Impact of stimulation among non-crying neonates with intact cord versus clamped cord on birth outcomes: observation study
BackgroundStimulation of non-crying neonates after birth can help transition to spontaneous breathing. In this study, we aim to assess the impact of intact versus clamped umbilical cord on spontaneous breathing after stimulation of non-crying neonates.MethodsThis is an observational study among non-...
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| creator | KC, Ashish Budhathoki, Shyam Sundar Thapa, Jeevan Niermeyer, Susan Gurung, Rejina Singhal, Nalini Basnet, Omkar Sharma, Srijana Bhattarai, Pratikshya Acharya, Ankit Jha, Anjani Kumar Pradhan, Yasho Vardhan Pyakurel, Sushil Nath Bajracharya, Kiran Verma, Sheela Bhandari, Amit Thapa, Anjana KC Bista, Krishna Prasad Paudel, Jhalak Sharma Khatri, Sangita Paudel, Leela |
| description | BackgroundStimulation of non-crying neonates after birth can help transition to spontaneous breathing. In this study, we aim to assess the impact of intact versus clamped umbilical cord on spontaneous breathing after stimulation of non-crying neonates.MethodsThis is an observational study among non-crying neonates (n=3073) born in hospitals of Nepal. Non-crying neonates born vaginally at gestational age ≥34 weeks were observed for their response to stimulation with the cord intact or clamped. Obstetric characteristics of the neonates were analysed. Association of spontaneous breathing with cord management was assessed using logistic regression.ResultsAmong non-crying neonates, 2563 received stimulation. Of these, a higher proportion of the neonates were breathing in the group with cord intact as compared with the group cord clamped (81.1% vs 68.9%, p |
| doi_str_mv | 10.1136/bmjpo-2021-001207 |
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In this study, we aim to assess the impact of intact versus clamped umbilical cord on spontaneous breathing after stimulation of non-crying neonates.MethodsThis is an observational study among non-crying neonates (n=3073) born in hospitals of Nepal. Non-crying neonates born vaginally at gestational age ≥34 weeks were observed for their response to stimulation with the cord intact or clamped. Obstetric characteristics of the neonates were analysed. Association of spontaneous breathing with cord management was assessed using logistic regression.ResultsAmong non-crying neonates, 2563 received stimulation. Of these, a higher proportion of the neonates were breathing in the group with cord intact as compared with the group cord clamped (81.1% vs 68.9%, p<0.0001). The use of bag-and-mask ventilation was lower among those who were stimulated with the cord intact than those who were stimulated with cord clamped (18.0% vs 32.4%, p<0.0001). The proportion of neonates with Apgar Score ≤3 at 1 min was lower with the cord intact than with cord clamped (7.6% vs 11.5%, p=0.001). In multivariate analysis, neonates with intact cord had 84% increased odds of spontaneous breathing (adjusted OR, 1.84; 95% CI: 1.48 to 2.29) compared with those with cord clamped.ConclusionsStimulation of non-crying neonates with intact cord was associated with more spontaneous breathing than among infants who were stimulated with cord clamped. Intact cord stimulation may help establish spontaneous breathing in apnoeic neonates, but residual confounding variables may be contributing to the findings. This study provides evidence for further controlled research to evaluate the effect of initial steps of resuscitation with cord intact.</description><identifier>ISSN: 2399-9772</identifier><identifier>EISSN: 2399-9772</identifier><identifier>DOI: 10.1136/bmjpo-2021-001207</identifier><identifier>PMID: 34660914</identifier><language>eng</language><publisher>LONDON: BMJ Publishing Group Ltd</publisher><subject>Amniotic fluid ; Apgar Score ; Babies ; Birth defects ; Childbirth & labor ; Data collection ; Epidemiology ; Feces ; Female ; Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi ; Fysiologi ; Gestational Age ; Heart rate ; Hemorrhage ; Hospitals ; Humans ; Induced labor ; Infant ; Infant, Newborn ; Life Sciences & Biomedicine ; Low income groups ; Lungs ; Neonatology ; Newborn ; Newborn babies ; Obstetrics ; Parturition ; Pediatrics ; Pediatrik ; Physiology ; Preeclampsia ; Pregnancy ; Public Health, Global Health, Social Medicine and Epidemiology ; Quality improvement ; Resuscitation ; Science & Technology ; Umbilical Cord ; Ventilators ; Womens health</subject><ispartof>BMJ paediatrics open, 2021-10, Vol.5 (1), p.e001207-e001207, Article 001207</ispartof><rights>Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.</rights><rights>2021 Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ . Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>2022 Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ. https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/ . Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ. 2022</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>true</woscitedreferencessubscribed><woscitedreferencescount>5</woscitedreferencescount><woscitedreferencesoriginalsourcerecordid>wos000703620400001</woscitedreferencesoriginalsourcerecordid><citedby>FETCH-LOGICAL-b634t-b3e5aab268004ff1121e4e34374ec20f93c93a30b0350719ec2676c7477403983</citedby><cites>FETCH-LOGICAL-b634t-b3e5aab268004ff1121e4e34374ec20f93c93a30b0350719ec2676c7477403983</cites><orcidid>0000-0002-5101-9460 ; 0000-0002-4262-3543 ; 0000-0002-0541-4486 ; 0000-0002-8614-1087</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://bmjpaedsopen.bmj.com/content/5/1/e001207.full.pdf$$EPDF$$P50$$Gbmj$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://bmjpaedsopen.bmj.com/content/5/1/e001207.full$$EHTML$$P50$$Gbmj$$Hfree_for_read</linktohtml><link.rule.ids>230,315,554,729,782,786,866,887,2104,2116,27931,27932,39265,53798,53800,55357,77668,77694</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/34660914$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink><backlink>$$Uhttps://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-457565$$DView record from Swedish Publication Index$$Hfree_for_read</backlink><backlink>$$Uhttps://gup.ub.gu.se/publication/334071$$DView record from Swedish Publication Index$$Hfree_for_read</backlink></links><search><creatorcontrib>KC, Ashish</creatorcontrib><creatorcontrib>Budhathoki, Shyam Sundar</creatorcontrib><creatorcontrib>Thapa, Jeevan</creatorcontrib><creatorcontrib>Niermeyer, Susan</creatorcontrib><creatorcontrib>Gurung, Rejina</creatorcontrib><creatorcontrib>Singhal, Nalini</creatorcontrib><creatorcontrib>Basnet, Omkar</creatorcontrib><creatorcontrib>Sharma, Srijana</creatorcontrib><creatorcontrib>Bhattarai, Pratikshya</creatorcontrib><creatorcontrib>Acharya, Ankit</creatorcontrib><creatorcontrib>Jha, Anjani Kumar</creatorcontrib><creatorcontrib>Pradhan, Yasho Vardhan</creatorcontrib><creatorcontrib>Pyakurel, Sushil Nath</creatorcontrib><creatorcontrib>Bajracharya, Kiran</creatorcontrib><creatorcontrib>Verma, Sheela</creatorcontrib><creatorcontrib>Bhandari, Amit</creatorcontrib><creatorcontrib>Thapa, Anjana KC</creatorcontrib><creatorcontrib>Bista, Krishna Prasad</creatorcontrib><creatorcontrib>Paudel, Jhalak Sharma</creatorcontrib><creatorcontrib>Khatri, Sangita</creatorcontrib><creatorcontrib>Paudel, Leela</creatorcontrib><creatorcontrib>Nepal Neonatal Network</creatorcontrib><title>Impact of stimulation among non-crying neonates with intact cord versus clamped cord on birth outcomes: observation study</title><title>BMJ paediatrics open</title><addtitle>bmjpo</addtitle><addtitle>BMJ Paediatrics Open</addtitle><addtitle>BMJ PAEDIATR OPEN</addtitle><addtitle>BMJ Paediatr Open</addtitle><description>BackgroundStimulation of non-crying neonates after birth can help transition to spontaneous breathing. In this study, we aim to assess the impact of intact versus clamped umbilical cord on spontaneous breathing after stimulation of non-crying neonates.MethodsThis is an observational study among non-crying neonates (n=3073) born in hospitals of Nepal. Non-crying neonates born vaginally at gestational age ≥34 weeks were observed for their response to stimulation with the cord intact or clamped. Obstetric characteristics of the neonates were analysed. Association of spontaneous breathing with cord management was assessed using logistic regression.ResultsAmong non-crying neonates, 2563 received stimulation. Of these, a higher proportion of the neonates were breathing in the group with cord intact as compared with the group cord clamped (81.1% vs 68.9%, p<0.0001). The use of bag-and-mask ventilation was lower among those who were stimulated with the cord intact than those who were stimulated with cord clamped (18.0% vs 32.4%, p<0.0001). The proportion of neonates with Apgar Score ≤3 at 1 min was lower with the cord intact than with cord clamped (7.6% vs 11.5%, p=0.001). In multivariate analysis, neonates with intact cord had 84% increased odds of spontaneous breathing (adjusted OR, 1.84; 95% CI: 1.48 to 2.29) compared with those with cord clamped.ConclusionsStimulation of non-crying neonates with intact cord was associated with more spontaneous breathing than among infants who were stimulated with cord clamped. Intact cord stimulation may help establish spontaneous breathing in apnoeic neonates, but residual confounding variables may be contributing to the findings. This study provides evidence for further controlled research to evaluate the effect of initial steps of resuscitation with cord intact.</description><subject>Amniotic fluid</subject><subject>Apgar Score</subject><subject>Babies</subject><subject>Birth defects</subject><subject>Childbirth & labor</subject><subject>Data collection</subject><subject>Epidemiology</subject><subject>Feces</subject><subject>Female</subject><subject>Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi</subject><subject>Fysiologi</subject><subject>Gestational Age</subject><subject>Heart rate</subject><subject>Hemorrhage</subject><subject>Hospitals</subject><subject>Humans</subject><subject>Induced labor</subject><subject>Infant</subject><subject>Infant, Newborn</subject><subject>Life Sciences & Biomedicine</subject><subject>Low income groups</subject><subject>Lungs</subject><subject>Neonatology</subject><subject>Newborn</subject><subject>Newborn babies</subject><subject>Obstetrics</subject><subject>Parturition</subject><subject>Pediatrics</subject><subject>Pediatrik</subject><subject>Physiology</subject><subject>Preeclampsia</subject><subject>Pregnancy</subject><subject>Public Health, Global Health, Social Medicine and Epidemiology</subject><subject>Quality improvement</subject><subject>Resuscitation</subject><subject>Science & Technology</subject><subject>Umbilical Cord</subject><subject>Ventilators</subject><subject>Womens health</subject><issn>2399-9772</issn><issn>2399-9772</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2021</creationdate><recordtype>article</recordtype><sourceid>9YT</sourceid><sourceid>ACMMV</sourceid><sourceid>HGBXW</sourceid><sourceid>EIF</sourceid><sourceid>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>D8T</sourceid><sourceid>DOA</sourceid><recordid>eNqNkk1v1DAQhiMEolXpD-CCInFBgoDtsZOYA1K1fK1UiQtwtRzH2XqVxIs_drX_HmdTtl2kIk4ejZ95Z0bzZtlzjN5iDOW7ZlhvbEEQwQVCmKDqUXZOgPOCVxV5fC8-yy69X6ME8ZpTRp5mZ0DLEnFMz7P9cthIFXLb5T6YIfYyGDvmcrDjKh_tWCi3N1Oo7SiD9vnOhJvcjGEqUta1-VY7H32uejlsdDvnkkJjXAJtDMoO2r_PbeO1287qPsR2_yx70sne68vb9yL78fnT98XX4vrbl-Xi6rpoSqChaEAzKRtS1gjRrsOYYE01UKioVgR1HBQHCahBwFCFeUqWVakqWlUUAa_hIlvOuq2Va7FxZpBuL6w04pCwbiWkC0b1WrCuQYpQCgwIlZxKqTAwyRnCLS0pT1rFrOV3ehObE7VV3IiUWkXhtQCgaZjEv3mQ_2h-Xh26xygoq1jJEv5hxhM76FbpMTjZn1Sd_ozmRqzsVtS0ris09Xt1K-Dsr6h9EIPxSve9TPeLXhBWA2CgDCX05V_o2kY3pksIwJhTSA6Bf1GEcShJzdhE4ZlSznrvdHccGSMxmVUczComs4rZrKnmxf1djxV_rJmA1zOw043tvDJ6VPqIJTtXKPVHFE3OTnT9__TChIMRFzaO4e6oaci79R6e_Dc2WhT8</recordid><startdate>20211001</startdate><enddate>20211001</enddate><creator>KC, 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of stimulation among non-crying neonates with intact cord versus clamped cord on birth outcomes: observation study</title><author>KC, Ashish ; Budhathoki, Shyam Sundar ; Thapa, Jeevan ; Niermeyer, Susan ; Gurung, Rejina ; Singhal, Nalini ; Basnet, Omkar ; Sharma, Srijana ; Bhattarai, Pratikshya ; Acharya, Ankit ; Jha, Anjani Kumar ; Pradhan, Yasho Vardhan ; Pyakurel, Sushil Nath ; Bajracharya, Kiran ; Verma, Sheela ; Bhandari, Amit ; Thapa, Anjana KC ; Bista, Krishna Prasad ; Paudel, Jhalak Sharma ; Khatri, Sangita ; Paudel, Leela</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-b634t-b3e5aab268004ff1121e4e34374ec20f93c93a30b0350719ec2676c7477403983</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2021</creationdate><topic>Amniotic fluid</topic><topic>Apgar Score</topic><topic>Babies</topic><topic>Birth defects</topic><topic>Childbirth & labor</topic><topic>Data collection</topic><topic>Epidemiology</topic><topic>Feces</topic><topic>Female</topic><topic>Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi</topic><topic>Fysiologi</topic><topic>Gestational Age</topic><topic>Heart rate</topic><topic>Hemorrhage</topic><topic>Hospitals</topic><topic>Humans</topic><topic>Induced labor</topic><topic>Infant</topic><topic>Infant, Newborn</topic><topic>Life Sciences & Biomedicine</topic><topic>Low income groups</topic><topic>Lungs</topic><topic>Neonatology</topic><topic>Newborn</topic><topic>Newborn babies</topic><topic>Obstetrics</topic><topic>Parturition</topic><topic>Pediatrics</topic><topic>Pediatrik</topic><topic>Physiology</topic><topic>Preeclampsia</topic><topic>Pregnancy</topic><topic>Public Health, Global Health, Social Medicine and Epidemiology</topic><topic>Quality improvement</topic><topic>Resuscitation</topic><topic>Science & Technology</topic><topic>Umbilical Cord</topic><topic>Ventilators</topic><topic>Womens 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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>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>Nursing & Allied Health Premium</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>PubMed Central (Full Participant titles)</collection><collection>SWEPUB Uppsala universitet full text</collection><collection>SwePub</collection><collection>SwePub Articles</collection><collection>SWEPUB Freely available online</collection><collection>SWEPUB Uppsala universitet</collection><collection>SwePub Articles full text</collection><collection>SWEPUB Göteborgs universitet</collection><collection>DOAJ Directory of Open Access Journals</collection><jtitle>BMJ paediatrics open</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>KC, Ashish</au><au>Budhathoki, Shyam Sundar</au><au>Thapa, Jeevan</au><au>Niermeyer, Susan</au><au>Gurung, Rejina</au><au>Singhal, Nalini</au><au>Basnet, Omkar</au><au>Sharma, Srijana</au><au>Bhattarai, Pratikshya</au><au>Acharya, Ankit</au><au>Jha, Anjani Kumar</au><au>Pradhan, Yasho Vardhan</au><au>Pyakurel, Sushil Nath</au><au>Bajracharya, Kiran</au><au>Verma, Sheela</au><au>Bhandari, Amit</au><au>Thapa, Anjana KC</au><au>Bista, Krishna Prasad</au><au>Paudel, Jhalak Sharma</au><au>Khatri, Sangita</au><au>Paudel, Leela</au><aucorp>Nepal Neonatal Network</aucorp><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Impact of stimulation among non-crying neonates with intact cord versus clamped cord on birth outcomes: observation study</atitle><jtitle>BMJ paediatrics open</jtitle><stitle>bmjpo</stitle><stitle>BMJ Paediatrics Open</stitle><stitle>BMJ PAEDIATR OPEN</stitle><addtitle>BMJ Paediatr Open</addtitle><date>2021-10-01</date><risdate>2021</risdate><volume>5</volume><issue>1</issue><spage>e001207</spage><epage>e001207</epage><pages>e001207-e001207</pages><artnum>001207</artnum><issn>2399-9772</issn><eissn>2399-9772</eissn><abstract>BackgroundStimulation of non-crying neonates after birth can help transition to spontaneous breathing. In this study, we aim to assess the impact of intact versus clamped umbilical cord on spontaneous breathing after stimulation of non-crying neonates.MethodsThis is an observational study among non-crying neonates (n=3073) born in hospitals of Nepal. Non-crying neonates born vaginally at gestational age ≥34 weeks were observed for their response to stimulation with the cord intact or clamped. Obstetric characteristics of the neonates were analysed. Association of spontaneous breathing with cord management was assessed using logistic regression.ResultsAmong non-crying neonates, 2563 received stimulation. Of these, a higher proportion of the neonates were breathing in the group with cord intact as compared with the group cord clamped (81.1% vs 68.9%, p<0.0001). The use of bag-and-mask ventilation was lower among those who were stimulated with the cord intact than those who were stimulated with cord clamped (18.0% vs 32.4%, p<0.0001). The proportion of neonates with Apgar Score ≤3 at 1 min was lower with the cord intact than with cord clamped (7.6% vs 11.5%, p=0.001). In multivariate analysis, neonates with intact cord had 84% increased odds of spontaneous breathing (adjusted OR, 1.84; 95% CI: 1.48 to 2.29) compared with those with cord clamped.ConclusionsStimulation of non-crying neonates with intact cord was associated with more spontaneous breathing than among infants who were stimulated with cord clamped. Intact cord stimulation may help establish spontaneous breathing in apnoeic neonates, but residual confounding variables may be contributing to the findings. This study provides evidence for further controlled research to evaluate the effect of initial steps of resuscitation with cord intact.</abstract><cop>LONDON</cop><pub>BMJ Publishing Group Ltd</pub><pmid>34660914</pmid><doi>10.1136/bmjpo-2021-001207</doi><tpages>8</tpages><orcidid>https://orcid.org/0000-0002-5101-9460</orcidid><orcidid>https://orcid.org/0000-0002-4262-3543</orcidid><orcidid>https://orcid.org/0000-0002-0541-4486</orcidid><orcidid>https://orcid.org/0000-0002-8614-1087</orcidid><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 2399-9772 |
| ispartof | BMJ paediatrics open, 2021-10, Vol.5 (1), p.e001207-e001207, Article 001207 |
| issn | 2399-9772 2399-9772 |
| language | eng |
| recordid | cdi_webofscience_primary_000703620400001 |
| source | BMJ Open Access Journals; MEDLINE; DOAJ Directory of Open Access Journals; Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals; SWEPUB Freely available online; Web of Science - Science Citation Index Expanded - 2021<img src="https://exlibris-pub.s3.amazonaws.com/fromwos-v2.jpg" />; PubMed Central |
| subjects | Amniotic fluid Apgar Score Babies Birth defects Childbirth & labor Data collection Epidemiology Feces Female Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi Fysiologi Gestational Age Heart rate Hemorrhage Hospitals Humans Induced labor Infant Infant, Newborn Life Sciences & Biomedicine Low income groups Lungs Neonatology Newborn Newborn babies Obstetrics Parturition Pediatrics Pediatrik Physiology Preeclampsia Pregnancy Public Health, Global Health, Social Medicine and Epidemiology Quality improvement Resuscitation Science & Technology Umbilical Cord Ventilators Womens health |
| title | Impact of stimulation among non-crying neonates with intact cord versus clamped cord on birth outcomes: observation study |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2024-12-04T11%3A50%3A11IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_webof&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Impact%20of%20stimulation%20among%20non-crying%20neonates%20with%20intact%20cord%20versus%20clamped%20cord%20on%20birth%20outcomes:%20observation%20study&rft.jtitle=BMJ%20paediatrics%20open&rft.au=KC,%20Ashish&rft.aucorp=Nepal%20Neonatal%20Network&rft.date=2021-10-01&rft.volume=5&rft.issue=1&rft.spage=e001207&rft.epage=e001207&rft.pages=e001207-e001207&rft.artnum=001207&rft.issn=2399-9772&rft.eissn=2399-9772&rft_id=info:doi/10.1136/bmjpo-2021-001207&rft_dat=%3Cproquest_webof%3E2583313450%3C/proquest_webof%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2593628553&rft_id=info:pmid/34660914&rft_doaj_id=oai_doaj_org_article_5fb0c24435324a94aac135a9501d4649&rfr_iscdi=true |