocks.
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Affiliation(s)
- H Jäntti
- Department of Anaesthesia and Intensive Care, Kuopio University Hospital, PO Box 1777, FIN-70210 Kuopio, Finland.
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In this issue. Resuscitation 2006. [DOI: 10.1016/j.resuscitation.2006.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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