Antimicrobial Stewardship & Healthcare Epidemiology最新文献

{"title":"Positivity of repeat nasal MRSA PCR screening: a single-center experience","authors":"Ali Earl, Sage B Greenlee, Karen Fong, Hannah Imlay, E. Spivak","doi":"10.1017/ash.2023.491","DOIUrl":"https://doi.org/10.1017/ash.2023.491","url":null,"abstract":"Abstract Repeating nasal methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reactions (PCRs) within 14 days may increase healthcare costs and inform anti-MRSA antibiotic therapy without known benefit. Within an inpatient admission, our retrospective, single-center evaluation found that conversion from negative to positive on repeat nasal MRSA PCR screen was uncommon (2%).","PeriodicalId":7953,"journal":{"name":"Antimicrobial Stewardship & Healthcare Epidemiology","volume":"82 18","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-12-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138604487","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":"Clinical reasoning for performance of transesophageal echocardiography in veterans with Staphylococcus aureus bacteremia","authors":"Emily C. Woods, Trisha S. M. Nakasone, C. Renault","doi":"10.1017/ash.2023.493","DOIUrl":"https://doi.org/10.1017/ash.2023.493","url":null,"abstract":"Abstract This study examined physicians’ reasoning about obtaining transesophageal echocardiography (TEE) in cases of Staphylococcus aureus bacteremia (SAB). In 221 cases of SAB over 5 years, the most common reasons for not performing TEE were clinical response to antibiotics, negative TTE results, and the expectation that TEE would not change management.","PeriodicalId":7953,"journal":{"name":"Antimicrobial Stewardship & Healthcare Epidemiology","volume":"66 3","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-12-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138604854","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":"Suboptimal antimicrobial discharge prescriptions at a tertiary referral children’s hospital","authors":"Yi Wolf Zhang, Sruti Paturi, Lauren Puckett, David Scheinker, Hayden T. Schwenk, Torsten A. Joerger","doi":"10.1017/ash.2023.488","DOIUrl":"https://doi.org/10.1017/ash.2023.488","url":null,"abstract":"Abstract Objective: To determine the rate of and factors associated with suboptimal discharge antimicrobial prescribing at a tertiary referral children’s hospital. Design: Retrospective cohort. Setting: Tertiary referral children’s hospital. Population: All enteral antimicrobial discharge prescriptions at Lucile Packard Children’s Hospital Stanford from January 1st, 2021 through December 31st, 2021. Method: All enteral discharge antimicrobials are routinely evaluated by our antimicrobial stewardship program within 48 hours of hospital discharge. Antimicrobials are determined to be optimal or suboptimal by an antimicrobial stewardship pharmacist after evaluating the prescribed choice of antimicrobial, dose, duration, dosing frequency, and formulation. The rate and factors associated with suboptimal antimicrobial discharge prescribing were evaluated. Results: Of 2,593 antimicrobial prescriptions ordered at discharge, 19.7% were suboptimal. Suboptimal prescriptions were due to incorrect duration (72.2%), dose (31.0%), dose frequency (23.3%), drug choice (6.5%), or formulation (5.7%). In total, 87.2% of antimicrobials for perioperative prophylaxis and 13.5% of treatment antimicrobials were suboptimal. Antimicrobials with the highest rate of suboptimal prescriptions were amoxicillin-clavulanate (40.7%), clindamycin (36.6%), and cephalexin (36.6%). Conclusion: Suboptimal antimicrobial discharge prescriptions are common and present an opportunity for antimicrobial stewardship programs during hospital transition of care. Factors associated with suboptimal prescriptions differ by antimicrobial and prescribed indication, indicating that multiple stewardship interventions may be needed to improve prescribing.","PeriodicalId":7953,"journal":{"name":"Antimicrobial Stewardship & Healthcare Epidemiology","volume":"2 5","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-12-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138602319","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":"Revolutionizing antimicrobial stewardship, infection prevention, and public health with artificial intelligence: the middle path","authors":"A. Marra, BJ Langford, Priya Nori, Gonzalo Bearman","doi":"10.1017/ash.2023.494","DOIUrl":"https://doi.org/10.1017/ash.2023.494","url":null,"abstract":"","PeriodicalId":7953,"journal":{"name":"Antimicrobial Stewardship & Healthcare Epidemiology","volume":"4 4","pages":""},"PeriodicalIF":0.0,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138609921","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":"Decolonization of hospital patients may aid efforts to reduce transmission of carbapenem-resistant Enterobacterales","authors":"Brajendra K. Singh, Prabasaj Paul, Camden D. Gowler, Sujan C. Reddy, Rachel B. Slayton","doi":"10.1017/ash.2023.303","DOIUrl":"https://doi.org/10.1017/ash.2023.303","url":null,"abstract":"Background: Multimodal approaches are often used to prevent transmission of antimicrobial-resistant pathogens among patients in healthcare settings; understanding the effect of individual interventions is challenging. We designed a model to compare the effectiveness of hand hygiene (HH) with or without decolonization in reducing patient colonization with carbapenem-resistant Enterobacterales (CRE). Methods: We developed an agent-based model to represent transmission of CRE in an acute-care hospital comprising 3 general wards and 2 ICUs, each with 20 single-occupancy rooms, located in a community of 85,000 people. The model accounted for the movement of healthcare personnel (HCP), including their visits to patients. CRE dynamics were modeled using a susceptible–infectious–susceptible framework with transmission occurring via HCP–patient contacts. The mean time to clearance of CRE colonization without intervention was 387 days (Zimmerman et al, 2013). Our baseline included a facility-level HH compliance of 30%, with an assumed efficacy of 50%. Contact precautions were employed for patients with CRE-positive cultures with assumed adherence and efficacy of 80% and 50%, respectively. Intervention scenarios included decolonization of culture-positive CRE patients, with a mean time to decolonization of 3 days. We considered 2 hypothetical intervention scenarios: (A) decolonization of patients with the baseline HH compliance and (B) decolonization with a slightly improved HH compliance of 35%. The hospital-level CRE incidence rate was used to compare the results from these intervention scenarios. Results: CRE incidence rates were lower in intervention scenarios than the baseline scenario (Fig. 1). The baseline mean incidence rate was 29.1 per 10,000 patient days. For decolonization with the baseline HH, the mean incidence rate decreased to 14.5 per 10,000 patient days, which is a 50.2% decrease relative to the baseline incidence (Table 1). The decolonization scenario with a slightly improved HH compliance of 35% produced a relative reduction of 71.9% relative to the baseline incidence. Conclusions: Our analysis shows that decolonization, combined with modest improvement in HH compliance, could lead to large decreases in pathogen transmission. In turn, this model implies that efforts to identify and improve decolonization strategies for better patient safety in health care may be needed and are worth exploring. Disclosures: None","PeriodicalId":7953,"journal":{"name":"Antimicrobial Stewardship & Healthcare Epidemiology","volume":"21 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135144278","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":"Incidence, risk factors, and outcomes of hospital-acquired infections with common respiratory viruses","authors":"Joshua Petrie, Riley Moore, Adam Lauring, Keith Kaye","doi":"10.1017/ash.2023.367","DOIUrl":"https://doi.org/10.1017/ash.2023.367","url":null,"abstract":"Background: We estimated the incidence of hospital-acquired respiratory virus infections (HARVIs) by viral species, and we identified risk factors for and outcomes of HARVIs. Methods: We identified a cohort of all inpatient admissions of ≥24 hours duration to University of Michigan hospitals during 3 study years (2017–2018, 2018–2019, and 2019–2020). HARVIs were defined as initial respiratory virus detection (adenovirus, coronaviruses, human metapneumovirus, influenza A and B, parainfluenza viruses, respiratory syncytial virus, or rhinovirus-enterovirus) in a clinical test ordered after the 95th percentile of the virus-specific incubation period. Incidence was calculated as the number of HARVIs per 10,000 patient admission days. Patient demographic and clinical characteristics were assessed as risk factors for HARVI in Cox proportional hazards models of the competing outcomes of HARVIs and hospital discharge. The association between time-varying HARVI status and the competing outcomes of discharge and in-hospital death was estimated in covariate-adjusted Cox-proportional hazards models. All analyses were performed separately for adult patients (aged ≥18 years) and pediatric patients (aged <18 years). Results: The overall incidences of HARVI were 8.5 and 3.0 per 10,000 admission days for pediatric and adult patients, respectively. Rhinovirus was the most common HARVI in both pediatric and adult patients, with incidences of 5.1 and 1.1 infections per 10,000 admission days, respectively. With the exception of influenza A, the incidence of HARVI was higher in pediatric patients than adult patients for all viral species. For adults, congestive heart failure, renal disease, and cancer all increased HARVI risk independent of their associations with extended hospital stays. Risk of HARVI was also elevated for patients admitted September through June relative to July admissions. For pediatric patients, chronic cardiovascular and respiratory conditions, cancer, medical-device dependence, and December admission increased risk of HARVI. Age, sex, and race were not associated with risk of HARVI for children or adults. Inpatient lengths of stay were longer for adults with HARVI compared to those without (range of virus-specific hazard ratios, 0.48– 0.77). However, estimated effects were not statistically significant for human metapneuomovirus, parainfluenza, or adenovirus. Only influenza A was associated with an increased risk of in-hospital death within 30 days of infection for adults. No HARVIs were associated with increased length of stay or risk of death for pediatric patients. Conclusions: The incidence of HARVI varied by viral species and was higher among pediatric patients. HARVIs increased the length of hospital stays for adults but not for pediatric patients. Disclosures: None","PeriodicalId":7953,"journal":{"name":"Antimicrobial Stewardship & Healthcare Epidemiology","volume":"2 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135144283","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":"Detecting fecal microbiota transplantation–associated infection transmission using shotgun metagenomic sequencing and clonality analysis","authors":"Emma Briars, Mohamad Sater, Nicole Billings, Ian Herriott, Emily MacLeod, Miriam Huntley","doi":"10.1017/ash.2023.345","DOIUrl":"https://doi.org/10.1017/ash.2023.345","url":null,"abstract":"Background: Fecal microbiota transplantation (FMT) is a widely used modality for safe and effective treatment of recurrent Clostridium difficile infections, and FMT is being explored for the treatment of additional indications including gastrointestinal diseases and neurological disorders. Although microbiota-based therapies like FMT utilize rigorous donor screening procedures, these procedures are limited in resolution and scope, and there remains a risk of transmission of FMT-associated infectious agents from donor stool to a FMT recipient. Critically, these health concerns led the FDA to issue a 2019 safety alert for the transmission risks associated with FMT and to update its guidelines for screening and reporting. In a suspected transmission event, there is uncertainty around the source of infection; thus, methods are needed to rapidly determine whether a patient’s infection is linked to the donor stool product. Methods: Here, we developed a laboratory service sequencing and bioinformatics pipeline within our CLIA-certified laboratory for investigating suspected FMT infection transmission by measuring genomic relatedness. Our pipeline performs deep sequencing of a metagenomic sample, whole-genome sequencing (WGS) of an isolate derived from the implicated patient infection and determines the genomic relatedness between the 2 using a SNP-based analysis. The workflow was validated in silico with synthetic metagenomic samples spiked-in with WGS of clinically relevant isolate strains at varying abundance. Results: The sample and sequencing library preparation workflow was optimized across a panel of metagenomic and mock fecal microbiome samples demonstrating reproducible and reduced-bias sequencing of metagenomic samples. Our pipeline demonstrates high sensitivity and specificity for clonality calls when a spiked in isolate genome achieves 5× depth for &gt;50% of the genome. We also demonstrated an interplay between abundance rate and sequencing depth for determining a clonality limit of detection. Conclusions: Taken together, our pipeline represents a new method that can support the clinical efforts of FMT and other microbiota-based therapies. References: US Food and Drug Administration. Important safety alert regarding use of fecal microbiota for transplantation and risk of serious adverse reactions due to transmission of multidrug-resistant organisms. Rockville, MD: Food and Drug Administration, 2019. DeFilipp Z, Bloom PP, Torres Soto M, et al. Drug-resistant E. coli bacteremia transmitted by fecal microbiota transplant. N Engl J Med 2019;381:2043–2050. Financial support: This study was funded by Day Zero Diagnostics. Disclosures: None","PeriodicalId":7953,"journal":{"name":"Antimicrobial Stewardship & Healthcare Epidemiology","volume":"253 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135144443","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":"Sex differences in knowledge and practices regarding antibiotics and antibiotic resistance in the Puerto Rican population","authors":"Yiana Toro-Garay, Tanialy Rivera-Santiago, Vilmarie Ortiz-Bonilla","doi":"10.1017/ash.2023.243","DOIUrl":"https://doi.org/10.1017/ash.2023.243","url":null,"abstract":"Background: Antibiotic resistance is one of the biggest threats to global health, and by 2050 it is expected to cause 10 million deaths per year globally. Sex differences depend on context and sociodemographic factors; therefore, studies addressing sex differences have been inconclusive. Furthermore, to our knowledge, sex differences in the Puerto Rican population have not been analyzed. We sought to understand whether knowledge and practices regarding antibiotic use and antibiotic resistance in the Puerto Rican population differ by sex. Methods: A convenience sampling was performed at outpatient clinics across Puerto Rico. Those who agreed to participate completed a self-report questionnaire aimed to address demographics, antibiotic knowledge, and experiences. Bivariate analyses were performed using Stata version 17.0 software. Results: In total, 252 participants received the questionnaire, and 250 completed it. Most of the participants were female (71.2%), aged &gt;56 years (40.0%), and had a high school diploma (40.4%). Women had 2.71 (95% CI, 1.1–6.8, P ). Conclusions: Women perceived themselves to be more knowledgeable regarding antibiotic use and resistance than men. However, no difference in actual knowledge could be identified. Similarly, antibiotic-related practices did not differ by sex except for using previously saved antibiotic treatment, and men had higher odds of conducting this practice. Further studies should be conducted to understand the factors that influence these behavioral practices, and educational interventions should focus on addressing misconceptions regarding antibiotics and antibiotic resistance. Disclosures: None","PeriodicalId":7953,"journal":{"name":"Antimicrobial Stewardship & Healthcare Epidemiology","volume":"84 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135144444","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":"Assessment of changes in the national surveillance data for adult and pediatric VAE during the COVID-19 pandemic in hospitals","authors":"Vaishnavi Pattabiraman, Jennifer Watkins, Sheila Abner, Lindsey Lastinger","doi":"10.1017/ash.2023.406","DOIUrl":"https://doi.org/10.1017/ash.2023.406","url":null,"abstract":"Background: Among US acute-care hospitals (ACHs) reporting to the NHSN, significant increases in the incidence of Ventilator-Associated Events (VAEs) were observed during the COVID-19 pandemic years in comparison with 2019. We assessed changes in the national event-level VAE data, including the incidence of specific event-types: Ventilator-Associated Condition (VAC), Infection-related Ventilator-Associated Complication (IVAC) and Possible Ventilator-Associated Pneumonia (PVAP). We also examined changes in associated pathogens, and we evaluated incidence density rates (IDRs) of pediatric VAE (PedVAE) before and during the pandemic years. Methods: We analyzed data on VAE and PedVAE reported to NHSN between 2019 through the second quarter of 2022 (2022Q2) in ACHs. Annual proportions of VAC, IVAC, or PVAP were calculated; changes versus 2019 were assessed. The 10 most common PVAP pathogens reported annually were examined, and the percentages and ranks for each were calculated. Among pediatric and neonatal locations, PedVAE IDR were calculated as the number of events per 1,000 ventilator days and were compared between the pre-pandemic and pandemic years. All comparisons were conducted using a mid-P exact test, and P<0.05 was considered statistically significant. Results: Between 1,266 - 1,357 ACHs reported VAE data each year. A total of 24,836 (2019), 37,592 (2020), and 50,362 (2021) VAEs were reported. The proportion of VAC events in 2020 (64.1%) was significantly higher than in 2019 (62.9%), while the 2020 and 2021 PVAP proportions (8.7% and 9.2%, respectively) were significantly lower than in 2019 (10.0%). The majority of VAEs were reported from the same location types annually. The top 3 PVAP pathogens reported for each year remained unchanged: Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella. However, the proportion identified as Haemophilus influenzae decreased significantly each year from 2019-2021, with the rank dropping from #5 in 2019 (6.6%) to #10 in 2021 (2.3%). Between 199 – 257 ACHs conducted PedVAE surveillance. PedVAE IDR were significantly lower in 2020 (0.8), 2021 (1.1), and the first half of 2022 (0.8) when compared to 2019 (1.3). Conclusions: This study provides a national view of specific VAEs before and during the COVID-19 pandemic. Some changes in the associated pathogens, and the proportions of VAC and PVAP, were observed. This study is the first to produce national benchmarks for PedVAE IDR. Additional ACHs conducting PedVAE surveillance in NHSN would improve the representativeness of our results. Disclosures: None","PeriodicalId":7953,"journal":{"name":"Antimicrobial Stewardship & Healthcare Epidemiology","volume":"8 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135144450","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":"Comparison of clinical antibiotic susceptibility testing interpretations to CLSI standard interpretations","authors":"Erin Hitchingham, Ashley Gambrell, Raquel Villegas, Daniel Muleta","doi":"10.1017/ash.2023.392","DOIUrl":"https://doi.org/10.1017/ash.2023.392","url":null,"abstract":"Background: Clinical antibiotic susceptibility testing (AST) interpretations based on minimum inhibitory concentrations (MIC) breakpoints are important for both clinical decision making and some reportable condition criteria. Standardization of MIC breakpoints across clinical laboratories is lacking; AST instruments are often validated for outdated Clinical and Laboratory Standards Institute (CLSI) MIC breakpoint guidelines. In this study, we analyzed the agreement between the reported clinical laboratory AST interpretations and the guideline CLSI interpretation. Methods: Clinical laboratory AST data collected from the Multisite Gram-Negative Surveillance Initiative (MuGSI) carbapenem-resistant Enterobacterales (CRE) surveillance program in Tennessee between 2019 and 2021 were utilized. MIC values from the clinical instrument were used to calculate CLSI standard interpretations following the 2019–2021 CLSI M100 guidelines. Agreement between the clinical laboratory and CLSI interpretations of the reported MIC values were measured using a weighted Cohen κ calculated in SAS version 9.4 software. Total matches were isolates with identical CLSI and clinical laboratory interpretations. Results: In total, 14 antibiotics were assessed. Of those, 9 antibiotics had at least moderate agreement (κ &gt; 0.41) between interpretations. Agreement between the clinical laboratory and the CLSI interpretations were near perfect (κ &gt; 0.81) for 3 antibiotics. Agreement between the clinical laboratory and the CLSI interpretations were poor for cefazolin (0.06) and ertapenem (0.14). Cefotaxime (−0.07) was the only antibiotic that suggested no agreement. Conclusions: Of the antibiotics included in the analysis, 36% had less than moderate agreement between clinical laboratory and CLSI AST interpretations. Given the increases in antimicrobial resistance globally and the emphasis placed on antibiotic stewardship, standardization across clinical AST panels should be prioritized. Inconsistencies have the potential to contribute to inappropriate antibiotic use in addition to under- or overidentification of reportable conditions, including CRE. Disclosures: None","PeriodicalId":7953,"journal":{"name":"Antimicrobial Stewardship & Healthcare Epidemiology","volume":"13 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135144462","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}