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Giugni C, Cecchi C, Giometto S, Lucenteforte E, Mondardini C, Chiusolo F, Giannini A, Astuto M, Figini M, Piazza M, Tosoni A, Ricci Z. What Italian PICU Healthcare Providers Think About Donation After Cardiocirculatory Determination of Death: A National Survey. Pediatr Transplant 2024; 28:e14806. [PMID: 38923333 DOI: 10.1111/petr.14806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 04/18/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Italy presently does not have a pediatric organ donation program after cardiocirculatory determination of death (pDCDD). Before implementing a pDCDD program, many centers globally have conducted studies on the attitudes of pediatric intensive care unit (PICU) staff. This research aims to minimize potential adverse reactions and evaluate the acceptance of the novel donation practice. METHODS We conducted an electronic and anonymous survey on attitudes toward pDCDD among healthcare professionals (HCPs) working at eight Italian PICUs. The survey had three parts: (I) questions about general demographic data; (II) 18 statements about personal wishes to donate, experience of discussing donation, and knowledge about donation; (III) attitudinal statements regarding two pediatric Maastricht III scenarios of organ donation. RESULTS The response rate was 54.4%, and the majority of respondents were nurses. Of those who responded, 45.3% worked in the Center, 40.8% in the North, and 12.8% in the South of Italy. In total, 93.9% supported pediatric organ and tissue donation, 90.3% supported donation after neurological determination of death (DNDD), 78.2% supported pDCDD, and 69.7% felt comfortable about the idea of participating in pDCDD on Type III patients, with a higher percentage of supportive responses in the Center (77.2%) than in the North (65.1%) and South (54.5%) of Italy (p-value < 0.004). Concerning scenarios, 79.3% of participants believed that organ retrieval took place in a patient who was already deceased. Overall, 27.3% considered their knowledge about DCDD to be adequate. CONCLUSIONS Our study provides insight into the attitudes and knowledge of PICU staff members regarding pDCDD in Italy. Despite a general lack of knowledge on the subject, respondents showed positive attitudes toward pDCDD and a strong consensus that the Italian legislation protocol for determining death based on cardiocirculatory criteria respects the "dead donor rule." There were several distinctions among the northern, central, and southern regions of Italy, and in our view, these disparities can be attributed to the varying practices of commemorating the deceased. In order to assess how practice and training influence the attitude of PICU staff members, it would be interesting to repeat the survey after the implementation of a program.
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Affiliation(s)
- Cristina Giugni
- Department of Anesthesiology and Critical Care Medicine, Pediatric Intensive Care Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Costanza Cecchi
- Department of Anesthesiology and Critical Care Medicine, Pediatric Intensive Care Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Sabrina Giometto
- Unit of Medical Statistics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ersilia Lucenteforte
- Department of Statistics, Computer Science and Applications "G. Parenti", University of Florence, Florence, Italy
| | - Cristina Mondardini
- Pediatric Intensive Care Unit, Hospital Department of Women's and Children's, IRCCS Azienda Ospedaliero-Universitaria, Bologna, Italy
| | - Fabrizio Chiusolo
- Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Giannini
- Department of Anesthesiology and Critical Care Medicine, Pediatric Intensive Care Unit, Ospedale dei Bambini ASST-Spedali Civili, Brescia, Italy
| | - Marinella Astuto
- Department of Medical and Surgical Medicine, Intensive Care Unite 1, AOU Policlinico San Marco, Catania, Italy
| | - Maria Figini
- Pediatric Intensive Care Unit, IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marcello Piazza
- Pediatric Intensive Care Unit and Trauma Center, ARNAS Civico e Di Cristina, Palermo, Italy
| | - Alvise Tosoni
- Pediatric Intensive Care Unit, Department of Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Zaccaria Ricci
- Department of Anesthesiology and Critical Care Medicine, Pediatric Intensive Care Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Anesthesiology and Critical Care Medicine, Department of Health Science, University of Florence, Florence, Italy
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Gaillard-Le Roux B, Cremer R, de Saint Blanquat L, Beaux J, Blanot S, Bonnin F, Bordet F, Deho A, Dupont S, Klusiewicz A, Lafargue A, Lemains M, Merchaoui Z, Quéré R, Samyn M, Saulnier ML, Temper L, Michel F, Dauger S. Organ donation by Maastricht-III pediatric patients: Recommendations of the Groupe Francophone de Réanimation et Urgences Pédiatriques (GFRUP) and Association des Anesthésistes Réanimateurs Pédiatriques d'Expression Française (ADARPEF) Part I: Ethical considerations and family care. Arch Pediatr 2022; 29:502-508. [DOI: 10.1016/j.arcped.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 05/04/2022] [Accepted: 06/18/2022] [Indexed: 11/27/2022]
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Skowronski G, Ramnani A, Walton-Sonda D, Forlini C, O'Leary MJ, O'Reilly L, Sheahan L, Stewart C, Kerridge I. A scoping review of the perceptions of death in the context of organ donation and transplantation. BMC Med Ethics 2021; 22:167. [PMID: 34922506 PMCID: PMC8684159 DOI: 10.1186/s12910-021-00734-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Socio-cultural perceptions surrounding death have profoundly changed since the 1950s with development of modern intensive care and progress in solid organ transplantation. Despite broad support for organ transplantation, many fundamental concepts and practices including brain death, organ donation after circulatory death, and some antemortem interventions to prepare for transplantation continue to be challenged. Attitudes toward the ethical issues surrounding death and organ donation may influence support for and participation in organ donation but differences between and among diverse populations have not been studied. OBJECTIVES In order to clarify attitudes toward brain death, organ donation after circulatory death and antemortem interventions in the context of organ donation, we conducted a scoping review of international English-language quantitative surveys in various populations. STUDY APPRAISAL A search of literature up to October 2020 was performed, using multiple databases. After screening, 45 studies were found to meet pre-specified inclusion criteria. RESULTS 32 studies examined attitudes to brain death, predominantly in healthcare professionals. In most, around 75% of respondents accepted brain death as equivalent to death of the person. Less common perspectives included equating death with irreversible coma and willingness to undertake organ donation even if it caused death. 14 studies examined attitudes to organ donation following circulatory death. Around half of respondents in most studies accepted that death could be confidently diagnosed after only 5 min of cardiorespiratory arrest. The predominant reason was lack of confidence in doctors or diagnostic procedures. Only 6 studies examined attitudes towards antemortem interventions in prospective organ donors. Most respondents supported minimally invasive procedures and only where specific consent was obtained. CONCLUSIONS Our review suggests a considerable proportion of people, including healthcare professionals, have doubts about the medical and ethical validity of modern determinations of death. The prognosis of brain injury was a more common concern in the context of organ donation decision-making than certainty of death.
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Affiliation(s)
- George Skowronski
- Sydney Health Ethics, University of Sydney, Sydney, Australia. .,St George Hospital, Gray Street, Kogarah, NSW, 2217, Australia.
| | | | | | | | | | - Lisa O'Reilly
- South East Sydney Local Health District, Sydney, Australia
| | - Linda Sheahan
- Sydney Health Ethics, University of Sydney, Sydney, Australia
| | | | - Ian Kerridge
- Sydney Health Ethics, University of Sydney, Sydney, Australia.,Haematology Department, Royal North Shore Hospital, St Leonards, Australia
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O'Leary MJ, Skowronski G, Critchley C, O'Reilly L, Forlini C, Sheahan L, Stewart C, Kerridge I. Death determination, organ donation and the importance of the Dead Donor Rule following withdrawal of life-sustaining treatment: A survey of community opinions. Intern Med J 2021; 52:238-248. [PMID: 33528090 DOI: 10.1111/imj.15221] [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: 09/28/2020] [Revised: 01/05/2021] [Accepted: 01/17/2021] [Indexed: 12/01/2022]
Abstract
Organ donation (OD) following circulatory determination of death (DCDD) is an increasing source of transplant organs but little is known about community opinions on treatment withdrawal, death determination death and acceptance of OD in DCDD. To determine attitudes on death determination, the importance of patient choice in treatment withdrawal and OD agreement, and the importance of the 'Dead Donor Rule', we undertook a scenario-based online survey of 1017 members of the Australian general public. Mean levels of agreement across respondent's responses to statements were compared by repeated measures ANOVA. 54% (548) of respondents agreed that a DCDD scenario patient could be declared dead 2 minutes after circulatory standstill, however over 80% nonetheless agreed OD would be appropriate, including 77% (136/176) of those disagreeing with 2-minute death declaration. 48% (484) supported OD even if it caused the patient's death. 75% (766) accepted relatively benign ante-mortem treatments administered to improve transplant outcomes. Over 70% supported a high quadriplegic patient's request to be allowed to die, with 61% (622) agreeing that he should be allowed to donate his organs under anaesthesia, but 60% (610) also agreed that he should first be declared dead. In conclusion, we found high levels of support for treatment withdrawal in severe brain injury and when requested by a quadriplegic patient. While there was variable agreement with the timing of death determination and with OD under anaesthesia, support for OD was high in both scenarios. For many people death determination prior to OD may not be of paramount importance. This article is protected by copyright. All rights reserved.
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Ethics of Approaching Parents for Pediatric Donation After Circulatory Death. CURRENT PEDIATRICS REPORTS 2019. [DOI: 10.1007/s40124-019-00205-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Controlled donation after circulatory death (DCD) donors: A focus on the utilization of pediatric donors and outcomes after lung transplantation. J Heart Lung Transplant 2019; 38:1089-1096. [DOI: 10.1016/j.healun.2019.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 06/15/2019] [Accepted: 06/15/2019] [Indexed: 12/18/2022] Open
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Pediatric donation after circulatory determination of death (pDCD): A narrative review. Paediatr Respir Rev 2019; 29:3-8. [PMID: 29716830 DOI: 10.1016/j.prrv.2018.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 03/13/2018] [Indexed: 01/30/2023]
Abstract
Pediatric donation after circulatory death (pDCD) is an established pathway for organ donation. It remains, however, a relatively rare event worldwide, and most clinicians outside of the pediatric intensive care unit (PICU) are unfamiliar with it. The goal of this review is to introduce the processes and concepts of pDCD. While most children die in circumstances that would not allow pDCD, many children that die after withdrawal of life sustaining therapy (WLST) may be eligible for donation of some organs. The potential benefits of this practice to patients on the wait list are well known, but donation can also be an opportunity to honor a patient's or family's desire to altruistically improve the lives of others. Offering the possibility of donation requires careful attention to ethical principles to ensure that conflicts of interest are avoided and that the family is free to make an independent, fully informed decision. Doing so allows families and decision makers the autonomy to decide if donation is something they wish to incorporate into end-of-life care.
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Pediatric Donation After Circulatory Determination of Death: Canadian Guidelines Define Parameters of Consensus and Uncertainty. Pediatr Crit Care Med 2017; 18:1068-1070. [PMID: 29099447 DOI: 10.1097/pcc.0000000000001322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Suttle ML, Jenkins TL, Tamburro RF. End-of-Life and Bereavement Care in Pediatric Intensive Care Units. Pediatr Clin North Am 2017; 64:1167-1183. [PMID: 28941542 PMCID: PMC5747301 DOI: 10.1016/j.pcl.2017.06.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Most childhood deaths in the United States occur in hospitals. Pediatric intensive care clinicians must anticipate and effectively treat dying children's pain and suffering and support the psychosocial and spiritual needs of families. These actions may help family members adjust to their loss, particularly bereaved parents who often experience reduced mental and physical health. Candid and compassionate communication is paramount to successful end-of-life (EOL) care as is creating an environment that fosters meaningful family interaction. EOL care in the pediatric intensive care unit is associated with challenging ethical issues, of which clinicians must maintain a sound and working understanding.
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Affiliation(s)
- Markita L. Suttle
- Department of Critical Care Medicine, Nationwide Children's Hospital
| | - Tammara L. Jenkins
- Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Robert F. Tamburro
- Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
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Gelbart B. Challenges of paediatric organ donation. J Paediatr Child Health 2017; 53:534-539. [PMID: 28398658 DOI: 10.1111/jpc.13541] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 01/20/2017] [Accepted: 01/20/2017] [Indexed: 11/29/2022]
Abstract
Paediatric organ donation represents a small fraction of overall organ donation in Australia and New Zealand and indeed world-wide. Many factors contribute to low donation rates including low paediatric intensive care mortality, consent rates and medical suitability relating to disease, age and size. In the past decade, the re-emergence of donation after circulatory death has changed the landscape for the paediatric population. This article reviews the current status and challenges of organ donation for the paediatric population.
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Affiliation(s)
- Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children's Hospital, Murdoch Children's Research Institute, DonateLife, Victoria, Melbourne, Victoria, Australia
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Electroencephalographic Recordings During Withdrawal of Life-Sustaining Therapy Until 30 Minutes After Declaration of Death. Can J Neurol Sci 2017; 44:139-145. [PMID: 28231862 DOI: 10.1017/cjn.2016.309] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The timing of the circulatory determination of death for organ donation presents a medical and ethical challenge. Concerns have been raised about the timing of electrocerebral inactivity in relation to the cessation of circulatory function in organ donation after cardio-circulatory death. Nonprocessed electroencephalographic (EEG) measures have not been characterized and may provide insight into neurological function during this process. METHODS We assessed electrocortical data in relation to cardiac function after withdrawal of life-sustaining therapy and in the postmortem period after cardiac arrest for four patients in a Canadian intensive care unit. Subhairline EEG and cardio-circulatory monitoring including electrocardiogram, arterial blood pressure (ABP), and oxygen saturation were captured. RESULTS Electrocerebral inactivity preceded the cessation of the cardiac rhythm and ABP in three patients. In one patient, single delta wave bursts persisted following the cessation of both the cardiac rhythm and ABP. There was a significant difference in EEG amplitude between the 30-minute period before and the 5-minute period following ABP cessation for the group, but we did not observe any well-defined EEG states following the early cardiac arrest period. CONCLUSIONS In a case series of four patients, EEG inactivity preceded electrocardiogram and ABP inactivity during the dying process in three patients. Further study of the electroencephalogram during the withdrawal of life sustaining therapies will add clarity to medical, ethical, and legal concerns for donation after circulatory determined death.
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Pana R, Hornby L, Shemie SD, Dhanani S, Teitelbaum J. Time to loss of brain function and activity during circulatory arrest. J Crit Care 2016; 34:77-83. [PMID: 27288615 DOI: 10.1016/j.jcrc.2016.04.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 04/03/2016] [Accepted: 04/04/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE Brain function during the dying process and around the time of cardiac arrest is poorly understood. To better inform the clinical physiology of the dying process and organ donation practices, we performed a scoping review of the literature to assess time to loss of brain function and activity after circulatory arrest. MATERIALS AND METHODS Medline and Embase databases were searched from inception to June 2014 for articles reporting the time interval to loss of brain function or activity after loss of systemic circulation. RESULTS Thirty-nine studies met selection criteria. Seven human studies and 10 animal studies reported that electroencephalography (EEG) activity is lost less than 30seconds after abrupt circulatory arrest. In the setting of existing brain injury, with progressive loss of oxygenated circulation, loss of EEG may occur before circulatory arrest. Cortical evoked potentials may persist for several minutes after loss of circulation. CONCLUSION The time required to lose brain function varied according to clinical context and method by which this function is measured. Most studies show that clinical loss of consciousness and loss of EEG activity occur within 30seconds after abrupt circulatory arrest and may occur before circulatory arrest after progressive hypoxia-ischemia. Prospective clinical studies are required to confirm these observations.
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Affiliation(s)
- R Pana
- Division of Neurology, McGill University Health Center, Montreal, QC, Canada.
| | - L Hornby
- Division of Pediatric Critical Care, Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada; Deceased Donation, Canadian Blood Services, Ottawa, ON, Canada
| | - S D Shemie
- Deceased Donation, Canadian Blood Services, Ottawa, ON, Canada; Division of Critical Care, Montreal Children's Hospital, McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - S Dhanani
- Children's Hospital of Eastern Ontario, Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - J Teitelbaum
- Division of Neurology and Neurosurgery, McGill University Health Center, Montreal Neurological Institute, Montreal, QC, Canada
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Abstract
OBJECTIVE Although pediatric donation after circulatory determination of death is increasing in frequency, there are no national or international donation after circulatory determination of death guidelines specific to pediatrics. This scoping review was performed to map the pediatric donation after circulatory determination of death literature, identify pediatric donation after circulatory determination of death knowledge gaps, and inform the development of national or regional pediatric donation after circulatory determination of death guidelines. DATA SOURCES Terms related to pediatric donation after circulatory determination of death were searched in Embase and MEDLINE, as well as the non-MEDLINE sources in PubMed from 1980 to May 2014. STUDY SELECTION Seven thousand five hundred ninety-seven references were discovered and 85 retained for analysis. All references addressing pediatric donation after circulatory determination of death were considered. Exclusion criteria were articles that did not address pediatric patients, animal or laboratory studies, surgical techniques, and local pediatric donation after circulatory determination of death protocols. Narrative reviews and opinion articles were the most frequently discovered reference (25/85) and the few discovered studies were observational or qualitative and almost exclusively retrospective. DATA EXTRACTION Retained references were divided into themes and analyzed using qualitative methodology. DATA SYNTHESIS The main discovered themes were 1) studies estimating the number of potential pediatric donation after circulatory determination of death donors and their impact on donation; 2) ethical issues in pediatric donation after circulatory determination of death; 3) physiology of the dying process after withdrawal of life-sustaining therapy; 4) cardiac pediatric donation after circulatory determination of death; and 5) neonatal pediatric donation after circulatory determination of death. Donor estimates suggest that pediatric donation after circulatory determination of death will remain an event less common than brain death, albeit with the potential to substantially expand the existing organ donation pool. Limited data suggest outcomes comparable with organs donated after neurologic determination of death. Although there is continued debate around ethical aspects of pediatric donation after circulatory determination of death, all pediatric donation after circulatory determination of death publications from professional societies contend that pediatric donation after circulatory determination of death can be practiced ethically. CONCLUSIONS This review provides a comprehensive overview of the published literature related to pediatric donation after circulatory determination of death. In addition to informing the development of pediatric-specific guidelines, this review serves to highlight several important knowledge gaps in this topic.
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Sarnaik AA. Neonatal and Pediatric Organ Donation: Ethical Perspectives and Implications for Policy. Front Pediatr 2015; 3:100. [PMID: 26636051 PMCID: PMC4646954 DOI: 10.3389/fped.2015.00100] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/02/2015] [Indexed: 11/20/2022] Open
Abstract
The lifesaving processes of organ donation and transplantation in neonatology and pediatrics carry important ethical considerations. The medical community must balance the principles of autonomy, non-maleficence, beneficence, and justice to ensure the best interest of the potential donor and to provide equitable benefit to society. Accordingly, the US Organ Procurement and Transplantation Network (OPTN) has established procedures for the ethical allocation of organs depending on several donor-specific and recipient-specific factors. To maximize the availability of transplantable organs and opportunities for dying patients and families to donate, the US government has mandated that hospitals refer potential donors in a timely manner. Expedient investigation and diagnosis of brain death where applicable are also crucial, especially in neonates. Empowering trained individuals from organ procurement organizations to discuss organ donation with families has also increased rates of consent. Other efforts to increase organ supply include recovery from donors who die by circulatory criteria (DCDD) in addition to donation after brain death (DBD), and from neonates born with immediately lethal conditions such as anencephaly. Ethical considerations in DCDD compared to DBD include a potential conflict of interest between the dying patient and others who may benefit from the organs, and the precision of the declaration of death of the donor. Most clinicians and ethicists believe in the appropriateness of the Dead Donor Rule, which states that vital organs should only be recovered from people who have died. The medical community can maximize the interests of organ donors and recipients by observing the Dead Donor Rule and acknowledging the ethical considerations in organ donation.
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Affiliation(s)
- Ajit A. Sarnaik
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA
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Examining Knowledge, Attitudes, and Behavior—The Unique Function of Survey Research in Illuminating Ethical Concerns in the Practice of Intensive Care*. Crit Care Med 2013; 41:1819-20. [DOI: 10.1097/ccm.0b013e318291337f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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