Percutaneous ultrasound guided radiofrequency and microwave ablation in the treatment of hepatic metastases. A monocentric initial experience
Percutaneous radiofrequency (RFA) and microwave ablation (MWA) are currently the best treatment options forpatients with liver metastases (LM) who cannot undergo a liver resection procedure. Presently, few studies have evaluated theefficacy of tumor ablation in beginner's hands but none at all...
Gespeichert in:
| Veröffentlicht in: | Medical ultrasonography 2019-08, Vol.21 (3), p.217-224 |
|---|---|
| Hauptverfasser: | , , , , , , , , , |
| Format: | Artikel |
| Sprache: | eng |
| Schlagworte: | |
| Online-Zugang: | Volltext |
| Tags: |
Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
|
| container_end_page | 224 |
|---|---|
| container_issue | 3 |
| container_start_page | 217 |
| container_title | Medical ultrasonography |
| container_volume | 21 |
| creator | Sparchez, Zeno Mocan, Tudor Hajjar, Nadim All Bartos, Adrian Hagiu, Claudia Matei, Daniela Craciun, Rares Mocan, Lavinia Patricia Sparchez, Mihaela Leucuta, Daniel Corneliu |
| description | Percutaneous radiofrequency (RFA) and microwave ablation (MWA) are currently the best treatment options forpatients with liver metastases (LM) who cannot undergo a liver resection procedure. Presently, few studies have evaluated theefficacy of tumor ablation in beginner's hands but none at all in hepatic metastasis. Our aim was to report the initial experiencewith ultrasound as a tool to guide tumor ablation in a low volume center with no experience in tumor ablation.
We conducted a retrospective cohort study, on a series of 61 patients who had undergone percutaneous US-guided ablations for 82 LM between 2010 and 2015. Long term outcome predictors were assessed using univariate and multivariate analysis.
Complete ablation was achieved in 86.9% of cases (53/61). All MWA sessions (20/20) attained ablation margins >5mm, compared to 79% (49/62) for RFA sessions (p=0.031). Ablation time was significantly shorter for MWA, with a median duration of 10 minutes (range: 6-12) vs. 14 minutes (range: 10-19.5, p=0.003). There was no statistically significant difference in local tumor progression (LTP)-free survival rates between MWA and RFA (p=0.154). On univariate analysis, significant predictors for local recurrence were multiple metastases (p=0.013) and ablation margins |
| doi_str_mv | 10.11152/mu-1957 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_journals_2402557351</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2402557351</sourcerecordid><originalsourceid>FETCH-LOGICAL-c311t-950b5ef8537e3a46a5c0a3215772a7895a09c9b514fd3735c9ed785e7ff102d93</originalsourceid><addsrcrecordid>eNo9kN9qFjEQxYMo9qMW-gQS8MabrZlks9lclmK1ULAX9nqZzc7ayLfJZ_5o-xC-s9G2wsBcnN-c4RzGTkGcAYCWH7bagdXmBdtJMQzdOPTqJdvB2PddD0YesZOc_SykgsFoK16zIwW9GcDaHft9Q8nVgoFizbzuS8Ica1j4t-oXWnjCxcc10Y9KwT1wbMrmXYq_8CdxnPdYfAzcB17uiJdEWDYKhceV39GhiY5vVDC3oXzGz_kWQ3SNSE3xwRePe073B0q--dMb9mrFfaaTp33Mbi8_fr343F1_-XR1cX7dOQVQOqvFrGkdtTKksB9QO4FKgjZGohmtRmGdnTX066KM0s7SYkZNZl1ByMWqY_bu0feQYkuWy_Q91hTay0n2QmrdjqBR7x-pljfnROt0SH7D9DCBmP5VP211-lt9Q98-GdZ5o-U_-Fy0-gPsYYE2</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2402557351</pqid></control><display><type>article</type><title>Percutaneous ultrasound guided radiofrequency and microwave ablation in the treatment of hepatic metastases. A monocentric initial experience</title><source>MEDLINE</source><source>EZB-FREE-00999 freely available EZB journals</source><creator>Sparchez, Zeno ; Mocan, Tudor ; Hajjar, Nadim All ; Bartos, Adrian ; Hagiu, Claudia ; Matei, Daniela ; Craciun, Rares ; Mocan, Lavinia Patricia ; Sparchez, Mihaela ; Leucuta, Daniel Corneliu</creator><creatorcontrib>Sparchez, Zeno ; Mocan, Tudor ; Hajjar, Nadim All ; Bartos, Adrian ; Hagiu, Claudia ; Matei, Daniela ; Craciun, Rares ; Mocan, Lavinia Patricia ; Sparchez, Mihaela ; Leucuta, Daniel Corneliu</creatorcontrib><description>Percutaneous radiofrequency (RFA) and microwave ablation (MWA) are currently the best treatment options forpatients with liver metastases (LM) who cannot undergo a liver resection procedure. Presently, few studies have evaluated theefficacy of tumor ablation in beginner's hands but none at all in hepatic metastasis. Our aim was to report the initial experiencewith ultrasound as a tool to guide tumor ablation in a low volume center with no experience in tumor ablation.
We conducted a retrospective cohort study, on a series of 61 patients who had undergone percutaneous US-guided ablations for 82 LM between 2010 and 2015. Long term outcome predictors were assessed using univariate and multivariate analysis.
Complete ablation was achieved in 86.9% of cases (53/61). All MWA sessions (20/20) attained ablation margins >5mm, compared to 79% (49/62) for RFA sessions (p=0.031). Ablation time was significantly shorter for MWA, with a median duration of 10 minutes (range: 6-12) vs. 14 minutes (range: 10-19.5, p=0.003). There was no statistically significant difference in local tumor progression (LTP)-free survival rates between MWA and RFA (p=0.154). On univariate analysis, significant predictors for local recurrence were multiple metastases (p=0.013) and ablation margins <5 mm (p<.001), both retaining significance on multivariate analysis. Significant predictors for distant recurrence on both univariate and multivariate analysis were multiple metastases (p<0.001) and non-colorectal cancer metastases (p<0.05).
A larger than 5 mm ablation size is critical for local tumor control. We favor the use of MWA due to its ability to achieve ablation in significantlyshorter times with less incomplete ablations.</description><identifier>ISSN: 1844-4172</identifier><identifier>EISSN: 2066-8643</identifier><identifier>DOI: 10.11152/mu-1957</identifier><identifier>PMID: 31476199</identifier><language>eng</language><publisher>Romania: Romanian Society of Ultrasonography in Medicine and Biology</publisher><subject>Ablation ; Ablation Techniques - methods ; Cancer therapies ; Catheter Ablation - methods ; Chemotherapy ; Cohort Studies ; Colorectal cancer ; Computed tomography ; Electrodes ; Female ; Gallbladder ; Heat sinks ; Humans ; Laboratory tests ; Liver ; Liver - diagnostic imaging ; Liver - surgery ; Liver Neoplasms - diagnostic imaging ; Liver Neoplasms - secondary ; Liver Neoplasms - surgery ; Magnetic resonance imaging ; Male ; Medical imaging ; Metastasis ; Microwaves ; Middle Aged ; Parameter identification ; Patients ; Radio frequency ; Retrospective Studies ; Studies ; Tomography ; Treatment Outcome ; Tumors ; Ultrasonic imaging ; Ultrasonography, Interventional - methods</subject><ispartof>Medical ultrasonography, 2019-08, Vol.21 (3), p.217-224</ispartof><rights>Copyright Romanian Society of Ultrasonography in Medicine and Biology 2019</rights><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c311t-950b5ef8537e3a46a5c0a3215772a7895a09c9b514fd3735c9ed785e7ff102d93</citedby></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,780,784,27924,27925</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/31476199$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Sparchez, Zeno</creatorcontrib><creatorcontrib>Mocan, Tudor</creatorcontrib><creatorcontrib>Hajjar, Nadim All</creatorcontrib><creatorcontrib>Bartos, Adrian</creatorcontrib><creatorcontrib>Hagiu, Claudia</creatorcontrib><creatorcontrib>Matei, Daniela</creatorcontrib><creatorcontrib>Craciun, Rares</creatorcontrib><creatorcontrib>Mocan, Lavinia Patricia</creatorcontrib><creatorcontrib>Sparchez, Mihaela</creatorcontrib><creatorcontrib>Leucuta, Daniel Corneliu</creatorcontrib><title>Percutaneous ultrasound guided radiofrequency and microwave ablation in the treatment of hepatic metastases. A monocentric initial experience</title><title>Medical ultrasonography</title><addtitle>Med Ultrason</addtitle><description>Percutaneous radiofrequency (RFA) and microwave ablation (MWA) are currently the best treatment options forpatients with liver metastases (LM) who cannot undergo a liver resection procedure. Presently, few studies have evaluated theefficacy of tumor ablation in beginner's hands but none at all in hepatic metastasis. Our aim was to report the initial experiencewith ultrasound as a tool to guide tumor ablation in a low volume center with no experience in tumor ablation.
We conducted a retrospective cohort study, on a series of 61 patients who had undergone percutaneous US-guided ablations for 82 LM between 2010 and 2015. Long term outcome predictors were assessed using univariate and multivariate analysis.
Complete ablation was achieved in 86.9% of cases (53/61). All MWA sessions (20/20) attained ablation margins >5mm, compared to 79% (49/62) for RFA sessions (p=0.031). Ablation time was significantly shorter for MWA, with a median duration of 10 minutes (range: 6-12) vs. 14 minutes (range: 10-19.5, p=0.003). There was no statistically significant difference in local tumor progression (LTP)-free survival rates between MWA and RFA (p=0.154). On univariate analysis, significant predictors for local recurrence were multiple metastases (p=0.013) and ablation margins <5 mm (p<.001), both retaining significance on multivariate analysis. Significant predictors for distant recurrence on both univariate and multivariate analysis were multiple metastases (p<0.001) and non-colorectal cancer metastases (p<0.05).
A larger than 5 mm ablation size is critical for local tumor control. We favor the use of MWA due to its ability to achieve ablation in significantlyshorter times with less incomplete ablations.</description><subject>Ablation</subject><subject>Ablation Techniques - methods</subject><subject>Cancer therapies</subject><subject>Catheter Ablation - methods</subject><subject>Chemotherapy</subject><subject>Cohort Studies</subject><subject>Colorectal cancer</subject><subject>Computed tomography</subject><subject>Electrodes</subject><subject>Female</subject><subject>Gallbladder</subject><subject>Heat sinks</subject><subject>Humans</subject><subject>Laboratory tests</subject><subject>Liver</subject><subject>Liver - diagnostic imaging</subject><subject>Liver - surgery</subject><subject>Liver Neoplasms - diagnostic imaging</subject><subject>Liver Neoplasms - secondary</subject><subject>Liver Neoplasms - surgery</subject><subject>Magnetic resonance imaging</subject><subject>Male</subject><subject>Medical imaging</subject><subject>Metastasis</subject><subject>Microwaves</subject><subject>Middle Aged</subject><subject>Parameter identification</subject><subject>Patients</subject><subject>Radio frequency</subject><subject>Retrospective Studies</subject><subject>Studies</subject><subject>Tomography</subject><subject>Treatment Outcome</subject><subject>Tumors</subject><subject>Ultrasonic imaging</subject><subject>Ultrasonography, Interventional - methods</subject><issn>1844-4172</issn><issn>2066-8643</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2019</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><recordid>eNo9kN9qFjEQxYMo9qMW-gQS8MabrZlks9lclmK1ULAX9nqZzc7ayLfJZ_5o-xC-s9G2wsBcnN-c4RzGTkGcAYCWH7bagdXmBdtJMQzdOPTqJdvB2PddD0YesZOc_SykgsFoK16zIwW9GcDaHft9Q8nVgoFizbzuS8Ica1j4t-oXWnjCxcc10Y9KwT1wbMrmXYq_8CdxnPdYfAzcB17uiJdEWDYKhceV39GhiY5vVDC3oXzGz_kWQ3SNSE3xwRePe073B0q--dMb9mrFfaaTp33Mbi8_fr343F1_-XR1cX7dOQVQOqvFrGkdtTKksB9QO4FKgjZGohmtRmGdnTX066KM0s7SYkZNZl1ByMWqY_bu0feQYkuWy_Q91hTay0n2QmrdjqBR7x-pljfnROt0SH7D9DCBmP5VP211-lt9Q98-GdZ5o-U_-Fy0-gPsYYE2</recordid><startdate>20190831</startdate><enddate>20190831</enddate><creator>Sparchez, Zeno</creator><creator>Mocan, Tudor</creator><creator>Hajjar, Nadim All</creator><creator>Bartos, Adrian</creator><creator>Hagiu, Claudia</creator><creator>Matei, Daniela</creator><creator>Craciun, Rares</creator><creator>Mocan, Lavinia Patricia</creator><creator>Sparchez, Mihaela</creator><creator>Leucuta, Daniel Corneliu</creator><general>Romanian Society of Ultrasonography in Medicine and Biology</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>7RV</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8FE</scope><scope>8FG</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>ARAPS</scope><scope>BENPR</scope><scope>BGLVJ</scope><scope>BYOGL</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>HCIFZ</scope><scope>K9.</scope><scope>KB0</scope><scope>M0S</scope><scope>M1P</scope><scope>NAPCQ</scope><scope>P5Z</scope><scope>P62</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope></search><sort><creationdate>20190831</creationdate><title>Percutaneous ultrasound guided radiofrequency and microwave ablation in the treatment of hepatic metastases. A monocentric initial experience</title><author>Sparchez, Zeno ; Mocan, Tudor ; Hajjar, Nadim All ; Bartos, Adrian ; Hagiu, Claudia ; Matei, Daniela ; Craciun, Rares ; Mocan, Lavinia Patricia ; Sparchez, Mihaela ; Leucuta, Daniel Corneliu</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c311t-950b5ef8537e3a46a5c0a3215772a7895a09c9b514fd3735c9ed785e7ff102d93</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2019</creationdate><topic>Ablation</topic><topic>Ablation Techniques - methods</topic><topic>Cancer therapies</topic><topic>Catheter Ablation - methods</topic><topic>Chemotherapy</topic><topic>Cohort Studies</topic><topic>Colorectal cancer</topic><topic>Computed tomography</topic><topic>Electrodes</topic><topic>Female</topic><topic>Gallbladder</topic><topic>Heat sinks</topic><topic>Humans</topic><topic>Laboratory tests</topic><topic>Liver</topic><topic>Liver - diagnostic imaging</topic><topic>Liver - surgery</topic><topic>Liver Neoplasms - diagnostic imaging</topic><topic>Liver Neoplasms - secondary</topic><topic>Liver Neoplasms - surgery</topic><topic>Magnetic resonance imaging</topic><topic>Male</topic><topic>Medical imaging</topic><topic>Metastasis</topic><topic>Microwaves</topic><topic>Middle Aged</topic><topic>Parameter identification</topic><topic>Patients</topic><topic>Radio frequency</topic><topic>Retrospective Studies</topic><topic>Studies</topic><topic>Tomography</topic><topic>Treatment Outcome</topic><topic>Tumors</topic><topic>Ultrasonic imaging</topic><topic>Ultrasonography, Interventional - methods</topic><toplevel>online_resources</toplevel><creatorcontrib>Sparchez, Zeno</creatorcontrib><creatorcontrib>Mocan, Tudor</creatorcontrib><creatorcontrib>Hajjar, Nadim All</creatorcontrib><creatorcontrib>Bartos, Adrian</creatorcontrib><creatorcontrib>Hagiu, Claudia</creatorcontrib><creatorcontrib>Matei, Daniela</creatorcontrib><creatorcontrib>Craciun, Rares</creatorcontrib><creatorcontrib>Mocan, Lavinia Patricia</creatorcontrib><creatorcontrib>Sparchez, Mihaela</creatorcontrib><creatorcontrib>Leucuta, Daniel Corneliu</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>Nursing & Allied Health Database</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>ProQuest SciTech Collection</collection><collection>ProQuest Technology Collection</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>Advanced Technologies & Aerospace Collection</collection><collection>ProQuest Central</collection><collection>Technology Collection</collection><collection>East Europe, Central Europe Database</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>SciTech Premium Collection</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Nursing & Allied Health Premium</collection><collection>Advanced Technologies & Aerospace Database</collection><collection>ProQuest Advanced Technologies & Aerospace Collection</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><jtitle>Medical ultrasonography</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Sparchez, Zeno</au><au>Mocan, Tudor</au><au>Hajjar, Nadim All</au><au>Bartos, Adrian</au><au>Hagiu, Claudia</au><au>Matei, Daniela</au><au>Craciun, Rares</au><au>Mocan, Lavinia Patricia</au><au>Sparchez, Mihaela</au><au>Leucuta, Daniel Corneliu</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Percutaneous ultrasound guided radiofrequency and microwave ablation in the treatment of hepatic metastases. A monocentric initial experience</atitle><jtitle>Medical ultrasonography</jtitle><addtitle>Med Ultrason</addtitle><date>2019-08-31</date><risdate>2019</risdate><volume>21</volume><issue>3</issue><spage>217</spage><epage>224</epage><pages>217-224</pages><issn>1844-4172</issn><eissn>2066-8643</eissn><abstract>Percutaneous radiofrequency (RFA) and microwave ablation (MWA) are currently the best treatment options forpatients with liver metastases (LM) who cannot undergo a liver resection procedure. Presently, few studies have evaluated theefficacy of tumor ablation in beginner's hands but none at all in hepatic metastasis. Our aim was to report the initial experiencewith ultrasound as a tool to guide tumor ablation in a low volume center with no experience in tumor ablation.
We conducted a retrospective cohort study, on a series of 61 patients who had undergone percutaneous US-guided ablations for 82 LM between 2010 and 2015. Long term outcome predictors were assessed using univariate and multivariate analysis.
Complete ablation was achieved in 86.9% of cases (53/61). All MWA sessions (20/20) attained ablation margins >5mm, compared to 79% (49/62) for RFA sessions (p=0.031). Ablation time was significantly shorter for MWA, with a median duration of 10 minutes (range: 6-12) vs. 14 minutes (range: 10-19.5, p=0.003). There was no statistically significant difference in local tumor progression (LTP)-free survival rates between MWA and RFA (p=0.154). On univariate analysis, significant predictors for local recurrence were multiple metastases (p=0.013) and ablation margins <5 mm (p<.001), both retaining significance on multivariate analysis. Significant predictors for distant recurrence on both univariate and multivariate analysis were multiple metastases (p<0.001) and non-colorectal cancer metastases (p<0.05).
A larger than 5 mm ablation size is critical for local tumor control. We favor the use of MWA due to its ability to achieve ablation in significantlyshorter times with less incomplete ablations.</abstract><cop>Romania</cop><pub>Romanian Society of Ultrasonography in Medicine and Biology</pub><pmid>31476199</pmid><doi>10.11152/mu-1957</doi><tpages>8</tpages><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 1844-4172 |
| ispartof | Medical ultrasonography, 2019-08, Vol.21 (3), p.217-224 |
| issn | 1844-4172 2066-8643 |
| language | eng |
| recordid | cdi_proquest_journals_2402557351 |
| source | MEDLINE; EZB-FREE-00999 freely available EZB journals |
| subjects | Ablation Ablation Techniques - methods Cancer therapies Catheter Ablation - methods Chemotherapy Cohort Studies Colorectal cancer Computed tomography Electrodes Female Gallbladder Heat sinks Humans Laboratory tests Liver Liver - diagnostic imaging Liver - surgery Liver Neoplasms - diagnostic imaging Liver Neoplasms - secondary Liver Neoplasms - surgery Magnetic resonance imaging Male Medical imaging Metastasis Microwaves Middle Aged Parameter identification Patients Radio frequency Retrospective Studies Studies Tomography Treatment Outcome Tumors Ultrasonic imaging Ultrasonography, Interventional - methods |
| title | Percutaneous ultrasound guided radiofrequency and microwave ablation in the treatment of hepatic metastases. A monocentric initial experience |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2024-12-24T19%3A53%3A48IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_cross&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Percutaneous%20ultrasound%20guided%20radiofrequency%20and%20microwave%20ablation%20in%20the%20treatment%20of%20hepatic%20metastases.%20A%20monocentric%20initial%20experience&rft.jtitle=Medical%20ultrasonography&rft.au=Sparchez,%20Zeno&rft.date=2019-08-31&rft.volume=21&rft.issue=3&rft.spage=217&rft.epage=224&rft.pages=217-224&rft.issn=1844-4172&rft.eissn=2066-8643&rft_id=info:doi/10.11152/mu-1957&rft_dat=%3Cproquest_cross%3E2402557351%3C/proquest_cross%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2402557351&rft_id=info:pmid/31476199&rfr_iscdi=true |