A quality improvement project to reduce hypothermia in infants undergoing MRI scanning
Background Hypothermia prevention strategies during MRI scanning under general anesthesia in infants may pose a challenge due to the MRI scanner’s technical constraints. Previous studies have demonstrated conflicting results related to increase or decrease in post-scan temperatures in children. We n...
Gespeichert in:
| Veröffentlicht in: | Pediatric radiology 2016-07, Vol.46 (8), p.1187-1198 |
|---|---|
| Hauptverfasser: | , , , , , , , |
| Format: | Artikel |
| Sprache: | eng |
| Schlagworte: | |
| Online-Zugang: | Volltext |
| Tags: |
Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
|
| container_end_page | 1198 |
|---|---|
| container_issue | 8 |
| container_start_page | 1187 |
| container_title | Pediatric radiology |
| container_volume | 46 |
| creator | Dalal, Priti G. Porath, Janelle Parekh, Uma Dhar, Padmani Wang, Ming Hulse, Michael Mujsce, Dennis McQuillan, Patrick M. |
| description | Background
Hypothermia prevention strategies during MRI scanning under general anesthesia in infants may pose a challenge due to the MRI scanner’s technical constraints. Previous studies have demonstrated conflicting results related to increase or decrease in post-scan temperatures in children. We noted occurrences of post-scan hypothermia in anesthetized infants despite the use of routine passive warming techniques.
Objective
The aims of our quality improvement project were (a) to identify variables associated with post-scan hypothermia in infants and (b) to develop and implement processes to reduce occurrence of hypothermia in neonatal intensive care unit (NICU) infants undergoing MRI.
Materials and methods
One hundred sixty-four infants undergoing MRI scanning were prospectively audited for post-scan body temperatures. A multidisciplinary team identified potential variables associated with post-scan hypothermia and designed preventative strategies: protocol development, risk factor identification, vigilance and use of a vacuum immobilizer. Another audit was performed, specifically focusing on NICU infants.
Results
In the initial phase, we found that younger age (
P
= 0.002), lower weight (
P
= 0.005), lower pre-scan temperature (
P
|
| doi_str_mv | 10.1007/s00247-016-3592-0 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_1808666749</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>4095015461</sourcerecordid><originalsourceid>FETCH-LOGICAL-c405t-968c673bbd77e999177ee0c37c23b3787ef1e3906560376030f75a7baee4fb6c3</originalsourceid><addsrcrecordid>eNqFkVFLHDEQx0NR6qn9AL5IwJe-bJ0ku5nNo0hbBYsg6mvI5mbPPW6zZ7JbuG9vrqelCFLIMBPym39m-DN2IuCbAMDzBCBLLEDoQlVGFvCJzUSpZCGMqffYDBSIAsrSHLDDlJYAoCqhPrMDiSA1yGrGHi_48-RW3bjhXb-Ow2_qKYw8V0vyIx8HHmk-eeJPm_UwPlHsO8e7kE_rwpj4FOYUF0MXFvzX3TVP3oWQL8dsv3WrRF9e8xF7-PH9_vKquLn9eX15cVP4EqqxMLr2GlXTzBHJGCNyIvAKvVSNwhqpFaQM6EqDwhzQYuWwcURl22ivjtjXnW4e-HmiNNq-S55WKxdomJIVNdRaayzN_1E0dZ6gxi169g5dDlMMeZE_lASJJWZK7Cgfh5QitXYdu97FjRVgt_7YnT82-2O3_ljIPaevylPT0_xvx5shGZA7IOWnsKD4z9cfqr4A_RmZpw</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>1798202747</pqid></control><display><type>article</type><title>A quality improvement project to reduce hypothermia in infants undergoing MRI scanning</title><source>MEDLINE</source><source>SpringerLink</source><creator>Dalal, Priti G. ; Porath, Janelle ; Parekh, Uma ; Dhar, Padmani ; Wang, Ming ; Hulse, Michael ; Mujsce, Dennis ; McQuillan, Patrick M.</creator><creatorcontrib>Dalal, Priti G. ; Porath, Janelle ; Parekh, Uma ; Dhar, Padmani ; Wang, Ming ; Hulse, Michael ; Mujsce, Dennis ; McQuillan, Patrick M.</creatorcontrib><description>Background
Hypothermia prevention strategies during MRI scanning under general anesthesia in infants may pose a challenge due to the MRI scanner’s technical constraints. Previous studies have demonstrated conflicting results related to increase or decrease in post-scan temperatures in children. We noted occurrences of post-scan hypothermia in anesthetized infants despite the use of routine passive warming techniques.
Objective
The aims of our quality improvement project were (a) to identify variables associated with post-scan hypothermia in infants and (b) to develop and implement processes to reduce occurrence of hypothermia in neonatal intensive care unit (NICU) infants undergoing MRI.
Materials and methods
One hundred sixty-four infants undergoing MRI scanning were prospectively audited for post-scan body temperatures. A multidisciplinary team identified potential variables associated with post-scan hypothermia and designed preventative strategies: protocol development, risk factor identification, vigilance and use of a vacuum immobilizer. Another audit was performed, specifically focusing on NICU infants.
Results
In the initial phase, we found that younger age (
P
= 0.002), lower weight (
P
= 0.005), lower pre-scan temperature (
P
< 0.01), primary anesthetic technique with propofol (
P
< 0.01), advanced airway devices (
P
= 0.02) and being in the NICU (
P
< 0.01) were associated with higher odds for developing post-scan decrease in body temperature. Quality improvement processes decreased the occurrence of hypothermia in NICU infants undergoing MRI scanning from 65% to 18% (95% confidence interval for the difference, 26-70%,
P
< 0.001).
Conclusion
Several variables, including being in the NICU, are associated with a decrease in post-scan temperature in infants undergoing MRI scanning under sedation/general anesthesia. Implementation of strategies to prevent hypothermia in infants may be challenging in the high-risk MRI environment. We were able to minimize this problem in clinical practice by applying quality improvement principles.</description><identifier>ISSN: 0301-0449</identifier><identifier>EISSN: 1432-1998</identifier><identifier>DOI: 10.1007/s00247-016-3592-0</identifier><identifier>PMID: 27026025</identifier><language>eng</language><publisher>Berlin/Heidelberg: Springer Berlin Heidelberg</publisher><subject>Age Factors ; Anesthesia, General ; Body Weight ; Female ; Humans ; Hypothermia - prevention & control ; Imaging ; Infant ; Infant, Newborn ; Intensive Care Units, Neonatal ; Magnetic Resonance Imaging ; Male ; Medicine ; Medicine & Public Health ; Neuroradiology ; Nuclear Medicine ; Oncology ; Original Article ; Pediatrics ; Prospective Studies ; Quality Improvement ; Radiology ; Risk Factors ; Ultrasound</subject><ispartof>Pediatric radiology, 2016-07, Vol.46 (8), p.1187-1198</ispartof><rights>Springer-Verlag Berlin Heidelberg 2016</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c405t-968c673bbd77e999177ee0c37c23b3787ef1e3906560376030f75a7baee4fb6c3</citedby><cites>FETCH-LOGICAL-c405t-968c673bbd77e999177ee0c37c23b3787ef1e3906560376030f75a7baee4fb6c3</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://link.springer.com/content/pdf/10.1007/s00247-016-3592-0$$EPDF$$P50$$Gspringer$$H</linktopdf><linktohtml>$$Uhttps://link.springer.com/10.1007/s00247-016-3592-0$$EHTML$$P50$$Gspringer$$H</linktohtml><link.rule.ids>314,780,784,27915,27916,41479,42548,51310</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/27026025$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Dalal, Priti G.</creatorcontrib><creatorcontrib>Porath, Janelle</creatorcontrib><creatorcontrib>Parekh, Uma</creatorcontrib><creatorcontrib>Dhar, Padmani</creatorcontrib><creatorcontrib>Wang, Ming</creatorcontrib><creatorcontrib>Hulse, Michael</creatorcontrib><creatorcontrib>Mujsce, Dennis</creatorcontrib><creatorcontrib>McQuillan, Patrick M.</creatorcontrib><title>A quality improvement project to reduce hypothermia in infants undergoing MRI scanning</title><title>Pediatric radiology</title><addtitle>Pediatr Radiol</addtitle><addtitle>Pediatr Radiol</addtitle><description>Background
Hypothermia prevention strategies during MRI scanning under general anesthesia in infants may pose a challenge due to the MRI scanner’s technical constraints. Previous studies have demonstrated conflicting results related to increase or decrease in post-scan temperatures in children. We noted occurrences of post-scan hypothermia in anesthetized infants despite the use of routine passive warming techniques.
Objective
The aims of our quality improvement project were (a) to identify variables associated with post-scan hypothermia in infants and (b) to develop and implement processes to reduce occurrence of hypothermia in neonatal intensive care unit (NICU) infants undergoing MRI.
Materials and methods
One hundred sixty-four infants undergoing MRI scanning were prospectively audited for post-scan body temperatures. A multidisciplinary team identified potential variables associated with post-scan hypothermia and designed preventative strategies: protocol development, risk factor identification, vigilance and use of a vacuum immobilizer. Another audit was performed, specifically focusing on NICU infants.
Results
In the initial phase, we found that younger age (
P
= 0.002), lower weight (
P
= 0.005), lower pre-scan temperature (
P
< 0.01), primary anesthetic technique with propofol (
P
< 0.01), advanced airway devices (
P
= 0.02) and being in the NICU (
P
< 0.01) were associated with higher odds for developing post-scan decrease in body temperature. Quality improvement processes decreased the occurrence of hypothermia in NICU infants undergoing MRI scanning from 65% to 18% (95% confidence interval for the difference, 26-70%,
P
< 0.001).
Conclusion
Several variables, including being in the NICU, are associated with a decrease in post-scan temperature in infants undergoing MRI scanning under sedation/general anesthesia. Implementation of strategies to prevent hypothermia in infants may be challenging in the high-risk MRI environment. We were able to minimize this problem in clinical practice by applying quality improvement principles.</description><subject>Age Factors</subject><subject>Anesthesia, General</subject><subject>Body Weight</subject><subject>Female</subject><subject>Humans</subject><subject>Hypothermia - prevention & control</subject><subject>Imaging</subject><subject>Infant</subject><subject>Infant, Newborn</subject><subject>Intensive Care Units, Neonatal</subject><subject>Magnetic Resonance Imaging</subject><subject>Male</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Neuroradiology</subject><subject>Nuclear Medicine</subject><subject>Oncology</subject><subject>Original Article</subject><subject>Pediatrics</subject><subject>Prospective Studies</subject><subject>Quality Improvement</subject><subject>Radiology</subject><subject>Risk Factors</subject><subject>Ultrasound</subject><issn>0301-0449</issn><issn>1432-1998</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2016</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>AZQEC</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><sourceid>GNUQQ</sourceid><recordid>eNqFkVFLHDEQx0NR6qn9AL5IwJe-bJ0ku5nNo0hbBYsg6mvI5mbPPW6zZ7JbuG9vrqelCFLIMBPym39m-DN2IuCbAMDzBCBLLEDoQlVGFvCJzUSpZCGMqffYDBSIAsrSHLDDlJYAoCqhPrMDiSA1yGrGHi_48-RW3bjhXb-Ow2_qKYw8V0vyIx8HHmk-eeJPm_UwPlHsO8e7kE_rwpj4FOYUF0MXFvzX3TVP3oWQL8dsv3WrRF9e8xF7-PH9_vKquLn9eX15cVP4EqqxMLr2GlXTzBHJGCNyIvAKvVSNwhqpFaQM6EqDwhzQYuWwcURl22ivjtjXnW4e-HmiNNq-S55WKxdomJIVNdRaayzN_1E0dZ6gxi169g5dDlMMeZE_lASJJWZK7Cgfh5QitXYdu97FjRVgt_7YnT82-2O3_ljIPaevylPT0_xvx5shGZA7IOWnsKD4z9cfqr4A_RmZpw</recordid><startdate>20160701</startdate><enddate>20160701</enddate><creator>Dalal, Priti G.</creator><creator>Porath, Janelle</creator><creator>Parekh, Uma</creator><creator>Dhar, Padmani</creator><creator>Wang, Ming</creator><creator>Hulse, Michael</creator><creator>Mujsce, Dennis</creator><creator>McQuillan, Patrick M.</creator><general>Springer Berlin Heidelberg</general><general>Springer Nature B.V</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>7QP</scope><scope>7RV</scope><scope>7TK</scope><scope>7U9</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8FE</scope><scope>8FG</scope><scope>8FH</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>ARAPS</scope><scope>AZQEC</scope><scope>BBNVY</scope><scope>BENPR</scope><scope>BGLVJ</scope><scope>BHPHI</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>H94</scope><scope>HCIFZ</scope><scope>K9-</scope><scope>K9.</scope><scope>KB0</scope><scope>LK8</scope><scope>M0R</scope><scope>M0S</scope><scope>M1P</scope><scope>M7N</scope><scope>M7P</scope><scope>NAPCQ</scope><scope>P5Z</scope><scope>P62</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>7X8</scope><scope>7QO</scope><scope>8FD</scope><scope>FR3</scope><scope>P64</scope></search><sort><creationdate>20160701</creationdate><title>A quality improvement project to reduce hypothermia in infants undergoing MRI scanning</title><author>Dalal, Priti G. ; Porath, Janelle ; Parekh, Uma ; Dhar, Padmani ; Wang, Ming ; Hulse, Michael ; Mujsce, Dennis ; McQuillan, Patrick M.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c405t-968c673bbd77e999177ee0c37c23b3787ef1e3906560376030f75a7baee4fb6c3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2016</creationdate><topic>Age Factors</topic><topic>Anesthesia, General</topic><topic>Body Weight</topic><topic>Female</topic><topic>Humans</topic><topic>Hypothermia - prevention & control</topic><topic>Imaging</topic><topic>Infant</topic><topic>Infant, Newborn</topic><topic>Intensive Care Units, Neonatal</topic><topic>Magnetic Resonance Imaging</topic><topic>Male</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Neuroradiology</topic><topic>Nuclear Medicine</topic><topic>Oncology</topic><topic>Original Article</topic><topic>Pediatrics</topic><topic>Prospective Studies</topic><topic>Quality Improvement</topic><topic>Radiology</topic><topic>Risk Factors</topic><topic>Ultrasound</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Dalal, Priti G.</creatorcontrib><creatorcontrib>Porath, Janelle</creatorcontrib><creatorcontrib>Parekh, Uma</creatorcontrib><creatorcontrib>Dhar, Padmani</creatorcontrib><creatorcontrib>Wang, Ming</creatorcontrib><creatorcontrib>Hulse, Michael</creatorcontrib><creatorcontrib>Mujsce, Dennis</creatorcontrib><creatorcontrib>McQuillan, Patrick M.</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>Calcium & Calcified Tissue Abstracts</collection><collection>ProQuest Nursing and Allied Health Journals</collection><collection>Neurosciences Abstracts</collection><collection>Virology and AIDS Abstracts</collection><collection>ProQuest 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>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>ProQuest Central (Alumni)</collection><collection>ProQuest Central</collection><collection>Advanced Technologies & Aerospace Collection</collection><collection>ProQuest Central Essentials</collection><collection>Biological Science Collection</collection><collection>AUTh Library subscriptions: ProQuest Central</collection><collection>Technology Collection</collection><collection>ProQuest Natural Science Collection</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central</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>Consumer Health Database</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Biological Sciences</collection><collection>ProQuest Consumer Health Database</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</collection><collection>Algology Mycology and Protozoology Abstracts (Microbiology C)</collection><collection>Biological Science 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><collection>MEDLINE - Academic</collection><collection>Biotechnology Research Abstracts</collection><collection>Technology Research Database</collection><collection>Engineering Research Database</collection><collection>Biotechnology and BioEngineering Abstracts</collection><jtitle>Pediatric radiology</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Dalal, Priti G.</au><au>Porath, Janelle</au><au>Parekh, Uma</au><au>Dhar, Padmani</au><au>Wang, Ming</au><au>Hulse, Michael</au><au>Mujsce, Dennis</au><au>McQuillan, Patrick M.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>A quality improvement project to reduce hypothermia in infants undergoing MRI scanning</atitle><jtitle>Pediatric radiology</jtitle><stitle>Pediatr Radiol</stitle><addtitle>Pediatr Radiol</addtitle><date>2016-07-01</date><risdate>2016</risdate><volume>46</volume><issue>8</issue><spage>1187</spage><epage>1198</epage><pages>1187-1198</pages><issn>0301-0449</issn><eissn>1432-1998</eissn><abstract>Background
Hypothermia prevention strategies during MRI scanning under general anesthesia in infants may pose a challenge due to the MRI scanner’s technical constraints. Previous studies have demonstrated conflicting results related to increase or decrease in post-scan temperatures in children. We noted occurrences of post-scan hypothermia in anesthetized infants despite the use of routine passive warming techniques.
Objective
The aims of our quality improvement project were (a) to identify variables associated with post-scan hypothermia in infants and (b) to develop and implement processes to reduce occurrence of hypothermia in neonatal intensive care unit (NICU) infants undergoing MRI.
Materials and methods
One hundred sixty-four infants undergoing MRI scanning were prospectively audited for post-scan body temperatures. A multidisciplinary team identified potential variables associated with post-scan hypothermia and designed preventative strategies: protocol development, risk factor identification, vigilance and use of a vacuum immobilizer. Another audit was performed, specifically focusing on NICU infants.
Results
In the initial phase, we found that younger age (
P
= 0.002), lower weight (
P
= 0.005), lower pre-scan temperature (
P
< 0.01), primary anesthetic technique with propofol (
P
< 0.01), advanced airway devices (
P
= 0.02) and being in the NICU (
P
< 0.01) were associated with higher odds for developing post-scan decrease in body temperature. Quality improvement processes decreased the occurrence of hypothermia in NICU infants undergoing MRI scanning from 65% to 18% (95% confidence interval for the difference, 26-70%,
P
< 0.001).
Conclusion
Several variables, including being in the NICU, are associated with a decrease in post-scan temperature in infants undergoing MRI scanning under sedation/general anesthesia. Implementation of strategies to prevent hypothermia in infants may be challenging in the high-risk MRI environment. We were able to minimize this problem in clinical practice by applying quality improvement principles.</abstract><cop>Berlin/Heidelberg</cop><pub>Springer Berlin Heidelberg</pub><pmid>27026025</pmid><doi>10.1007/s00247-016-3592-0</doi><tpages>12</tpages></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0301-0449 |
| ispartof | Pediatric radiology, 2016-07, Vol.46 (8), p.1187-1198 |
| issn | 0301-0449 1432-1998 |
| language | eng |
| recordid | cdi_proquest_miscellaneous_1808666749 |
| source | MEDLINE; SpringerLink |
| subjects | Age Factors Anesthesia, General Body Weight Female Humans Hypothermia - prevention & control Imaging Infant Infant, Newborn Intensive Care Units, Neonatal Magnetic Resonance Imaging Male Medicine Medicine & Public Health Neuroradiology Nuclear Medicine Oncology Original Article Pediatrics Prospective Studies Quality Improvement Radiology Risk Factors Ultrasound |
| title | A quality improvement project to reduce hypothermia in infants undergoing MRI scanning |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-14T17%3A45%3A23IST&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=A%20quality%20improvement%20project%20to%20reduce%20hypothermia%20in%20infants%20undergoing%20MRI%20scanning&rft.jtitle=Pediatric%20radiology&rft.au=Dalal,%20Priti%20G.&rft.date=2016-07-01&rft.volume=46&rft.issue=8&rft.spage=1187&rft.epage=1198&rft.pages=1187-1198&rft.issn=0301-0449&rft.eissn=1432-1998&rft_id=info:doi/10.1007/s00247-016-3592-0&rft_dat=%3Cproquest_cross%3E4095015461%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=1798202747&rft_id=info:pmid/27026025&rfr_iscdi=true |