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W2589004364 abstract "HomeCirculationVol. 135, No. 11Telemedicine in Pediatric Cardiology: A Scientific Statement From the American Heart Association Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBTelemedicine in Pediatric Cardiology: A Scientific Statement From the American Heart Association Gary M. Satou, MD, FAHA, Chair, Karen Rheuban, MD, Dale Alverson, MD, Mark Lewin, MD, Christopher Mahnke, MD, James Marcin, MD, Gerard R. Martin, MD, FAHA, Lisa Schmitz Mazur, JD, David J. Sahn, MD, FAHA, Sanket Shah, MD, Reed Tuckson, MD, Catherine L. Webb, MD, FAHA and Craig A. Sable, MD, FAHA, Vice ChairOn behalf of the American Heart Association Congenital Cardiac Disease Committee of the Council on Cardiovascular Disease in the Young and Council on Quality Care and Outcomes Research Gary M. SatouGary M. Satou Search for more papers by this author , Karen RheubanKaren Rheuban Search for more papers by this author , Dale AlversonDale Alverson Search for more papers by this author , Mark LewinMark Lewin Search for more papers by this author , Christopher MahnkeChristopher Mahnke Search for more papers by this author , James MarcinJames Marcin Search for more papers by this author , Gerard R. MartinGerard R. Martin Search for more papers by this author , Lisa Schmitz MazurLisa Schmitz Mazur Search for more papers by this author , David J. SahnDavid J. Sahn Search for more papers by this author , Sanket ShahSanket Shah Search for more papers by this author , Reed TucksonReed Tuckson Search for more papers by this author , Catherine L. WebbCatherine L. Webb Search for more papers by this author and Craig A. SableCraig A. Sable Search for more papers by this author and On behalf of the American Heart Association Congenital Cardiac Disease Committee of the Council on Cardiovascular Disease in the Young and Council on Quality Care and Outcomes Research Originally published13 Feb 2017https://doi.org/10.1161/CIR.0000000000000478Circulation. 2017;135:e648–e678Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2017: Previous Version 1 Advancements in technology and broadband have revolutionized the current practice of medicine. The field of pediatric cardiology is no exception given the need for prompt diagnosis and reliance on cardiac imaging to identify infants and children with potentially life-threatening cardiovascular disease. As the relationship between telemedicine and pediatric cardiology has advanced, it has created a need to develop a broad, comprehensive document reviewing all the various aspects of telemedicine in pediatric cardiology. For more than a decade, a significant body of literature has been published describing individual experiences and practices, yet there remains no comprehensive statement or document summarizing this rapidly advancing field. In an effort to describe the collective experience and to provide structure and guidance for pediatric cardiology practitioners and healthcare providers, we have developed a scientific statement on the use of telemedicine in pediatric cardiology.Specific areas explored in this document include both neonatal and fetal tele-echocardiography, implications for training community sonographers, pulse oximetry programs, qualitative improvement and appropriate use criteria initiatives, and remote electrophysiological monitoring. This document also includes teleconsultation and teleausculation, direct-to-consumer and home monitoring programs, and a look into the use of telemedicine and pediatric cardiology in the intensive care setting. Furthermore, a detailed review of the legislative, public policy, and legal aspects of telemedicine is provided, along with financial and reimbursement information.Several terms are used in the literature interchangeably; a brief explanation is provided to help readers of this document. The term telehealth is defined as the use of technology to bridge distances in any aspect of medicine; telemedicine is the specific application of technology to conduct clinical medicine at a distance. The term telecardiology is defined as the broad application of telemedicine in the field of cardiology specifically, and tele-echocardiography is the most common application used within this field.Echocardiography and TelemedicineEchocardiography is the most commonly used noninvasive cardiovascular imaging modality and is considered to be both safe and cost-effective. Tele-echocardiography can be described as a process in which a provider or a technician obtains cardiovascular ultrasound images from a given patient and these images are subsequently transmitted to an offsite location where a cardiologist can provide further analysis and interpretation. Thus, tele-echocardiography enables expert interpretation and consultation in a rapid and potentially geographically disparate fashion, enabling prompt and accurate decision making involving triage, transport, and therapeutic priorities. Tele-echocardiography is now routinely used across the age and subspecialty spectrum in pediatric cardiology.Clinical Scenarios: Fetal Echocardiography and Fetal Cardiac MonitoringFetal tele-echocardiography increases prenatal detection of critical congenital heart disease (CCHD). Sharma et al1 reported that adequate screening for fetal heart disease is feasible and that community acceptance for telemedicine-assisted fetal cardiac screening and counseling is not adversely affected by a lack of direct personal contact with a specialist. Prenatal detection of CCHD in turn has been shown to improve postnatal surgical2–4 and heart transplantation outcomes.5 Most commonly, fetal tele-echocardiography is used to refer delivery to a place where a neonatal intervention can be performed. A few centers in North America also use tele-echocardiography for referral for fetal intervention. However, fetal tele-echocardiography is also used across all links of the referral chain, from the primary obstetrician’s office to the quaternary fetal healthcare facility. It is routinely performed by obstetricians, maternal-fetal medicine specialists, and pediatric cardiologists to screen for congenital heart disease and fetal arrhythmias. If pathology is suspected or detected, these providers can refer patients to a higher level of care. Commonly, a referring clinic or hospital uploads the fetal ultrasound or echocardiogram images to a secure virtual network or a computer server of a tertiary care fetal health center. The tertiary care center then provides consultation and management recommendations. Occasionally, study image disks or videotapes of echocardiograms are sent for interpretation and reporting. In the current era of the gigabit Internet, secure digital transfer is much quicker and hence the preferred method of delivery. Some tertiary care fetal health centers offer a remote fetal tele-echocardiography service, which enables a hospital or clinic to transmit live echocardiographic images over the Internet to an attending cardiologist at an external facility. This allows instant feedback and counseling via audio or both audio and video. Because access to fetal cardiac expertise is limited for people in remote or rural locations, fetal tele-echocardiography is felt to be very helpful in these populations. As telemedicine becomes more frequently used in the delivery of maternal fetal medicine consultations, the use of fetal ultrasound to detect CCHD can also help pediatric cardiologists prepare families for delivery and treatment options.6–8In cases of fetal arrhythmias, fetal tele-echocardiography can be diagnostic. In the case of fetal bradycardia secondary to atrioventricular block, tertiary care fetal health centers can use fetal tele-echocardiography to guide and monitor pharmacotherapy. Periodic fetal tele-echocardiography monitoring of fetuses with heart block may be useful in determining the optimal gestational age for a cesarean section at a center where postnatal permanent pacemaker implantation will occur.9 Fetal tele-echocardiography similarly can play a critical role in diagnosing and treating fetal tachycardia. Transplacental or direct fetal antiarrhythmia treatment, follow-up evaluations, and delivery plans can be appropriately determined on review of the images. Of note, several commercial and US Food and Drug Administration (FDA)–approved handheld Doppler fetal heart rate monitors are readily available for use. Prospective parents can purchase them at low cost on the Internet. These devices hold promise, especially if they have Bluetooth or network connectivity. However, more data are needed to assess the utility of these devices for future home monitoring.10 Physician input is critical because inappropriate use of home monitoring can do more harm than good.11Clinical Scenarios: Neonatal CardiologyTable 1 provides a comprehensive list of 33 publications in pediatric tele-echocardiography, 16 of which are from institutions outside the continental United States, reflecting the global interest in telemedicine in pediatric cardiology. Single-center studies on neonatal telecardiology have shown this technology to be accurate and cost-effective, to have a positive impact on patient care, and to prevent unnecessary transports.12,15,16,18,25,27,28,36,37 When not diagnosed prenatally, newborns with congenital heart disease are often delivered or present to a primary care setting where expert cardiovascular evaluation may not be available. Management decisions based on incomplete or delayed diagnostic information may result in morbidity and mortality or unnecessary transfer. The diagnosis, clinical management, and triaging of a sick newborn with suspected congenital heart disease can be done quickly with tele-echocardiography. Randolph et al26 reported that using tele-echocardiography resulted in a complete diagnosis for 132 (99%) of 133 patients and a clinically adequate diagnosis for the remaining patient (1%). In their study, patient transfer was recommended or avoided in 7 patients, an immediate change in local medical management occurred in an additional 25 (19%) of 133 neonatal patients, and congenital heart disease not requiring immediate treatment was noted in 47 (35%) infants.Table 1. History of Pediatric/Congenital Tele-Echocardiography PublicationsAuthorLocationYearKey FindingsFinley and colleagues12–14Nova Scotia1989, 1997, 2004Real time over POTS, cost savings, tele-educationSobczyk et al15Kentucky1993Store and forward over POTSFisher and colleagues16,17Chicago, IL1996Real time over single ISDN lineCasey and colleagues18–21Ireland1996, 1998, 2008Real time over low-bandwidth connectionRendina et al22–24North Carolina1997, 1998Outcomes and reduced length of stayHouston et al25Glasgow, UK1999100% accuracy requires 3 ISDN linesRandolph et al26Minnesota1999Accuracy, management over T1Sable et al27New Orleans, LA1999Accuracy, proficiency, cost savings over 3 ISDN linesScholz and colleagues28,29Iowa1999, 2001Minimal difference: cardiologist vs pediatrician ordering echocardiograms in children <1 y of ageSable et al30Washington, DC2002500 studies/3 ISDN lines/impact on practiceSharma et al1New York2003Efficacy of fetal tele-echocardiographyWidmer et al31Switzerland2003Real time over 3 ISDN lines/feasibility and accuracyMunir et al32Hawaii2004Live and store and forward between Hawaii and GuamSahn et al33Portland, OR2004Remote real-time image control and optimizationWoodson et al34Washington, DC2004Forward-and-store tele-echocardiographyCastela et al35Portugal20051761 consultations over 5 y, mostly electiveLewin et al36Seattle, WA2006769 studies/3 ISDN lines/99% accurateAwadallah et al37South Dakota2006Neonatal tele-echocardiography triageSekar and Vilvanathan38India2007Real time/small aperture satellite bandwidthKosutic et al39London, UK2007Belgrade to London conference over single ISDN lineGomes et al40Portugal2010Fetal, neonatal, and pediatric consultations in real timeMcCrossan et al8,41Ireland2011, 2012Fetal tele-echocardiography accuracy and skill transferHaley et al42Arizona2012Real time telemedicine more accurate than recorded echocardiogramsDehghani et al43Canada2013Videoconferencing for ACHD managementWebb et al44United States (9 sites)2013Multicenter prospective case-control study: tele-echocardiography decreases transports, length of stay, and high-risk medicationsKrishnan et al45Washington, DC2014Technology transition, >10 000 studies/15 yACHD indicates adult with congenital heart disease; ISDN, Integrated Services Digital Network; POTS, plain old telephone systems; and T1, Terrestrial-1.Rendina and colleagues22,23 evaluated the impact of telecardiology on the length of stay of low-birth-weight infants in a regional level III neonatal intensive care unit (ICU) in North Carolina. They found a reduction in length of stay of 5.4 days in the first 6 months of their study compared with the 6 months before telemedicine. They projected that the cost savings over a 1-year period would be $1.3 million. The cost attributable to telemedicine in their model was $33 per echocardiogram. Additional monetary benefits of telemedicine that are more difficult to quantify include cost savings from the prevention of delayed or incorrect management and the avoidance of the financial burden of travel and lost wages for the patient’s family.46 In a large study of 500 echocardiograms by Sable et al,30 comparison of final videotape interpretation with the initial tele-echocardiography diagnosis resulted in 1 minor diagnostic change (membranous versus inlet ventricular septal defect). The diagnosis was altered in 3 patients. Tele-echocardiography had an immediate impact on patient care in 151 studies.A multicenter study from 9 centers across the United States evaluated 338 pairs of babies (with and without access to telemedicine) with no or minor heart disease matched for study indication, diagnosis, gestational age, birth weight, and sex.44 This study showed a statistically significant reduction in percentage of babies transferred to a tertiary care hospital (10% versus 5%) and in total and ICU length of stay. Additionally, the use of indomethacin to close a patent ductus arteriosus and the use of inotropic support were less in the telemedicine group, thereby showing that telemedicine both is diagnostic and can reduce exposure to risky, unnecessary treatments and transports.CCHD Screening and Pulse OximetryIn recent times, pulse oximetry has been found to be an effective screening mechanism for CCHD in the newborn nursery.47 The American Heart Association, American College of Cardiology, and American Academy of Pediatrics all have endorsed CCHD screening.48 Since 2011, CCHD screening has been adopted by legislation or regulation in 43 of the 50 states. A 2009 scientific statement by the American Heart Association and American Academy of Pediatrics thoroughly examined the role of pulse oximetry in examining newborns for CCHD.49 In addition to defining the scope of the problem and science behind screening with pulse oximetry, this statement was the first to identify access to pediatric subspecialists as a barrier to implementation of CCHD screening and to suggest telemedicine as a potential solution. It is estimated that 15% of births occur in nonmetropolitan areas where there is limited access to pediatric echocardiography or sonographers trained in pediatrics.Strategies for implementing screening for CCHD were discussed at a stakeholder meeting in 2011 and published in Pediatrics.50 Once again, the potential role of telemedicine was stressed in providing access to pediatric cardiologists for the discussion of positive screens and performance/interpretation/reporting of echocardiograms, which are necessary for both false-positive and true-positive screens. Telemedicine has been shown to be useful in the assessment of the newborn with suspected CCHD by either symptoms or physical findings in the newborn nursery.30The greatest potential for telemedicine is in the confirmatory testing. Once a positive screen is obtained, telemedicine can provide timely access to pediatric subspecialists in neonatology or cardiology for assessment and recommendation. The current recommendations are for immediate assessment by a licensed, independent practitioner to determine whether there are noncardiac or cardiac causes of low blood oxygen saturations. Verbal communication, chest x-rays, laboratory assessments, and echocardiograms can all be shared by telemedicine technology. Whether in a rural setting with limited pediatric subspecialists or a suburban setting where there is need for rapid decision making, telemedicine can expedite movement to more precise cardiac care or prevent unnecessary care or transport to tertiary centers.Initially, there was great concern about the number of potential false-positive screens for CCHD by pulse oximetry and the burden on pediatric cardiologists to respond to increased demand. It has been shown that the increase in cardiology consultations or echocardiograms to a delivery service is negligible compared with the number of false-positive echocardiograms resulting from heart murmurs.51 In the United Kingdom, not all positive screens result in an echocardiogram because transitional circulation and infectious and pulmonary processes have been found to be the cause of the majority of positive screens in the first day of life. Finally, in calculations of the find rate of CCHD for echocardiograms performed on the basis of reason for referral, 1 CCHD is identified per 100 echocardiograms for murmur versus 1 CCHD identified per 6.8 echocardiograms for pulse oximetry screening.51Clinical Scenarios: Pediatric Age GroupOutside the neonatal period, pediatric tele-echocardiography continues to offer value and convenience. Urgent evaluations are usually performed in acute care facilities; that is, emergency rooms or ICUs that do not have immediate access to onsite cardiologists. Tele-echocardiography may provide additional crucial information about cardiac function, valvular disease, pericardial effusions, and wall motion in critically ill children and can also be used for the diagnosis or exclusion of congenital/critical heart disease.46 Widmer and colleagues31 prospectively validated remote interpretation of echocardiograms performed in a remote hospital by a sonographer experienced in pediatric echocardiography. The quality of transmitted echocardiographic images was sufficient for evaluation except in 1 case. In 191 (98%) children, he remote echocardiographic diagnosis was correct, as confirmed by follow-up face-to-face consultations. The authors postulated that the reasons for inaccurate diagnoses may include inadequate or incomplete clinical examination by the referring physician, inability of the pediatric cardiologist to examine the child, lack of experience of the examining technician, and lack of clarity in visualizing heart structures. A few of these limitations will be overcome by sonographer training and the use of other telemedicine technologies such as videoconferencing.Clinical Scenario: Adult Congenital Heart DiseaseThe first recommendation from the 2008 American Heart Association/American College of Cardiology guidelines for the management of adult congenital heart disease (ACHD) is as follows: “An individual primary caregiver or cardiologist without specific training and expertise in ACHD should manage the care of adults with complex and moderate congenital heart disease only in collaboration with level 2 or level 3 ACHD specialists.”52 In a recently published, population-based Canadian study, there was a clear reduction in mortality after publication of these guidelines and subsequent care coordination with specialized ACHD care centers.53 However, the number of specialized ACHD care centers and providers across the world is limited. Increasing geographical distance between the patient and the ACHD referral center explains the existing care gap for patients with ACHD. Hence, collaborative care between the local primary care and specialized ACHD referral center is a model of care with potential advantages for both the patient and healthcare institutions. Telemedicine and tele-echocardiography can provide that bridge quite easily and prevent loss to specialty follow-up and resultant adverse outcomes.Dehghani and colleagues43 reported their model of tele-echocardiography and videoconferencing for patients with ACHD. In their system, all pertinent investigations and interventions, including past surgical operative reports and disks of imaging studies, were received by the host institution a week before the scheduled patient care meeting. During meetings, clinical presentations and display of pertinent imaging were live and in real time, allowing commentary from all those attending the videoconference. From their study, Dehghani et al concluded that telehealth is a feasible medium for arriving at consensus recommendations in the management of patients with ACHD living in geographically remote areas.Evolution of the TechnologySolutions for live and store-and-forward telemedicine have evolved significantly. Most early telemedicine studies used point-to-point ISDN (Integrated Services Digital Network) and T-1 (Terrestrial-1) connections for live telemedicine.16,17,25,27,30,34,54 Although ISDN provided acceptable bandwidth and image quality, developments over the past 5 years have made this technology obsolete. IP (Internet Protocol) allows multipoint connectivity from anywhere on any device that is connected to a network that is able to run videoconferencing software. Today, this includes room and desktop telemedicine systems, personal computers, tablets, and smartphones. Store-and-forward telemedicine is also greatly enhanced by modern technology and high-speed connections. Studies can be transmitted over secure FTP (file transfer protocol) and VPN (virtual private network) or accessed via remote connection to PACS (picture archiving and communication system) networks through client or Web-based programs. Cloud servers are enabling echocardiograms to be transmitted and accessed from anywhere in the world.55,56 This expansion of technology mandates a need for diligent attention to security and a dramatic increase in dependence on technical support staff.For some, real-time or interactive (live) tele-echocardiography is recommended/preferred.19,30 The advantage of this approach is that additional real-time images can be obtained by interactive scanning, with the sonographer following the directions of the reviewing cardiologist.19,37,57 This approach may allow the tele-echocardiography to be more informative in terms of the amount of information obtained, but it can be more time consuming given the commitment of time and attention needed in real time. It has been reported that when sonographers become proficient at obtaining pertinent details related to the pathology, the need for real-time expert cardiology feedback wanes. In the alternative and most commonly used store-and-forward model, the institution where the patient is records the images and then transfers the study via the Internet to the tertiary care institution using the recipient’s image database server.34 At present, many believe the store-and-forward model works just as well as live interactive tele-echocardiography. Either way, clear communication between the 2 sites on urgency, symptoms, and the clinical question at hand is critical to the success and accuracy of tele-echocardiography.Krishnan et al45 reported the technology transition at a single center with >10 000 telemedicine transmissions from 24 sites in 7 states and territories between 2001 and 2012. Abnormalities were detected in >40% of the studies, including >100 patients with life-threatening defects. More than 150 patients were transported for surgical, catheter-based, or medical intervention. Critical heart disease was ruled out in >75 patients, thus preventing unnecessary transports. Medical management or outpatient follow-up was recommended in approximately half of the studies. After IP expansion, a significant increase in telecardiology use took place, with no adverse effect on efficiency or diagnostic accuracy. IP expansion paralleled a change from a predominance of live transmissions to store-and-forward transmissions.Implications for Training of Sonographers at Community-Based SettingsAlthough there are several published guidelines for the training and practice of pediatric echocardiography, these guidelines are targeted to those physicians and sonographers who are practicing in pediatrics full-time at institutions that have pediatric cardiologists on site.58–61 These documents are very comprehensive and beyond the scope of the community sonographer who has not undergone formal training. This section has thus been created to provide the collective authors’ pragmatic or real-world approach to providing pediatric echocardiography experience to community sonographers, who are often limited in time allowed for education and training given their day-to-day work responsibilities.Although having pediatric transthoracic echocardiography available in all community-based settings is ideal, a number of barriers currently challenge comprehensive implementation of this service. These include equipment issues, sonographer training and skill, and rural center volume.Community hospitals may not have the ability to upgrade ultrasound equipment as frequently as large tertiary care institutions. Their ultrasound equipment may not be specific for cardiac examinations, and 1 machine may be required to function for the examination of multiple organ systems. In preparing a community hospital to serve a triage function for pediatric heart disease, it is important to work with the equipment manufacturer to install a pediatric cardiac preset into whatever ultrasound equipment is available. In addition, transducers specific for cardiac ultrasound are imperative. For pediatric patients, transducers ranging in frequency from 5 to 12 MHz are most commonly used today. Depending on the manufacturer of the equipment, several frequencies may be combined into 1 transducer.In terms of training and skill, sonographers in community hospital settings are usually trained in adult echocardiography. They are proficient in scanning adult-sized patients who have predominantly normal intracardiac anatomy but may have valvular heart disease or cardiomyopathy. These sonographers often lack specific training and experience in working with infants and children in both the hospital and outpatient settings. This usually includes suboptimal exposure to and knowledge of congenital heart defects and their unique imaging needs. Newborn babies and crying toddlers are an intimidating challenge to a sonographer who is used to scanning cooperative adults. Having an uncooperative patient challenges a sonographer to obtain the normal ultrasound views, but the challenge is compounded when that patient, whether infant, child, or adult, has abnormal intracardiac anatomy.Additional training for community sonographers to perform a triage echocardiogram in patients with congenital heart disease requires explanation of how to visualize shunts at the atrial, ventricular, and ductal levels from several different echocardiographic views and a basic understanding of aortic arch abnormalities. It should also incorporate the ability to image ≥1 pulmonary vein connections to rule out total anomalous pulmonary venous return. In general, adult sonographers are less likely to be familiar and comfortable with suprasternal notch and subcostal views; therefore, it is suggested that teaching or training would include methods of obtaining these 2 families of ultrasound planes. It is also helpful to include instruction in instrumentation and “knobology” for pediatric studies, preferably with pediatric specific presets. Often, a standardized pediatric imaging protocol exists that has been developed by the tertiary care facility that is collaborating with the community site. It can be very helpful to develop a simple worksheet that can be filled out by the sonographer after each study has been completed. This ensures that the sonographer develops a routine pattern of thinking when performing a pediatric echocardiogram in terms of cardiac anatomy, septal integrity, myocardial function, and valvular and aortic arch issues.Ideally, a representative from the collaborating tertiary center should initiate training in real time with one-on-one instruction. In cases when a pediatric cardiologist has a clinic at the community hospital, the pediatric cardiologist may be able to provide instruction and supervision for the sonographer the same day that the patients are seen in clinic. Alternatively, in another training pattern, a pediatric sonographer from the tertiary care institution can travel to the community hospital for regularly scheduled instructional/scanning sessions. This can be helpful even if the subjects scanned are unlikely to have abnormal cardiac anatomy.Finally, community sonographers can visit or rotate to the tertiary care institution for several days with the goal of in-depth scanning of pediatric patients, preferably those with congenital heart disease. This training can occur under the tutelage of one of the pediatric sonographers who has been designated as an educator or is accustomed to teaching others. Obtaining permission for visiting sonographers to perform hands-on scanning at the tertiary care center can be problematic in some institutions and usually requires the involvement of and clearance with hospital administration. Aft" @default.
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W2589004364 title "Telemedicine in Pediatric Cardiology: A Scientific Statement From the American Heart Association" @default.
W2589004364 cites W125863393 @default.
W2589004364 cites W1493198941 @default.
W2589004364 cites W1542587704 @default.
W2589004364 cites W1589618532 @default.
W2589004364 cites W1591788502 @default.
W2589004364 cites W1616073113 @default.
W2589004364 cites W167010418 @default.
W2589004364 cites W17487838 @default.
W2589004364 cites W1778049949 @default.
W2589004364 cites W1798590123 @default.
W2589004364 cites W1859007358 @default.
W2589004364 cites W1891872093 @default.
W2589004364 cites W1898412150 @default.
W2589004364 cites W1911333296 @default.
W2589004364 cites W1933967300 @default.
W2589004364 cites W1964454984 @default.
W2589004364 cites W1968005701 @default.
W2589004364 cites W1969685654 @default.
W2589004364 cites W1969833809 @default.
W2589004364 cites W1971772971 @default.
W2589004364 cites W1973055120 @default.
W2589004364 cites W1973106434 @default.
W2589004364 cites W1973406952 @default.
W2589004364 cites W1975289892 @default.
W2589004364 cites W1976780375 @default.
W2589004364 cites W1979961279 @default.
W2589004364 cites W1985222693 @default.
W2589004364 cites W1985485648 @default.
W2589004364 cites W1985566315 @default.
W2589004364 cites W1985617564 @default.
W2589004364 cites W1985856068 @default.
W2589004364 cites W1988356365 @default.
W2589004364 cites W1990162674 @default.
W2589004364 cites W1990968231 @default.
W2589004364 cites W1991203221 @default.
W2589004364 cites W1995649660 @default.
W2589004364 cites W1996346147 @default.
W2589004364 cites W1996873664 @default.
W2589004364 cites W1998630656 @default.
W2589004364 cites W1998949264 @default.
W2589004364 cites W1999946680 @default.
W2589004364 cites W2002307021 @default.
W2589004364 cites W2002459758 @default.
W2589004364 cites W2004605959 @default.
W2589004364 cites W2005045546 @default.
W2589004364 cites W2008824635 @default.
W2589004364 cites W2010075808 @default.
W2589004364 cites W2010433771 @default.
W2589004364 cites W2011612452 @default.
W2589004364 cites W2012122440 @default.
W2589004364 cites W2012217086 @default.
W2589004364 cites W2014226842 @default.
W2589004364 cites W2016280305 @default.
W2589004364 cites W2017409544 @default.
W2589004364 cites W2018250721 @default.
W2589004364 cites W2027099726 @default.
W2589004364 cites W2027689395 @default.
W2589004364 cites W2028549333 @default.
W2589004364 cites W2029143233 @default.
W2589004364 cites W2031753964 @default.
W2589004364 cites W2035102633 @default.
W2589004364 cites W2035486958 @default.
W2589004364 cites W2035489015 @default.
W2589004364 cites W2037728355 @default.
W2589004364 cites W2038531431 @default.
W2589004364 cites W2040244694 @default.
W2589004364 cites W2041637846 @default.
W2589004364 cites W2043676721 @default.
W2589004364 cites W2045277650 @default.
W2589004364 cites W2045406029 @default.
W2589004364 cites W2045479790 @default.
W2589004364 cites W2045491633 @default.
W2589004364 cites W2046251711 @default.
W2589004364 cites W2050365953 @default.
W2589004364 cites W2050833203 @default.
W2589004364 cites W2053190795 @default.
W2589004364 cites W2054291958 @default.
W2589004364 cites W2055011562 @default.
W2589004364 cites W2055278493 @default.
W2589004364 cites W2057527187 @default.
W2589004364 cites W2060640694 @default.
W2589004364 cites W2062377487 @default.