Quality of life and symptom intensity over time in people with cancer receiving palliative care: Results from the international European Palliative Care Cancer Symptom study
People with advanced cancer experience multiple symptoms during their illness trajectory, which can fluctuate in intensity. To describe the course of self-reported quality of life, emotional functioning, physical functioning and symptom intensity over time in cancer patients receiving palliative car...
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| creator | Verkissen, Mariëtte N Hjermstad, Marianne J Van Belle, Simon Kaasa, Stein Deliens, Luc Pardon, Koen |
| description | People with advanced cancer experience multiple symptoms during their illness trajectory, which can fluctuate in intensity.
To describe the course of self-reported quality of life, emotional functioning, physical functioning and symptom intensity over time in cancer patients receiving palliative care.
Longitudinal study with monthly assessments, using the EORTC QLQ-C15-PAL. Data were analysed (1) prospectively, from baseline to ≥8-month follow-up; and (2) retrospectively, by taking death as index date and comparing results from three cross-sectional subsamples at different stages of illness (time to death ≥6, 5-3 and 2-0 months). Linear mixed models were calculated.
A total of 1739 patients (mean age 66, 50% male) from 30 palliative care centers in 12 countries were included.
In prospective analyses, quality of life, functioning and symptoms-except nausea/vomiting-remained generally stable over time. In retrospective analyses, patients 2-0 months before death reported significantly lower quality of life and physical functioning scores than those 5-3 months before death, who in turn scored lower than those ≥6 months before death, suggesting progressive decline. Emotional functioning remained initially unchanged, but decreased in the last months. Pain, fatigue and appetite loss showed a stable increase in intensity towards death. Dyspnea, insomnia and constipation increased from 5-3 to 2-0 months before death. Nausea/vomiting only increased when comparing those ≥6 months before death with those 2-0 months before death.
While the prospective approach showed predominantly stable patterns for quality of life, functioning and symptom severity throughout study duration, retrospective analyses indicated that deterioration was already apparent before the terminal phase and accelerated close to death. Our findings support the importance of early symptom identification and treatment in this population, and highlight the need for further studies to explore what characterizes those with either lower or higher symptom burden at different time points towards death. |
| doi_str_mv | 10.1371/journal.pone.0222988 |
| format | Article |
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To describe the course of self-reported quality of life, emotional functioning, physical functioning and symptom intensity over time in cancer patients receiving palliative care.
Longitudinal study with monthly assessments, using the EORTC QLQ-C15-PAL. Data were analysed (1) prospectively, from baseline to ≥8-month follow-up; and (2) retrospectively, by taking death as index date and comparing results from three cross-sectional subsamples at different stages of illness (time to death ≥6, 5-3 and 2-0 months). Linear mixed models were calculated.
A total of 1739 patients (mean age 66, 50% male) from 30 palliative care centers in 12 countries were included.
In prospective analyses, quality of life, functioning and symptoms-except nausea/vomiting-remained generally stable over time. In retrospective analyses, patients 2-0 months before death reported significantly lower quality of life and physical functioning scores than those 5-3 months before death, who in turn scored lower than those ≥6 months before death, suggesting progressive decline. Emotional functioning remained initially unchanged, but decreased in the last months. Pain, fatigue and appetite loss showed a stable increase in intensity towards death. Dyspnea, insomnia and constipation increased from 5-3 to 2-0 months before death. Nausea/vomiting only increased when comparing those ≥6 months before death with those 2-0 months before death.
While the prospective approach showed predominantly stable patterns for quality of life, functioning and symptom severity throughout study duration, retrospective analyses indicated that deterioration was already apparent before the terminal phase and accelerated close to death. Our findings support the importance of early symptom identification and treatment in this population, and highlight the need for further studies to explore what characterizes those with either lower or higher symptom burden at different time points towards death.</description><identifier>ISSN: 1932-6203</identifier><identifier>EISSN: 1932-6203</identifier><identifier>DOI: 10.1371/journal.pone.0222988</identifier><identifier>PMID: 31596849</identifier><language>eng</language><publisher>United States: Public Library of Science</publisher><subject>Aged ; Appetite loss ; Biology and Life Sciences ; Cancer ; Cancer patients ; Cancer research ; Care and treatment ; Constipation ; Correlation analysis ; Death ; Dyspnea ; Emotions ; Europe ; Female ; Health aspects ; Hospitals ; Humans ; Insomnia ; Internationality ; Male ; Management ; Marital status ; Medical research ; Medicine ; Medicine and Health Sciences ; Mortality ; Nausea ; Neoplasms - pathology ; Neoplasms - therapy ; Oncology ; Pain ; Palliation ; Palliative Care ; Patients ; Quality of Life ; Respiration ; Sleep disorders ; Social Sciences ; Systematic review ; Time Factors ; Vomiting</subject><ispartof>PloS one, 2019-10, Vol.14 (10), p.e0222988-e0222988</ispartof><rights>COPYRIGHT 2019 Public Library of Science</rights><rights>2019 Verkissen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License: http://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>info:eu-repo/semantics/openAccess</rights><rights>2019 Verkissen et al 2019 Verkissen et al</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c609t-c2561539f71590982c91d6e25d7f6f9fb667b762b8d0cc411495b74138be6813</citedby><cites>FETCH-LOGICAL-c609t-c2561539f71590982c91d6e25d7f6f9fb667b762b8d0cc411495b74138be6813</cites><orcidid>0000-0002-7797-5290</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6784977/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6784977/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,723,776,780,860,881,2096,2915,23845,26544,27901,27902,53766,53768,79569,79570</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/31596849$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Verkissen, Mariëtte N</creatorcontrib><creatorcontrib>Hjermstad, Marianne J</creatorcontrib><creatorcontrib>Van Belle, Simon</creatorcontrib><creatorcontrib>Kaasa, Stein</creatorcontrib><creatorcontrib>Deliens, Luc</creatorcontrib><creatorcontrib>Pardon, Koen</creatorcontrib><title>Quality of life and symptom intensity over time in people with cancer receiving palliative care: Results from the international European Palliative Care Cancer Symptom study</title><title>PloS one</title><addtitle>PLoS One</addtitle><description>People with advanced cancer experience multiple symptoms during their illness trajectory, which can fluctuate in intensity.
To describe the course of self-reported quality of life, emotional functioning, physical functioning and symptom intensity over time in cancer patients receiving palliative care.
Longitudinal study with monthly assessments, using the EORTC QLQ-C15-PAL. Data were analysed (1) prospectively, from baseline to ≥8-month follow-up; and (2) retrospectively, by taking death as index date and comparing results from three cross-sectional subsamples at different stages of illness (time to death ≥6, 5-3 and 2-0 months). Linear mixed models were calculated.
A total of 1739 patients (mean age 66, 50% male) from 30 palliative care centers in 12 countries were included.
In prospective analyses, quality of life, functioning and symptoms-except nausea/vomiting-remained generally stable over time. In retrospective analyses, patients 2-0 months before death reported significantly lower quality of life and physical functioning scores than those 5-3 months before death, who in turn scored lower than those ≥6 months before death, suggesting progressive decline. Emotional functioning remained initially unchanged, but decreased in the last months. Pain, fatigue and appetite loss showed a stable increase in intensity towards death. Dyspnea, insomnia and constipation increased from 5-3 to 2-0 months before death. Nausea/vomiting only increased when comparing those ≥6 months before death with those 2-0 months before death.
While the prospective approach showed predominantly stable patterns for quality of life, functioning and symptom severity throughout study duration, retrospective analyses indicated that deterioration was already apparent before the terminal phase and accelerated close to death. Our findings support the importance of early symptom identification and treatment in this population, and highlight the need for further studies to explore what characterizes those with either lower or higher symptom burden at different time points towards death.</description><subject>Aged</subject><subject>Appetite loss</subject><subject>Biology and Life Sciences</subject><subject>Cancer</subject><subject>Cancer patients</subject><subject>Cancer research</subject><subject>Care and treatment</subject><subject>Constipation</subject><subject>Correlation analysis</subject><subject>Death</subject><subject>Dyspnea</subject><subject>Emotions</subject><subject>Europe</subject><subject>Female</subject><subject>Health aspects</subject><subject>Hospitals</subject><subject>Humans</subject><subject>Insomnia</subject><subject>Internationality</subject><subject>Male</subject><subject>Management</subject><subject>Marital status</subject><subject>Medical research</subject><subject>Medicine</subject><subject>Medicine and Health Sciences</subject><subject>Mortality</subject><subject>Nausea</subject><subject>Neoplasms - pathology</subject><subject>Neoplasms - therapy</subject><subject>Oncology</subject><subject>Pain</subject><subject>Palliation</subject><subject>Palliative Care</subject><subject>Patients</subject><subject>Quality of Life</subject><subject>Respiration</subject><subject>Sleep disorders</subject><subject>Social Sciences</subject><subject>Systematic review</subject><subject>Time Factors</subject><subject>Vomiting</subject><issn>1932-6203</issn><issn>1932-6203</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2019</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>BENPR</sourceid><sourceid>3HK</sourceid><sourceid>DOA</sourceid><recordid>eNptUttuEzEQXSEQLYU_QGAJCfGS4MuuveYBqaoKVKrEre-W451NXDn2YnuD8lH8I0666QXxYlszZ86cM56qeknwnDBB3l-HMXrt5kPwMMeUUtm2j6pjIhmdcYrZ43vvo-pZStcYN6zl_Gl1xEgjeVvL4-rP91E7m7co9MjZHpD2HUrb9ZDDGlmfwad9dgMRZbuGEkMDhMEB-m3zChntTUlFMGA31i_RoJ2zOtsNlFyED-gHpNHlhPpYGPMK9qxFebahyEfnYwwDaI--3RWelcJy7Jl_TlpSHrvt8-pJr12CF9N9Ul19Or86-zK7_Pr54uz0cmY4lnlmaMNJw2Qvik8sW2ok6TjQphM972W_4FwsBKeLtsPG1ITUslmImrB2Abwl7KR6fUM7uJDUNOikKMOMcF7wBXFxg-iCvlZDtGsdtypoq_aBEJdKx2yNA9WAxgZLEKyRddtpDazvSenWCkEM5YXr49RtXKyhM-Bz1O4B6cOMtyu1DBvFRflCIe7kmmhTtl75ELUiuG2oEoLKpiDeTS1i-DVCymptkwHntIcw3jgTtaCiLdA3_0D_739CLXWxaH0fijKzI1WnHFPS0obtnL29h1qBdnmVght3X58eAuuDg5BShP7WPcFqt-0HEWq37Wra9lL26v7kbosO683-AvqO_V4</recordid><startdate>20191009</startdate><enddate>20191009</enddate><creator>Verkissen, Mariëtte N</creator><creator>Hjermstad, Marianne J</creator><creator>Van Belle, Simon</creator><creator>Kaasa, Stein</creator><creator>Deliens, Luc</creator><creator>Pardon, Koen</creator><general>Public Library of Science</general><general>PLOS</general><general>Public Library of Science (PLoS)</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7QG</scope><scope>7QL</scope><scope>7QO</scope><scope>7RV</scope><scope>7SN</scope><scope>7SS</scope><scope>7T5</scope><scope>7TG</scope><scope>7TM</scope><scope>7U9</scope><scope>7X2</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8AO</scope><scope>8C1</scope><scope>8FD</scope><scope>8FE</scope><scope>8FG</scope><scope>8FH</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABJCF</scope><scope>ABUWG</scope><scope>AEUYN</scope><scope>AFKRA</scope><scope>ARAPS</scope><scope>ATCPS</scope><scope>AZQEC</scope><scope>BBNVY</scope><scope>BENPR</scope><scope>BGLVJ</scope><scope>BHPHI</scope><scope>C1K</scope><scope>CCPQU</scope><scope>D1I</scope><scope>DWQXO</scope><scope>FR3</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>H94</scope><scope>HCIFZ</scope><scope>K9.</scope><scope>KB.</scope><scope>KB0</scope><scope>KL.</scope><scope>L6V</scope><scope>LK8</scope><scope>M0K</scope><scope>M0S</scope><scope>M1P</scope><scope>M7N</scope><scope>M7P</scope><scope>M7S</scope><scope>NAPCQ</scope><scope>P5Z</scope><scope>P62</scope><scope>P64</scope><scope>PATMY</scope><scope>PDBOC</scope><scope>PHGZM</scope><scope>PHGZT</scope><scope>PIMPY</scope><scope>PJZUB</scope><scope>PKEHL</scope><scope>PPXIY</scope><scope>PQEST</scope><scope>PQGLB</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>PTHSS</scope><scope>PYCSY</scope><scope>RC3</scope><scope>7X8</scope><scope>3HK</scope><scope>5PM</scope><scope>DOA</scope><orcidid>https://orcid.org/0000-0002-7797-5290</orcidid></search><sort><creationdate>20191009</creationdate><title>Quality of life and symptom intensity over time in people with cancer receiving palliative care: Results from the international European Palliative Care Cancer Symptom study</title><author>Verkissen, Mariëtte N ; Hjermstad, Marianne J ; Van Belle, Simon ; Kaasa, Stein ; Deliens, Luc ; Pardon, Koen</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c609t-c2561539f71590982c91d6e25d7f6f9fb667b762b8d0cc411495b74138be6813</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2019</creationdate><topic>Aged</topic><topic>Appetite loss</topic><topic>Biology and Life Sciences</topic><topic>Cancer</topic><topic>Cancer patients</topic><topic>Cancer research</topic><topic>Care and treatment</topic><topic>Constipation</topic><topic>Correlation analysis</topic><topic>Death</topic><topic>Dyspnea</topic><topic>Emotions</topic><topic>Europe</topic><topic>Female</topic><topic>Health aspects</topic><topic>Hospitals</topic><topic>Humans</topic><topic>Insomnia</topic><topic>Internationality</topic><topic>Male</topic><topic>Management</topic><topic>Marital status</topic><topic>Medical research</topic><topic>Medicine</topic><topic>Medicine and Health Sciences</topic><topic>Mortality</topic><topic>Nausea</topic><topic>Neoplasms - pathology</topic><topic>Neoplasms - therapy</topic><topic>Oncology</topic><topic>Pain</topic><topic>Palliation</topic><topic>Palliative Care</topic><topic>Patients</topic><topic>Quality of Life</topic><topic>Respiration</topic><topic>Sleep disorders</topic><topic>Social Sciences</topic><topic>Systematic review</topic><topic>Time Factors</topic><topic>Vomiting</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Verkissen, Mariëtte N</creatorcontrib><creatorcontrib>Hjermstad, Marianne J</creatorcontrib><creatorcontrib>Van Belle, Simon</creatorcontrib><creatorcontrib>Kaasa, Stein</creatorcontrib><creatorcontrib>Deliens, Luc</creatorcontrib><creatorcontrib>Pardon, Koen</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Animal Behavior Abstracts</collection><collection>Bacteriology Abstracts (Microbiology B)</collection><collection>Biotechnology Research Abstracts</collection><collection>Nursing & Allied Health Database</collection><collection>Ecology Abstracts</collection><collection>Entomology Abstracts (Full archive)</collection><collection>Immunology Abstracts</collection><collection>Meteorological & Geoastrophysical Abstracts</collection><collection>Nucleic Acids Abstracts</collection><collection>Virology and AIDS Abstracts</collection><collection>Agricultural Science Collection</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>ProQuest Pharma Collection</collection><collection>Public Health Database</collection><collection>Technology Research Database</collection><collection>ProQuest SciTech Collection</collection><collection>ProQuest Technology Collection</collection><collection>ProQuest Natural Science Collection</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Materials Science & Engineering Collection</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest One Sustainability</collection><collection>ProQuest Central UK/Ireland</collection><collection>Advanced Technologies & Aerospace Collection</collection><collection>Agricultural & Environmental Science Collection</collection><collection>ProQuest Central Essentials</collection><collection>Biological Science Collection</collection><collection>ProQuest Central</collection><collection>Technology Collection</collection><collection>Natural Science Collection</collection><collection>Environmental Sciences and Pollution Management</collection><collection>ProQuest One Community College</collection><collection>ProQuest Materials Science Collection</collection><collection>ProQuest Central Korea</collection><collection>Engineering Research Database</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>SciTech Premium Collection</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Materials Science Database</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Meteorological & Geoastrophysical Abstracts - 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Academic</collection><collection>NORA - Norwegian Open Research Archives</collection><collection>PubMed Central (Full Participant titles)</collection><collection>DOAJ Directory of Open Access Journals</collection><jtitle>PloS one</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Verkissen, Mariëtte N</au><au>Hjermstad, Marianne J</au><au>Van Belle, Simon</au><au>Kaasa, Stein</au><au>Deliens, Luc</au><au>Pardon, Koen</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Quality of life and symptom intensity over time in people with cancer receiving palliative care: Results from the international European Palliative Care Cancer Symptom study</atitle><jtitle>PloS one</jtitle><addtitle>PLoS One</addtitle><date>2019-10-09</date><risdate>2019</risdate><volume>14</volume><issue>10</issue><spage>e0222988</spage><epage>e0222988</epage><pages>e0222988-e0222988</pages><issn>1932-6203</issn><eissn>1932-6203</eissn><abstract>People with advanced cancer experience multiple symptoms during their illness trajectory, which can fluctuate in intensity.
To describe the course of self-reported quality of life, emotional functioning, physical functioning and symptom intensity over time in cancer patients receiving palliative care.
Longitudinal study with monthly assessments, using the EORTC QLQ-C15-PAL. Data were analysed (1) prospectively, from baseline to ≥8-month follow-up; and (2) retrospectively, by taking death as index date and comparing results from three cross-sectional subsamples at different stages of illness (time to death ≥6, 5-3 and 2-0 months). Linear mixed models were calculated.
A total of 1739 patients (mean age 66, 50% male) from 30 palliative care centers in 12 countries were included.
In prospective analyses, quality of life, functioning and symptoms-except nausea/vomiting-remained generally stable over time. In retrospective analyses, patients 2-0 months before death reported significantly lower quality of life and physical functioning scores than those 5-3 months before death, who in turn scored lower than those ≥6 months before death, suggesting progressive decline. Emotional functioning remained initially unchanged, but decreased in the last months. Pain, fatigue and appetite loss showed a stable increase in intensity towards death. Dyspnea, insomnia and constipation increased from 5-3 to 2-0 months before death. Nausea/vomiting only increased when comparing those ≥6 months before death with those 2-0 months before death.
While the prospective approach showed predominantly stable patterns for quality of life, functioning and symptom severity throughout study duration, retrospective analyses indicated that deterioration was already apparent before the terminal phase and accelerated close to death. Our findings support the importance of early symptom identification and treatment in this population, and highlight the need for further studies to explore what characterizes those with either lower or higher symptom burden at different time points towards death.</abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>31596849</pmid><doi>10.1371/journal.pone.0222988</doi><orcidid>https://orcid.org/0000-0002-7797-5290</orcidid><oa>free_for_read</oa></addata></record> |
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| issn | 1932-6203 1932-6203 |
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| source | Public Library of Science (PLoS) Journals Open Access; MEDLINE; NORA - Norwegian Open Research Archives; DOAJ Directory of Open Access Journals; Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals; PubMed Central; Free Full-Text Journals in Chemistry |
| subjects | Aged Appetite loss Biology and Life Sciences Cancer Cancer patients Cancer research Care and treatment Constipation Correlation analysis Death Dyspnea Emotions Europe Female Health aspects Hospitals Humans Insomnia Internationality Male Management Marital status Medical research Medicine Medicine and Health Sciences Mortality Nausea Neoplasms - pathology Neoplasms - therapy Oncology Pain Palliation Palliative Care Patients Quality of Life Respiration Sleep disorders Social Sciences Systematic review Time Factors Vomiting |
| title | Quality of life and symptom intensity over time in people with cancer receiving palliative care: Results from the international European Palliative Care Cancer Symptom study |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-02-21T20%3A53%3A58IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-gale_plos_&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Quality%20of%20life%20and%20symptom%20intensity%20over%20time%20in%20people%20with%20cancer%20receiving%20palliative%20care:%20Results%20from%20the%20international%20European%20Palliative%20Care%20Cancer%20Symptom%20study&rft.jtitle=PloS%20one&rft.au=Verkissen,%20Mari%C3%ABtte%20N&rft.date=2019-10-09&rft.volume=14&rft.issue=10&rft.spage=e0222988&rft.epage=e0222988&rft.pages=e0222988-e0222988&rft.issn=1932-6203&rft.eissn=1932-6203&rft_id=info:doi/10.1371/journal.pone.0222988&rft_dat=%3Cgale_plos_%3EA602182536%3C/gale_plos_%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2303166411&rft_id=info:pmid/31596849&rft_galeid=A602182536&rft_doaj_id=oai_doaj_org_article_5ea0c09e735948daae3ff17418771c26&rfr_iscdi=true |