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Chan A, De Simoni A, Wileman V, Holliday L, Newby CJ, Chisari C, Ali S, Zhu N, Padakanti P, Pinprachanan V, Ting V, Griffiths CJ. Digital interventions to improve adherence to maintenance medication in asthma. Cochrane Database Syst Rev 2022; 6:CD013030. [PMID: 35691614 PMCID: PMC9188849 DOI: 10.1002/14651858.cd013030.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Asthma is the most common chronic lung condition worldwide, affecting 334 million adults and children globally. Despite the availability of effective treatment, such as inhaled corticosteroids (ICS), adherence to maintenance medication remains suboptimal. Poor ICS adherence leads to increased asthma symptoms, exacerbations, hospitalisations, and healthcare utilisation. Importantly, suboptimal use of asthma medication is a key contributor to asthma deaths. The impact of digital interventions on adherence and asthma outcomes is unknown. OBJECTIVES To determine the effectiveness of digital interventions for improving adherence to maintenance treatments in asthma. SEARCH METHODS We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted the most recent searches on 1 June 2020, with no restrictions on language of publication. A further search was run in October 2021, but studies were not fully incorporated. SELECTION CRITERIA We included randomised controlled trials (RCTs) including cluster- and quasi-randomised trials of any duration in any setting, comparing a digital adherence intervention with a non-digital adherence intervention or usual care. We included adults and children with a clinical diagnosis of asthma, receiving maintenance treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures for data collection. We used GRADE to assess quantitative outcomes where data were available. MAIN RESULTS We included 40 parallel randomised controlled trials (RCTs) involving adults and children with asthma (n = 15,207), of which eight are ongoing studies. Of the included studies, 30 contributed data to at least one meta-analysis. The total number of participants ranged from 18 to 8517 (median 339). Intervention length ranged from two to 104 weeks. Most studies (n = 29) reported adherence to maintenance medication as their primary outcome; other outcomes such as asthma control and quality of life were also commonly reported. Studies had low or unclear risk of selection bias but high risk of performance and detection biases due to inability to blind the participants, personnel, or outcome assessors. A quarter of the studies had high risk of attrition bias and selective outcome reporting. We examined the effect of digital interventions using meta-analysis for the following outcomes: adherence (16 studies); asthma control (16 studies); asthma exacerbations (six studies); unscheduled healthcare utilisation (four studies); lung function (seven studies); and quality of life (10 studies). Pooled results showed that patients receiving digital interventions may have increased adherence (mean difference of 14.66 percentage points, 95% confidence interval (CI) 7.74 to 21.57; low-certainty evidence); this is likely to be clinically significant in those with poor baseline medication adherence. Subgroup analysis by type of intervention was significant (P = 0.001), with better adherence shown with electronic monitoring devices (EMDs) (23 percentage points over control, 95% CI 10.84 to 34.16; seven studies), and with short message services (SMS) (12 percentage points over control, 95% CI 6.22 to 18.03; four studies). No significant subgroup differences were seen for interventions having an in-person component versus fully digital interventions, adherence feedback, one or multiple digital components to the intervention, or participant age. Digital interventions were likely to improve asthma control (standardised mean difference (SMD) 0.31 higher, 95% CI 0.17 to 0.44; moderate-certainty evidence) - a small but likely clinically significant effect. They may reduce asthma exacerbations (risk ratio 0.53, 95% CI 0.32 to 0.91; low-certainty evidence). Digital interventions may result in a slight change in unscheduled healthcare utilisation, although some studies reported no or a worsened effect. School or work absence data could not be included for meta-analysis due to the heterogeneity in reporting and the low number of studies. They may result in little or no difference in lung function (forced expiratory volume in one second (FEV1)): there was an improvement of 3.58% predicted FEV1, 95% CI 1.00% to 6.17%; moderate-certainty evidence); however, this is unlikely to be clinically significant as the FEV1 change is below 12%. Digital interventions likely increase quality of life (SMD 0.26 higher, 95% CI 0.07 to 0.45; moderate-certainty evidence); however, this is a small effect that may not be clinically significant. Acceptability data showed positive attitudes towards digital interventions. There were no data on cost-effectiveness or adverse events. Our confidence in the evidence was reduced by risk of bias and inconsistency. AUTHORS' CONCLUSIONS Overall, digital interventions may result in a large increase in adherence (low-certainty evidence). There is moderate-certainty evidence that digital adherence interventions likely improve asthma control to a degree that is clinically significant, and likely increase quality of life, but there is little or no improvement in lung function. The review found low-certainty evidence that digital interventions may reduce asthma exacerbations. Subgroup analyses show that EMDs may improve adherence by 23% and SMS interventions by 12%, and interventions with an in-person element and adherence feedback may have greater benefits for asthma control and adherence, respectively. Future studies should include percentage adherence as a routine outcome measure to enable comparison between studies and meta-analysis, and use validated questionnaires to assess adherence and outcomes.
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Affiliation(s)
- Amy Chan
- Centre for Behavioural Medicine, Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
- Asthma UK Centre for Applied Research, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Anna De Simoni
- Wolfson Institute of Population Health, Centre for Primary Care Asthma UK Centre for Applied Research, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Vari Wileman
- Centre for Behavioural Medicine, Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Lois Holliday
- Wolfson Institute of Population Health, Centre for Primary Care Asthma UK Centre for Applied Research, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Chris J Newby
- Research Design Service, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Claudia Chisari
- Centre for Behavioural Medicine, Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Sana Ali
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Natalee Zhu
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | | | | | - Victoria Ting
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | - Chris J Griffiths
- Asthma UK Centre for Applied Research, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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De Simoni A, Fleming L, Holliday L, Horne R, Priebe S, Bush A, Sheikh A, Griffiths C. Electronic reminders and rewards to improve adherence to inhaled asthma treatment in adolescents: a non-randomised feasibility study in tertiary care. BMJ Open 2021; 11:e053268. [PMID: 34716166 PMCID: PMC8559117 DOI: 10.1136/bmjopen-2021-053268] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To test the feasibility and acceptability of a short-term reminder and incentives intervention in adolescents with low adherence to asthma medications. METHODS Mixed-methods feasibility study in a tertiary care clinic. Adolescents recruited to a 24-week programme with three 8-weekly visits, receiving electronic reminders to prompt inhaled corticosteroid (ICS) inhalation through a mobile app coupled with electronic monitoring devices (EMD). From the second visit, monetary incentives based on adherence of ICS inhalation: £1 per dose, maximum £2 /day, up to £112/study, collected as gift cards at the third visit. End of study interviews and questionnaires assessing perceptions of asthma and ICS, analysed using the Perceptions and Practicalities Framework. PARTICIPANTS Adolescents (11-18 years) with documented low ICS adherence (<80% by EMD), and poor asthma control at the first clinic visit. RESULTS 10 out of 12 adolescents approached were recruited (7 males, 3 females, 12-16 years). Eight participants provided adherence measures up to the fourth visits and received rewards. Mean study duration was 281 days, with 7/10 participants unable to attend their fourth visit due to COVID-19 lockdown. Only 3/10 participants managed to pair the app/EMD up to the fourth visit, which was associated with improved ICS adherence (from 0.51, SD 0.07 to 0.86, SD 0.05). Adherence did not change in adolescents unable to pair the app/EMD. The intervention was acceptable to participants and parents/guardians. Exit interviews showed that participants welcomed reminders and incentives, though expressed frustration with app/EMD technological difficulties. Participants stated the intervention helped through reminding ICS doses, promoting self-monitoring and increasing motivation to take inhalers. CONCLUSIONS An intervention using electronic reminders and incentives through an app coupled with an EMD was feasible and acceptable to adolescents with asthma. A pilot randomised controlled trial is warranted to better estimate the effect size on adherence, with improved technical support for the EMD.
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Affiliation(s)
- Anna De Simoni
- Wolfson Institute of Population Health, Queen Mary University of London, Asthma UK Centre for Applied Research, London, UK
| | - Louise Fleming
- Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, Asthma UK Centre for Applied Research, London, UK
| | - Lois Holliday
- Wolfson Institute of Population Health, Queen Mary University of London, Asthma UK Centre for Applied Research, London, UK
| | - Robert Horne
- Centre for Behavioural Medicine, UCL School of Pharmacy - UCL, Asthma UK Centre for Applied Research, London, UK
| | - Stefan Priebe
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, UK
| | - Andrew Bush
- Biomedical Research Unit at the Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, Asthma UK Centre for Applied Research, London, UK
| | - Aziz Sheikh
- Usher Institute - University of Edinburgh, Asthma UK Centre for Applied Research, Edinburgh, UK
| | - Chris Griffiths
- Wolfson Institute of Population Health, Queen Mary University of London, Asthma UK Centre for Applied Research, London, UK
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Lim S, Barratt B, Holliday L, Griffiths CJ, Mudway IS. Characterising professional drivers' exposure to traffic-related air pollution: Evidence for reduction strategies from in-vehicle personal exposure monitoring. Environ Int 2021; 153:106532. [PMID: 33812042 DOI: 10.1016/j.envint.2021.106532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/26/2021] [Accepted: 03/14/2021] [Indexed: 06/12/2023]
Abstract
Professional drivers working in congested urban areas are required to work near harmful traffic related pollutants for extended periods, representing a significant, but understudied occupational risk. This study collected personal black carbon (BC) exposures for 141 drivers across seven sectors in London. The aim of the study was to assess the magnitude and the primary determinants of their exposure, leading to the formulation of targeted exposure reduction strategies for the occupation. Each participant's personal BC exposures were continuously measured using real-time monitors for 96 h, incorporating four shifts per participant. 'At work' BC exposures (3.1 ± 3.5 µg/m3) were 2.6 times higher compared to when 'not at work' (1.2 ± 0.7 µg/m3). Workers spent 19% of their time 'at work driving', however this activity contributed 36% of total BC exposure, highlighting the disproportionate effect driving had on their daily exposure. Taxi drivers experienced the highest BC exposures due to the time they spent working in congested central London, while emergency services had the lowest. Spikes in exposure were observed while driving and were at times greater than 100 µg/m3. The most significant determinants of drivers' exposures were driving in tunnels, congestion, location, day of week and time of shift. Driving with closed windows significantly reduced exposures and is a simple behaviour change drivers could implement. Our results highlight strategies by which employers and local policy makers can reduce professional drivers' exposure to traffic-related air pollution.
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Affiliation(s)
- Shanon Lim
- MRC Centre for Environment and Health, Imperial College London, SW7 2AZ London, UK.
| | - Benjamin Barratt
- MRC Centre for Environment and Health, Imperial College London, SW7 2AZ London, UK; NIHR Environmental Exposure and Health HPRU, Imperial College London, UK
| | - Lois Holliday
- Institute of Population Health Sciences, Asthma UK Centre for Applied Research, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Chris J Griffiths
- Institute of Population Health Sciences, Asthma UK Centre for Applied Research, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | - Ian S Mudway
- MRC Centre for Environment and Health, Imperial College London, SW7 2AZ London, UK; MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK; NIHR Environmental Exposure and Health HPRU, Imperial College London, UK
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Heal C, Gorges H, van Driel ML, Tapley A, Davis J, Davey A, Holliday L, Ball J, Najib N, Spike N, FitzGerald K, Magin P. Antibiotic stewardship in skin infections: a cross-sectional analysis of early-career GP's management of impetigo. BMJ Open 2019; 9:e031527. [PMID: 31662391 PMCID: PMC6830714 DOI: 10.1136/bmjopen-2019-031527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To establish the prevalence and associations of systemic antibiotic prescription for impetigo by early-career general practitioners (GPs) (GP registrars in their first 18 months in general practice). DESIGN A cross-sectional analysis of data from the Registrar Clinical Encounters in Training (ReCEnT) study. SETTING ReCEnT is an ongoing multisite cohort study of Australian registrars' in-consultation clinical practice across five Australian states. PARTICIPANTS Registrars participating in ReCEnT from 2010 to 2017. OUTCOME MEASURES Management of impetigo with systemic antibiotics. RESULTS 1741 registrars (response rate 96%) provided data from 384 731 problems identified in 246 434 consultations. Impetigo, on first presentation or follow-up, was managed in 930 (0.38%, 95% CI 0.35 to 0.40) consultations and comprised 0.24% (95% CI 0.23 to 0.26) of problems. 683 patients presented with a new diagnosis of impetigo of which 38/683 (5.6%) were not prescribed antibiotics; 239/683 (35.0%) were prescribed solely topical antibiotics; 306/683 (44.8%) solely systemic antibiotics and 100/683 (14.6%) both systemic and topical antibiotics. The most common systemic antibiotic prescribed was cephalexin (53.5%). Variables independently associated with prescription of systemic antibiotics were an inner regional (compared with major city) location (OR 1.82, 95% CI 1.06 to 3.13; p=0.028), seeking in-consultation information or advice (OR 2.17, 95% CI 1.47 to 3.23; p<0.001) and ordering pathology (OR 2.13, 95% CI 1.37 to 3.33; p=0.01). CONCLUSIONS Australian early-career GPs prescribe systemic antibiotics (the majority broad-spectrum) for a high proportion of initial impetigo presentations. Impetigo guidelines should clearly specify criteria for systemic antibiotic prescription and individual antibiotic choice. The role of non-antibiotic management and topical antiseptics needs to be explored further.
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Affiliation(s)
- Clare Heal
- School of Medicine and Dentistry, James Cook University, Mackay, Queensland, Australia
| | - Hilary Gorges
- Department of General Practice and Rural Medicine, James Cook University, Mackay, Queensland, Australia
| | - Mieke L van Driel
- Academic Discipline of General Practice, University of Queensland, Brisbane, Queensland, Australia
| | - Amanda Tapley
- NSW & ACT Research and Evaluation Unit, GP Synergy Ltd - Newcastle, Newcastle, New South Wales, Australia
- Discipline of General Practice, School of Medicine & Public Health, University of Newcastle, Callaghan, New South Wales, Australia
| | - Josh Davis
- Global and Tropical Health Division, Menzies School of Health Research, Casuarina, New South Wales, Australia
| | - Andrew Davey
- GP Synergy Ltd, Liverpool Westfield, New South Wales, Australia
| | - L Holliday
- The University of Newcastle, Newcastle, New South Wales, Australia
| | - Jean Ball
- Clinical Research Design and Statistics, The University of Newcastle Hunter Medical Research Institute, New Lambton, New South Wales, Australia
| | - Nashwa Najib
- GP Synergy Ltd, Liverpool Westfield, New South Wales, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | | | - Parker Magin
- Discipline of General Practice, University of Newcastle, Callaghan, New South Wales, Australia
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Magin P, Moad D, Tapley A, Holliday L, Davey A, Spike N, FitzGerald K, Kirby C, Bentley M, Turnock A, van Driel ML, Fielding A. New alumni EXperiences of Training and independent Unsupervised Practice (NEXT-UP): protocol for a cross-sectional study of early career general practitioners. BMJ Open 2019; 9:e029585. [PMID: 31152045 PMCID: PMC6549658 DOI: 10.1136/bmjopen-2019-029585] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION General practice in Australia, as in many countries, faces challenges in the areas of workforce capacity and workforce distribution. General practice vocational training in Australia not only addresses the training of competent independent general practitioners (GPs) but also addresses these workforce issues. This study aims to establish the prevalence and associations of early career (within 2 years of completion of vocational training) GPs' practice characteristics; and also to establish their perceptions of utility of their training in preparing them for independent practice. METHODS AND ANALYSIS This will be a cross-sectional questionnaire study. Participants will be former registrars ('alumni') of three regional training organisations (RTOs) who achieved general practice Fellowship (qualifying them for independent practice) between January 2016 and July 2018 inclusive. The questionnaire data will be linked to data collected as part of the participants' educational programme with the RTOs. Outcomes will include alumni rurality of practice; socioeconomic status of practice; retention within their RTO's geographic footprint; workload; provision of nursing home care, after-hours care and home visits; and involvement in general practice teaching and supervision. Associations of these outcomes will be established with logistic regression. The utility of RTO-provided training versus in-practice training in preparing the early career GP for unsupervised post-Ffellowship practice in particular aspects of practice will be assessed with χ2 tests. ETHICS AND DISSEMINATION Ethics approval is by the University of Newcastle Human Research Ethics Committee, approval numbers H-2018-0333 and H-2009-0323. The findings of this study will be widely disseminated via conference presentations and publication in peer-reviewed journals, educational practice translational workshops and the GP Synergy Research subwebsite.
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Affiliation(s)
- Parker Magin
- Discipline of General Practice, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- NSW and ACT Research and Evaluation Unit, GP Synergy Ltd – Newcastle, Mayfield West, New South Wales, Australia
| | - Dominica Moad
- Discipline of General Practice, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- NSW and ACT Research and Evaluation Unit, GP Synergy Ltd – Newcastle, Mayfield West, New South Wales, Australia
| | - Amanda Tapley
- Discipline of General Practice, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- NSW and ACT Research and Evaluation Unit, GP Synergy Ltd – Newcastle, Mayfield West, New South Wales, Australia
| | - L Holliday
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | - Andrew Davey
- Discipline of General Practice, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- NSW and ACT Research and Evaluation Unit, GP Synergy Ltd – Newcastle, Mayfield West, New South Wales, Australia
| | - Neil Spike
- Eastern Victoria General Practice Training, Churchill, Victoria, Australia
- Department of General Practice, University of Melbourne, Parkville, Victoria, Australia
| | | | - Catherine Kirby
- Eastern Victoria General Practice Training, Churchill, Victoria, Australia
- School of Rural Health, Monash University, Clayton, Victoria, Australia
| | - Michael Bentley
- General Practice Training Tasmania, Hobart, Tasmania, Australia
| | - Allison Turnock
- Department of Health, Hobart, Tasmania, Australia
- Centre for Rural Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Mieke L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Alison Fielding
- Discipline of General Practice, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
- NSW and ACT Research and Evaluation Unit, GP Synergy Ltd – Newcastle, Mayfield West, New South Wales, Australia
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Mody N, Ramsay S, Ferraro C, Hewitt M, Gill E, Holliday L, Ikharia A, Reeves I. Audit of HIV testing in a multispecialty acute admissions unit in a London general hospital. Br J Vener Dis 2016; 92:239. [DOI: 10.1136/sextrans-2015-052458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 12/06/2015] [Indexed: 11/04/2022]
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Abstract
Discusses quality costing as part of an overall Total Quality Management
(TQM) strategy and describes and analyses a practical quality costing
exercise. Argues that quality costing exercises can provide considerable
opportunity to be more efficient whilst enhancing the quality of patient
care. Evaluates the benefits of the exercise and discusses its
application to other areas.
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Holliday L. Chains lean to specialized outlets in home care market. MPS 1980; 11:1, 24, 27 passim. [PMID: 10249174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Holliday L. For the well-dressed trend-setter: a surgical scrub suit. MPS 1980; 11:1, 36-7. [PMID: 10249168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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Holliday L. Resinography—An introduction to the definition, identification and recognition of resins, polymers and fibers. POLYMER 1977. [DOI: 10.1016/0032-3861(77)90047-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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