Pub Date : 2024-11-01DOI: 10.1016/j.mpaic.2024.08.008
Amy LK. Sadler, Paul DW. Fettes
Spinal anaesthesia involves the injection of local anaesthetic solution into the intrathecal space. It is a widely practised anaesthetic technique that can provide surgical anaesthesia for procedures below the umbilicus. Due to the proximity of the central nervous system, safe practice is of paramount importance and requires a good understanding of relevant anatomy, physiology and pharmacology. Complications are rare but need to be recognized and managed rapidly and appropriately.
{"title":"Spinal anaesthesia","authors":"Amy LK. Sadler, Paul DW. Fettes","doi":"10.1016/j.mpaic.2024.08.008","DOIUrl":"10.1016/j.mpaic.2024.08.008","url":null,"abstract":"<div><div>Spinal anaesthesia involves the injection of local anaesthetic solution into the intrathecal space. It is a widely practised anaesthetic technique that can provide surgical anaesthesia for procedures below the umbilicus. Due to the proximity of the central nervous system, safe practice is of paramount importance and requires a good understanding of relevant anatomy, physiology and pharmacology. Complications are rare but need to be recognized and managed rapidly and appropriately.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 11","pages":"Pages 758-761"},"PeriodicalIF":0.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142592794","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}
Pub Date : 2024-11-01DOI: 10.1016/j.mpaic.2024.08.003
Dominic O’Connor, Jeremy Radcliffe
Anaesthesia inhibits a variety of the protective mechanisms usually in place to protect us from harm and prevent damage to vulnerable tissues. In addition, anaesthesia and patient positioning may impose physiological stresses on these tissues. Patients are often required to assume positions for surgery which would be intolerable without anaesthesia; these positions may introduce hazards which can lead to injury. Positioning of patients under anaesthesia is an important subject for anaesthetists to consider, since patient positioning has implications upon the patient’s physiological responses as well as potentially causing injury to the patient. We describe the considerations for the anaesthetist when positioning the surgical patient. We discuss the positions commonly used for surgical patients and relate the challenges associated with each of these positions, challenges which can be physical as well as physiological. Staffing and equipment provision levels must be adequate to cope with the complexity predicted in positioning an individual patient. The anaesthetist also needs to consider the relatively restricted access to the patient for intervention when in the prone or lateral positions.
{"title":"Patient positioning in anaesthesia","authors":"Dominic O’Connor, Jeremy Radcliffe","doi":"10.1016/j.mpaic.2024.08.003","DOIUrl":"10.1016/j.mpaic.2024.08.003","url":null,"abstract":"<div><div>Anaesthesia inhibits a variety of the protective mechanisms usually in place to protect us from harm and prevent damage to vulnerable tissues. In addition, anaesthesia and patient positioning may impose physiological stresses on these tissues. Patients are often required to assume positions for surgery which would be intolerable without anaesthesia; these positions may introduce hazards which can lead to injury. Positioning of patients under anaesthesia is an important subject for anaesthetists to consider, since patient positioning has implications upon the patient’s physiological responses as well as potentially causing injury to the patient. We describe the considerations for the anaesthetist when positioning the surgical patient. We discuss the positions commonly used for surgical patients and relate the challenges associated with each of these positions, challenges which can be physical as well as physiological. Staffing and equipment provision levels must be adequate to cope with the complexity predicted in positioning an individual patient. The anaesthetist also needs to consider the relatively restricted access to the patient for intervention when in the prone or lateral positions.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 11","pages":"Pages 743-748"},"PeriodicalIF":0.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142593748","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}
Pub Date : 2024-11-01DOI: 10.1016/j.mpaic.2024.08.015
William L Malein, Calum RK Grant
Managing perioperative anticoagulation and antiplatelet medication is a daily challenge for anaesthetists. Balancing the risks of surgical bleeding and complications of regional anaesthesia must be weighed against time to theatre and the risk of perioperative thrombotic events. The anaesthetist is particularly concerned about compressive vertebral canal haematomas (VCH) which may occur following spinal, epidural or para-vertebral techniques. There is also concern about bleeding complications following peripheral nerve blockade. This article attempts to put the risk of these complications into context and references key international guidelines on peri-procedural management of the broad range of anticoagulant and antiplatelet medication in current use.
{"title":"Regional anaesthesia in patients taking anticoagulant drugs","authors":"William L Malein, Calum RK Grant","doi":"10.1016/j.mpaic.2024.08.015","DOIUrl":"10.1016/j.mpaic.2024.08.015","url":null,"abstract":"<div><div>Managing perioperative anticoagulation and antiplatelet medication is a daily challenge for anaesthetists. Balancing the risks of surgical bleeding and complications of regional anaesthesia must be weighed against time to theatre and the risk of perioperative thrombotic events. The anaesthetist is particularly concerned about compressive vertebral canal haematomas (VCH) which may occur following spinal, epidural or para-vertebral techniques. There is also concern about bleeding complications following peripheral nerve blockade. This article attempts to put the risk of these complications into context and references key international guidelines on peri-procedural management of the broad range of anticoagulant and antiplatelet medication in current use.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 11","pages":"Pages 762-767"},"PeriodicalIF":0.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142593749","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}
Pub Date : 2024-11-01DOI: 10.1016/j.mpaic.2024.08.010
Peter B Williamson, C Stephanie Cattlin
Central venous cannulation using the basic principles of the Seldinger technique is a core skill for anaesthetists and critical care doctors in situations where intravenous access is difficult or multiple infusions are required. While potentially lifesaving, central venous cannulation carries the risk of serious morbidity (or even mortality). Mitigating these risks through aseptic technique, ultrasound guidance and timely management of complications is vital.
{"title":"Central venous cannulation","authors":"Peter B Williamson, C Stephanie Cattlin","doi":"10.1016/j.mpaic.2024.08.010","DOIUrl":"10.1016/j.mpaic.2024.08.010","url":null,"abstract":"<div><div>Central venous cannulation using the basic principles of the Seldinger technique is a core skill for anaesthetists and critical care doctors in situations where intravenous access is difficult or multiple infusions are required. While potentially lifesaving, central venous cannulation carries the risk of serious morbidity (or even mortality). Mitigating these risks through aseptic technique, ultrasound guidance and timely management of complications is vital.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 11","pages":"Pages 786-787"},"PeriodicalIF":0.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142593753","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}
Pub Date : 2024-11-01DOI: 10.1016/j.mpaic.2024.08.006
Jill Keohone, Paul McConnell
Advances in the care of critically unwell patients have begun to blur the boundaries between life and death; coupled with an ageing population, intensive care physicians routinely make difficult decisions in their clinical work. The model of supported decision-making with patients has become standard, however, patients in the intensive care unit (ICU) are often unable to express their wishes at the point of admission. Recent legal cases have resulted in increased scrutiny upon the decisions we make when caring for patients unable to consent to treatment, due to incapacity and critical illness, particularly when they involve the limitation or discontinuation of life supporting therapies. A robust understanding and application of the moral, ethical and legal frameworks are useful to aid in making decisions in patients’ best interests when faced with clinical dilemmas on the ICU.
{"title":"Ethical issues in resuscitation and intensive care","authors":"Jill Keohone, Paul McConnell","doi":"10.1016/j.mpaic.2024.08.006","DOIUrl":"10.1016/j.mpaic.2024.08.006","url":null,"abstract":"<div><div>Advances in the care of critically unwell patients have begun to blur the boundaries between life and death; coupled with an ageing population, intensive care physicians routinely make difficult decisions in their clinical work. The model of supported decision-making with patients has become standard, however, patients in the intensive care unit (ICU) are often unable to express their wishes at the point of admission. Recent legal cases have resulted in increased scrutiny upon the decisions we make when caring for patients unable to consent to treatment, due to incapacity and critical illness, particularly when they involve the limitation or discontinuation of life supporting therapies. A robust understanding and application of the moral, ethical and legal frameworks are useful to aid in making decisions in patients’ best interests when faced with clinical dilemmas on the ICU.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 11","pages":"Pages 788-791"},"PeriodicalIF":0.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142593754","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}
Pub Date : 2024-11-01DOI: 10.1016/j.mpaic.2024.08.005
Ruth McGovern, Leo G Kevin
Administration of medications in advance of induction of anaesthesia, ‘premedication’, has a long history. With the earliest inhalational agents, ether and chloroform, induction was characterized by a prolonged period of involuntary movements, excessive salivation and feelings of severe anxiety. It became common practice, therefore, to premedicate patients with agents such as scopalamine (an early anticholinergic) to reduce secretions, and morphine, to reduce irritability and anaesthetic requirements. In the 1950s came intravenous induction agents and halogenated inhalation agents, and a smoother and more predictable induction and early maintenance phase, with much reduced salivation. The practice of premedication lingered however, although its main purpose was now simply to alleviate patient anxiety. The invention of benzodiazepines in the late 1950s was nicely timed to find for them a niche as favoured anxiolytic premedication. This persisted for many years. In modern anaesthesia practice, sedative/anxiolytic premedication is much less commonly used than heretofore. The pre-assessment consultation with the anaesthetist has largely replaced routine premedication for the purpose of alleviating anxiety, as several studies show that this can be quite effective in achieving a calm patient. The term premedication has lately taken on a broader meaning. It is now understood to include considerations regarding which of the patient's long-term medications should be withheld or continued in advance of their operation, and the introduction of medications with the aim of optimizing medical conditions or to improve certain peri-operative outcomes.
In this article we will first discuss premedication for the purposes of sedation/anxiolysis. We will then systematically examine some of the medications that are commonly the focus of preoperative decisions in the surgical patient. The list of medications discussed is by no means exhaustive. Finally, we will look at premedication in special patient populations.
{"title":"Premedication","authors":"Ruth McGovern, Leo G Kevin","doi":"10.1016/j.mpaic.2024.08.005","DOIUrl":"10.1016/j.mpaic.2024.08.005","url":null,"abstract":"<div><div>Administration of medications in advance of induction of anaesthesia, ‘premedication’, has a long history. With the earliest inhalational agents, ether and chloroform, induction was characterized by a prolonged period of involuntary movements, excessive salivation and feelings of severe anxiety. It became common practice, therefore, to premedicate patients with agents such as scopalamine (an early anticholinergic) to reduce secretions, and morphine, to reduce irritability and anaesthetic requirements. In the 1950s came intravenous induction agents and halogenated inhalation agents, and a smoother and more predictable induction and early maintenance phase, with much reduced salivation. The practice of premedication lingered however, although its main purpose was now simply to alleviate patient anxiety. The invention of benzodiazepines in the late 1950s was nicely timed to find for them a niche as favoured anxiolytic premedication. This persisted for many years. In modern anaesthesia practice, sedative/anxiolytic premedication is much less commonly used than heretofore. The pre-assessment consultation with the anaesthetist has largely replaced routine premedication for the purpose of alleviating anxiety, as several studies show that this can be quite effective in achieving a calm patient. The term premedication has lately taken on a broader meaning. It is now understood to include considerations regarding which of the patient's long-term medications should be withheld or continued in advance of their operation, and the introduction of medications with the aim of optimizing medical conditions or to improve certain peri-operative outcomes.</div><div>In this article we will first discuss premedication for the purposes of sedation/anxiolysis. We will then systematically examine some of the medications that are commonly the focus of preoperative decisions in the surgical patient. The list of medications discussed is by no means exhaustive. Finally, we will look at premedication in special patient populations.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 11","pages":"Pages 749-752"},"PeriodicalIF":0.2,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142593746","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}
Pub Date : 2024-10-01DOI: 10.1016/j.mpaic.2024.06.008
James Barrowman, Ming Wilson
The clotting cascade is a complex process and is an important survival mechanism. Major haemorrhage and thromboembolic events remain major causes of increased morbidity and mortality. Drugs affecting coagulation have primarily been utilized to treat or reduce the risk of thromboembolic events. However, the recent progress in the management of major trauma and treating coagulopathy has resulted in further research and development of drugs that improve clotting function. Knowledge of drugs used for both clinical circumstances is now required when working in anaesthesia or intensive care.
{"title":"Drugs affecting coagulation","authors":"James Barrowman, Ming Wilson","doi":"10.1016/j.mpaic.2024.06.008","DOIUrl":"10.1016/j.mpaic.2024.06.008","url":null,"abstract":"<div><div>The clotting cascade is a complex process and is an important survival mechanism. Major haemorrhage and thromboembolic events remain major causes of increased morbidity and mortality. Drugs affecting coagulation have primarily been utilized to treat or reduce the risk of thromboembolic events. However, the recent progress in the management of major trauma and treating coagulopathy has resulted in further research and development of drugs that improve clotting function. Knowledge of drugs used for both clinical circumstances is now required when working in anaesthesia or intensive care.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 10","pages":"Pages 714-722"},"PeriodicalIF":0.2,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142419317","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}
Pub Date : 2024-10-01DOI: 10.1016/j.mpaic.2024.07.008
Graham Bell, William Shankey-Smith
Airway management is one of the fundamental skills of any anaesthetist. Considerable anatomical changes occur between birth and adulthood during the development of the paediatric airway. Knowledge of these changes will influence airway planning during childhood. Airway obstruction complicates airway management and any anaesthetist working with children should be able to assess the airway for the presence of obstruction and generate a differential diagnosis of cause. This article aims to summarize key anatomical features of the paediatric airway, common causes of airway obstruction in children and provide suggestions for how to manage these patients.
{"title":"Acute and chronic airway obstruction in children","authors":"Graham Bell, William Shankey-Smith","doi":"10.1016/j.mpaic.2024.07.008","DOIUrl":"10.1016/j.mpaic.2024.07.008","url":null,"abstract":"<div><div>Airway management is one of the fundamental skills of any anaesthetist. Considerable anatomical changes occur between birth and adulthood during the development of the paediatric airway. Knowledge of these changes will influence airway planning during childhood. Airway obstruction complicates airway management and any anaesthetist working with children should be able to assess the airway for the presence of obstruction and generate a differential diagnosis of cause. This article aims to summarize key anatomical features of the paediatric airway, common causes of airway obstruction in children and provide suggestions for how to manage these patients.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 10","pages":"Pages 677-684"},"PeriodicalIF":0.2,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142419788","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}
Pub Date : 2024-10-01DOI: 10.1016/j.mpaic.2024.07.005
Thokozani M Zhande, Alasdair Howie
A thorough understanding of the airway anatomy, as well as the differences that exist between the paediatric and the adult airway is crucial for one to safely manage it. The human airway originates from the primitive foregut at 4 weeks' gestation and fully matures at 36 weeks’ gestation. At birth, the term neonate has a relatively large head, flat occiput, short neck, small mouth opening and a small mandible; features which make them prone to upper airway obstruction as well as a difficult laryngoscopy. Neonates are obligate nasal breathers; allowing them to breathe and suckle simultaneously. The Hagen–Poiseuille equation explains how nasal congestion causes obstruction in neonates which can lead to the development of significant respiratory distress.
The subglottic area of the airway is the most susceptible area to damage from intubation or instrumentation of the airway resulting in subglottic stenosis. Correct endotracheal tube sizing and meticulous attention to detail with respect to cuff pressure are essential to prevent damage to the airway.
{"title":"Developmental anatomy of the airway","authors":"Thokozani M Zhande, Alasdair Howie","doi":"10.1016/j.mpaic.2024.07.005","DOIUrl":"10.1016/j.mpaic.2024.07.005","url":null,"abstract":"<div><div>A thorough understanding of the airway anatomy, as well as the differences that exist between the paediatric and the adult airway is crucial for one to safely manage it. The human airway originates from the primitive foregut at 4 weeks' gestation and fully matures at 36 weeks’ gestation. At birth, the term neonate has a relatively large head, flat occiput, short neck, small mouth opening and a small mandible; features which make them prone to upper airway obstruction as well as a difficult laryngoscopy. Neonates are obligate nasal breathers; allowing them to breathe and suckle simultaneously. The Hagen–Poiseuille equation explains how nasal congestion causes obstruction in neonates which can lead to the development of significant respiratory distress.</div><div>The subglottic area of the airway is the most susceptible area to damage from intubation or instrumentation of the airway resulting in subglottic stenosis. Correct endotracheal tube sizing and meticulous attention to detail with respect to cuff pressure are essential to prevent damage to the airway.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 10","pages":"Pages 671-676"},"PeriodicalIF":0.2,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142419789","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}
Pub Date : 2024-10-01DOI: 10.1016/j.mpaic.2024.07.003
Frances Lanaghan, Peter Stenhouse
Nosocomial infections are associated with a significant morbidity, mortality, resource and financial burden in ICU. Critical care patients are at an increased risk of developing infections compared to patients elsewhere in hospital due to underlying comorbidities of the patient, the acute disease process and treatments required. There is a strong association with indwelling devices in the ICU population. As such, daily review of ongoing requirement for the invasive device and the application of care bundles, as well as the introduction of local policies targeting hand hygiene and infection control protocols to manage infections have been promoted. Ventilator-acquired pneumonia and catheter-related infections are most common. Management of these frequently involves empirical antimicrobials, although targeted therapy based on culture sensitivities and input from the local microbiology team and infection control team are suggested. There is an increasing burden of antimicrobial resistance in part due to the clinical condition of ICU patients and the frequent use of empirical broad-spectrum antibiotics.
{"title":"Nosocomial infections in the intensive care unit","authors":"Frances Lanaghan, Peter Stenhouse","doi":"10.1016/j.mpaic.2024.07.003","DOIUrl":"10.1016/j.mpaic.2024.07.003","url":null,"abstract":"<div><div>Nosocomial infections are associated with a significant morbidity, mortality, resource and financial burden in ICU. Critical care patients are at an increased risk of developing infections compared to patients elsewhere in hospital due to underlying comorbidities of the patient, the acute disease process and treatments required. There is a strong association with indwelling devices in the ICU population. As such, daily review of ongoing requirement for the invasive device and the application of care bundles, as well as the introduction of local policies targeting hand hygiene and infection control protocols to manage infections have been promoted. Ventilator-acquired pneumonia and catheter-related infections are most common. Management of these frequently involves empirical antimicrobials, although targeted therapy based on culture sensitivities and input from the local microbiology team and infection control team are suggested. There is an increasing burden of antimicrobial resistance in part due to the clinical condition of ICU patients and the frequent use of empirical broad-spectrum antibiotics.</div></div>","PeriodicalId":45856,"journal":{"name":"Anaesthesia and Intensive Care Medicine","volume":"25 10","pages":"Pages 652-656"},"PeriodicalIF":0.2,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142419796","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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