Journal of Trauma and Acute Care Surgery最新文献

{"title":"American Association for the Surgery of Trauma pancreatic organ injury scale: 2024 Revision.","authors":"David M Notrica, Gail T Tominaga, Joel A Gross, Richard N Southard, Mark E McOmber, Marie Crandall, Rosemary Kozar, Krista L Kaups, Kevin M Schuster, Chad G Ball","doi":"10.1097/TA.0000000000004522","DOIUrl":"https://doi.org/10.1097/TA.0000000000004522","url":null,"abstract":"<p><strong>Background: </strong>The American Association for the Surgery of Trauma Organ Injury Scale (OIS) Committee published the original pancreatic OIS in 1990 with the authors acknowledging at the time that the classification would need to undergo \"continued refinement as clinical experience dictates.\" The current OIS overemphasizes injury location over ductal integrity; modifications are needed to improve concordance between OIS, therapy, and outcomes and promote accuracy in quality assessment and research.</p><p><strong>Methods: </strong>A subcommittee of the American Association for the Surgery of Trauma and invited experts in radiology and interventional gastroenterology were chosen. Contemporary literature was reviewed, and a standardized iterative and collegial process was used to arrive at consensus.</p><p><strong>Results: </strong>The pancreatic OIS is anatomically based on operative, radiographic, or pathologic findings. Major changes to the grading system include moving lacerations of the pancreatic head without ductal injury from Grade IV to Grade II. Injuries to the duct in the neck, body, or tail remain Grade III but are further subclassified to distinguish between deep parenchymal injuries without ductal interrogation, partial ductal injuries, and complete ductal transection. Grade IV injuries follow the same nomenclature but for injuries to the right of the portal vein or superior mesenteric vein. Grade V injuries are destructive injuries of the pancreatic head with nonviable parenchyma. These injuries are further subgraded based on ductal injuries.</p><p><strong>Conclusion: </strong>The pancreatic OIS schema is revised based on contemporary experience informed by the current understanding of outcomes and treatment, including operative management and outcomes. Increasing grades now more closely reflect increasing severity.</p><p><strong>Level of evidence: </strong>Expert Opinion; Level V.</p>","PeriodicalId":17453,"journal":{"name":"Journal of Trauma and Acute Care Surgery","volume":" ","pages":""},"PeriodicalIF":2.9,"publicationDate":"2025-02-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143080554","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evidence-based, cost-effective management of acute appendicitis: An algorithm of the Journal of Trauma and Acute Care Surgery emergency general surgery algorithms work group.","authors":"Jose J Diaz, Lena Napolitano, David H Livingston, Todd Costantini, Kenji Inaba, Walter L Biffl, Robert Winchell, Ali Salim, Raul Coimbra","doi":"10.1097/TA.0000000000004569","DOIUrl":"https://doi.org/10.1097/TA.0000000000004569","url":null,"abstract":"","PeriodicalId":17453,"journal":{"name":"Journal of Trauma and Acute Care Surgery","volume":" ","pages":""},"PeriodicalIF":2.9,"publicationDate":"2025-02-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143080557","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Letter re: \"Timing of venous thromboembolism prophylaxis initiation and complications in polytrauma patients with high-risk bleeding orthopedic interventions: A nationwide analysis\".","authors":"Nickolas Hernandez, Nikita Nunes Espat, Adel Elkbuli","doi":"10.1097/TA.0000000000004496","DOIUrl":"https://doi.org/10.1097/TA.0000000000004496","url":null,"abstract":"","PeriodicalId":17453,"journal":{"name":"Journal of Trauma and Acute Care Surgery","volume":" ","pages":""},"PeriodicalIF":2.9,"publicationDate":"2025-02-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143189216","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Factors affecting the direct red cell effect on thrombosis: Hematocrit dilution and injury patterns.","authors":"Adam D Price, Ellen R Becker, Ryan C Chae, Matthew R Baucom, Taylor E Wallen, Rebecca Schuster, Lisa England, Timothy A Pritts, Michael D Goodman","doi":"10.1097/TA.0000000000004513","DOIUrl":"10.1097/TA.0000000000004513","url":null,"abstract":"<p><strong>Background: </strong>Red blood cell (RBC) aggregation can be initiated by calcium and tissue factor, which may independently contribute to microvascular and macrovascular thrombosis after injury and transfusion. Previous studies have demonstrated that increased blood storage duration may contribute to thrombotic events. The aims of this study were to first determine the effect of blood product components, age, and hematocrit (HCT) on the aggregability of RBCs, followed by measurement of RBC aggregability in two specific injury models including traumatic brain injury (TBI) and hemorrhagic shock.</p><p><strong>Methods: </strong>Human whole blood (WB) units were obtained following the standard 21-day storage period. Whole blood was separated into components including RBCs, platelet-rich plasma (PRP), and platelet-poor plasma (PPP) via serial centrifugation and diluted to a standardized HCT on Days 2 and 23 following isolation. Finally, WB was collected from murine models of TBI and hemorrhagic shock at sequential, postinjury timepoints. Whole blood and component groups were analyzed for RBC aggregability with calcium and tissue factor initiated electrical impedance aggregometry.</p><p><strong>Results: </strong>At both timepoints, nondiluted HCT RBCs demonstrated similar aggregability to standardized-HCT RBCs when diluted with phosphate buffered saline (PBS). Red blood cells diluted with PRP and PPP demonstrated significantly higher aggregation than RBCs diluted with PBS at both timepoints. Reconstitution with PRP and PPP demonstrated similar aggregability. Murine RBCs demonstrated increased aggregation at the 4-hour postinjury timepoint following TBI and decreased aggregation at the 1-hour postinjury following hemorrhagic shock.</p><p><strong>Conclusion: </strong>Neither hemoconcentration or age of donated blood products affect the calcium and tissue-factor dependent aggregability of RBCs. Further, RBC aggregation is increased in the presence of plasma, not platelets-indicating a potential role for plasma in regulating RBC aggregation. Finally, injury patterns including TBI and hemorrhagic shock may influence hypercoagulability or coagulopathy via change in RBC aggregability.</p>","PeriodicalId":17453,"journal":{"name":"Journal of Trauma and Acute Care Surgery","volume":" ","pages":"197-203"},"PeriodicalIF":2.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142950667","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Do emergency Medicaid programs improve post-discharge health care access for trauma patients? A statewide mixed-methods study.","authors":"Lisa Marie Knowlton, Katherine Arnow, Zaria Cosby, Kristen Davis, Wesley D Hendricks, Alexander B Gibson, Peiqi Chen, Arden M Morris, Todd H Wagner","doi":"10.1097/TA.0000000000004519","DOIUrl":"10.1097/TA.0000000000004519","url":null,"abstract":"<p><strong>Background: </strong>Hospital presumptive eligibility (HPE) emergency Medicaid programs offset patient bills at hospitalization and can provide long-term Medicaid coverage. We characterized postdischarge outpatient health care utilization among HPE Medicaid trauma patients and identified patient access facilitators and barriers once newly insured. We hypothesized utilization would be increased among HPE trauma patients compared with other HPE patients, but that challenges in access to care would remain.</p><p><strong>Methods: </strong>We performed a convergent mixed methods study of California HPE beneficiaries using a 2016 to 2021 customized statewide longitudinal claims dataset from the Department of Health Care Services. We compared adults 18 years and older with a diagnosis to other HPE patients. Patients were tracked for 2 months postdischarge to evaluate health care utilization: outpatient specialist visits, emergency room (ER) visits, readmissions, and mental health. Thematic analysis of semistructured interviews with HPE Medicaid patients aimed to understand facilitators and barriers to access to care (n = 20).</p><p><strong>Results: </strong>Among 199,885 HPE patients, 39,677 (19.8%) had a primary diagnosis of trauma. In the 2 months postdischarge, 40.8% of trauma vs. 36.6% of nontrauma accessed outpatient specialist services; 18.6% vs. 17.2% returned to ED, 8.4% vs. 10.2% were readmitted; and 1.4% vs. 1.8% accessed mental health services. In adjusted analyses, trauma HPE patients had 1.18 increased odds of accessing outpatient specialist services ( p < 0.01). Patients cited HPE facilitators to accessing care: rapid insurance acquisition, outpatient follow-up, hospital staff support, as well as ongoing barriers to access (HPE program information recall, lack of hospital staff follow up postdischarge, and difficulty navigating a complex health care system).</p><p><strong>Conclusion: </strong>Hospital presumptive eligibility Medicaid is associated with higher rates of outpatient specialist visits and fewer readmissions following injury, suggesting improved trauma patient access. Opportunities to improve appropriateness of health care utilization include more robust and longitudinal education and engagement with HPE Medicaid patients to help them navigate newfound access to services.</p><p><strong>Level of evidence: </strong>Prognostic and Epidemiological; Level III.</p>","PeriodicalId":17453,"journal":{"name":"Journal of Trauma and Acute Care Surgery","volume":" ","pages":"219-227"},"PeriodicalIF":2.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142864753","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of the Good Samaritan Law on bystander intervention willingness and perceived legal risks in India.","authors":"Divya Kewalramani, Rachel L Choron, Daniel Whitley, Amanda Teichman, Karuna Raina, Gautam Singh, Charoo Piplani, Zachary Englert, Joseph Hanna, Gregory L Peck, Philip S Barie, Piyush Tewari, Mayur Narayan","doi":"10.1097/TA.0000000000004525","DOIUrl":"10.1097/TA.0000000000004525","url":null,"abstract":"<p><strong>Background: </strong>Road traffic crashes (RTCs) are a global health burden, particularly in India, where response times for first responders can be prolonged. Prior to enactment of a Good Samaritan Law (GSL) in 2016, involved bystanders could face criminal and financial liability for assisting at an RTC site. This study evaluates the impact of GSL on bystander RTC attitudes, awareness, and experiences in India, comparing outcomes pre- and post-GSL implementation across metropolitan cities (MCs) and nonmetropolitan cities (NMCs). We hypothesized that GSL would lead to increased bystander willingness to assist the RTC victim.</p><p><strong>Methods: </strong>This retrospective, cross-sectional, observational study analyzed data from two national surveys conducted in 2013 (pre-GSL, n = 1,027) and 2018 (post-GSL, n = 3,667) across 7 and 11 Indian cities, respectively. Difference-in-difference analysis, propensity score matching, and regression models were used to assess changes in willingness to assist RTC victims, awareness of GSL, legal and financial fears, and awareness of GSL.</p><p><strong>Results: </strong>Post-GSL implementation saw an increase in willingness to assist RTC victims (Δ = +65.4%, p < 0.001) and substantial decreases in fear regarding legal (Δ = -81%, p < 0.001) and financial consequences (Δ = -75.8%, p < 0.001) of rendering assistance. GSL awareness was higher in NMCs (n = 2,215, 31.2%) compared with MCs (n = 838, 9.25%) among general citizens ( p < 0.001). Males showed higher willingness to assist RTC victims ( p < 0.01), whereas individuals with postgraduate education demonstrated increased awareness of GSL ( p < 0.01).</p><p><strong>Conclusion: </strong>The implementation of GSL in India has transformed bystander intervention in RTCs, increasing the reported likelihood of assistance and substantially reducing legal and financial concerns. This shift demonstrates GSL's potential to improve outcomes for RTC victims. However, disparities in awareness between MCs and NMCs, as well as sex- and education-based differences, highlight the need for targeted educational campaigns. Future initiatives should focus on improving application of the law and strengthening the entire trauma chain of survival.</p><p><strong>Level of evidence: </strong>Prognostic and Epidemiological; Level III.</p>","PeriodicalId":17453,"journal":{"name":"Journal of Trauma and Acute Care Surgery","volume":" ","pages":"228-235"},"PeriodicalIF":2.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142932227","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The inability to predict futility in hemorrhaging trauma patients using 4-hour transfusion volumes and rates.","authors":"Jan-Michael Van Gent, Thomas W Clements, Bedda L Rosario-Rivera, Stephen R Wisniewski, Jeremy W Cannon, Martin A Schreiber, Ernest E Moore, Nicholas Namias, Jason L Sperry, Bryan A Cotton","doi":"10.1097/TA.0000000000004541","DOIUrl":"10.1097/TA.0000000000004541","url":null,"abstract":"<p><strong>Background: </strong>Blood shortages and utilization stewardship have motivated the trauma community to evaluate futility cutoffs during massive transfusions (MTs). Recent single-center studies have confirmed meaningful survival in ultra-MT (≥20 U) and super-MT (≥50 U), while others advocate for earlier futility cut points. We sought to evaluate whether transfusion volume and intensity cut points could predict 100% mortality in a multicenter analysis.</p><p><strong>Methods: </strong>A prospective, multicenter, observational cohort study was performed at seven trauma centers. Injured patients at risk for MT who required both blood transfusion and hemorrhage control procedures were enrolled. Four-hour volumes and intensities (average units per hour) were evaluated. Primary outcome of interest was 28-day mortality.</p><p><strong>Results: </strong>A total of 1,047 patients met the study inclusion with an overall mortality rate of 17% (n = 176). The median age was 35 years, 80% were male, and 62% had a penetrating mechanism, with an Injury Severity Score of 22. At 4 hours, transfusion volumes below 110 U and transfusion intensity averaging up to 21 U/h did not demonstrate futility. Total transfusion volume above 110 U was associated with 100% mortality (n = 9). Multivariable analysis noted only nonmodifiable risk factors as predictors of increased mortality (blunt mechanism, shock index).</p><p><strong>Conclusion: </strong>In this study from seven Level 1 trauma centers, survival was observed at transfusion volumes up to 110 U and at transfusion velocities up to 21 U/h during the first 4 hours of resuscitation. Data are limited on transfusion volumes above 110 U in the first 4 hours. Survival can be observed in both the ultra and super-MT settings.</p><p><strong>Level of evidence: </strong>Therapeutic/Care Management; Level II.</p>","PeriodicalId":17453,"journal":{"name":"Journal of Trauma and Acute Care Surgery","volume":" ","pages":"236-242"},"PeriodicalIF":2.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142931592","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Interhospital variability of risk-adjusted mortality rates and associated structural factors in patients undergoing emergency laparotomy: England and Wales population-level analysis.","authors":"Alexander R Darbyshire, Stuart J Mercer, Sonal Arora, Philip H Pucher","doi":"10.1097/TA.0000000000004455","DOIUrl":"10.1097/TA.0000000000004455","url":null,"abstract":"<p><strong>Background: </strong>Emergency surgical admissions represent the majority of general surgical workload. Interhospital variations in outcomes are well recognized. This analysis of a national laparotomy data set compared the best- and worst-performing hospitals according to 30-day mortality and examined differences in process and structural factors.</p><p><strong>Methods: </strong>A retrospective multicenter cohort study was performed using data from the England and Wales National Emergency Laparotomy Audit (December 2013 to November 2020). The data set was divided into quintiles based on the risk-adjusted mortality calculated using the National Emergency Laparotomy Audit score risk prediction model. Primary outcome was 30-day mortality. Hospital-level factors were compared across all five quintiles, and logistic regression analysis was conducted comparing the lowest with the highest risk-adjusted mortality quintiles.</p><p><strong>Results: </strong>Risk-adjusted 30-day mortality in the poorest performing quintile was significantly higher than that of the best performing (11.4% vs. 6.6%) despite equivalent predicted mortality (9.4% vs. 9.7%). The best-performing quintile was more likely to be a tertiary surgical (49.5% vs. 37.1%, p < 0.001) or medical school-affiliated center (26.4% vs. 18.0%, p < 0.001). In logistic regression analysis, the strongest associations were for surgery performed in a tertiary center (odds ratio, 0.690 [95% confidence interval, 0.652-0.731], p < 0.001) and if surgery was performed by a gastrointestinal specialist (0.655 [0.626-0.685], p < 0.001). Smaller differences were seen for postoperative intensive care stay (0.848 [0.808-0.890], p < 0.001) and consultant anesthetist involvement (0.900 [0.837-0.967], p = 0.004).</p><p><strong>Discussion: </strong>This study has identified significant variability in postoperative mortality across hospitals. Structural factors such as gastrointestinal specialist delivered emergency laparotomy and tertiary surgical center status appear to be associated with improved outcomes.</p><p><strong>Level of evidence: </strong>Prognostic and Epidemiological; Level III.</p>","PeriodicalId":17453,"journal":{"name":"Journal of Trauma and Acute Care Surgery","volume":" ","pages":"295-301"},"PeriodicalIF":2.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142349168","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Thoracic irrigation for traumatic hemothorax: A systematic review and meta-analysis.","authors":"Nicole B Lyons, Brianna L Collie, Michael D Cobler-Lichter, Jessica M Delamater, Larisa Shagabayeva, Luciana Tito-Bustillos, Kenneth G Proctor, Julie Y Valenzuela, Jonathan P Meizoso, Nicholas Namias","doi":"10.1097/TA.0000000000004479","DOIUrl":"10.1097/TA.0000000000004479","url":null,"abstract":"<p><strong>Background: </strong>Traumatic hemothoraces (HTXs) are common, and tube thoracostomy (TT) insertion is generally the initial management. However, a retained HTX can develop into a fibrothorax or empyema requiring secondary intervention. We hypothesized that irrigation of the thoracic cavity at the time of TT may prevent retained HTX.</p><p><strong>Methods: </strong>Pubmed, EMBASE, and Scopus were searched from inception to May 2024. Studies with adult trauma patients with traumatic HTX who received a TT and had patients who underwent thoracic irrigation were included. The primary outcome was failure rate, defined as retained HTX requiring a second intervention. Cumulative analysis was performed with χ 2 for dichotomous variables and unpaired t test for continuous variables. A fixed-effects model was applied for meta-analysis.</p><p><strong>Results: </strong>Six studies were included in the analysis; two retrospective and four prospective observational studies. These studies included 1,319 patients (513 irrigated TT, 837 nonirrigated TT). The mean age of patients was 45 years, 81% were male, mean Injury Severity Score was 21, and 42% had penetrating trauma. Failure rate was significantly lower in the irrigation group on cumulative analysis (10.7% vs. 18.2%, p < 0.001) and meta-analysis (effect size, 0.704; 95% confidence interval, 0.218-1.190; I2 = 0.4; p < 0.001]. In addition, on meta-analysis, the irrigation group had a shorter TT duration and hospital and ICU length of stay (all p < 0.05). There were no differences in overall infectious complications, readmission, or mortality; however, all the models favored the irrigation group.</p><p><strong>Conclusion: </strong>Patients who undergo simultaneous TT and thoracic irrigation have a lower rate of retained HTX and require fewer secondary interventions. Thoracic irrigation for traumatic HTX should be considered; however, randomized studies are needed prior to development of guidelines.</p><p><strong>Level of evidence: </strong>Systematic Review/Meta-analysis; Level III.</p>","PeriodicalId":17453,"journal":{"name":"Journal of Trauma and Acute Care Surgery","volume":" ","pages":"337-343"},"PeriodicalIF":2.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142605255","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Author reply: Letter to the Editor regarding \"Blunt cerebrovascular injury: The case for universal screening\".","authors":"Stefan W Leichtle, Sudha Jayaraman, Edgar B Rodas, Michel B Aboutanos","doi":"10.1097/TA.0000000000004295","DOIUrl":"10.1097/TA.0000000000004295","url":null,"abstract":"","PeriodicalId":17453,"journal":{"name":"Journal of Trauma and Acute Care Surgery","volume":" ","pages":"e8-e9"},"PeriodicalIF":2.9,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142932205","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}