Pub Date : 2025-02-05DOI: 10.1016/j.amjsurg.2025.116239
Nader Zamani , Sherene E. Sharath , Panos Kougias
Introduction
The objective was to characterize the interactive effects of cardiovascular disease (CVD) and chronic kidney disease (CKD) on long-term mortality following major operations.
Methods
We performed a national, retrospective cohort study of patients undergoing high-risk operations from 1991 through 2018 using the VA Corporate Data Warehouse and Surgical Quality Improvement Program. Preoperative exposures included CVD (history of angina, CHF, MI, stroke, peripheral arterial disease, and related procedures) and CKD Stages III-V. The primary outcome was long-term mortality.
Results
514,057 operations were included. After adjustment, the interaction between CVD and CKD Stage III (HR 1.38, 95% CI: 1.35–1.42), Stage IV (HR 1.91, 95% CI: 1.83–2.01), and Stage V (HR 2.70, 95% CI: 2.59–2.81) progressively conferred increasing risk of mortality.
Conclusions
In the setting of major operations, it is more accurate to interpret CVD and CKD in context of one another while accounting for the degree of baseline renal dysfunction.
{"title":"Combined influence of cardiovascular disease and chronic kidney disease on long-term mortality following major operations","authors":"Nader Zamani , Sherene E. Sharath , Panos Kougias","doi":"10.1016/j.amjsurg.2025.116239","DOIUrl":"10.1016/j.amjsurg.2025.116239","url":null,"abstract":"<div><h3>Introduction</h3><div>The objective was to characterize the interactive effects of cardiovascular disease (CVD) and chronic kidney disease (CKD) on long-term mortality following major operations.</div></div><div><h3>Methods</h3><div>We performed a national, retrospective cohort study of patients undergoing high-risk operations from 1991 through 2018 using the VA Corporate Data Warehouse and Surgical Quality Improvement Program. Preoperative exposures included CVD (history of angina, CHF, MI, stroke, peripheral arterial disease, and related procedures) and CKD Stages III-V. The primary outcome was long-term mortality.</div></div><div><h3>Results</h3><div>514,057 operations were included. After adjustment, the interaction between CVD and CKD Stage III (HR 1.38, 95% CI: 1.35–1.42), Stage IV (HR 1.91, 95% CI: 1.83–2.01), and Stage V (HR 2.70, 95% CI: 2.59–2.81) progressively conferred increasing risk of mortality.</div></div><div><h3>Conclusions</h3><div>In the setting of major operations, it is more accurate to interpret CVD and CKD in context of one another while accounting for the degree of baseline renal dysfunction.</div></div>","PeriodicalId":7771,"journal":{"name":"American journal of surgery","volume":"242 ","pages":"Article 116239"},"PeriodicalIF":2.7,"publicationDate":"2025-02-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143429161","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-05DOI: 10.1016/j.amjsurg.2025.116240
Eric Bao, Sarah Nathaniel, Nargiz Seyidova, Olachi Oleru, Abigail Tirrell, Peter W Henderson
{"title":"My thoughts: Development of a database selection tool for large database research.","authors":"Eric Bao, Sarah Nathaniel, Nargiz Seyidova, Olachi Oleru, Abigail Tirrell, Peter W Henderson","doi":"10.1016/j.amjsurg.2025.116240","DOIUrl":"https://doi.org/10.1016/j.amjsurg.2025.116240","url":null,"abstract":"","PeriodicalId":7771,"journal":{"name":"American journal of surgery","volume":" ","pages":"116240"},"PeriodicalIF":2.7,"publicationDate":"2025-02-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143397917","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The prognostic factors for overall survival (OS) in perihilar cholangiocarcinoma (pCCA) included resection margin (RM) and lymph node metastases (LNM). Nevertheless, the advantage associated with a negative RM in patients with LNM remains unresolved.
Methods
The study retrospectively analyzed patients with pCCA underwent curative-intent resection between October 2013 and December 2018. The evaluation of the OS was conducted based on the presence of LNM and the status of RM.
Results
Of the 167 resected pCCA patients, 87 (52.1 %) were LNM negative, and 80 (47.9 %) were LNM positive. Of the 87 LNM-negative patients, 68 (78.2 %) were R0 resections, and 19 (21.8 %) were R1 resections. In LNM-negative patients, the OS was longer in the R0 resection than the R1 resection group (median survival time (MST) of 32.1 vs 15.7 months, respectively; p < 0.001). Of the 80 LNM-positive patients, 35 were R0 resections and 45 were R1 resections. Among patients with LNM positivity, the OS rates were similar between the groups who underwent R1 resection and R0 resection (MST of 8.4 vs 8.0 months, respectively; p = 0.109).
Conclusion
In patients with pCCA, the RM status was the most important prognostic factor for LNM-negative patients. However, there was no impact in LNM-positive patients.
{"title":"The impact of resection margin status according to lymph node metastasis on the survival outcome of perihilar cholangiocarcinoma","authors":"Poowanai Sarkhampee, Weeris Ouransatien, Satsawat Chansitthichok, Nithi Lertsawatvicha, Paiwan Wattanarath","doi":"10.1016/j.amjsurg.2025.116236","DOIUrl":"10.1016/j.amjsurg.2025.116236","url":null,"abstract":"<div><h3>Background</h3><div>The prognostic factors for overall survival (OS) in perihilar cholangiocarcinoma (pCCA) included resection margin (RM) and lymph node metastases (LNM). Nevertheless, the advantage associated with a negative RM in patients with LNM remains unresolved.</div></div><div><h3>Methods</h3><div>The study retrospectively analyzed patients with pCCA underwent curative-intent resection between October 2013 and December 2018. The evaluation of the OS was conducted based on the presence of LNM and the status of RM.</div></div><div><h3>Results</h3><div>Of the 167 resected pCCA patients, 87 (52.1 %) were LNM negative, and 80 (47.9 %) were LNM positive. Of the 87 LNM-negative patients, 68 (78.2 %) were R0 resections, and 19 (21.8 %) were R1 resections. In LNM-negative patients, the OS was longer in the R0 resection than the R1 resection group (median survival time (MST) of 32.1 vs 15.7 months, respectively; p < 0.001). Of the 80 LNM-positive patients, 35 were R0 resections and 45 were R1 resections. Among patients with LNM positivity, the OS rates were similar between the groups who underwent R1 resection and R0 resection (MST of 8.4 vs 8.0 months, respectively; p = 0.109).</div></div><div><h3>Conclusion</h3><div>In patients with pCCA, the RM status was the most important prognostic factor for LNM-negative patients. However, there was no impact in LNM-positive patients.</div></div>","PeriodicalId":7771,"journal":{"name":"American journal of surgery","volume":"242 ","pages":"Article 116236"},"PeriodicalIF":2.7,"publicationDate":"2025-02-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143387347","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-03DOI: 10.1016/j.amjsurg.2025.116231
Mustafa Abid , Mark Holmes , Anthony Charles
Background
General Surgeon Workforce Density (WFD) is used to approximate surgical access. Treatment-incidence ratios (TIR) provide a novel measure of care access. TIR's association with General Surgeon WFD has not been evaluated.
Study design
Retrospective cohort study of North Carolina inpatient discharges (2016–2019). The association between county and Hospital Service Area (HSA) TIRs for general surgical diseases was analyzed using adjusted linear and logistic regression.
Results
When adjusting for pertinent covariates, county General Surgeon WFD and TIR (−0.0009, 95 % CI -0.028,0.026; p 0.95) and HSA General Surgeon WFD and TIR (0.008, 95 % CI -0.021,0.037; p 0.58) were not statistically significantly associated. The odds of a county 0.91 (95 % CI 0.42,1.97; p 0.82) or HSA (OR 0.93, 95 % CI 0.43,2.04; p 0.86) having a high TIR was not associated with WFD.
Conclusion
General Surgeon WFD is not associated with disease-specific procedural rates of common surgical conditions at the county or HSA level.
{"title":"General surgeon workforce density is not associated with treatment-incidence ratios at the county or hospital service area level in North Carolina","authors":"Mustafa Abid , Mark Holmes , Anthony Charles","doi":"10.1016/j.amjsurg.2025.116231","DOIUrl":"10.1016/j.amjsurg.2025.116231","url":null,"abstract":"<div><h3>Background</h3><div>General Surgeon Workforce Density (WFD) is used to approximate surgical access. Treatment-incidence ratios (TIR) provide a novel measure of care access. TIR's association with General Surgeon WFD has not been evaluated.</div></div><div><h3>Study design</h3><div>Retrospective cohort study of North Carolina inpatient discharges (2016–2019). The association between county and Hospital Service Area (HSA) TIRs for general surgical diseases was analyzed using adjusted linear and logistic regression.</div></div><div><h3>Results</h3><div>When adjusting for pertinent covariates, county General Surgeon WFD and TIR (−0.0009, 95 % CI -0.028,0.026; p 0.95) and HSA General Surgeon WFD and TIR (0.008, 95 % CI -0.021,0.037; p 0.58) were not statistically significantly associated. The odds of a county 0.91 (95 % CI 0.42,1.97; p 0.82) or HSA (OR 0.93, 95 % CI 0.43,2.04; p 0.86) having a high TIR was not associated with WFD.</div></div><div><h3>Conclusion</h3><div>General Surgeon WFD is not associated with disease-specific procedural rates of common surgical conditions at the county or HSA level.</div></div>","PeriodicalId":7771,"journal":{"name":"American journal of surgery","volume":"242 ","pages":"Article 116231"},"PeriodicalIF":2.7,"publicationDate":"2025-02-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143419134","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-03DOI: 10.1016/j.amjsurg.2025.116234
Yasmin Arda, John O Hwabejire
{"title":"Housing, health, and harm: Gentrification's impact on firearm violence and access to care.","authors":"Yasmin Arda, John O Hwabejire","doi":"10.1016/j.amjsurg.2025.116234","DOIUrl":"https://doi.org/10.1016/j.amjsurg.2025.116234","url":null,"abstract":"","PeriodicalId":7771,"journal":{"name":"American journal of surgery","volume":" ","pages":"116234"},"PeriodicalIF":2.7,"publicationDate":"2025-02-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143373648","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-02DOI: 10.1016/j.amjsurg.2025.116229
Sarah Lu, Katrina Nietsch, Akiro Duey, Bashar Zaidat, Laura C Mazudie Ndjonko, Nancy Shrestha, Jun Kim, Samuel K Cho
Background: High-energy lower extremity injury presents with difficult clinical decisions because successful limb salvage is the best scenario for complex traumas, but early amputation may be necessary to limit complications. Artificial Intelligence is a tool rising in popularity to help make clinical judgements.
Purpose/questions: The aim of this study is to determine whether ChatGPT-4 can produce accurate recommendations for limb salvage or amputation given various patient scenarios.
Methods: Various lower leg trauma scenarios were given to the appropriate use criteria for limb salvage made by AAOS or ChatGPT-4. A recommendation score for limb salvage and early amputation were collected. Tests to determine statistical significance between AAOS and ChatGPT-4 were performed.
Results: A total of 196 patient scenario combinations were utilized. The mean error for limb salvage and early amputation were -0.3 and -0.2 respectively. AAOS and ChatGPT had significant positive correlations when predicting limb salvage and early amputation scores. The effect size of limb salvage and early amputation was -0.094 and -0.14, respectively.
Conclusion: ChatGPT-4 generally under-estimates appropriateness scores for both limb salvage and early amputation treatment options, but produces similar scores. ChatGPT-4 may be used to aid physicians in choosing between limb salvage and early amputation, though with caution.
{"title":"Management of lower extremity traumas: Comparing appropriate use criteria ChatGPT recommendations.","authors":"Sarah Lu, Katrina Nietsch, Akiro Duey, Bashar Zaidat, Laura C Mazudie Ndjonko, Nancy Shrestha, Jun Kim, Samuel K Cho","doi":"10.1016/j.amjsurg.2025.116229","DOIUrl":"https://doi.org/10.1016/j.amjsurg.2025.116229","url":null,"abstract":"<p><strong>Background: </strong>High-energy lower extremity injury presents with difficult clinical decisions because successful limb salvage is the best scenario for complex traumas, but early amputation may be necessary to limit complications. Artificial Intelligence is a tool rising in popularity to help make clinical judgements.</p><p><strong>Purpose/questions: </strong>The aim of this study is to determine whether ChatGPT-4 can produce accurate recommendations for limb salvage or amputation given various patient scenarios.</p><p><strong>Methods: </strong>Various lower leg trauma scenarios were given to the appropriate use criteria for limb salvage made by AAOS or ChatGPT-4. A recommendation score for limb salvage and early amputation were collected. Tests to determine statistical significance between AAOS and ChatGPT-4 were performed.</p><p><strong>Results: </strong>A total of 196 patient scenario combinations were utilized. The mean error for limb salvage and early amputation were -0.3 and -0.2 respectively. AAOS and ChatGPT had significant positive correlations when predicting limb salvage and early amputation scores. The effect size of limb salvage and early amputation was -0.094 and -0.14, respectively.</p><p><strong>Conclusion: </strong>ChatGPT-4 generally under-estimates appropriateness scores for both limb salvage and early amputation treatment options, but produces similar scores. ChatGPT-4 may be used to aid physicians in choosing between limb salvage and early amputation, though with caution.</p>","PeriodicalId":7771,"journal":{"name":"American journal of surgery","volume":" ","pages":"116229"},"PeriodicalIF":2.7,"publicationDate":"2025-02-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143405392","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.amjsurg.2024.116133
Nicolas Mourad , Kelsey Stefanyk , Dominique Vervoort
Background
Over 100 countries do not have a local cardiac surgeon, whereas capacity, coverage, or cultural constrains may limit access to cardiac surgical care in-country. This scoping review aims to summarize the current literature of patients seeking cardiac surgical care abroad and determine research gaps for this understudied aspect of global surgical care.
Methods
A scoping review was conducted on patients seeking cardiac surgery outside of their home country using MEDLINE, EMBASE, CINAHL, SCOPUS, WHO Global Index Medicus, and PubMed databases. Relevant articles were descriptively and quantitatively summarized.
Results
Out of a total of 49 articles and 6351 patients, the most common procedures were coronary artery bypass grafts & valve procedures (N = 3948; 62 %) and congenital heart disease repairs (N = 2049; 32 %). The most prevalent countries of origin were Japan, Nigeria, and the United Arab Emirates. The United States, France, and the United Kingdom were the most common destination countries. Most patients (N = 1483; 23 %) sought care abroad due to limited therapeutic options in the home country. Funding sources stemmed comparably from government funding, non-governmental organization funding, and out-of-pocket payments.
Conclusions
The extent of and reasons for individuals traveling abroad for cardiac surgery are poorly described. Localizing cardiac care, while requiring significant resources, may lead to substantial cost savings and improved access to care. Until then, improving access to international travel for cardiac surgery remains an important strategy.
背景：100多个国家没有当地的心脏外科医生，而能力、覆盖范围或文化限制可能限制了国内心脏外科护理的可及性。本综述旨在总结目前国外寻求心脏外科治疗的患者的文献，并确定全球外科治疗中这一研究不足方面的研究空白。方法：使用MEDLINE、EMBASE、CINAHL、SCOPUS、WHO Global Index Medicus和PubMed数据库对在本国以外寻求心脏手术的患者进行范围审查。对相关文章进行了描述性和定量总结。结果：在49篇文章和6351例患者中，最常见的手术是冠状动脉旁路移植术和瓣膜手术(N = 3948；62%)和先天性心脏病修复(N = 2049；32%)。最普遍的原籍国是日本、尼日利亚和阿拉伯联合酋长国。美国、法国和英国是最常见的目的地国家。大多数患者(N = 1483；23%)由于本国治疗选择有限而到国外求医。资金来源主要有政府资助、非政府组织资助和自费。结论：人们对出国进行心脏手术的程度和原因描述甚少。心脏护理本地化虽然需要大量资源，但可能会节省大量成本并改善获得护理的机会。在此之前，改善心脏手术的国际旅行仍然是一个重要的策略。
{"title":"Crossing borders to meet cardiac surgical needs: A scoping review on patients seeking cardiac surgery abroad","authors":"Nicolas Mourad , Kelsey Stefanyk , Dominique Vervoort","doi":"10.1016/j.amjsurg.2024.116133","DOIUrl":"10.1016/j.amjsurg.2024.116133","url":null,"abstract":"<div><h3>Background</h3><div>Over 100 countries do not have a local cardiac surgeon, whereas capacity, coverage, or cultural constrains may limit access to cardiac surgical care in-country. This scoping review aims to summarize the current literature of patients seeking cardiac surgical care abroad and determine research gaps for this understudied aspect of global surgical care.</div></div><div><h3>Methods</h3><div>A scoping review was conducted on patients seeking cardiac surgery outside of their home country using MEDLINE, EMBASE, CINAHL, SCOPUS, WHO Global Index Medicus, and PubMed databases. Relevant articles were descriptively and quantitatively summarized.</div></div><div><h3>Results</h3><div>Out of a total of 49 articles and 6351 patients, the most common procedures were coronary artery bypass grafts & valve procedures (N = 3948; 62 %) and congenital heart disease repairs (N = 2049; 32 %). The most prevalent countries of origin were Japan, Nigeria, and the United Arab Emirates. The United States, France, and the United Kingdom were the most common destination countries. Most patients (N = 1483; 23 %) sought care abroad due to limited therapeutic options in the home country. Funding sources stemmed comparably from government funding, non-governmental organization funding, and out-of-pocket payments.</div></div><div><h3>Conclusions</h3><div>The extent of and reasons for individuals traveling abroad for cardiac surgery are poorly described. Localizing cardiac care, while requiring significant resources, may lead to substantial cost savings and improved access to care. Until then, improving access to international travel for cardiac surgery remains an important strategy.</div></div>","PeriodicalId":7771,"journal":{"name":"American journal of surgery","volume":"240 ","pages":"Article 116133"},"PeriodicalIF":2.7,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142821615","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Single-site studies have found variable associations between gender and entrustment-based interactions during surgical residency. We sought to assess the relationship between resident sex and intraoperative entrustment at multiple institutions.
Methods
Surgical cases were observed at four university-based training programs. Faculty entrustment and resident entrustability were rated using OpTrust. OpTrust is a validated intraoperative entrustment measurement tool which enables trained third-party raters to objectively score resident and faculty behaviors in the operating room. Independent sample t-tests and regression analysis with cluster adjusted standard errors were used.
Results
337 cases were observed which included 149 residents (54 % female) and 97 faculty members (30 % female). There was no difference in resident entrustability based on resident sex (p = 0.30). Female residents were more likely to be involved in cases rated as more difficult (p = 0.04). At a single site, male residents scored higher on resident entrustability (p = 0.007) and faculty entrustment (p = 0.022).
Conclusion
Entrustment did not differ based on resident sex on a multi-institutional scale; however, at a single site, there was a difference; suggesting there are multi-factorial issues contributing to differences in training.
{"title":"Multi-institutional study examining intraoperative entrustment and resident sex","authors":"Samantha Baker , Julie Evans , Niki Matusko , Brenessa Lindeman , Sarah Jung , Sebin Choi , Rebecca Minter , Mackenzie Cook , Karen Brasel , Gurjit Sandhu","doi":"10.1016/j.amjsurg.2024.115925","DOIUrl":"10.1016/j.amjsurg.2024.115925","url":null,"abstract":"<div><h3>Introduction</h3><div>Single-site studies have found variable associations between gender and entrustment-based interactions during surgical residency. We sought to assess the relationship between resident sex and intraoperative entrustment at multiple institutions.</div></div><div><h3>Methods</h3><div>Surgical cases were observed at four university-based training programs. Faculty entrustment and resident entrustability were rated using OpTrust. OpTrust is a validated intraoperative entrustment measurement tool which enables trained third-party raters to objectively score resident and faculty behaviors in the operating room. Independent sample t-tests and regression analysis with cluster adjusted standard errors were used.</div></div><div><h3>Results</h3><div>337 cases were observed which included 149 residents (54 % female) and 97 faculty members (30 % female). There was no difference in resident entrustability based on resident sex (p = 0.30). Female residents were more likely to be involved in cases rated as more difficult (p = 0.04). At a single site, male residents scored higher on resident entrustability (p = 0.007) and faculty entrustment (p = 0.022).</div></div><div><h3>Conclusion</h3><div>Entrustment did not differ based on resident sex on a multi-institutional scale; however, at a single site, there was a difference; suggesting there are multi-factorial issues contributing to differences in training.</div></div>","PeriodicalId":7771,"journal":{"name":"American journal of surgery","volume":"240 ","pages":"Article 115925"},"PeriodicalIF":2.7,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142144972","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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