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Chavez AA, Simmonds KP, Venkatachalam AM, Ifejika NL. Health Care Disparities in Stroke Rehabilitation. Phys Med Rehabil Clin N Am 2024; 35:293-303. [PMID: 38514219 DOI: 10.1016/j.pmr.2023.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Stroke outcomes are influenced by factors such as education, lifestyle, and access to care, which determine the extent of functional recovery. Disparities in stroke rehabilitation research have traditionally included age, race/ethnicity, and sex, but other areas make up a gap in the literature. This article conducted a literature review of original research articles published between 2008 and 2022. The article also expands on research that highlights stroke disparities in risk factors, rehabilitative stroke care, language barriers, outcomes for stroke survivors, and interventions focused on rehabilitative stroke disparities.
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Affiliation(s)
- Audrie A Chavez
- Brain Injury Medicine Fellow, Spaulding Rehabilitation, Harvard University, Cambridge, MA, USA
| | - Kent P Simmonds
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Nneka L Ifejika
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center, Dallas, TX, USA; Department of Neurology, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Stop 9055, Dallas, TX 75390-9055, USA.
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Hsiao CC, Cheng CG, Chen CC, Chiu HW, Lin HC, Cheng CA. Semantic Visualization in Functional Recovery Prediction of Intravenous Thrombolysis following Acute Ischemic Stroke in Patients by Using Biostatistics: An Exploratory Study. J Pers Med 2023; 13:jpm13040624. [PMID: 37109009 PMCID: PMC10143597 DOI: 10.3390/jpm13040624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/16/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
(1) Background: Intravenous thrombolysis following acute ischemic stroke (AIS) can reduce disability and increase the survival rate. We designed a functional recovery analysis by using semantic visualization to predict the recovery probability in AIS patients receiving intravenous thrombolysis; (2) Methods: We enrolled 131 AIS patients undergoing intravenous thrombolysis from 2011 to 2015 at the Medical Center in northern Taiwan. An additional 54 AIS patients were enrolled from another community hospital. A modified Rankin Score ≤2 after 3 months of follow-up was defined as favorable recovery. We used multivariable logistic regression with forward selection to construct a nomogram; (3) Results: The model included age and the National Institutes of Health Stroke Scale (NIHSS) score as immediate pretreatment parameters. A 5.23% increase in the functional recovery probability occurred for every 1-year reduction in age, and a 13.57% increase in the functional recovery probability occurred for every NIHSS score reduction. The sensitivity, specificity, and accuracy of the model in the validation dataset were 71.79%, 86.67%, and 75.93%, respectively, and the area under the receiver operating characteristic curve (AUC) was 0.867; (4) Conclusions: Semantic visualization-based functional recovery prediction models may help physicians assess the recovery probability before patients undergo emergency intravenous thrombolysis.
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Affiliation(s)
- Chih-Chun Hsiao
- Department of Nursing, Taoyuan Armed Forces General Hospital, Taoyuan 32549, Taiwan
| | - Chun-Gu Cheng
- Department of Emergency Medicine, Taoyuan Armed Forces General Hospital, Taoyuan 32549, Taiwan
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
| | - Cheng-Chueh Chen
- Department of General Surgery, China Medical University Beigang Hospital, Yunlin 65152, Taiwan
| | - Hung-Wen Chiu
- Graduate Institute of Medical Informatics, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan
| | - Hui-Chen Lin
- School of Nursing, College of Nursing, Taipei Medical University, Taipei 11031, Taiwan
| | - Chun-An Cheng
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei 11490, Taiwan
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Venkatachalam AM, Rabroker A, Stone S, Manchi MR, Sengupta S, Ifejika NL. Effect of an Interdisciplinary Stroke Consult Service on the Transition to Post-Acute Rehabilitation. Arch Phys Med Rehabil 2022; 103:1338-1344. [DOI: 10.1016/j.apmr.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 03/08/2022] [Accepted: 03/20/2022] [Indexed: 11/27/2022]
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Abstract
ABSTRACT Stroke, the most common form of cerebrovascular disease, is a leading cause of death and disability throughout the world. There have been no significant advances in the development of effective therapeutics for hemorrhagic stroke, and for ischemic stroke highly effective, evidence-based therapies such as alteplase and mechanical thrombectomy are widely underutilized. Improving outcomes for patients experiencing ischemic stroke requires faster recognition and appropriate intervention within the treatment window (the first 24 hours after symptom onset). This article discusses the pathophysiology underlying the various types of ischemic stroke; the risk factors for ischemic stroke; stroke presentation; and the evidence-based treatments, nursing assessments, and monitoring protocols that are critical to patient recovery.
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Affiliation(s)
- Heather H Washington
- Nneka Lotea Ifejika is an associate professor of physical medicine and rehabilitation and section chief of stroke rehabilitation at the University of Texas Southwestern (UT Southwestern) Medical Center, Dallas, where Heather H. Washington is an acute care NP in the Department of Neurology, and Kimberly R. Glaser is an acute care NP in the Division of Neurocritical Care. Contact author: Nneka Lotea Ifejika, . The authors and planners have disclosed no potential conflicts of interest, financial or otherwise. A podcast with the authors is available at www.ajnonline.com
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Nathaniel TI, Cochran T, Chaves J, Fulmer E, Sosa C, Yi S, Fredwall M, Sternberg S, Blackhurst D, Nelson A, Leacock R. Co-morbid conditions in use of recombinant tissue plasminogen activator (rt-PA) for the treatment of acute ischaemic stroke. Brain Inj 2016; 30:1261-5. [DOI: 10.1080/02699052.2016.1186840] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ifejika NL, Noser EA, Grotta JC, Savitz SI. Swipe out Stroke: Feasibility and efficacy of using a smart-phone based mobile application to improve compliance with weight loss in obese minority stroke patients and their carers. Int J Stroke 2016; 11:593-603. [PMID: 26956032 DOI: 10.1177/1747493016631557] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/25/2015] [Indexed: 02/01/2023]
Abstract
RATIONALE Swipe out Stroke (SOS) examines the use of a smartphone-based mobile application to reduce obesity in high-risk minority stroke patients. At record-high levels in the United States, obesity disproportionately affects minorities and is highly correlated with cerebrovascular disease. Unfortunately, structured weight loss programs are expensive, and compliance significantly decreases upon program completion. Mobile health (mHealth) technology is an innovative, cost-effective way to bridge this gap. Minorities spend over 4.5 billion dollars annually on consumer electronics, making studies that utilize mHealth applications ideal for health promotion and disease prevention. AIMS AND DESIGN SOS is a prospective, randomized-controlled trial with open blinded endpoint comparing an mHealth based dietary intervention to usual care to facilitate weight reduction. Ischemic and hemorrhagic stroke survivors and their carers are recruited from the acute care service of a Houston-based comprehensive stroke center. A neurorehabilitation physician or vascular neurologist meets with participants during the index hospitalization, a baseline clinic visit, followed by visits at 1, 3, and 6 month intervals. The SOS Team focuses on feasible modifications to the Southern dietary pattern (fried foods, fatty foods, added fats, eggs, processed meats, such as bacon and ham, organ meats (e.g., liver), and sweetened drinks) and caloric restriction to facilitate a 5% reduction in total body weight. Practical barriers to adherence are addressed, such as access to transportation, financial limitations, and depression. STUDY OUTCOMES The primary dependent measure is a reduction of total body weight. Secondary outcomes include systolic blood pressure, hemoglobin A1c, low-density lipoprotein, triglycerides, and Factor VIII. CONCLUSION SOS will determine whether a Phase III effectiveness trial of a smartphone-based mobile application to address obesity-related health disparities is warranted throughout the Southeastern United States (Stroke Belt).
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Affiliation(s)
- Nneka Lotea Ifejika
- University of Texas Health Science Center at Houston (UTHealth) McGovern Medical School, Houston, USA
| | - Elizabeth Anne Noser
- University of Texas Health Science Center at Houston (UTHealth) McGovern Medical School, Houston, USA
| | - James C Grotta
- University of Texas Health Science Center at Houston (UTHealth) McGovern Medical School, Houston, USA
| | - Sean I Savitz
- University of Texas Health Science Center at Houston (UTHealth) McGovern Medical School, Houston, USA
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Ifejika NL, Vahidy F, Aramburo-Maldonado LA, Cai C, Sline MR, Grotta JC, Savitz SI. Acute Intravenous Tissue Plasminogen Activator Therapy does not Impact Community Discharge after Inpatient Rehabilitation. INTERNATIONAL JOURNAL OF NEUROREHABILITATION 2015; 2:183. [PMID: 26722667 PMCID: PMC4694634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND AND PURPOSE Discharge status and acute re-hospitalization are used as indicators of stroke severity and recovery. Intravenous t-PA (tissue plasminogen activator) is one of two treatments shown to have a positive impact. Stroke rehabilitation patients are an important population who will end up integrated back into the community, institutionalized or hospitalized due to late stroke complications. We sought to determine factors contributing to post rehabilitation discharge and acute re-hospitalization, in particular, the impact of t-PA therapy. METHODS Retrospective analysis of census data from ischemic stroke patients on the UTHealth Stroke/Neurorehabilitation Services at Memorial Hermann Hospital - Texas Medical Center between Jan 2011 and Nov 2013, discharged to the Community, SNF (Skilled Nursing Facility) or AC (Acute Care). Demographics and NIHSS (National Institutes of Health Stroke Scale) were collected. Discharge FIM (Functional Independence Measure) was the reference standard. Genitourinary infections were a negative mediator in the multivariate regression. RESULTS Of 346 patients, 274 returned to the community, 47 to SNF, and 25 to AC. NIHSS AND T-PA THERAPY Median NIHSS values were 8 in the community group, 11 in SNF and 9.5 in AC. 31.8% of patients received IV t-PA in the community group, 23.4% in SNF and 24% in AC. There were no statistically differences in community discharge rates. COMMUNITY VS AC One day increase in rehabilitation hospitalization correlated with 19% decreased odds of AC readmission (OR 0.81; P=0.001). One unit discharge FIM increase correlated with 13% decreased odds of AC readmission (OR 0.87; P=0.003). COMMUNITY VS SNF One year age increase correlated with 4% increased odds of SNF admission (OR 1.04; P=0.02). CONCLUSIONS Intense rehabilitation evidenced by FIM improvement and length of stay, impacts community discharge in mild to moderate stroke patients. t-PA had no effect. This study is limited by sample size, retrospective design and undetermined psychosocial factors.
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Affiliation(s)
- Nneka L Ifejika
- Department of Neurology (N.L.I., F.V., L.A.A., M.R.S., S.I.S,), University of Texas Health Science, Center at Houston Medical School, Houston, Texas, USA
- Department of Physical Medicine and Rehabilitation (N.L.I.), University of Texas Health Science Center at Houston Medical School, Houston, Texas, USA
| | - Farhaan Vahidy
- Department of Neurology (N.L.I., F.V., L.A.A., M.R.S., S.I.S,), University of Texas Health Science, Center at Houston Medical School, Houston, Texas, USA
| | - Linda A Aramburo-Maldonado
- Department of Physical Medicine and Rehabilitation (N.L.I.), University of Texas Health Science Center at Houston Medical School, Houston, Texas, USA
| | - Chunyan Cai
- Division of Clinical and Translational Sciences, Department of Internal Medicine (C.C.), University of Texas Health Science Center at Houston Medical School, Houston, Texas, USA
| | - Melvin R Sline
- Department of Neurology (N.L.I., F.V., L.A.A., M.R.S., S.I.S,), University of Texas Health Science, Center at Houston Medical School, Houston, Texas, USA
| | - James C Grotta
- Mischer Neuroscience Institute (J.C.G.), Memorial Hermann Hospital-Texas Medical Center, Houston, Texas, USA
| | - Sean I Savitz
- Department of Neurology (N.L.I., F.V., L.A.A., M.R.S., S.I.S,), University of Texas Health Science, Center at Houston Medical School, Houston, Texas, USA
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Nguyen VQ, PrvuBettger J, Guerrier T, Hirsch MA, Thomas JG, Pugh TM, Rhoads CF. Factors Associated With Discharge to Home Versus Discharge to Institutional Care After Inpatient Stroke Rehabilitation. Arch Phys Med Rehabil 2015; 96:1297-303. [DOI: 10.1016/j.apmr.2015.03.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 03/04/2015] [Accepted: 03/14/2015] [Indexed: 11/27/2022]
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A case-control study of the effectiveness of tissue plasminogen activator on 6 month patients--reported outcomes and health care utilization. J Stroke Cerebrovasc Dis 2014; 23:2914-2919. [PMID: 25440368 DOI: 10.1016/j.jstrokecerebrovasdis.2014.07.049] [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: 05/30/2014] [Revised: 07/07/2014] [Accepted: 07/18/2014] [Indexed: 11/20/2022] Open
Abstract
We examined the benefit of tissue plasminogen activator (tPA), delivered as part of usual stroke management, on patient-reported outcomes and health care utilization. Using a case control design, patients who received tPA as part of usual stroke management were compared with patients who would have received tPA had they arrived to the hospital within the therapeutic time window. Data were collected from surveys 6 months after stroke using standardized patient-reported outcome measures and questions about health care utilization. Demographic and medical data were acquired from hospital records. Patients were matched on stroke severity, age, race, and gender. Matching was done with 1:2 ratio of tPA to controls. Results were compared between groups with 1-tailed tests because of a directionally specific hypothesis in favor of the tPA group. The tPA (n = 78) and control (n = 156) groups were matched across variables, except for stroke severity, which was better in the control group; subsequent analyses controlled for this mismatch. The tPA group reported better physical function, communication, cognitive ability, depressive symptomatology, and quality of life/participation compared with the control group. Fewer people in the tPA group reported skilled nursing facility stays, emergency department visits, and rehospitalizations after their stroke compared with controls. Reports of other postacute services were not different between groups. Although it is known that tPA reduces disability, this is the first study to demonstrate the effectiveness of tPA in improving meaningful, patient-reported outcomes. Thus, use of tPA provides a large benefit to the daily lives of people with ischemic stroke.
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Inpatient rehabilitation centers and concern for increasing volume of ischemic stroke patients requiring rehabilitation. South Med J 2014; 106:693-6. [PMID: 24305530 DOI: 10.1097/smj.0000000000000036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To determine whether prolonged length of stay (pLOS) in ischemic stroke is related to delays in discharge disposition arrangement. METHODS We designed a retrospective study to compare patients with acute ischemic stroke who experienced pLOS to those who did not experience pLOS. Patients who have had acute ischemic stroke between July 2008 and December 2010 were included unless they arrived >48 hours after time last seen normal, had an unknown last seen normal, or experienced an in-hospital stroke. pLOS was defined in our prospective stroke registry (before the generation of this research question) as hospitalization extended for ≥ 24 hours more than necessary to determine neurologic stability and next level of care/disposition for a given patient. We characterized the frequency of each cause of pLOS and further investigated the destinations that were more frequently associated with pLOS among patients with delay resulting from arranging discharge disposition. RESULTS Of the 274 patients included, 106 (31.9%) had pLOS. Reasons for pLOS were discharge disposition (48.1%), non-neurologic medical complications (36.8%), delays in imaging studies (20.8%), awaiting procedure (10.4%), and neurologic complications (9.4%). Among patients with pLOS caused by delayed disposition, more than half were awaiting placement in an inpatient rehabilitation facility. CONCLUSIONS For the majority of our patients, pLOS was caused by acquired medical complications and delayed disposition, most commonly inpatient rehabilitation. Further efforts are needed to prevent complications and further investigation is necessary to identify the factors that may contribute to delayed discharge to inpatient rehabilitation facilities, which may include delayed planning or heightened scrutiny of insurance companies regarding their beneficiaries.
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Lyerly MJ, Albright KC, Boehme AK, Bavarsad Shahripour R, Houston JT, Rawal PV, Kapoor N, Alvi M, Sisson A, Alexandrov AW, Alexandrov AV. Safety of protocol violations in acute stroke tPA administration. J Stroke Cerebrovasc Dis 2013; 23:855-60. [PMID: 23954609 DOI: 10.1016/j.jstrokecerebrovasdis.2013.07.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 07/06/2013] [Accepted: 07/08/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intravenous (IV) tissue plasminogen activator remains the only approved therapy for acute ischemic stroke (AIS) in the United States; however, less than 10% of patients receive treatment. This is partially because of the large number of contraindications, narrow treatment window, and physician reluctance to deviate from these criteria. METHODS We retrospectively analyzed consecutive patients who received IV thrombolysis at our stroke center for National Institute of Neurological Disorders and Stroke (NINDS) protocol violations and rates of symptomatic intracerebral hemorrhage (sICH). Other outcome variables included systemic hemorrhage, modified Rankin Scale at discharge, and discharge disposition. RESULTS A total of 212 patients were identified in our stroke registry between 2009 and 2011 and included in the analysis. Protocol violations occurred in 76 patients (36%). The most common violations were thrombolysis beyond 3 hours (26%), aggressive blood pressure management (15%), elevated prothrombin time (PT) or partial thromboplastin time (PTT) (6.6%), minor or resolving deficits (4.2%), unclear time of onset (3.9%), and stroke within 3 months (3%). There were no significant differences in any of the safety outcomes or discharge disposition between patients with or without protocol violations. Controlling for age, National Institutes of Health Stroke Scale on admission, and glucose on admission, there was no significant increase in sICH (odds ratio: 3.8; 95% confidence interval: .37-38.72) in the patients who had protocol violations. CONCLUSIONS Despite more than one third of patients receiving thrombolysis with protocol violations, overall rates of hemorrhage remained low and did not differ from those who did not have violations. Our data support the need to expand access to thrombolysis in AIS patients.
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Affiliation(s)
- Michael J Lyerly
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham Veterans Affairs Medical Center, Birmingham, Alabama.
| | - Karen C Albright
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama; Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education (COERE), University of Alabama at Birmingham, Birmingham, Alabama; Center for Excellence in Comparative Effectiveness Research for Eliminating Disparities, Minority Health and Health Disparities Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Amelia K Boehme
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama
| | - Reza Bavarsad Shahripour
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - James T Houston
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pawan V Rawal
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Niren Kapoor
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Muhammad Alvi
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - April Sisson
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Anne W Alexandrov
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama; School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrei V Alexandrov
- Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Hospital-Acquired Symptomatic Urinary Tract Infection in Patients Admitted to an Academic Stroke Center Affects Discharge Disposition. PM R 2012; 5:9-15. [DOI: 10.1016/j.pmrj.2012.08.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 08/01/2012] [Accepted: 08/05/2012] [Indexed: 11/22/2022]
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