FRINK Linked Data Fragments server

Matches in SemOpenAlex for { <https://semopenalex.org/work/W2561898068> ?p ?o ?g. }

• W2561898068 endingPage "479" @default.
• W2561898068 startingPage "475" @default.
• W2561898068 abstract "See “Outcomes of pregnancies for women undergoing endoscopy while they were pregnant: a nationwide cohort study,” by Ludvigsson JF, Lebwohl B, Ekbom A, et al, on page 554. See “Outcomes of pregnancies for women undergoing endoscopy while they were pregnant: a nationwide cohort study,” by Ludvigsson JF, Lebwohl B, Ekbom A, et al, on page 554. From 1957 to 1962, an epidemic of about 4000 cases of phocomelia, a severe, congenital malformation of deformed or rudimentary limbs, occurred from in utero fetal exposure to thalidomide1Curran W.I. The thalidomide tragedy in Germany: the end of a historic medicolegal trail.N Engl J Med. 1971; 284: 481-482Crossref PubMed Scopus (27) Google Scholar after its administration to pregnant mothers to treat nausea and vomiting or anxiety during the first trimester of pregnancy, even though thalidomide had been shown to be safe and efficacious in both nonpregnant laboratory animals and nonpregnant subjects enrolled in clinical trials.2Yaffe S.J. Introduction.in: Briggs G.G. Freeman R.K. Yaffe S.J. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. 7th ed. Lippincott Williams & Wilkins, Philadelphia2005: XIII-XIXGoogle Scholar The medical community therefore codified through the United States Food and Drug Administration Drug Regulation Act of 1962 that the safety of drugs during pregnancy cannot be extrapolated from clinical studies in nonpregnant patients, but must be demonstrated directly by clinical studies in pregnant patients.2Yaffe S.J. Introduction.in: Briggs G.G. Freeman R.K. Yaffe S.J. Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. 7th ed. Lippincott Williams & Wilkins, Philadelphia2005: XIII-XIXGoogle Scholar This principle was extended subsequently to determine the risks of endoscopy during pregnancy to the pregnant patient and the fetus in utero by specific clinical studies on pregnant patients undergoing endoscopy. Although studies on endoscopy in nonpregnant patients normally require only a few days of postprocedure follow-up to assess endoscopy safety, studies on endoscopy in pregnant patients must follow the pregnancy until after delivery, up to 9 months after the endoscopy, to assess the health of the newborn, and perhaps require even further follow-up of the newborn for several years thereafter to detect subtle neuropsychiatric deficits that may not manifest until years after birth. The baseline risk of poor fetal outcomes is small, requiring the analysis of a large study population of pregnant patients undergoing endoscopy to provide robust statistical power to exclude that relatively small increases in clinically devastating, poor fetal outcomes, such as major congenital malformations, are statistically significantly higher than the baseline rate. Indications for endoscopy are common during pregnancy. For example, esophagogastroduodenoscopy (EGD) is commonly indicated during pregnancy for abdominal pain, upper gastrointestinal bleeding, dysphagia, and abnormal radiographic findings; and uncommonly indicated during pregnancy for pyrosis, suspected gastroesophageal reflux, dyspepsia, or nausea and vomiting.3Cappell M.S. The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy.Gastroenterol Clin N Am. 2003; 32: 123-179Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar About 2% of the female population or about 1% of the entire population (including males) is pregnant at any given time.4Division of Reproductive Health, Centers for Disease Control. Estimating the number of pregnant women in a geographic area. Available at: https://www.cdc.gov/reproductivehealth/emergency/pdfs/pregnacyestimatobrochure508.pdf. Accessed January 3, 2017. http://wiki.answers.com/O/What_percentage_of_the_female_poulatiomis_pregnant_at_any_one_time (2010).Google Scholar Given that 18.4 million patients undergo endoscopy per annum in the United States,5Peery A.F. Dellon E.S. Lund J. et al.Burden of gastrointestinal disease in the United States: 2012 update.Gastroenterology. 2012; 143: 1179-1187.e3Abstract Full Text Full Text PDF PubMed Scopus (1414) Google Scholar ceteris paribus about 184,000 pregnant females (18,400,000 endoscopies × 1% annual incidence of pregnancy in population) may be expected to have standard indications for gastrointestinal endoscopy per annum. Facing a pressing clinical decision on whether to perform versus not perform endoscopy in a given pregnant patient with an important, urgent, endoscopic indication, the gastroenterologist does not have the leisure time to prepare a protocol to study the safety of endoscopy during pregnancy, secure institutional review board approval, abstract patient data, analyze it, and then rationally decide on whether to perform endoscopy in this patient based on conclusions from this new study. No, the gastroenterologist must decide in real time using his or her clinical judgment, based on preexisting published data, tempered by expert opinion, and limited by informed patient consent. The more previously published studies, the larger they are, and the better their quality, then the more evidence based will be the clinical decision. Faced in 1991 with a pregnant patient requiring EGD for the strong, urgent, indication of active upper gastrointestinal bleeding, I performed therapeutic EGD, relying primarily on data extrapolated from the general nonpregnant population, clinical intuition, and anecdotal experience. The preexistent data on endoscopy during pregnancy then consisted of only scattered case reports; a study of EGD findings in 43 pregnant patients that was irrelevant to fetal safety of endoscopy during pregnancy because it lacked data on fetal outcome6Castro L.P. Reflux esophagitis as the cause of heartburn in pregnancy.Am J Obstet Gynecol. 1967; 98: 1-10Abstract Full Text PDF PubMed Scopus (54) Google Scholar; and 1 study showing 2 of 15 pregnant patients (13.3%) undergoing flexible esophagoscopy or gastroscopy in the late 1950s had poor fetal outcomes.7McCall M.L. Weschler R.L. Anzalone J.T. et al.Endoscopic studies of esophagus and stomach during pregnancy.Am J Obstet Gynecol. 1961; 82: 1125-1133Abstract Full Text PDF Google Scholar Unfortunately, this last study was insufficiently powered to quantify fetal risks. Yes, a retrospective mailed survey among 3300 gastroenterologists reported a 3% rate of poor fetal outcomes among 73 pregnant patients undergoing EGD,8Frank B. Endoscopy in pregnancy.in: Karlstadt R.G. Surawicz C.M. Croitoru R. Gastrointestinal disorders during pregnancy. American College of Gastroenterology, Arlington, VA1994: 24-29Google Scholar but this study was subject to a low response rate (73 respondents out of 3300 gastroenterologists), severe selection bias because of reliance on voluntary reporting, and recall bias because of reliance on physician memory in retrospectively reporting cases.3Cappell M.S. The fetal safety and clinical efficacy of gastrointestinal endoscopy during pregnancy.Gastroenterol Clin N Am. 2003; 32: 123-179Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar My colleagues and I then performed numerous studies on endoscopy during pregnancy to generate more data. Despite these and several other studies during the ensuing 25 years, the data still included insufficient numbers of studied patients to quantify risks with narrow confidence intervals. Physicians rarely and reluctantly perform endoscopy during pregnancy in the United States. The so-called Hippocratic injunction, “First, do no harm,”9Smith C.M. Origin and uses of primum non nocere–above all, do no harm!.J Clin Pharmacol. 2005; 45: 371-377Crossref PubMed Scopus (245) Google Scholar likely stifles performing endoscopy during pregnancy, especially given the potential, but inadequately defined, risks of major congenital malformations or miscarriages. At my institution, all female patients of childbearing age must perforce undergo a beta human chorionic gonadotropin serum pregnancy test before endoscopy, and patients testing positively are strongly advised against undergoing endoscopy, unless the endoscopy is strongly indicated, partly because of medicolegal considerations. Cappell et al10Cappell M.S. Fox S.R. Gorrepati N. Safety and efficacy of colonoscopy during pregnancy: an analysis of pregnancy outcome in 20 patients.J Reprod Med. 2010; 55: 115-123PubMed Google Scholar identified only 20 colonoscopies during pregnancy among >125,000 colonoscopies (rate of <0.016%) performed at 2 extremely large hospitals, William Beaumont Hospital at Royal Oak and at Troy, Michigan, during a 22-year study period, comprising a 66-fold lower rate of colonoscopy in pregnancy than the expected rate of 1% of all colonoscopies. In the mailed survey only 2.2% of >3300 gastroenterologists reported ever having performed endoscopy during pregnancy.8Frank B. Endoscopy in pregnancy.in: Karlstadt R.G. Surawicz C.M. Croitoru R. Gastrointestinal disorders during pregnancy. American College of Gastroenterology, Arlington, VA1994: 24-29Google Scholar Yet endoscopy is often clearly beneficial in nonpregnant patients, such as therapeutic EGD for active upper gastrointestinal bleeding11Cappell M.S. Therapeutic endoscopy for acute upper gastrointestinal bleeding.Nat Rev Gastroenterol Hepatol. 2010; 7: 214-229Crossref PubMed Scopus (35) Google Scholar or therapeutic endoscopic retrograde cholangiopancreatography for symptomatic choledocholithiasis,12Cappell M.S. Risks versus benefits of gastrointestinal endoscopy during pregnancy.Nat Rev Gastroenterol Hepatol. 2011; 8: 610-634Crossref PubMed Scopus (36) Google Scholar and denial of such strongly indicated endoscopies during pregnancy just because of potential, but unproven, fetal risks may prove deleterious to both the pregnant patient and her fetus in utero. How do we break this vicious cycle of avoidance of endoscopy owing to feared risks leading to few and small new clinical studies leading to continuing avoidance of endoscopy during pregnancy? By generating more data and performing better studies to provide evidence-based guidelines to promote a virtuous cycle that should result in more endoscopies performed during pregnancy to produce more patient data available for analysis. I commend the landmark study by Ludvigsson et al,13Ludvigsson J.F. Lebwohl B. Ekbom A. et al.Outcomes of pregnancies for women undergoing endoscopy while they were pregnant: a nationwide cohort study.Gastroenterology. 2017; 152: 554-563Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar who used a large national registry to study this question. Their study population of some 3000 pregnant patients undergoing endoscopy greatly exceeds the several hundred pregnant patients heretofore reported and provides robust power to investigate the statistical significance of uncommon, but important, pregnancy complications, such as congenital malformations. For example, this study demonstrates the highly important clinical finding that the relative risk of any major congenital malformation after endoscopy versus no endoscopy during pregnancy is 0.98, with a narrow 95% confidence interval of 0.82 to 1.19.13Ludvigsson J.F. Lebwohl B. Ekbom A. et al.Outcomes of pregnancies for women undergoing endoscopy while they were pregnant: a nationwide cohort study.Gastroenterology. 2017; 152: 554-563Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar National registry studies require less labor to obtain data than traditional chart-based studies. For our prior report, my colleagues and I had to (1) travel repeatedly to 8 hospitals for an up to 14-year chart study to accumulate 83 pregnant patients undergoing EGD, (2) secure 8 institutional review board approvals, and (3) laboriously, manually abstract the clinical data from the then-paper medical charts before analyzing the data.14Cappell M.S. Colon V.J. Sidhom O.A. A study of eight medical centers of the safety and clinical efficacy of esophagogastroduodenoscopy in 83 pregnant females with follow-up of fetal outcome with comparison control groups.Am J Gastroenterol. 1996; 91: 348-354PubMed Google Scholar In contrast, today clinical researchers can accumulate data on >3000 pregnant patients undergoing endoscopy (1) via a computerized registry from an entire country at 1 setting, at any location without travel via the Internet, (2) secure approval from only 1 institutional review board, which is easily obtained because patient data in a national registry are already deidentified, and (3) access an already populated computerized database without having to review medical charts manually.13Ludvigsson J.F. Lebwohl B. Ekbom A. et al.Outcomes of pregnancies for women undergoing endoscopy while they were pregnant: a nationwide cohort study.Gastroenterology. 2017; 152: 554-563Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Limitations of registry studies include the following. First, fewer data are available on individual patients than in studies based on medical chart reviews. For example, the aforementioned study of 83 pregnant patients undergoing EGD reported data on procedure indication, medications, maternal procedural complications, comorbidities, vital signs at beginning endoscopy, and others,14Cappell M.S. Colon V.J. Sidhom O.A. A study of eight medical centers of the safety and clinical efficacy of esophagogastroduodenoscopy in 83 pregnant females with follow-up of fetal outcome with comparison control groups.Am J Gastroenterol. 1996; 91: 348-354PubMed Google Scholar which were unavailable for analysis in the Registry Study13Ludvigsson J.F. Lebwohl B. Ekbom A. et al.Outcomes of pregnancies for women undergoing endoscopy while they were pregnant: a nationwide cohort study.Gastroenterology. 2017; 152: 554-563Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar (Table 1). Second, the medical chart can be re-reviewed in chart-based studies to mine new parameters as becomes necessary. For example, Cappell et al14Cappell M.S. Colon V.J. Sidhom O.A. A study of eight medical centers of the safety and clinical efficacy of esophagogastroduodenoscopy in 83 pregnant females with follow-up of fetal outcome with comparison control groups.Am J Gastroenterol. 1996; 91: 348-354PubMed Google Scholar were able to add new data on hospital medications at endoscopy in the 83 pregnant patients as requested by the reviewers, and were able to add new data on fetal monitoring during endoscopy after completing their initial data analysis. In contrast, a registry contains a fixed, preexistent, clinical dataset that cannot be expanded to mine data on new parameters, even if these parameters prove to be important.Table 1Strengths and Limitations of The Swedish National Registry Study on Safety of Endoscopy During Pregnancy∗Many of the limitations owing to unavailability of data in the Registry Study were not limitations in traditional manual medical chart reviews because the data were available in the medical chart (see discussion in the text).Study strengthsConsequences or pathophysiologyStudy population of 3052 women undergoing endoscopy during pregnancyThis number of patients undergoing EGD, colonoscopy, or sigmoidoscopy during pregnancy is large and much greater than that in all previously reported studies combined. This increases the power and reliability of statistical comparisons which is especially important for determining statistical significance of uncommon major complications, such as major congenital malformations.Swedish Patient Registry includes >99% of all somatic inpatient care in Sweden.National patient registry very likely captures nearly all pregnant patients in Sweden, avoiding potential bias from excluded or unregistered patients, who might be expected to be sicker because of avoidance of the medical system. Also this registry is likely to include virtually all pregnant patients undergoing endoscopy.Swedish Medical Birth Registry includes pregnancy outcomes of many essential variables for all pregnant patients in Sweden.Linking of Patient Registry with Birth Registry permits analysis of pregnancy outcomes for individual pregnant patients.Study weaknesses or limitationsConsequences or pathophysiologyGeneral criticisms Retrospective study design.Data much more secure in prospective than in retrospective studies. No statistical adjustment for large number of statistical comparisons.Statistically significant differences for a given parameter may arise by chance from excessive statistical comparisons. Neonatal death within 28 days after birth considered a secondary outcome.Neonatal death <28 days after delivery may be considered a main outcome measure because of its devastating effect that could potentially be related to the antecedent endoscopy. Alcohol or illicit drug use during pregnancy not analyzed.Alcohol or illicit drug abuse during pregnancy may contribute to congenital malformations. General comorbidities such as diabetes or cardiovascular disease, and pregnancy-related diseases were not analyzed. No data on severity of analyzed diseases.Comorbidities in expectant mother can contribute to poor fetal outcomes. No segregation of data according to type of hospital: community versus tertiary care hospital.Type of hospital might affect fetal outcome: positive effect of tertiary hospitals because of more expert care versus negative effect of sicker patients transferred to tertiary care hospitals. Spontaneous abortions <22 weeks of pregnancy not analyzed (data apparently unavailable in registry).Endoscopy during first one-half of pregnancy could theoretically cause involuntary abortions, a critical negative result regarding endoscopy safety during pregnancy.Criticisms related to endoscopic data No data reported on suspected maternal procedure-related complications based on event occurring during or <24 hours after procedure.Even if the procedure leads to a good fetal outcome at delivery, it is critical to analyze whether the mother suffered procedural complications. For example, maternal respiratory arrest during procedure would be considered an unfavorable outcome even if patient or fetus suffered no long-term deleterious effects. All complications occurring <24 hr postprocedure should be attributed to the procedure and reported. Data not segregated for therapeutic versus exclusively diagnostic endoscopy, for example, diagnostic ERCP versus ERCP with sphincterotomy and stone removal.Benefits of therapeutic endoscopy are likely much greater than benefits of purely diagnostic endoscopy. No data on benefits of endoscopy. No data on yield of diagnostic endoscopy. No data on efficacy of therapeutic endoscopy, for example, successful hemostasis with therapeutic endoscopy for GI bleeders.Decision of whether to perform endoscopy during pregnancy depends on weighing risks versus benefits. No data on patient position during endoscopy.Placement of pregnant patient in right lateral decubitus position during colonoscopy may decrease pressure on uterus and promote uterine blood flow. This is an important consideration when endoscopy is performed for acute GI bleeding. No data on endoscopy indications. Might be helpful to segregate data based on indication for endoscopy, for example, EGD indication of acute UGI bleeding versus nausea and vomiting.Benefits of endoscopy closely linked to procedure indication. For example, endoscopy for acute UGI bleeding is likely to be highly beneficial, whereas endoscopy for nausea and vomiting is likely to rarely show GI pathology because it is usually owing to nausea and vomiting of pregnancy or hyperemesis gravidarum. For patients undergoing endoscopy for GI bleeding, no data on hemoglobin level and number of units of packed erythrocytes transfused before endoscopy.Severe GI bleeding and inadequate patient resuscitation before endoscopy may constitute risk factors for endoscopic complications. No data on vital signs before, during, or after endoscopy during pregnancy.Vital signs during endoscopy may be a valuable parameter of patient and fetal safety during endoscopy. No data on oxygen saturation before, during, or immediately after endoscopy performed during pregnancy.Oxygen saturation during endoscopy may be a valuable predictor of patient and fetal safety during endoscopy. No data on endoscopic complications. No data on whether endoscopy had to be aborted because of complications.Significant endoscopic complications, even if only transient, should be considered a poor endoscopy outcome. No data on fetal monitoring during endoscopy.Fetal monitoring may prove useful to monitor fetal stress during endoscopy that might herald fetal complications. No data on sedative and anesthetic drug administration during endoscopy.Important to analyze use and dosage of sedative and anesthetic medications as potential causes of endoscopic complications, for example, respiratory arrest with propofol administration. No data on MAC during endoscopy.Important to analyze whether use of MAC affects rate of endoscopic complications. Predictive value of stated diseases in registry is only 85%-95% leading to a 5%-15% error rate.Nontrivial error rate of 5%-15% for reported diseases, which might affect statistical analysis. No data on use of radiation or quantitation of fetal exposure to radiation via densitometry measurements during ERCP.Radiation exposure is a known teratogen and may result in leukemia or neurologic damage appreciated many years after delivery.GI, gastrointestinal; EGD, esophagogastroduodenoscopy; ERCP, endoscopic retrograde cholangiopancreatography; MAC, monitored anesthesia care; UGI, upper gastrointestinal.∗ Many of the limitations owing to unavailability of data in the Registry Study were not limitations in traditional manual medical chart reviews because the data were available in the medical chart (see discussion in the text). Open table in a new tab GI, gastrointestinal; EGD, esophagogastroduodenoscopy; ERCP, endoscopic retrograde cholangiopancreatography; MAC, monitored anesthesia care; UGI, upper gastrointestinal. Third, reported data on endoscopy outcomes are incomplete in the Registry Study. Cappell et al14Cappell M.S. Colon V.J. Sidhom O.A. A study of eight medical centers of the safety and clinical efficacy of esophagogastroduodenoscopy in 83 pregnant females with follow-up of fetal outcome with comparison control groups.Am J Gastroenterol. 1996; 91: 348-354PubMed Google Scholar reported on the diagnostic and therapeutic benefits of EGD performed during pregnancy, and on endoscopic complications in the pregnant mother, which are important in decisions on whether to perform endoscopy during pregnancy. Such data are unavailable in the Registry Study.13Ludvigsson J.F. Lebwohl B. Ekbom A. et al.Outcomes of pregnancies for women undergoing endoscopy while they were pregnant: a nationwide cohort study.Gastroenterology. 2017; 152: 554-563Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Fortunately, these 3 limitations are mostly mitigated by a negative study: this Registry Study demonstrates that endoscopic examination is generally not associated with mild-to-moderately increased rates of poor fetal outcomes. This report strongly supports the highly important clinical finding that endoscopy during pregnancy is very likely relatively safe to the fetus in utero. However, a positive study demonstrating a moderately increased risk of poor fetal outcomes from endoscopy during pregnancy would require analysis of many additional clinical variables, such as sedatives, anesthetics, procedure indication, endoscopic therapy, and so on (Table 1), to identify contributors or predictors of poor outcomes, to identify contraindications for endoscopy during pregnancy, and to study the pathophysiology of poor fetal outcomes after endoscopy during pregnancy. Favorable endoscopic outcomes do not require this analysis. By analogy, consider 1 endoscopy in 1 patient, regardless of patient sex or pregnancy status. If the procedure outcome is favorable, this procedure is highly unlikely to be investigated, and the judgment and competence of the endoscopist and anesthesiologist performing this endoscopy would not be questioned. If the procedure outcome is poor, say an intraprocedural patient fatality, the procedure would surely face intense scrutiny by an army of investigators, including morbidity and mortality committee members, hospital administrators, and potentially plaintiff attorneys, judge, and jury. I complement the investigators for using as control groups prior and subsequent pregnancies <1 year of the index pregnancy in which the patient did not undergo endoscopy. Yet the very fact of pregnancy occurring within 1 year after an index pregnancy may imply that the patient was relatively healthy during the index pregnancy. In conclusion, this landmark study illustrates the statistical power of a registry study derived from a large study population, but demonstrates the aforementioned limitations. Adequately powered studies, like this one, provide the basis for promulgating evidence-based guidelines on whether to perform endoscopy. Guidelines should be stratified according to specific endoscopic test, endoscopic indication, and patient status; should be graded as strongly, moderately, and weakly indicated or not indicated; and should be rated according to the strength of the evidence. These newly published data13Ludvigsson J.F. Lebwohl B. Ekbom A. et al.Outcomes of pregnancies for women undergoing endoscopy while they were pregnant: a nationwide cohort study.Gastroenterology. 2017; 152: 554-563Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar should prompt a new systematic review of this subject to promulgate new, revised guidelines on endoscopy indications during pregnancy. Outcomes of Pregnancies for Women Undergoing Endoscopy While They Were Pregnant: A Nationwide Cohort StudyGastroenterologyVol. 152Issue 3PreviewEndoscopy is an integral part of the investigation and management of gastrointestinal disease. We aimed to examine outcomes of pregnancies for women who underwent endoscopy during their pregnancy. Full-Text PDF Covering the CoverGastroenterologyVol. 152Issue 3PreviewIn a nationwide, population-based study, exposure to endoscopy during pregnancy was associated with a minor increased risk of preterm birth or small for gestational age, but not congenital malformations or stillbirth. Full-Text PDF" @default.
• W2561898068 created "2017-01-06" @default.
• W2561898068 creator A5038604520 @default.
• W2561898068 date "2017-02-01" @default.
• W2561898068 modified "2023-09-25" @default.
• W2561898068 title "Evaluating the Safety of Endoscopy During Pregnancy: The Robust Statistical Power vs Limitations of a National Registry Study" @default.
• W2561898068 cites W1481799070 @default.
• W2561898068 cites W1582414631 @default.
• W2561898068 cites W2016710541 @default.
• W2561898068 cites W2022922443 @default.
• W2561898068 cites W2027241669 @default.
• W2561898068 cites W2028285327 @default.
• W2561898068 cites W2039934504 @default.
• W2561898068 cites W2045276152 @default.
• W2561898068 cites W2099365012 @default.
• W2561898068 cites W2218645039 @default.
• W2561898068 cites W2419196185 @default.
• W2561898068 cites W2534500546 @default.
• W2561898068 cites W2588420542 @default.
• W2561898068 doi "https://doi.org/10.1053/j.gastro.2016.12.014" @default.
• W2561898068 hasPubMedId "https://pubmed.ncbi.nlm.nih.gov/28038928" @default.
• W2561898068 hasPublicationYear "2017" @default.
• W2561898068 type Work @default.
• W2561898068 sameAs 2561898068 @default.
• W2561898068 citedByCount "2" @default.
• W2561898068 countsByYear W25618980682018 @default.
• W2561898068 countsByYear W25618980682020 @default.
• W2561898068 crossrefType "journal-article" @default.
• W2561898068 hasAuthorship W2561898068A5038604520 @default.
• W2561898068 hasBestOaLocation W25618980681 @default.
• W2561898068 hasConcept C105795698 @default.
• W2561898068 hasConcept C131872663 @default.
• W2561898068 hasConcept C141071460 @default.
• W2561898068 hasConcept C2778451229 @default.
• W2561898068 hasConcept C33923547 @default.
• W2561898068 hasConcept C71924100 @default.
• W2561898068 hasConcept C96608239 @default.
• W2561898068 hasConceptScore W2561898068C105795698 @default.
• W2561898068 hasConceptScore W2561898068C131872663 @default.
• W2561898068 hasConceptScore W2561898068C141071460 @default.
• W2561898068 hasConceptScore W2561898068C2778451229 @default.
• W2561898068 hasConceptScore W2561898068C33923547 @default.
• W2561898068 hasConceptScore W2561898068C71924100 @default.
• W2561898068 hasConceptScore W2561898068C96608239 @default.
• W2561898068 hasIssue "3" @default.
• W2561898068 hasLocation W25618980681 @default.
• W2561898068 hasLocation W25618980682 @default.
• W2561898068 hasOpenAccess W2561898068 @default.
• W2561898068 hasPrimaryLocation W25618980681 @default.
• W2561898068 hasRelatedWork W2313802994 @default.
• W2561898068 hasRelatedWork W2391778245 @default.
• W2561898068 hasRelatedWork W2403726136 @default.
• W2561898068 hasRelatedWork W2404146888 @default.
• W2561898068 hasRelatedWork W2405232492 @default.
• W2561898068 hasRelatedWork W2413394245 @default.
• W2561898068 hasRelatedWork W2474093687 @default.
• W2561898068 hasRelatedWork W2783428915 @default.
• W2561898068 hasRelatedWork W3030951041 @default.
• W2561898068 hasRelatedWork W4250651714 @default.
• W2561898068 hasVolume "152" @default.
• W2561898068 isParatext "false" @default.
• W2561898068 isRetracted "false" @default.
• W2561898068 magId "2561898068" @default.
• W2561898068 workType "article" @default.