The Permanente journal最新文献

{"title":"The Impact of Digital Health Solutions on Bridging the Health Care Gap in Rural Areas: A Scoping Review.","authors":"Karla C Maita, Michael J Maniaci, Clifton R Haider, Francisco R Avila, Ricardo A Torres-Guzman, Sahar Borna, Julianne J Lunde, Jordan D Coffey, Bart M Demaerschalk, Antonio Jorge Forte","doi":"10.7812/TPP/23.134","DOIUrl":"10.7812/TPP/23.134","url":null,"abstract":"<p><p>Digital health tools can improve health care access and outcomes for individuals with limited access to health care, particularly those residing in rural areas. This scoping review examines the existing literature on using digital tools in patients with limited access to health care in rural areas. It assesses their effectiveness in improving health outcomes. The review adopts a comprehensive search strategy to identify relevant studies from electronic databases, and the selected studies are analyzed descriptively. The findings highlight the advantages and barriers of digital health interventions in rural populations. The advantages include increased access to health care practitioners through teleconsultations, improved health care outcomes through remote monitoring, better disease management through mobile health applications and wearable devices, and enhanced access to specialized care and preventive programs. However, limited internet connectivity and a lack of familiarity with digital tools are barriers that must be addressed to ensure equitable access to digital health interventions in rural areas. Overall, digital tools improve health outcomes for individuals with limited health care access in rural areas.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"130-143"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404635/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141971913","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}

{"title":"Representativeness of Patients With Lung Cancer in an Integrated Health Care Delivery System.","authors":"Mike Z Yang, Raymond Liu, Julie Von Behren, Katherine Lin, Alyce S Adams, Lawrence H Kushi, Charles P Quesenberry, Jeffrey B Velotta, Melisa L Wong, Kelly C Young-Wolff, Scarlett L Gomez, Salma Shariff-Marco, Lori C Sakoda","doi":"10.7812/TPP/24.028","DOIUrl":"10.7812/TPP/24.028","url":null,"abstract":"<p><strong>Introduction: </strong>Observational research is important for understanding the real-world benefits of advancements in lung cancer care. Integrated health care systems, such as Kaiser Permanente Northern California, have extensive electronic health records suitable for such research, but the generalizability of their populations is often questioned.</p><p><strong>Methods: </strong>Leveraging data from the California Cancer Registry, the authors compared distributions of demographic and clinical characteristics, in addition to neighborhood and environmental conditions, between patients diagnosed with lung cancer from 2015 through 2019 at Kaiser Permanente Northern California, National Cancer Institute-designated cancer centers (NCICCs), and all other non-NCICC hospitals within the same catchment area.</p><p><strong>Results: </strong>Of 20,178 included patients, 30% were from Kaiser Permanente Northern California, 8% from NCICCs, and 62% from other non-NCICC hospitals. Compared to NCICC patients, Kaiser Permanente Northern California patients were more similar to other non-NCICC patients on most characteristics. Compared to other non-NCICC patients, Kaiser Permanente Northern California patients were slightly older, more likely to be female, and less likely to be Hispanic or Asian/Pacific Islander and to reside in lower socioeconomic status (SES) neighborhoods. In contrast, NCICC patients were younger, less likely to be female or from non-Asian/Pacific Islander minoritized racial groups, and more likely to present with early-stage disease and adenocarcinoma and to reside in neighborhoods with higher SES and lower air pollution than Kaiser Permanente Northern California or other non-NCICC patients.</p><p><strong>Discussion: </strong>Patients from Kaiser Permanente Northern California, compared to NCICCs, are more broadly representative of the underlying patient population with lung cancer.</p><p><strong>Conclusion: </strong>Research using electronic health record data from integrated health care systems can contribute generalizable real-world evidence to benchmark and improve lung cancer care.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"13-22"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404640/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141564422","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}

{"title":"Conceptual Model of and Intervention Development for Unplanned Suicide Attempts.","authors":"Ursula Whiteside, Julie Angerhofer Richards, Martina Fruhbauerova, Ghazaleh Shokouhaghaei","doi":"10.7812/TPP/24.035","DOIUrl":"10.7812/TPP/24.035","url":null,"abstract":"<p><strong>Introduction: </strong>More than half of those who die by suicide do not communicate about suicide prior to their death. This project describes the emotional state and decision-making among \"unplanned\" attempt survivors to inform a conceptual model and suicide prevention interventions.</p><p><strong>Methods: </strong>This qualitative study purposefully sampled patients who reported having no suicidal thoughts on a standardized mental health questionnaire within 60 days (about 2 months) prior to a nonfatal suicide attempt documented in the health record. Participants verbally consented to telephone interview participation. Semistructured audio-recorded interviews elicited suicide attempt survivor descriptions of their emotional state and experiences in the days, hours, and minutes leading up to their suicide attempt. Interviews were transcribed and analyzed using grounded theory. The biopsychosocial theory of emotion regulation informed conceptual model development.</p><p><strong>Results: </strong>Participants (N = 26) described 2 distinct \"phases\" prior to the attempt. First, a phase of increasing life stressors, transitory and nonspecific suicidal thoughts, and a reluctance to disclose experiences. Second, an overwhelming emotional state led to a sudden suicide attempt and nondisclosure due to the rapidity and intensity of the experience. These results informed the conceptual model and intervention development to manage unplanned and overwhelming urges to attempt suicide.</p><p><strong>Discussion: </strong>Qualitative analysis informed the development of an intervention for the high-intensity \"hot\" period preceding an attempt, including specific steps to manage a highly intense emotional state in combination with overwhelming urges to kill oneself.</p><p><strong>Conclusion: </strong>Future research is needed to evaluate whether and how this intervention helps support people with a chance of \"unplanned\" suicide attempts.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"117-129"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404629/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141894373","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}

{"title":"Racial and Ethnic Differences in the Prevalence of Severe Aortic Stenosis by Echocardiography.","authors":"Salam Allahwerdy, Fagen Xie, Botao Zhou, Yi-Lin Wu, Benjamin Wessler, Wansu Chen, Ming-Sum Lee","doi":"10.7812/TPP/24.038","DOIUrl":"10.7812/TPP/24.038","url":null,"abstract":"<p><strong>Background: </strong>Understanding the burden of aortic stenosis (AS) across diverse racial and ethnic populations is important to ensure equitable resource allocation. This study explored whether severe AS rate varies by race and ethnicity.</p><p><strong>Methods: </strong>The rates of severe AS, stratified by race and ethnicity, were calculated among 615,038 adults with a transthoracic echocardiogram. Logistic regression analysis was performed to identify factors associated with severe AS.</p><p><strong>Results: </strong>Severe AS rates ranged from 0.08% in adults < 50 years old to 3.8% in those ≥ 90 years old. Compared to non-Hispanic White and Asian American [adjusted odds ratio (aOR) = 0.47, 95% confidence interval (CI): 0.42-0.53] and non-Hispanic Black (aOR = 0.44, 95% CI: 0.39-0.50) patients were less likely to have severe AS, whereas Hispanic patients (aOR = 0.91, 95% CI: 0.87-0.98) had near similar likelihood. Age was the strongest risk factor for severe AS (compared to age < 50 years, aOR = 21.8, 95% CI: 17.8-26.6 for age 80-89 years, and aOR = 43.8, 95% 35.5-54.0 for age ≥ 90 years). Additional factors associated with severe AS included male sex (aOR = 1.38, 95% CI: 1.30-1.46) and diabetes (aOR = 1.23, 95% CI: 1.15-1.31).</p><p><strong>Conclusions: </strong>Asian American and non-Hispanic Black adults had lower rates of severe AS compared to White and Hispanic patients. The rate of severe AS progressively increases with age in all racial and ethnic groups, with higher rates in men compared with women. With a demographic shift toward an aging and more diverse population, the burden of AS is anticipated to rise. Ensuring adequate allocation of resources to meet the evolving needs of a diverse population remains a shared health care imperative.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"98-106"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404663/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141761001","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}

{"title":"Evaluating the Impact of Gender, Race, and Training Year on Internal Medicine Residents' Experiences Across the United States.","authors":"Grace Kim, Shweta Lodha, Lulu Wein, Lily Fahs, Ariana Allen, Jay Rathinavelu, Poonam Sharma, Sharon Fekrat","doi":"10.7812/TPP/24.085","DOIUrl":"10.7812/TPP/24.085","url":null,"abstract":"<p><strong>Introduction: </strong>Prior studies have highlighted experiences of bias within resident training based on trainees' gender and race and high rates of burnout. However, few studies have addressed the intersection between bias and wellness for residents in internal medicine (IM) programs. This study explores how race, gender, and training year affect IM residents' bias experiences and well-being.</p><p><strong>Methods: </strong>An anonymous survey with questions evaluating demographics and resident experiences of bias and perceptions of wellness and self-efficacy was distributed to 596 IM programs across the United States. Sixty-nine programs sent out the survey to their IM residents. Respondents to the survey included 176 residents. Descriptive analyses and χ² tests were performed.</p><p><strong>Results: </strong>Responses demonstrated that gender and race impacted residents' experiences with bias and misidentification. Eighty-eight percent of women compared to 1% of men, and 89% of Black residents compared to 3% of White residents reported being misidentified as a nonphysician due to gender and race, respectively. Degrees to which residents felt they were thriving in residency, experiencing burnout, and utilizing their strengths varied significantly by gender. Residents' self-perceived burnout levels were associated with being misidentified as not being a physician due to race. Experiences with bias also increased significantly with training year.</p><p><strong>Discussion: </strong>This study provides important insights into the impact of gender, race/ethnicity, and training year on IM residents' experiences with bias and self-perception.</p><p><strong>Conclusion: </strong>The findings emphasize the need for structural changes within IM residency programs to reduce experiences of bias and to better cultivate the wellness of residents.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"107-116"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404644/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142081557","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}

{"title":"Using Focus Groups to Evaluate a Self-Assessment Approach to Coproduction Value Creation in an International Community of Practice: Phase 2 of the CO-VALUE Study.","authors":"Rachel C Forcino, Bruce C Jobse, Jabeen Ahmad, Brant J Oliver","doi":"10.7812/TPP/24.009","DOIUrl":"10.7812/TPP/24.009","url":null,"abstract":"<p><strong>Introduction: </strong>Coproduction learning health system models clearly define the use of clinical and patient-reported data for system learning and quality improvement, but less is known about how to document formative learning about coproduction value creation over the course of a quality improvement initiative. The authors aimed to 1) assess the feasibility, utility, and acceptability of novel self-assessment tools for coproduction value creation and 2) identify domains of coproduction value creation.</p><p><strong>Methods: </strong>The authors conducted 4 focus groups with quality improvement teams from 4 health systems in the United States and Sweden between June 2021 and September 2023. A single analyst coded transcripts and proposed themes, with investigator triangulation validating results.</p><p><strong>Results: </strong>Participants found the self-assessment tools acceptable and useful. The improvement passport was seen as more feasible for routine use than the full self-assessment guide. Peer learning within the community of practice, diverse multidisciplinary improvement teams, and leadership support facilitated teams' work. Domains of coproduction value creation included communication, self-efficacy, interconnectedness, direct and indirect costs of health care utilization, health professional experience, and access to the right care.</p><p><strong>Discussion: </strong>Peer learning and camaraderie within the community of practice maintained momentum among participating teams during a challenging time of limited resources and mounting responsibilities in health care settings, suggesting enhanced resiliency through approaching difficult tasks in community.</p><p><strong>Conclusion: </strong>The authors identified themes of coproduction value creation and drivers of engagement. Future research will draw on the measurement domains established in this study to inform the development of measures of coproduction value creation. Those measures could then be incorporated into the data-rich environments of coproduction learning health systems to enhance focus on value from service user and professional perspectives.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"278-283"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404649/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142073931","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}

{"title":"Building Frontline Capability for Shared Decision-Making (SDM) in a Major Academic Oncology Center Caring for People With Non-Small Cell Lung Cancer: Performance Outcomes of a SDM Simulation Training Program.","authors":"Catherine C Alexander, Hasna Hakim, Elaine Rudell, Michele Ingram, Tarjani Agrawal, Patty Peterson, Marianne Davies, Kerin Adelson, Brant J Oliver","doi":"10.7812/TPP/23.160","DOIUrl":"10.7812/TPP/23.160","url":null,"abstract":"<p><strong>Background: </strong>There is a growing body of evidence on shared decision-making (SDM) training programs worldwide. However, there is wide variation in program design, duration, effectiveness, and evaluation in both academia (ie, medical school) and the practice setting. SDM training has been slow to integrate in practice settings.</p><p><strong>Methods: </strong>A pilot study of 6 multidisciplinary clinicians was conducted using quantitative and qualitative methods to evaluate changes in participant understanding and implementation of SDM in the practice setting. A 2-rater criterion-based evaluation method was used to assess a simulation-based case study role-play program using 7 domains of SDM pre and post training. The authors assessed whether clinicians addressed each of the 7 domains or what fraction of each domain was addressed as part of their simulation case study role-play performance. Focus groups were conducted pre- and postintervention to provide feedback to participants and to understand the clinician experience in greater detail.</p><p><strong>Results: </strong>The increase in improvement in SDM ranged from 17% to 37%, and 7 of 8 domains for which participants were rated showed significant improvement. The areas of greatest improvement were seen in determining a patient's goals/preferences, including risk tolerance regarding treatments (+37%) and values and self-efficacy (+37%).</p><p><strong>Conclusion: </strong>The results of this study reveal a significant shift in clinician awareness of a patient's goals, preferences, and values. Postintervention, clinicians began to understand the value of building a partnership with their patients whereby the patient becomes an active participant in their clinical care.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":"28 3","pages":"200-211"},"PeriodicalIF":0.0,"publicationDate":"2024-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11404653/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142296130","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}

{"title":"Tuberculosis Osteomyelitis of the Wrist.","authors":"Grace Kim, Kate E Lee, Anand Shah, Jessica Seidelman, Kevin A Wu, Diana M Cardona, Lana Wahid","doi":"10.7812/TPP/24.025","DOIUrl":"https://doi.org/10.7812/TPP/24.025","url":null,"abstract":"<p><p>Wrist <i>Mycobacterium tuberculosis</i> (TB) complex osteomyelitis is rare, with polymicrobial TB osteomyelitis even more uncommon. The authors describe an unusual case of polymicrobial TB wrist osteomyelitis. The case patient presented with a 2.5-year history of 2 insidiously growing nodules on his wrist. He underwent debridement, and tissue cultures grew methicillin-resistant <i>Staphylococcus aureus</i>, <i>Enterococcus faecalis</i>, and, later, TB complex. He was started on vancomycin, rifampin, isoniazid, pyrazinamide, and ethambutol with improvement in symptoms. This case emphasizes the importance of a broad differential and thorough workup for atypical presentations of osteomyelitis. Diagnosis of uncommon etiologies is essential for definitive treatment.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"1-5"},"PeriodicalIF":0.0,"publicationDate":"2024-06-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141451620","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}

{"title":"Surgical Management and Clinical Outcomes of Extracranial Carotid Artery Pseudoaneurysms.","authors":"Venkata Vineeth Vaddavalli, Ajay Savlania, Kishore Abuji, Lileshwar Kaman, Arunanshu Behera","doi":"10.7812/TPP/23.090","DOIUrl":"10.7812/TPP/23.090","url":null,"abstract":"<p><strong>Introduction: </strong>Extracranial carotid artery (CA) pseudoaneurysms are uncommon and can cause embolic stroke, compressive symptoms, or (rarely) can rupture. It is of paramount importance to treat this entity to avoid life-threatening complications. In this study, the authors described a cohort of patients that required open surgical repair.</p><p><strong>Methods: </strong>This article reported the authors' experience with open surgical repair of extracranial CA pseudoaneurysms by presenting a retrospective review of data at their institution from 2016 to 2022.</p><p><strong>Results: </strong>Of 8 patients that underwent open repair, 6 were male and 8 were female. The most common etiology was traumatic (penetrating trauma in 4 patients, iatrogenic injury in 2, and blunt trauma in 1) and 1 was infective. All patients presented with a neck mass, and 5 had compressive symptoms. Primary repair was performed in 4 patients, interposition graft using an autologous vein in 2, and patch repair in 2. None of the patients experienced perioperative mortality or stroke; nor did they develop any complications over a median follow-up period of 30 months.</p><p><strong>Conclusion: </strong>This report demonstrated that large-size extracranial pseudoaneurysms, whether traumatic or infective etiology, can be safely repaired using an open surgical approach.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"3-8"},"PeriodicalIF":0.0,"publicationDate":"2024-06-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11232904/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140319221","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}

{"title":"Managing Patients With Sympathetic Crashing Acute Pulmonary Edema (SCAPE) Using the SCAPE Treatment Protocol: A Case Series.","authors":"Ankur Verma, Sanjay Jaiswal, Anubhooti Mahawar, Maheshwar Lal, Saumya Gupta, Ruhima Begum","doi":"10.7812/TPP/23.149","DOIUrl":"10.7812/TPP/23.149","url":null,"abstract":"<p><p>Pulmonary edema refers to the accumulation of excessive fluid in the alveolar walls and alveolar spaces of the lungs. It is a life-threatening condition with a high mortality rate and requires immediate assessment and management. Use of intravenous nitroglycerin has been advocated for such cases. The authors present a case series of 3 patients who presented to the emergency department with sympathetic crashing acute pulmonary edema (SCAPE) and were managed with high-dose intravenous nitroglycerin and bilevel positive airway pressure support using the SCAPE treatment protocol, leading to early correction of blood pressure, avoidance of endotracheal intubation, and no episodes of hypotension or rebound hypertension. The authors recommend emergency physicians utilize the SCAPE treatment protocol while managing patients with SCAPE.</p>","PeriodicalId":23037,"journal":{"name":"The Permanente journal","volume":" ","pages":"116-120"},"PeriodicalIF":0.0,"publicationDate":"2024-06-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11249274/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140319220","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}