Pub Date : 2017-07-01DOI: 10.4103/2348-9995.221903
S. Grover, Mansi Somaiya
Electroconvulsive therapy (ECT) is one of the treatment modalities in psychiatry that has stood the test of time for years. ECT has been used in various psychiatric conditions in the elderly. Comorbid medical conditions and cognitive deficits have been the prime concerns in this population. The indications and contraindications of use of ECT in the elderly population are same as that in an adult. ECT has also been found to be effective in patients with Parkinson's disease and dementia. Pre-ECT evaluation and cognitive evaluation prior and during ECT are inevitable. The determination of right technique, dose, frequency, and assessment of side effects are prerequisites to the usage of ECT in elderly. Owing to risk of cognitive side effects, right unilateral ECT is preferred. In carefully selected indications, ECT may be a superior management modality than pharmacotherapy.
{"title":"Electroconvulsive therapy in the elderly","authors":"S. Grover, Mansi Somaiya","doi":"10.4103/2348-9995.221903","DOIUrl":"https://doi.org/10.4103/2348-9995.221903","url":null,"abstract":"Electroconvulsive therapy (ECT) is one of the treatment modalities in psychiatry that has stood the test of time for years. ECT has been used in various psychiatric conditions in the elderly. Comorbid medical conditions and cognitive deficits have been the prime concerns in this population. The indications and contraindications of use of ECT in the elderly population are same as that in an adult. ECT has also been found to be effective in patients with Parkinson's disease and dementia. Pre-ECT evaluation and cognitive evaluation prior and during ECT are inevitable. The determination of right technique, dose, frequency, and assessment of side effects are prerequisites to the usage of ECT in elderly. Owing to risk of cognitive side effects, right unilateral ECT is preferred. In carefully selected indications, ECT may be a superior management modality than pharmacotherapy.","PeriodicalId":16009,"journal":{"name":"Journal of Geriatric Mental Health","volume":"4 1","pages":"74 - 82"},"PeriodicalIF":0.0,"publicationDate":"2017-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48039655","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dimple Dadarwala, Jahnavi S. Kedare, A. Pusalkar, A. Subramanyam, R. Kamath
Introduction: The number of elder patients with severe psychiatric illnesses other than depression is increasing. Electroconvulsive therapy (ECT) has a special role in the treatment of late-life depression and other psychiatric conditions in the elderly. Using ECTs in the elderly could be difficult. In an Indian setting, ECT in the geriatric population is used as last resort of treatment which is in contrast to Western countries. There is dearth of data available for the use of ECT in the elderly in India. Methodology: Retrospective data review was carried out to identify patients 55 years or older who had received ECT from January 2014 to June 2016 in tertiary care teaching hospital in a metropolitan city in India. Results: A total of 304 ECTs were administered to 25 elderly aged >55 years with average of 12 ECTs per patient. Schizophrenia (56%) was the most common diagnosis among patients who were considered for ECT, and this was followed by major depression without psychotic features (24%) and major depression with psychotic features (8%). The most common indication to start ECT was nonresponsiveness to medications (92%). There was an increase in mean Mini-Mental State Examination (MMSE) scores from baseline (23.42) to the end of the sixth (24.60) and last ECT (24.60). Duration of current used during ECT had positive correlation with MMSE. Patients with comorbid medical illness (20%) received ECT without any complication. Conclusions: This study adds to scarce database on the use of ECT in old-age patients in India and adds to evidence that ECT is safe and effective treatment in old age with no negative impact on cognition.
{"title":"Electroconvulsive therapy in the elderly: Retrospective analysis from an urban general hospital psychiatry unit","authors":"Dimple Dadarwala, Jahnavi S. Kedare, A. Pusalkar, A. Subramanyam, R. Kamath","doi":"10.4103/JGMH.JGMH_6_17","DOIUrl":"https://doi.org/10.4103/JGMH.JGMH_6_17","url":null,"abstract":"Introduction: The number of elder patients with severe psychiatric illnesses other than depression is increasing. Electroconvulsive therapy (ECT) has a special role in the treatment of late-life depression and other psychiatric conditions in the elderly. Using ECTs in the elderly could be difficult. In an Indian setting, ECT in the geriatric population is used as last resort of treatment which is in contrast to Western countries. There is dearth of data available for the use of ECT in the elderly in India. Methodology: Retrospective data review was carried out to identify patients 55 years or older who had received ECT from January 2014 to June 2016 in tertiary care teaching hospital in a metropolitan city in India. Results: A total of 304 ECTs were administered to 25 elderly aged >55 years with average of 12 ECTs per patient. Schizophrenia (56%) was the most common diagnosis among patients who were considered for ECT, and this was followed by major depression without psychotic features (24%) and major depression with psychotic features (8%). The most common indication to start ECT was nonresponsiveness to medications (92%). There was an increase in mean Mini-Mental State Examination (MMSE) scores from baseline (23.42) to the end of the sixth (24.60) and last ECT (24.60). Duration of current used during ECT had positive correlation with MMSE. Patients with comorbid medical illness (20%) received ECT without any complication. Conclusions: This study adds to scarce database on the use of ECT in old-age patients in India and adds to evidence that ECT is safe and effective treatment in old age with no negative impact on cognition.","PeriodicalId":16009,"journal":{"name":"Journal of Geriatric Mental Health","volume":"4 1","pages":"123 - 126"},"PeriodicalIF":0.0,"publicationDate":"2017-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49634091","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Abha Thakurdesai, M. Thanki, A. Desousa, G. Rao, S. Tiwari
Repetitive transcranial magnetic stimulation (rTMS) has been used widely in adult patients with depression and resistant auditory hallucinations. There is a paucity of data for rTMS use in geriatric patients for these indications. Recent research has revealed newer avenues for the use of rTMS in clinical geriatric psychiatry practice which includes mild cognitive impairment and dementia. rTMS is also being looked at as an effective treatment when combined with cognitive training in the management of Alzheimer's disease. The present review discusses the various uses of rTMS in geriatric psychiatry. This paper analyzes the various studies done with rTMS in older patients in various indications and the safety and efficacy of the procedure are also evaluated. The need for further studies in this area using larger samples is also mentioned.
{"title":"Repetitive transcranial magnetic stimulation in geriatric psychiatry: A clinical overview","authors":"Abha Thakurdesai, M. Thanki, A. Desousa, G. Rao, S. Tiwari","doi":"10.4103/JGMH.JGMH_48_16","DOIUrl":"https://doi.org/10.4103/JGMH.JGMH_48_16","url":null,"abstract":"Repetitive transcranial magnetic stimulation (rTMS) has been used widely in adult patients with depression and resistant auditory hallucinations. There is a paucity of data for rTMS use in geriatric patients for these indications. Recent research has revealed newer avenues for the use of rTMS in clinical geriatric psychiatry practice which includes mild cognitive impairment and dementia. rTMS is also being looked at as an effective treatment when combined with cognitive training in the management of Alzheimer's disease. The present review discusses the various uses of rTMS in geriatric psychiatry. This paper analyzes the various studies done with rTMS in older patients in various indications and the safety and efficacy of the procedure are also evaluated. The need for further studies in this area using larger samples is also mentioned.","PeriodicalId":16009,"journal":{"name":"Journal of Geriatric Mental Health","volume":"4 1","pages":"99 - 105"},"PeriodicalIF":0.0,"publicationDate":"2017-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48138374","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
R. Vinutha, V. Narasimha, N. Deepa, C. Kumar, T. Jagadisha, S. Thangaraju, S. Bharath, M. Varghese
Background: Although electroconvulsive therapy (ECT) is a well-established treatment modality worldwide for elderly with severe psychiatric disorders, literature is sparse in India. Materials and Methods: A retrospective chart review of patients aged 60 years and above (n = 90) who received a course of ECTs between April 2003 and 2013 in National Institute of Mental Health and Neurosciences, Bengaluru, a tertiary care neuropsychiatric institute, was carried out. For each elderly person, the next consecutive nonelderly ECT patient was selected as a control (n = 85). Clinical, demographic, and ECT variables were compared. Results: Depression (n = 57; 63.3%) was the most common diagnosis for ECT among the elderly while schizophrenia (n = 28; 32.9%) was most common among controls (P < 0.01); suicidal ideas were the most common indication (n = 25; 28.4%) among the elderly while aggression was the most common indication among controls (n = 28; 33.3%) (P = 0.004). Elderly received more number of ECTs (mean [standard deviation (SD)] 8.0 [3.0] vs. 6.4 [2.8]; P ≤ 0.01), had higher seizure threshold (mean [SD] 135.3 [76.9] mc vs. 81.3 [54.2] mc; P < 0.01), and experienced lesser duration of motor seizures (mean [SD] 38.48 [9.72] s vs. 48.90 [14.66]; P < 0.01). Immediate post-ECT cognitive deficits were more in the elderly (n = 19; 21.6% vs. n = 7; 8.3%; P = 0.02). Case records showed no between-group differences both at the end of 3-month (P = 0.40) and 6-month (P = 0.50) follow-up for cognitive complaints. Mean (standard deviation) Clinical Global Impression-Improvement scores at the end of ECT course were 2.3 (0.9) versus 2.4 (0.8) (P = 0.5) among elderly and nonelderly, respectively. These scores were comparable at the end of 3 as well as 6 months' follow-up. Conclusions: This retrospective chart review showed ECT to be safe and effective for geriatric patients with severe psychiatric disorders including cognitive adverse effects. However, prospective studies would help to better establish cognitive adverse effects of ECT.
{"title":"Electroconvulsive therapy in the elderly and nonelderly: 10 years' retrospective comparison","authors":"R. Vinutha, V. Narasimha, N. Deepa, C. Kumar, T. Jagadisha, S. Thangaraju, S. Bharath, M. Varghese","doi":"10.4103/JGMH.JGMH_3_17","DOIUrl":"https://doi.org/10.4103/JGMH.JGMH_3_17","url":null,"abstract":"Background: Although electroconvulsive therapy (ECT) is a well-established treatment modality worldwide for elderly with severe psychiatric disorders, literature is sparse in India. Materials and Methods: A retrospective chart review of patients aged 60 years and above (n = 90) who received a course of ECTs between April 2003 and 2013 in National Institute of Mental Health and Neurosciences, Bengaluru, a tertiary care neuropsychiatric institute, was carried out. For each elderly person, the next consecutive nonelderly ECT patient was selected as a control (n = 85). Clinical, demographic, and ECT variables were compared. Results: Depression (n = 57; 63.3%) was the most common diagnosis for ECT among the elderly while schizophrenia (n = 28; 32.9%) was most common among controls (P < 0.01); suicidal ideas were the most common indication (n = 25; 28.4%) among the elderly while aggression was the most common indication among controls (n = 28; 33.3%) (P = 0.004). Elderly received more number of ECTs (mean [standard deviation (SD)] 8.0 [3.0] vs. 6.4 [2.8]; P ≤ 0.01), had higher seizure threshold (mean [SD] 135.3 [76.9] mc vs. 81.3 [54.2] mc; P < 0.01), and experienced lesser duration of motor seizures (mean [SD] 38.48 [9.72] s vs. 48.90 [14.66]; P < 0.01). Immediate post-ECT cognitive deficits were more in the elderly (n = 19; 21.6% vs. n = 7; 8.3%; P = 0.02). Case records showed no between-group differences both at the end of 3-month (P = 0.40) and 6-month (P = 0.50) follow-up for cognitive complaints. Mean (standard deviation) Clinical Global Impression-Improvement scores at the end of ECT course were 2.3 (0.9) versus 2.4 (0.8) (P = 0.5) among elderly and nonelderly, respectively. These scores were comparable at the end of 3 as well as 6 months' follow-up. Conclusions: This retrospective chart review showed ECT to be safe and effective for geriatric patients with severe psychiatric disorders including cognitive adverse effects. However, prospective studies would help to better establish cognitive adverse effects of ECT.","PeriodicalId":16009,"journal":{"name":"Journal of Geriatric Mental Health","volume":"4 1","pages":"127 - 130"},"PeriodicalIF":0.0,"publicationDate":"2017-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46883685","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Electroconvulsive therapy (ECT) is an important modality of treatment for various psychiatric disorders in all age groups. The trends of use of ECT in the elderly population have not been studied despite wide variation in the utilization of this treatment modality. Aim: This study aimed to evaluate the trends in use of ECT in geriatric patients at a tertiary care center over a period of 9 years. Methodology: Data were extracted from the departmental registry for the period of 2008–2016 to evaluate the total number of new patients attending the psychiatric services, total number of new elderly (i.e., ≥60 years) patients attending the psychiatric services, total number of inpatients, total number of elderly inpatients, total number of patients who received ECT, and total number of elderly patients who received ECT. Results: During the period of 2008–2016, elderly formed from 4.6% to 19.11% of the total number of patients who received ECT. There was an upward trend in the proportion of elderly patients receiving ECT, with a nearly 10-fold rise in absolute number and doubling of the percentage of elderly patients among those receiving ECT. Over the years, there was an increase in use of ECT among elderly inpatients and use of ECT as an outpatient treatment for elderly. Conclusion: Over the years, there has been increase in the absolute number as well as proportion of elderly patients receiving ECT. There is a significant increase in the use of ECT among elderly at the outpatient basis.
{"title":"Trends in use of electroconvulsive therapy among geriatric patients over a period of 9 years at a tertiary care center in North India","authors":"S. Grover, D. Dua, S. Chakrabarti, A. Avasthi","doi":"10.4103/JGMH.JGMH_27_17","DOIUrl":"https://doi.org/10.4103/JGMH.JGMH_27_17","url":null,"abstract":"Background: Electroconvulsive therapy (ECT) is an important modality of treatment for various psychiatric disorders in all age groups. The trends of use of ECT in the elderly population have not been studied despite wide variation in the utilization of this treatment modality. Aim: This study aimed to evaluate the trends in use of ECT in geriatric patients at a tertiary care center over a period of 9 years. Methodology: Data were extracted from the departmental registry for the period of 2008–2016 to evaluate the total number of new patients attending the psychiatric services, total number of new elderly (i.e., ≥60 years) patients attending the psychiatric services, total number of inpatients, total number of elderly inpatients, total number of patients who received ECT, and total number of elderly patients who received ECT. Results: During the period of 2008–2016, elderly formed from 4.6% to 19.11% of the total number of patients who received ECT. There was an upward trend in the proportion of elderly patients receiving ECT, with a nearly 10-fold rise in absolute number and doubling of the percentage of elderly patients among those receiving ECT. Over the years, there was an increase in use of ECT among elderly inpatients and use of ECT as an outpatient treatment for elderly. Conclusion: Over the years, there has been increase in the absolute number as well as proportion of elderly patients receiving ECT. There is a significant increase in the use of ECT among elderly at the outpatient basis.","PeriodicalId":16009,"journal":{"name":"Journal of Geriatric Mental Health","volume":"4 1","pages":"131 - 134"},"PeriodicalIF":0.0,"publicationDate":"2017-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47453779","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Electroconvulsive therapy (ECT) has been found to be a rapid and effective treatment strategy for psychiatric and neurological conditions in the elderly, but the administration of ECT in the elderly can be challenging due to a high risk of adverse events. The increased risk can be attributed to a declined physiological reserve, the presence of physical comorbidities, and the use of multiple drugs, which interact with the electrical stimulus and the anesthetic medications used during the ECT procedure. The selection of appropriate induction agents and muscle relaxants should be guided by patient's clinical status and the psychotropic drugs being used. Modifications in the doses of psychotropic drugs also need to be carried out before ECT to reduce cardiovascular and neurological side effects. Modification in the conduct of anesthesia can also aid in augmenting seizures and in preventing common side effects of ECT. A vital step in preventing adverse events in the elderly is carrying out a thorough pre.ECT evaluation. Despite these challenges, ECT can be carried out safely in elderly patients with severe comorbidities, provided clinical ECT, and anesthetic parameters are adequately optimized.
{"title":"Electroconvulsive therapy in the elderly: Anesthetic considerations and Psychotropic interactions","authors":"Harsh Garekar, S. Grover","doi":"10.4103/JGMH.JGMH_2_17","DOIUrl":"https://doi.org/10.4103/JGMH.JGMH_2_17","url":null,"abstract":"Electroconvulsive therapy (ECT) has been found to be a rapid and effective treatment strategy for psychiatric and neurological conditions in the elderly, but the administration of ECT in the elderly can be challenging due to a high risk of adverse events. The increased risk can be attributed to a declined physiological reserve, the presence of physical comorbidities, and the use of multiple drugs, which interact with the electrical stimulus and the anesthetic medications used during the ECT procedure. The selection of appropriate induction agents and muscle relaxants should be guided by patient's clinical status and the psychotropic drugs being used. Modifications in the doses of psychotropic drugs also need to be carried out before ECT to reduce cardiovascular and neurological side effects. Modification in the conduct of anesthesia can also aid in augmenting seizures and in preventing common side effects of ECT. A vital step in preventing adverse events in the elderly is carrying out a thorough pre.ECT evaluation. Despite these challenges, ECT can be carried out safely in elderly patients with severe comorbidities, provided clinical ECT, and anesthetic parameters are adequately optimized.","PeriodicalId":16009,"journal":{"name":"Journal of Geriatric Mental Health","volume":"4 1","pages":"83 - 98"},"PeriodicalIF":0.0,"publicationDate":"2017-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47497174","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Electroconvulsive therapy (ECT) is an effective therapeutic intervention in the elderly patients with major depression, especially those with psychosis, suicidality, catatonia, nutritional compromise, and resistance to medications. Response rates can be as high as 80%. We present an extensive review of the relevant literature, provide a description of the ECT program at Virginia Commonwealth University in Richmond, Virginia, USA, and present results of our experience with ECT in fifty elderly patients. The treatments were safe, well tolerated, and produced high response rates, variably between 68% and 84%. Patients in the long-term maintenance ECT program continue to show sustained benefits from ECT.
{"title":"Electroconvulsive therapy in geriatric patients: A literature review and program report from Virginia Commonwealth University, Richmond, Virginia, USA","authors":"A. Snyder, V. Venkatachalam, A. Pandurangi","doi":"10.4103/JGMH.JGMH_9_17","DOIUrl":"https://doi.org/10.4103/JGMH.JGMH_9_17","url":null,"abstract":"Electroconvulsive therapy (ECT) is an effective therapeutic intervention in the elderly patients with major depression, especially those with psychosis, suicidality, catatonia, nutritional compromise, and resistance to medications. Response rates can be as high as 80%. We present an extensive review of the relevant literature, provide a description of the ECT program at Virginia Commonwealth University in Richmond, Virginia, USA, and present results of our experience with ECT in fifty elderly patients. The treatments were safe, well tolerated, and produced high response rates, variably between 68% and 84%. Patients in the long-term maintenance ECT program continue to show sustained benefits from ECT.","PeriodicalId":16009,"journal":{"name":"Journal of Geriatric Mental Health","volume":"4 1","pages":"115 - 122"},"PeriodicalIF":0.0,"publicationDate":"2017-07-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41829528","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Health system that is chiefly financed by out of pocket expenditure can have varying impact on patients belonging to different income groups. The main objective of the present study was to assess the health-care utilization pattern and socioeconomic features of elderly who incurred catastrophic health expenditure. Materials and Methods: A community-based cross-sectional study was conducted employing multi-stage sampling technique to collect data from a total of 404 elderly residing in Lucknow district. Data were collected on health care utilization and related health care expenditure with by the means of a questionnaire. Results: Out of 404 elderly, 15.8% incurred catastrophic expenditure. Among all the study participants, 33.1% who sought in-patient care and 13.8% who sought exclusive out-patient care incurred catastrophic health expenditure. Conclusion: Proportion of those facing catastrophic expenditure was high among lower income group. Thus, patients who lie at the bottom of income pyramid need higher protection as compared to those who are at the top.
{"title":"Catastrophic health expenditure among geriatric population of Lucknow district, India","authors":"Pavan Pandey, S. Singh","doi":"10.4103/JGMH.JGMH_40_16","DOIUrl":"https://doi.org/10.4103/JGMH.JGMH_40_16","url":null,"abstract":"Background: Health system that is chiefly financed by out of pocket expenditure can have varying impact on patients belonging to different income groups. The main objective of the present study was to assess the health-care utilization pattern and socioeconomic features of elderly who incurred catastrophic health expenditure. Materials and Methods: A community-based cross-sectional study was conducted employing multi-stage sampling technique to collect data from a total of 404 elderly residing in Lucknow district. Data were collected on health care utilization and related health care expenditure with by the means of a questionnaire. Results: Out of 404 elderly, 15.8% incurred catastrophic expenditure. Among all the study participants, 33.1% who sought in-patient care and 13.8% who sought exclusive out-patient care incurred catastrophic health expenditure. Conclusion: Proportion of those facing catastrophic expenditure was high among lower income group. Thus, patients who lie at the bottom of income pyramid need higher protection as compared to those who are at the top.","PeriodicalId":16009,"journal":{"name":"Journal of Geriatric Mental Health","volume":"4 1","pages":"42 - 47"},"PeriodicalIF":0.0,"publicationDate":"2017-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43516294","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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