Pub Date : 2014-08-01DOI: 10.1192/pb.bp.114.046714
Vanathi Kennedy, Ravindra B Belgamwar
Aims and method Research shows that 16- to 19-year-olds express the greatest level of negative attitudes towards people with mental illness. Our aim was to assess the effectiveness of work experience placements in influencing secondary-school students' attitudes towards mental illness and career choices. The Adolescent Attitude Towards Mental Illness questionnaire measured and assessed the adolescents' attitude changes. Pre- and post-evaluation questionnaires assessed changes in their career choices. Results There was a statistically significant change in the adolescents' attitudes, especially regarding categorical thinking and perceptions that people with mental illness are violent and out of control. There was also a positive shift in their career choices towards options in the field of mental health. Clinical implications Work experience placements can have a positive impact on secondary-school students' attitudes towards mental illness and may improve the level of student recruitment into the field of psychiatry.
{"title":"Impact of work experience placements on school students' attitude towards mental illness.","authors":"Vanathi Kennedy, Ravindra B Belgamwar","doi":"10.1192/pb.bp.114.046714","DOIUrl":"10.1192/pb.bp.114.046714","url":null,"abstract":"<p><p>Aims and method Research shows that 16- to 19-year-olds express the greatest level of negative attitudes towards people with mental illness. Our aim was to assess the effectiveness of work experience placements in influencing secondary-school students' attitudes towards mental illness and career choices. The Adolescent Attitude Towards Mental Illness questionnaire measured and assessed the adolescents' attitude changes. Pre- and post-evaluation questionnaires assessed changes in their career choices. Results There was a statistically significant change in the adolescents' attitudes, especially regarding categorical thinking and perceptions that people with mental illness are violent and out of control. There was also a positive shift in their career choices towards options in the field of mental health. Clinical implications Work experience placements can have a positive impact on secondary-school students' attitudes towards mental illness and may improve the level of student recruitment into the field of psychiatry. </p>","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"159-63"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4115428/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680911","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-08-01DOI: 10.1192/pb.bp.113.045633
Jacqueline Hopson
To encourage psychiatric practitioners to be aware of and to work to counteract the representations of the profession as evil manipulators in fiction, film and popular culture. A wide-ranging number of representative sources portraying psychiatrists are explored. It is demonstrated that psychiatry is overwhelmingly presented in a damagingly negative light.
{"title":"The demonisation of psychiatrists in fiction (and why real psychiatrists might want to do something about it).","authors":"Jacqueline Hopson","doi":"10.1192/pb.bp.113.045633","DOIUrl":"https://doi.org/10.1192/pb.bp.113.045633","url":null,"abstract":"<p><p>To encourage psychiatric practitioners to be aware of and to work to counteract the representations of the profession as evil manipulators in fiction, film and popular culture. A wide-ranging number of representative sources portraying psychiatrists are explored. It is demonstrated that psychiatry is overwhelmingly presented in a damagingly negative light. </p>","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"175-9"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.bp.113.045633","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680914","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In her editorial, Rebecca McGuire-Snieckus warns clinicians against promoting optimism in their clients, since this can lead to unmet expectations and negative reactions when such expectations are not realised.1 In his commentary on the editorial, Femi Oyebode criticises Martin Seligman for exaggerating the importance of happiness at all costs as a goal of existence, and quotes Aristotle as stating that it is the mark of a courageous man to face things that are terrible to a human being.2 I wish to illustrate this in the context of family carers of relatives with schizophrenia. In particular, I focus on the overinvolved carer who is unable to relinquish her/his hopes and expectations for the affected relative. They are readily recognised by habitually referring to their relative in the past tense, for example, ‘she was such a beautiful girl’ or ‘he was such a good student’. This form of speech reveals the fact that the carer is living in the past and has not come to terms with the reality of their relative’s illness. This is particularly hard on the patient, who then feels driven to attempt to satisfy the carer’s need for their success, and fails again and again. The remedy is to offer the carer grief work to mourn their losses and to accept the reality of their relative’s disability and release both parties from this impasse, enabling them to develop a more realistic view. The patient will also benefit from grief work, administered separately from the carer.
{"title":"Hope and hopelessness in carers of a relative with schizophrenia.","authors":"Julian Leff","doi":"10.1192/pb.38.4.198a","DOIUrl":"https://doi.org/10.1192/pb.38.4.198a","url":null,"abstract":"In her editorial, Rebecca McGuire-Snieckus warns clinicians against promoting optimism in their clients, since this can lead to unmet expectations and negative reactions when such expectations are not realised.1 In his commentary on the editorial, Femi Oyebode criticises Martin Seligman for exaggerating the importance of happiness at all costs as a goal of existence, and quotes Aristotle as stating that it is the mark of a courageous man to face things that are terrible to a human being.2 I wish to illustrate this in the context of family carers of relatives with schizophrenia. In particular, I focus on the overinvolved carer who is unable to relinquish her/his hopes and expectations for the affected relative. They are readily recognised by habitually referring to their relative in the past tense, for example, ‘she was such a beautiful girl’ or ‘he was such a good student’. This form of speech reveals the fact that the carer is living in the past and has not come to terms with the reality of their relative’s illness. This is particularly hard on the patient, who then feels driven to attempt to satisfy the carer’s need for their success, and fails again and again. The remedy is to offer the carer grief work to mourn their losses and to accept the reality of their relative’s disability and release both parties from this impasse, enabling them to develop a more realistic view. The patient will also benefit from grief work, administered separately from the carer.","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"198"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.38.4.198a","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680931","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The article by Roychowdhury & Adshead starts to place violence risk assessment in the context of medical care.1 Although this is welcome, their partial defence of risk assessment in general, and of structured professional judgement in particular, is based on some significant distortions. The first distortion is the gross overestimation of the power of risk assessment to discriminate between low-risk and high-risk people. The authors present a contingency table that they imagine shows the ‘potential’ outcomes of a violence risk assessment (Table 2). Using their tabulated data, a diagnostic odds ratio for risk assessment can be calculated to be 81, indicating that the risk of violence in the high-risk group (50%) is hugely higher than in the low-risk group (1.2%). These figures are totally unrealistic. In fact, the diagnostic odds ratio of violence risk assessment in replication studies was recently estimated by meta-analysis2 to be 3. Roychowdhury & Adshead overestimate the discriminating power of risk assessment by 27 times. Moreover, even an unrealistically powerful risk assessment with diagnostic odds of 16 is of little or no value because of failure to detect potential violence in the low-risk group and the large proportion of false positives in the high-risk group.3 The second distortion relates to the underestimation of the precision of medical tests. In fact, the authors seem to have had difficulty finding any medical test with diagnostic odds that they could compare to a violence risk assessment. Instead they chose to compare two medical treatments. They argue that the high number-needed-to-treat as a result of a violence risk assessment is acceptable in psychiatry because in cardiology the number of bypass grafts needed to prevent one fatal outcome has been calculated to be 53.3 However, the meta-analysis they derived this figure from compared coronary bypass surgery to angioplasty - both of which are highly efficacious treatments for angina.3 In reality, medical tests that are used to diagnose conditions with serious implications for the patient are very accurate - biopsy is an excellent indicator of cancer and an angiogram a good indicator of coronary heart disease. Despite these limitations, I support the authors’ general idea of viewing risk assessment as a medical procedure. I would go further: surely violence risk assessment should be judged by the standards of evidence-based medicine. The real questions then become: (1) are there any rational interventions that can be justified in terms of cost and benefit that might reduce violence among high-risk patients (many of whom will not be violent) and yet should not be offered to low-risk patients (who commit as many or even the majority of acts of violence); and (2) is there evidence that shifting treatment resources from low-risk to high-risk people can, in any way, reduce overall levels of harm? The answer to both these questions is no.4,5 There is no doubt that medical di
{"title":"Risk assessment and evidence-based medicine.","authors":"Matthew Large","doi":"10.1192/pb.38.4.196","DOIUrl":"https://doi.org/10.1192/pb.38.4.196","url":null,"abstract":"The article by Roychowdhury & Adshead starts to place violence risk assessment in the context of medical care.1 Although this is welcome, their partial defence of risk assessment in general, and of structured professional judgement in particular, is based on some significant distortions. \u0000 \u0000The first distortion is the gross overestimation of the power of risk assessment to discriminate between low-risk and high-risk people. The authors present a contingency table that they imagine shows the ‘potential’ outcomes of a violence risk assessment (Table 2). Using their tabulated data, a diagnostic odds ratio for risk assessment can be calculated to be 81, indicating that the risk of violence in the high-risk group (50%) is hugely higher than in the low-risk group (1.2%). These figures are totally unrealistic. In fact, the diagnostic odds ratio of violence risk assessment in replication studies was recently estimated by meta-analysis2 to be 3. Roychowdhury & Adshead overestimate the discriminating power of risk assessment by 27 times. Moreover, even an unrealistically powerful risk assessment with diagnostic odds of 16 is of little or no value because of failure to detect potential violence in the low-risk group and the large proportion of false positives in the high-risk group.3 \u0000 \u0000The second distortion relates to the underestimation of the precision of medical tests. In fact, the authors seem to have had difficulty finding any medical test with diagnostic odds that they could compare to a violence risk assessment. Instead they chose to compare two medical treatments. They argue that the high number-needed-to-treat as a result of a violence risk assessment is acceptable in psychiatry because in cardiology the number of bypass grafts needed to prevent one fatal outcome has been calculated to be 53.3 However, the meta-analysis they derived this figure from compared coronary bypass surgery to angioplasty - both of which are highly efficacious treatments for angina.3 In reality, medical tests that are used to diagnose conditions with serious implications for the patient are very accurate - biopsy is an excellent indicator of cancer and an angiogram a good indicator of coronary heart disease. \u0000 \u0000Despite these limitations, I support the authors’ general idea of viewing risk assessment as a medical procedure. I would go further: surely violence risk assessment should be judged by the standards of evidence-based medicine. The real questions then become: (1) are there any rational interventions that can be justified in terms of cost and benefit that might reduce violence among high-risk patients (many of whom will not be violent) and yet should not be offered to low-risk patients (who commit as many or even the majority of acts of violence); and (2) is there evidence that shifting treatment resources from low-risk to high-risk people can, in any way, reduce overall levels of harm? \u0000 \u0000The answer to both these questions is no.4,5 There is no doubt that medical di","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"196"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.38.4.196","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680925","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-08-01DOI: 10.1192/pb.bp.114.048520
Julia Bland
{"title":"Profile: Stigma and the psychiatrist - Julia Bland talks to Dinesh Bhugra.","authors":"Julia Bland","doi":"10.1192/pb.bp.114.048520","DOIUrl":"https://doi.org/10.1192/pb.bp.114.048520","url":null,"abstract":"","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"180-2"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.bp.114.048520","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680916","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The OCTET study overcame many legal and ethical difficulties in setting up a randomised controlled trial (RCT) of community treatment orders (CTOs).1 We welcome the acknowledgment of some of the limitations of the trial, but are surprised that claims are still being made that the study demonstrates that CTOs do not achieve their principle purpose of reducing relapse and readmission.2 Imagine a hypothetical RCT comparing medication with placebo. The trial would be powered based on estimated effect size and its duration would be based on expected time for response. If, in this scenario, 25% of those in the placebo arm had inadvertently been given the active drug, and if the duration of the study had been only a third of that planned, it would be inconceivable that the investigators would claim a negative result proved the drug ineffective. Yet this is analogous to what has taken place with OCTET. In OCTET, median length of compulsion in the community was 183 days in the CTO group v. 8 days in the Section 17 group. Although this seems to indicate that it was a trial of people who were largely either subject to long periods of community compulsion (CTO group) or only a few days of compulsion (Section 17 group), a more detailed examination brings this into question. Almost 25% of the Section 17 group were still subject to compulsion by the end of the study, and the mean length of compulsion in this group was 46 days. In the CTO group, only 50% were subject to compulsion by the end of the study, with a mean length under compulsion of 170 days. This has two main implications. First, the difference in mean length of compulsion between the CTO group and the Section 17 group was only 125 days, or a little over 4 months. It is questionable whether this is sufficient time for any benefits of CTOs to become apparent, and presumably the initial intention had been to compare 12 months in each arm. Second, in effect, a quarter of the control group were receiving the same type of intervention as the CTO group throughout the course of the study. Any possible benefit in the CTO group would have been offset by the same effects in a large number of control subjects, leading to a large reduction in the power of the study and to type 2 error. The sensitivity analysis does nothing to address this loss of power. We contend that given these problems, in conjunction with the broader issues of recruitment and selection,3 it is not possible to claim that OCTET demonstrates CTOs to be ineffective.
{"title":"OCTET Study: flawed by type 2 error.","authors":"Andy J Owen, Deepak Mirok, Loopinder Sood","doi":"10.1192/pb.38.4.196b","DOIUrl":"https://doi.org/10.1192/pb.38.4.196b","url":null,"abstract":"The OCTET study overcame many legal and ethical difficulties in setting up a randomised controlled trial (RCT) of community treatment orders (CTOs).1 We welcome the acknowledgment of some of the limitations of the trial, but are surprised that claims are still being made that the study demonstrates that CTOs do not achieve their principle purpose of reducing relapse and readmission.2 \u0000 \u0000Imagine a hypothetical RCT comparing medication with placebo. The trial would be powered based on estimated effect size and its duration would be based on expected time for response. If, in this scenario, 25% of those in the placebo arm had inadvertently been given the active drug, and if the duration of the study had been only a third of that planned, it would be inconceivable that the investigators would claim a negative result proved the drug ineffective. Yet this is analogous to what has taken place with OCTET. \u0000 \u0000In OCTET, median length of compulsion in the community was 183 days in the CTO group v. 8 days in the Section 17 group. Although this seems to indicate that it was a trial of people who were largely either subject to long periods of community compulsion (CTO group) or only a few days of compulsion (Section 17 group), a more detailed examination brings this into question. Almost 25% of the Section 17 group were still subject to compulsion by the end of the study, and the mean length of compulsion in this group was 46 days. In the CTO group, only 50% were subject to compulsion by the end of the study, with a mean length under compulsion of 170 days. This has two main implications. \u0000 \u0000First, the difference in mean length of compulsion between the CTO group and the Section 17 group was only 125 days, or a little over 4 months. It is questionable whether this is sufficient time for any benefits of CTOs to become apparent, and presumably the initial intention had been to compare 12 months in each arm. \u0000 \u0000Second, in effect, a quarter of the control group were receiving the same type of intervention as the CTO group throughout the course of the study. Any possible benefit in the CTO group would have been offset by the same effects in a large number of control subjects, leading to a large reduction in the power of the study and to type 2 error. The sensitivity analysis does nothing to address this loss of power. We contend that given these problems, in conjunction with the broader issues of recruitment and selection,3 it is not possible to claim that OCTET demonstrates CTOs to be ineffective.","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"196-7"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.38.4.196b","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680927","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Roychowdhury & Adshead should be thanked for raising the issue of the ethics of the use of actuarial risk assessment in psychiatry.1 These ethics might at first appear obvious: medical practitioners must have an overriding duty to protect the public from serious crime. It follows that they must do everything possible to accurately assess the risk of such crime, including the use of these assessment instruments. However, as Roychowdhury & Adshead point out, these instruments will produce misleading results if the prevalence of the serious crime being considered in the relevant population is low or unknown. Indeed, they point out: ‘A key challenge in psychiatry is that base rates [of the prevalence of serious crime] are often not known, are low and vary for different types of violence.’ So if doctors use these assessments they risk wrongly identifying their patient as at high risk of committing a serious crime, and then act in a way that is not in the best interests of that patient. Such an act would of course be inconsistent with the duties of a doctor as set out by the General Medical Council (GMC) in Good Medical Practice.2 It follows that while the prevalence of particular serious crimes in various patient populations is unknown or is known to be low, the use of these actuarial risk assessments will remain unethical. As Roychowdhury & Ashhead conclude: ‘[structured professional judgement] tools used as checklists of risk factors without construction of risk scenarios or a risk management plan remains harmful and unethical practice.’ In my opinion psychiatrists would value guidance on this issue from the GMC.
{"title":"GMC guidance needed.","authors":"Keith E Dudleston","doi":"10.1192/pb.38.4.195b","DOIUrl":"https://doi.org/10.1192/pb.38.4.195b","url":null,"abstract":"Roychowdhury & Adshead should be thanked for raising the issue of the ethics of the use of actuarial risk assessment in psychiatry.1 These ethics might at first appear obvious: medical practitioners must have an overriding duty to protect the public from serious crime. It follows that they must do everything possible to accurately assess the risk of such crime, including the use of these assessment instruments. However, as Roychowdhury & Adshead point out, these instruments will produce misleading results if the prevalence of the serious crime being considered in the relevant population is low or unknown. Indeed, they point out: ‘A key challenge in psychiatry is that base rates [of the prevalence of serious crime] are often not known, are low and vary for different types of violence.’ So if doctors use these assessments they risk wrongly identifying their patient as at high risk of committing a serious crime, and then act in a way that is not in the best interests of that patient. Such an act would of course be inconsistent with the duties of a doctor as set out by the General Medical Council (GMC) in Good Medical Practice.2 It follows that while the prevalence of particular serious crimes in various patient populations is unknown or is known to be low, the use of these actuarial risk assessments will remain unethical. As Roychowdhury & Ashhead conclude: ‘[structured professional judgement] tools used as checklists of risk factors without construction of risk scenarios or a risk management plan remains harmful and unethical practice.’ In my opinion psychiatrists would value guidance on this issue from the GMC.","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"195-6"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.38.4.195b","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32680924","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2014-08-01DOI: 10.1192/pb.bp.113.044693
Tania Louise Gergel
Challenges to psychiatric stigma fall between a rock and a hard place. Decreasing one prejudice may inadvertently increase another. Emphasising similarities between mental illness and 'ordinary' experience to escape the fear-related prejudices associated with the imagined 'otherness' of persons with mental illness risks conclusions that mental illness indicates moral weakness and the loss of any benefits of a medical model. An emphasis on illness and difference from normal experience risks a response of fear of the alien. Thus, a 'likeness-based' and 'unlikeness-based' conception of psychiatric stigma can lead to prejudices stemming from paradoxically opposing assumptions about mental illness. This may create a troubling impasse for anti-stigma campaigns.
{"title":"Too similar, too different: the paradoxical dualism of psychiatric stigma.","authors":"Tania Louise Gergel","doi":"10.1192/pb.bp.113.044693","DOIUrl":"https://doi.org/10.1192/pb.bp.113.044693","url":null,"abstract":"<p><p>Challenges to psychiatric stigma fall between a rock and a hard place. Decreasing one prejudice may inadvertently increase another. Emphasising similarities between mental illness and 'ordinary' experience to escape the fear-related prejudices associated with the imagined 'otherness' of persons with mental illness risks conclusions that mental illness indicates moral weakness and the loss of any benefits of a medical model. An emphasis on illness and difference from normal experience risks a response of fear of the alien. Thus, a 'likeness-based' and 'unlikeness-based' conception of psychiatric stigma can lead to prejudices stemming from paradoxically opposing assumptions about mental illness. This may create a troubling impasse for anti-stigma campaigns. </p>","PeriodicalId":90710,"journal":{"name":"Psychiatric bulletin (2014)","volume":"38 4","pages":"148-51"},"PeriodicalIF":0.0,"publicationDate":"2014-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1192/pb.bp.113.044693","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"32679953","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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