Intraductal papillary mucinous neoplasm of the pancreas: diagnostic performance of the 2017 international consensus guidelines using CT and MRI
Objectives To assess the diagnostic performance of the 2017 international consensus guidelines for intraductal papillary mucinous neoplasm (IPMN) of the pancreas and to compare the diagnostic performance and intermodality agreement between contrast-enhanced CT and MRI. Methods We retrospectively eva...
Gespeichert in:
| Veröffentlicht in: | European radiology 2021-07, Vol.31 (7), p.4774-4784 |
|---|---|
| Hauptverfasser: | , , , , |
| Format: | Artikel |
| Sprache: | eng |
| Schlagworte: | |
| Online-Zugang: | Volltext |
| Tags: |
Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
|
| container_end_page | 4784 |
|---|---|
| container_issue | 7 |
| container_start_page | 4774 |
| container_title | European radiology |
| container_volume | 31 |
| creator | Min, Ji Hye Kim, Young Kon Kim, Seon Kyoung Kim, Honsoul Ahn, Soohyun |
| description | Objectives
To assess the diagnostic performance of the 2017 international consensus guidelines for intraductal papillary mucinous neoplasm (IPMN) of the pancreas and to compare the diagnostic performance and intermodality agreement between contrast-enhanced CT and MRI.
Methods
We retrospectively evaluated patients with surgical resection of IPMN of the pancreas who underwent preoperative CT and MRI between 2009 and 2019. Two radiologists evaluated the clinical and imaging features of IPMN of pancreas according to the 2017 international consensus guideline. Univariable and multivariable analyses were performed to identify significant predictors of malignancy in IPMN. The diagnostic abilities of CT and MRI were compared, and their intermodality agreement was determined.
Results
Of 175 patients (mean age, 64 years; 116 males), 88 (50.3%) had malignant IPMN. On multivariable analysis, all three high-risk stigmata (main pancreatic duct [MPD] ≥ 10 mm, mural nodule ≥ 5 mm, and obstructive jaundice) and two worrisome features (MPD 5–9 mm and elevated carbohydrate antigen 19–9) were associated with malignant IPMN on CT and MRI (
p
< 0.05). A mural nodule < 5 mm on MRI was also associated with malignant IPMN (OR 5.3,
p
= 0.009). The diagnostic accuracy of high-risk stigmata showed no difference between CT and MRI (73.7% vs. 75.4%,
p
= 0.505), with good to excellent intermodality agreement.
Conclusions
Current high-risk stigmata had the strongest association with malignant IPMN on CT and MRI. Although MRI is superior to CT for identifying mural nodules, diagnostic performance for differentiating malignant from benign IPMNs was similar between CT and MRI.
Key Points
• The current high-risk stigmata in the 2017 International Consensus Guidelines had the strongest association with malignant IPMN on CT and MRI.
• MRI is better than CT for identifying enhancing mural nodule.
• Diagnostic performance for differentiating malignant from benign IPMNs was similar between CT and MRI. |
| doi_str_mv | 10.1007/s00330-020-07583-1 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_2476127603</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2476127603</sourcerecordid><originalsourceid>FETCH-LOGICAL-c441t-8b7ac4e217514cfee85e0e33b67c8ae934cdd3dc837539dab70f31d36da44d173</originalsourceid><addsrcrecordid>eNp9kc-KFDEQxoMo7jj6Ah4k4MVLa5JKTzreZPDPwIog6zlkkuoxS3fSJp3DPoWvbNbZVfDgoahD_eorvvoIec7Za86YelMYA2AdE61UP0DHH5ANlyA6zgb5kGyYhqFTWssL8qSUa8aY5lI9JhcAkmmlhw35eYhrtr661U50sUuYJptv6FxdiKkWGjEtky0zTSNdv2NDostoy1vqgz3FVNbg6IJ5THluI7znBOOKhrhijnYNKTZ1l2LBWJroqQaPU4hYaC0hnuj-itro6eevh6fk0Wings_u-pZ8-_D-av-pu_zy8bB_d9k5KfnaDUdlnUTBVc-lGxGHHhkCHHfKDRY1SOc9eDeA6kF7e1RsBO5h562UnivYkldn3SWnHxXLauZQHDb3zXEtRki140Lt2oe35OU_6HWqzdbUqF6KHgRo3ihxplxOpWQczZLD3H5pODO3cZlzXKbFZX7HZW6XXtxJ1-OM_s_KfT4NgDNQ2iieMP-9_R_ZXwrcodM</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2542532391</pqid></control><display><type>article</type><title>Intraductal papillary mucinous neoplasm of the pancreas: diagnostic performance of the 2017 international consensus guidelines using CT and MRI</title><source>Springer Nature - Complete Springer Journals</source><creator>Min, Ji Hye ; Kim, Young Kon ; Kim, Seon Kyoung ; Kim, Honsoul ; Ahn, Soohyun</creator><creatorcontrib>Min, Ji Hye ; Kim, Young Kon ; Kim, Seon Kyoung ; Kim, Honsoul ; Ahn, Soohyun</creatorcontrib><description>Objectives
To assess the diagnostic performance of the 2017 international consensus guidelines for intraductal papillary mucinous neoplasm (IPMN) of the pancreas and to compare the diagnostic performance and intermodality agreement between contrast-enhanced CT and MRI.
Methods
We retrospectively evaluated patients with surgical resection of IPMN of the pancreas who underwent preoperative CT and MRI between 2009 and 2019. Two radiologists evaluated the clinical and imaging features of IPMN of pancreas according to the 2017 international consensus guideline. Univariable and multivariable analyses were performed to identify significant predictors of malignancy in IPMN. The diagnostic abilities of CT and MRI were compared, and their intermodality agreement was determined.
Results
Of 175 patients (mean age, 64 years; 116 males), 88 (50.3%) had malignant IPMN. On multivariable analysis, all three high-risk stigmata (main pancreatic duct [MPD] ≥ 10 mm, mural nodule ≥ 5 mm, and obstructive jaundice) and two worrisome features (MPD 5–9 mm and elevated carbohydrate antigen 19–9) were associated with malignant IPMN on CT and MRI (
p
< 0.05). A mural nodule < 5 mm on MRI was also associated with malignant IPMN (OR 5.3,
p
= 0.009). The diagnostic accuracy of high-risk stigmata showed no difference between CT and MRI (73.7% vs. 75.4%,
p
= 0.505), with good to excellent intermodality agreement.
Conclusions
Current high-risk stigmata had the strongest association with malignant IPMN on CT and MRI. Although MRI is superior to CT for identifying mural nodules, diagnostic performance for differentiating malignant from benign IPMNs was similar between CT and MRI.
Key Points
• The current high-risk stigmata in the 2017 International Consensus Guidelines had the strongest association with malignant IPMN on CT and MRI.
• MRI is better than CT for identifying enhancing mural nodule.
• Diagnostic performance for differentiating malignant from benign IPMNs was similar between CT and MRI.</description><identifier>ISSN: 0938-7994</identifier><identifier>EISSN: 1432-1084</identifier><identifier>DOI: 10.1007/s00330-020-07583-1</identifier><identifier>PMID: 33409798</identifier><language>eng</language><publisher>Berlin/Heidelberg: Springer Berlin Heidelberg</publisher><subject>Antigens ; Carbohydrates ; Computed tomography ; Diagnostic Radiology ; Diagnostic systems ; Guidelines ; Hepatobiliary-Pancreas ; Imaging ; Internal Medicine ; Interventional Radiology ; Jaundice ; Magnetic resonance imaging ; Malignancy ; Medical diagnosis ; Medicine ; Medicine & Public Health ; Neuroradiology ; Nodules ; Pancreas ; Pancreatic cancer ; Radiology ; Tumors ; Ultrasound</subject><ispartof>European radiology, 2021-07, Vol.31 (7), p.4774-4784</ispartof><rights>European Society of Radiology 2021</rights><rights>European Society of Radiology 2021.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c441t-8b7ac4e217514cfee85e0e33b67c8ae934cdd3dc837539dab70f31d36da44d173</citedby><cites>FETCH-LOGICAL-c441t-8b7ac4e217514cfee85e0e33b67c8ae934cdd3dc837539dab70f31d36da44d173</cites><orcidid>0000-0002-3070-4880</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://link.springer.com/content/pdf/10.1007/s00330-020-07583-1$$EPDF$$P50$$Gspringer$$H</linktopdf><linktohtml>$$Uhttps://link.springer.com/10.1007/s00330-020-07583-1$$EHTML$$P50$$Gspringer$$H</linktohtml><link.rule.ids>314,776,780,27903,27904,41467,42536,51297</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/33409798$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Min, Ji Hye</creatorcontrib><creatorcontrib>Kim, Young Kon</creatorcontrib><creatorcontrib>Kim, Seon Kyoung</creatorcontrib><creatorcontrib>Kim, Honsoul</creatorcontrib><creatorcontrib>Ahn, Soohyun</creatorcontrib><title>Intraductal papillary mucinous neoplasm of the pancreas: diagnostic performance of the 2017 international consensus guidelines using CT and MRI</title><title>European radiology</title><addtitle>Eur Radiol</addtitle><addtitle>Eur Radiol</addtitle><description>Objectives
To assess the diagnostic performance of the 2017 international consensus guidelines for intraductal papillary mucinous neoplasm (IPMN) of the pancreas and to compare the diagnostic performance and intermodality agreement between contrast-enhanced CT and MRI.
Methods
We retrospectively evaluated patients with surgical resection of IPMN of the pancreas who underwent preoperative CT and MRI between 2009 and 2019. Two radiologists evaluated the clinical and imaging features of IPMN of pancreas according to the 2017 international consensus guideline. Univariable and multivariable analyses were performed to identify significant predictors of malignancy in IPMN. The diagnostic abilities of CT and MRI were compared, and their intermodality agreement was determined.
Results
Of 175 patients (mean age, 64 years; 116 males), 88 (50.3%) had malignant IPMN. On multivariable analysis, all three high-risk stigmata (main pancreatic duct [MPD] ≥ 10 mm, mural nodule ≥ 5 mm, and obstructive jaundice) and two worrisome features (MPD 5–9 mm and elevated carbohydrate antigen 19–9) were associated with malignant IPMN on CT and MRI (
p
< 0.05). A mural nodule < 5 mm on MRI was also associated with malignant IPMN (OR 5.3,
p
= 0.009). The diagnostic accuracy of high-risk stigmata showed no difference between CT and MRI (73.7% vs. 75.4%,
p
= 0.505), with good to excellent intermodality agreement.
Conclusions
Current high-risk stigmata had the strongest association with malignant IPMN on CT and MRI. Although MRI is superior to CT for identifying mural nodules, diagnostic performance for differentiating malignant from benign IPMNs was similar between CT and MRI.
Key Points
• The current high-risk stigmata in the 2017 International Consensus Guidelines had the strongest association with malignant IPMN on CT and MRI.
• MRI is better than CT for identifying enhancing mural nodule.
• Diagnostic performance for differentiating malignant from benign IPMNs was similar between CT and MRI.</description><subject>Antigens</subject><subject>Carbohydrates</subject><subject>Computed tomography</subject><subject>Diagnostic Radiology</subject><subject>Diagnostic systems</subject><subject>Guidelines</subject><subject>Hepatobiliary-Pancreas</subject><subject>Imaging</subject><subject>Internal Medicine</subject><subject>Interventional Radiology</subject><subject>Jaundice</subject><subject>Magnetic resonance imaging</subject><subject>Malignancy</subject><subject>Medical diagnosis</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Neuroradiology</subject><subject>Nodules</subject><subject>Pancreas</subject><subject>Pancreatic cancer</subject><subject>Radiology</subject><subject>Tumors</subject><subject>Ultrasound</subject><issn>0938-7994</issn><issn>1432-1084</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2021</creationdate><recordtype>article</recordtype><sourceid>BENPR</sourceid><recordid>eNp9kc-KFDEQxoMo7jj6Ah4k4MVLa5JKTzreZPDPwIog6zlkkuoxS3fSJp3DPoWvbNbZVfDgoahD_eorvvoIec7Za86YelMYA2AdE61UP0DHH5ANlyA6zgb5kGyYhqFTWssL8qSUa8aY5lI9JhcAkmmlhw35eYhrtr661U50sUuYJptv6FxdiKkWGjEtky0zTSNdv2NDostoy1vqgz3FVNbg6IJ5THluI7znBOOKhrhijnYNKTZ1l2LBWJroqQaPU4hYaC0hnuj-itro6eevh6fk0Wings_u-pZ8-_D-av-pu_zy8bB_d9k5KfnaDUdlnUTBVc-lGxGHHhkCHHfKDRY1SOc9eDeA6kF7e1RsBO5h562UnivYkldn3SWnHxXLauZQHDb3zXEtRki140Lt2oe35OU_6HWqzdbUqF6KHgRo3ihxplxOpWQczZLD3H5pODO3cZlzXKbFZX7HZW6XXtxJ1-OM_s_KfT4NgDNQ2iieMP-9_R_ZXwrcodM</recordid><startdate>20210701</startdate><enddate>20210701</enddate><creator>Min, Ji Hye</creator><creator>Kim, Young Kon</creator><creator>Kim, Seon Kyoung</creator><creator>Kim, Honsoul</creator><creator>Ahn, Soohyun</creator><general>Springer Berlin Heidelberg</general><general>Springer Nature B.V</general><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7QO</scope><scope>7RV</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8AO</scope><scope>8FD</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>FR3</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>HCIFZ</scope><scope>K9.</scope><scope>KB0</scope><scope>LK8</scope><scope>M0S</scope><scope>M1P</scope><scope>M7P</scope><scope>NAPCQ</scope><scope>P5Z</scope><scope>P62</scope><scope>P64</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0002-3070-4880</orcidid></search><sort><creationdate>20210701</creationdate><title>Intraductal papillary mucinous neoplasm of the pancreas: diagnostic performance of the 2017 international consensus guidelines using CT and MRI</title><author>Min, Ji Hye ; Kim, Young Kon ; Kim, Seon Kyoung ; Kim, Honsoul ; Ahn, Soohyun</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c441t-8b7ac4e217514cfee85e0e33b67c8ae934cdd3dc837539dab70f31d36da44d173</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2021</creationdate><topic>Antigens</topic><topic>Carbohydrates</topic><topic>Computed tomography</topic><topic>Diagnostic Radiology</topic><topic>Diagnostic systems</topic><topic>Guidelines</topic><topic>Hepatobiliary-Pancreas</topic><topic>Imaging</topic><topic>Internal Medicine</topic><topic>Interventional Radiology</topic><topic>Jaundice</topic><topic>Magnetic resonance imaging</topic><topic>Malignancy</topic><topic>Medical diagnosis</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Neuroradiology</topic><topic>Nodules</topic><topic>Pancreas</topic><topic>Pancreatic cancer</topic><topic>Radiology</topic><topic>Tumors</topic><topic>Ultrasound</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Min, Ji Hye</creatorcontrib><creatorcontrib>Kim, Young Kon</creatorcontrib><creatorcontrib>Kim, Seon Kyoung</creatorcontrib><creatorcontrib>Kim, Honsoul</creatorcontrib><creatorcontrib>Ahn, Soohyun</creatorcontrib><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Biotechnology Research Abstracts</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 Pharma Collection</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>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>Advanced Technologies & Aerospace 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>ProQuest One Community College</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>SciTech Premium Collection</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>ProQuest Biological Science Collection</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Medical Database</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>Biotechnology and BioEngineering Abstracts</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><jtitle>European radiology</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Min, Ji Hye</au><au>Kim, Young Kon</au><au>Kim, Seon Kyoung</au><au>Kim, Honsoul</au><au>Ahn, Soohyun</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Intraductal papillary mucinous neoplasm of the pancreas: diagnostic performance of the 2017 international consensus guidelines using CT and MRI</atitle><jtitle>European radiology</jtitle><stitle>Eur Radiol</stitle><addtitle>Eur Radiol</addtitle><date>2021-07-01</date><risdate>2021</risdate><volume>31</volume><issue>7</issue><spage>4774</spage><epage>4784</epage><pages>4774-4784</pages><issn>0938-7994</issn><eissn>1432-1084</eissn><abstract>Objectives
To assess the diagnostic performance of the 2017 international consensus guidelines for intraductal papillary mucinous neoplasm (IPMN) of the pancreas and to compare the diagnostic performance and intermodality agreement between contrast-enhanced CT and MRI.
Methods
We retrospectively evaluated patients with surgical resection of IPMN of the pancreas who underwent preoperative CT and MRI between 2009 and 2019. Two radiologists evaluated the clinical and imaging features of IPMN of pancreas according to the 2017 international consensus guideline. Univariable and multivariable analyses were performed to identify significant predictors of malignancy in IPMN. The diagnostic abilities of CT and MRI were compared, and their intermodality agreement was determined.
Results
Of 175 patients (mean age, 64 years; 116 males), 88 (50.3%) had malignant IPMN. On multivariable analysis, all three high-risk stigmata (main pancreatic duct [MPD] ≥ 10 mm, mural nodule ≥ 5 mm, and obstructive jaundice) and two worrisome features (MPD 5–9 mm and elevated carbohydrate antigen 19–9) were associated with malignant IPMN on CT and MRI (
p
< 0.05). A mural nodule < 5 mm on MRI was also associated with malignant IPMN (OR 5.3,
p
= 0.009). The diagnostic accuracy of high-risk stigmata showed no difference between CT and MRI (73.7% vs. 75.4%,
p
= 0.505), with good to excellent intermodality agreement.
Conclusions
Current high-risk stigmata had the strongest association with malignant IPMN on CT and MRI. Although MRI is superior to CT for identifying mural nodules, diagnostic performance for differentiating malignant from benign IPMNs was similar between CT and MRI.
Key Points
• The current high-risk stigmata in the 2017 International Consensus Guidelines had the strongest association with malignant IPMN on CT and MRI.
• MRI is better than CT for identifying enhancing mural nodule.
• Diagnostic performance for differentiating malignant from benign IPMNs was similar between CT and MRI.</abstract><cop>Berlin/Heidelberg</cop><pub>Springer Berlin Heidelberg</pub><pmid>33409798</pmid><doi>10.1007/s00330-020-07583-1</doi><tpages>11</tpages><orcidid>https://orcid.org/0000-0002-3070-4880</orcidid></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0938-7994 |
| ispartof | European radiology, 2021-07, Vol.31 (7), p.4774-4784 |
| issn | 0938-7994 1432-1084 |
| language | eng |
| recordid | cdi_proquest_miscellaneous_2476127603 |
| source | Springer Nature - Complete Springer Journals |
| subjects | Antigens Carbohydrates Computed tomography Diagnostic Radiology Diagnostic systems Guidelines Hepatobiliary-Pancreas Imaging Internal Medicine Interventional Radiology Jaundice Magnetic resonance imaging Malignancy Medical diagnosis Medicine Medicine & Public Health Neuroradiology Nodules Pancreas Pancreatic cancer Radiology Tumors Ultrasound |
| title | Intraductal papillary mucinous neoplasm of the pancreas: diagnostic performance of the 2017 international consensus guidelines using CT and MRI |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-27T13%3A43%3A52IST&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=Intraductal%20papillary%20mucinous%20neoplasm%20of%20the%20pancreas:%20diagnostic%20performance%20of%20the%202017%20international%20consensus%20guidelines%20using%20CT%20and%20MRI&rft.jtitle=European%20radiology&rft.au=Min,%20Ji%20Hye&rft.date=2021-07-01&rft.volume=31&rft.issue=7&rft.spage=4774&rft.epage=4784&rft.pages=4774-4784&rft.issn=0938-7994&rft.eissn=1432-1084&rft_id=info:doi/10.1007/s00330-020-07583-1&rft_dat=%3Cproquest_cross%3E2476127603%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=2542532391&rft_id=info:pmid/33409798&rfr_iscdi=true |