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  • 1
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    Effect of Direct Transportation to Thrombectomy-Capable Center vs Local Stroke Center on Neurological Outcomes in Patients With Suspected Large-Vessel Occlusion Stroke in Nonurban Areas : The RACECAT Randomized Clinical Trial
    American Medical Association (AMA) ; 2022
    In:  JAMA Vol. 327, No. 18 ( 2022-05-10), p. 1782-
    Details
    In: JAMA, American Medical Association (AMA), Vol. 327, No. 18 ( 2022-05-10), p. 1782-
    Abstract: In nonurban areas with limited access to thrombectomy-capable centers, optimal prehospital transport strategies in patients with suspected large-vessel occlusion stroke are unknown. Objective To determine whether, in nonurban areas, direct transport to a thrombectomy-capable center is beneficial compared with transport to the closest local stroke center. Design, Setting, and Participants Multicenter, population-based, cluster-randomized trial including 1401 patients with suspected acute large-vessel occlusion stroke attended by emergency medical services in areas where the closest local stroke center was not capable of performing thrombectomy in Catalonia, Spain, between March 2017 and June 2020. The date of final follow-up was September 2020. Interventions Transportation to a thrombectomy-capable center (n = 688) or the closest local stroke center (n = 713). Main Outcomes and Measures The primary outcome was disability at 90 days based on the modified Rankin Scale (mRS; scores range from 0 [no symptoms] to 6 [death] ) in the target population of patients with ischemic stroke. There were 11 secondary outcomes, including rate of intravenous tissue plasminogen activator administration and thrombectomy in the target population and 90-day mortality in the safety population of all randomized patients. Results Enrollment was halted for futility following a second interim analysis. The 1401 enrolled patients were included in the safety analysis, of whom 1369 (98%) consented to participate and were included in the as-randomized analysis (56% men; median age, 75 [IQR, 65-83] years; median National Institutes of Health Stroke Scale score, 17 [IQR, 11-21] ); 949 (69%) comprised the target ischemic stroke population included in the primary analysis. For the primary outcome in the target population, median mRS score was 3 (IQR, 2-5) vs 3 (IQR, 2-5) (adjusted common odds ratio [OR], 1.03; 95% CI, 0.82-1.29). Of 11 reported secondary outcomes, 8 showed no significant difference. Compared with patients first transported to local stroke centers, patients directly transported to thrombectomy-capable centers had significantly lower odds of receiving intravenous tissue plasminogen activator (in the target population, 229/482 [47.5%] vs 282/467 [60.4%]; OR, 0.59; 95% CI, 0.45-0.76) and significantly higher odds of receiving thrombectomy (in the target population, 235/482 [48.8%] vs 184/467 [39.4%]; OR, 1.46; 95% CI, 1.13-1.89). Mortality at 90 days in the safety population was not significantly different between groups (188/688 [27.3%] vs 194/713 [27.2%]; adjusted hazard ratio, 0.97; 95% CI, 0.79-1.18). Conclusions and Relevance In nonurban areas in Catalonia, Spain, there was no significant difference in 90-day neurological outcomes between transportation to a local stroke center vs a thrombectomy-capable referral center in patients with suspected large-vessel occlusion stroke. These findings require replication in other settings. Trial Registration ClinicalTrials.gov Identifier: NCT02795962
    Type of Medium: Online Resource
    ISSN: 0098-7484
    URL: Article
    DOI: 10.1001/jama.2022.4404
    RVK:
    XA 10000
    Language: English
    Publisher: American Medical Association (AMA)
    Publication Date: 2022
    detail.hit.zdb_id: 2958-0
    detail.hit.zdb_id: 2018410-4
    SSG: 5,21
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  • 2
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    Workflows and Outcomes in Patients With Suspected Large Vessel Occlusion Stroke Triaged in Urban and Nonurban Areas
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke Vol. 53, No. 12 ( 2022-12), p. 3728-3740
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 53, No. 12 ( 2022-12), p. 3728-3740
    Abstract: We aim to compare the outcome of patients from urban areas, where the referral center is able to perform thrombectomy, with patients from nonurban areas enrolled in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion). Methods: Patients with suspected large vessel occlusion stroke, as evaluated by a Rapid Arterial Occlusion Evaluation score of ≥5, from urban catchment areas of thrombectomy-capable centers during RACECAT trial enrollment period were included in the Stroke Code Registry of Catalonia. Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with an ischemic stroke. Secondary outcomes included mortality at 90 days, rate of thrombolysis and thrombectomy, time from onset to thrombolysis, and thrombectomy initiation. Propensity score matching was used to assemble a cohort of patients with similar characteristics. Results: The analysis included 1369 patients from nonurban areas and 2502 patients from urban areas. We matched 920 patients with an ischemic stroke from urban areas and nonurban areas based on their propensity scores. Patients with ischemic stroke from nonurban areas had higher degrees of disability at 90 days (median [interquartle range] modified Rankin Scale score, 3 [2–5] versus 3 [1–5], common odds ratio, 1.25 [95% CI, 1.06–1.48] ); the observed average effect was only significant in patients with large vessel stroke (common odds ratio, 1.36 [95% CI, 1.08–1.65]). Mortality rate was similar between groups(odds ratio, 1.02 [95% CI, 0.81–1.28] ). Patients from nonurban areas had higher odds of receiving thrombolysis (odds ratio, 1.36 [95% CI, 1.16–1.67]), lower odds of receiving thrombectomy(odds ratio, 0.61 [95% CI, 0.51–0.75] ), and longer time from stroke onset to thrombolysis (mean difference 38 minutes [95% CI, 25–52]) and thrombectomy(mean difference 66 minutes [95% CI, 37–95] ). Conclusions: In Catalonia, Spain, patients with large vessel occlusion stroke triaged in nonurban areas had worse neurological outcomes than patients from urban areas, where the referral center was able to perform thrombectomy. Interventions aimed at improving organizational practices and the development of thrombectomy capabilities in centers located in remote areas should be pursued. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02795962.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.122.040768
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
    detail.hit.zdb_id: 1467823-8
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  • 3
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    Association of Time of Day With Outcomes Among Patients Triaged for a Suspected Severe Stroke in Nonurban Catalonia
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Stroke Vol. 54, No. 3 ( 2023-03), p. 770-780
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 54, No. 3 ( 2023-03), p. 770-780
    Abstract: We aim to assess whether time of day modified the treatment effect in the RACECAT trial (Direct Transfer to an Endovascular Center Compared to Transfer to the Closest Stroke Center in Acute Stroke Patients With Suspected Large Vessel Occlusion Trial), a cluster-randomized trial that did not demonstrate the benefit of direct transportation to a thrombectomy-capable center versus nearest local stroke center for patients with a suspected large vessel stroke triaged in nonurban Catalonia between March 2017 and June 2020. Methods: We performed a post hoc analysis of RACECAT to evaluate if the association between initial transport routing and functional outcome differed according to trial enrollment time: daytime (8:00 am –8:59 pm ) and nighttime (9:00 pm –7:59 am ). Primary outcome was disability at 90 days, as assessed by the shift analysis on the modified Rankin Scale score, in patients with ischemic stroke. Subgroup analyses according to stroke subtype were evaluated. Results: We included 949 patients with an ischemic stroke, of whom 258 patients(27%) were enrolled during nighttime. Among patients enrolled during nighttime, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days (adjusted common odds ratio [acOR] , 1.620 [95% CI, 1.020–2.551]); no significant difference between trial groups was present during daytime (acOR, 0.890 [95% CI, 0.680–1.163] ; P interaction =0.014). Influence of nighttime on the treatment effect was only evident in patients with large vessel occlusion(daytime, acOR 0.766 [95% CI, 0.548–1.072]; nighttime, acOR, 1.785 [95% CI, 1.024–3.112] ; P interaction 〈 0.01); no heterogeneity was observed for other stroke subtypes ( P interaction 〉 0.1 for all comparisons). We observed longer delays in alteplase administration, interhospital transfers, and mechanical thrombectomy initiation during nighttime in patients allocated to local stroke centers. Conclusions: Among patients evaluated during nighttime for a suspected acute severe stroke in non-urban areas of Catalonia, direct transport to a thrombectomy-capable center was associated with lower degrees of disability at 90 days. This association was only evident in patients with confirmed large vessel occlusion on vascular imaging. Time delays in alteplase administration and interhospital transfers might mediate the observed differences in clinical outcome. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02795962.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.122.041013
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
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  • 4
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    Abstract WP4: Intravenous Thrombolysis And Outcomes In Patients With Large-vessel Stroke Directly Admitted Or Transferred To A Thrombectomy-capable Center
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Stroke Vol. 54, No. Suppl_1 ( 2023-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 54, No. Suppl_1 ( 2023-02)
    Abstract: Objective: To assess whether the effect of intravenous thrombolysis in patients with large-vessel occlusion differed between patients directly admitted to thrombectomy-capable centers and patients transferred from local stroke centers without thrombectomy capabilities. Methods: We included 3206 patients with an acute ischemic large-vessel stroke with first imaging within 7 hours after onset that were directly admitted to thrombectomy-capable centers and treated with thrombectomy, or transferred from local stroke centers for thrombectomy evaluation, between 2017 and 2021 in Catalonia, Spain. Primary outcome was the degree of disability at 90 days, as evaluated by the shift analysis on the mRs score. Secondary outcomes included mortality at 90 days and the rate of parenchymal hemorrhage and successful reperfusion. Inverse-probability weighting clustered at the type of stroke center was used to estimate the effects. Results: The analysis included 2268 patients (975[49%] treated with thrombolysis) directly admitted to thrombectomy-capable centers and 938 patients (580[66%] treated with thrombolysis and 616[67%] treated with thrombectomy) transferred from local stroke centers (mean age 72±13 years, median NIHSS score 17[IQR 12-21] , 1363 female[48%]). Patients treated with intravenous thrombolysis were younger, had shorter time from onset to first image acquisition, and higher rates of wake-up stroke, atrial fibrillation and anticoagulation intake. The effect of intravenous thrombolysis on the primary outcome was similar in patients directly admitted to thrombectomy-capable centers (acOR 1.50, 95% CI 1.24-1.81) and patients transferred from local stroke centers (acOR 1.44, 95% CI 1.04 to 2.01)(p interaction =0.68). Patients treated with intravenous thrombolysis had lower mortality rate, higher rate of parenchymal hematoma and similar rate of successful reperfusion, with no difference according to type of center (p interaction 〉 0.1). Conclusion: Administration of intravenous thrombolysis in patients with a large-vessel stroke with intention to thrombectomy was associated with higher odds of good functional outcome and higher rates of parenchymal hematoma, independently of the type of stroke center were it was administered.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.54.suppl_1.WP4
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
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  • 5
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    Monocyte-to-Lymphocyte Ratio in Clot Analysis as a Marker of Cardioembolic Stroke Etiology
    Springer Science and Business Media LLC ; 2022
    In:  Translational Stroke Research Vol. 13, No. 6 ( 2022-12), p. 949-958
    Details
    In: Translational Stroke Research, Springer Science and Business Media LLC, Vol. 13, No. 6 ( 2022-12), p. 949-958
    Type of Medium: Online Resource
    ISSN: 1868-4483 , 1868-601X
    URL: Article
    DOI: 10.1007/s12975-021-00946-w
    Language: English
    Publisher: Springer Science and Business Media LLC
    Publication Date: 2022
    detail.hit.zdb_id: 2541897-X
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  • 6
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    Corrigendum to ‘Screening of Embolic Sources by Point-of-Care Ultrasound in the Acute Phase of Ischemic Stroke’ [Ultrasound in Med. & Biol. 46 (2020) 2173–2180]
    Elsevier BV ; 2021
    In:  Ultrasound in Medicine & Biology Vol. 47, No. 5 ( 2021-05), p. 1428-
    Details
    In: Ultrasound in Medicine & Biology, Elsevier BV, Vol. 47, No. 5 ( 2021-05), p. 1428-
    Type of Medium: Online Resource
    ISSN: 0301-5629
    URL: Article
    DOI: 10.1016/j.ultrasmedbio.2021.01.021
    RVK:
    XA 10000
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2021
    detail.hit.zdb_id: 1498918-9
    SSG: 12
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  • 7
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    Granulocytes-Rich Thrombi in Cerebral Large Vessel Occlusion Are Associated with Increased Stiffness and Poorer Revascularization Outcomes
    Springer Science and Business Media LLC ; 2023
    In:  Neurotherapeutics Vol. 20, No. 4 ( 2023-07), p. 1167-1176
    Details
    In: Neurotherapeutics, Springer Science and Business Media LLC, Vol. 20, No. 4 ( 2023-07), p. 1167-1176
    Abstract: We aim to identify a profile of intracranial thrombus resistant to recanalization by mechanical thrombectomy (MT) in acute stroke treatment. The first extracted clot of each MT was analyzed by flow cytometry obtaining the composition of the main leukocyte populations: granulocytes, monocytes, and lymphocytes. Demographics, reperfusion treatment, and grade of recanalization were registered. MT failure (MTF) was defined as final thrombolysis in cerebral infarction score IIa or lower and/or need of permanent intracranial stenting as a rescue therapy. To explore the relationship between stiffness of intracranial clots and cellular composition, unconfined compression tests were performed in other cohorts of cases. Thrombi obtained in 225 patients were analyzed. MTF were observed in 30 cases (13%). MTF was associated with atherosclerosis etiology (33.3% vs. 15.9%; p  = 0.021) and higher number of passes (3 vs. 2; p   〈  0.001). Clot analysis of MTF showed higher percentage of granulocytes [82.46 vs. 68.90% p   〈  0.001] and lower percentage of monocytes [9.18% vs.17.34%, p   〈  0.001] in comparison to successful MT cases. The proportio n of clot granulocytes (aOR 1.07; 95% CI 1.01–1.14) remained an independent marker of MTF. Among thirty-eight clots mechanically tested, there was a positive correlation between granulocyte proportion and thrombi stiffness (Pearson’s r  = 0.35, p  = 0.032), with a median clot stiffness of 30.2 (IQR, 18.9–42.7) kPa. Granulocytes-rich thrombi are harder to capture by mechanical thrombectomy due to increased stiffness, so a proportion of intracranial granulocytes might be useful to guide personalized endovascular procedures in acute stroke treatment.
    Type of Medium: Online Resource
    ISSN: 1933-7213 , 1878-7479
    URL: Article
    DOI: 10.1007/s13311-023-01385-1
    Language: English
    Publisher: Springer Science and Business Media LLC
    Publication Date: 2023
    detail.hit.zdb_id: 2279496-7
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  • 8
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    Abstract WMP66: Multiparametric Neuroimaging And Its Association With Non-Contrast Computed Tomography In Late Window Large Vessel Occlusion Acute Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke Vol. 53, No. Suppl_1 ( 2022-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 53, No. Suppl_1 ( 2022-02)
    Abstract: Background: Endovascular treatment (EVT) for acute ischemic stroke (AIS) between 6 to 24 hours is established as a standard of care among patients selected by multiparametric neuroimaging. Therefore, we aimed to explore neuroimaging parameters in late window AIS large vessel occlusion (LVO) patients and the association between findings in non-contrast computed tomography (NCCT) and multiparametric CT. Methods: We included consecutive AIS patients within 6-24 hours from symptoms onset with CTA-LVO. We studied potential associations between computed tomography mismatch defined by DAWN and/or DEFUSE-3 neuroimaging criteria (CTP-MM), infarct volume on CTP, and ASPECTS on NCCT. We also analyzed the association between neuroimaging parameters and outcome determined by 90-day mRS. Results: We included 206 patients, of which 176 (85.4%) presented CTP-MM and 184 (89.3%) presented with an ASPECTS ≥ 6 on admission. The rate of CTP-MM was 90.8% in patients with ASPECTS ≥ 6, as compared with 40.9% in those with low ASPECTS [Figure 1A] . The ASPECTS correlated with infarct core, determined by Cerebral Blood Flow 〈 30% volume (rP=-0.575, P 〈 0.001). In EVT-treated patients (185, 89.8%), after adjusting for identifiable confounders, the presence of CTP-MM was a predictor of 90-day functional independence (OR 3.38; 95%CI 1.01-11.29; P=0.048). We did not find an association between CTP-MM and 90-day functional disability (ordinal mRS shift, aOR 1.39; 95% CI 0.58-3.34; P=0.459) [Figure 1B] . Conclusions: A great majority of patients who presented a LVO in late window fulfilled guidelines imaging criteria to undergo EVT, especially those with high ASPECTS (≥ 6). Our data suggest that NCCT with CT angiography is a reasonable approach for acute ischemic stroke treatment selection also in the late window.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.53.suppl_1.WMP66
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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  • 9
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    Abstract TP128: Determinants of Hemorrhagic Transformation After Emergent Extracranial Internal Carotid Artery Stenting for Tandem Occlusions
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Stroke Vol. 51, No. Suppl_1 ( 2020-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 51, No. Suppl_1 ( 2020-02)
    Abstract: Background and Purpose: Extracranial internal carotid artery (ICA) lesion in the setting of tandem occlusions is a therapeutic challenge, and hemorrhagic transformation (HT) is one of the leading causes of poor clinical outcome. We aimed to determine determinants of HT for tandem occlusions undergoing emergent extracranial ICA stenting during endovascular treatment (EVT). Methods: We performed a prospective, observational cohort study of consecutive patients with non-cardioembolic ischemic stroke due to tandem occlusion who underwent EVT with extracranial ICA stent placement during the procedure from April 2013 to June 2019 in a single stroke center. We compared clinical (vascular risk factors, previous antiplatelet treatment, and IV rtPA), radiological (ASPECTS at admission and in-stent thrombosis at 24 hours) and serological (platelet count, fibrinogen, total cholesterol, HDL-cholesterol, and LDL-cholesterol) parameters according to the presence of HT in 24 hours CT-scan. Results: One-hundred and eight patients were included: 78.7% were men, mean age 68.5±14.3 years, median time from symptoms onset to treatment was 220 (150-337.5) minutes, median ASPECTS at admission was 9 (8-10). Eighty-six (79.6%) patients presented an extracranial ICA occlusion, and 22 (20.4%) a high-grade ( 〉 50%) stenosis. In 88 (81.5%) patients the etiology of extracranial ICA lesion was ateroma, and in 20 (18.5%) was a dissection. Intravenous rtPA was administered in 47 (43.5%) patients. Successful recanalization (mTICI ≥2b) was achieved in 83 (76.9%) patients, and extracranial ICA recanalization in 108 (100%) patients. Type 2 diabetes (OR 1.5, 95% CI 1.1-3.5), higher fibrinogen levels (OR 4.6, 95% CI 1.6-12.9), and ASPECTS 〈 7 at admission (OR 2.1, 95% IC 1.1-5.1) were found as independent predictors of HT in multiple logistic regression analysis. Conclusions: Patients with a non-cardioembolic ischemic stroke due to tandem occlusion who present type 2 diabetes, higher fibrinogen levels, or ASPECTS 〈 7 at admission are at high risk of HT. In these particular cases, it might be useful to stent with a stent that does not need double antiplatelet treatment immediately after the procedure.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.51.suppl_1.TP128
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
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  • 10
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    Abstract WP69: Does CBF Below 30% Actually Represent Infarct Core in Acute Ischemic Stroke? Proof of Mis-Concept
    Ovid Technologies (Wolters Kluwer Health) ; 2020
    In:  Stroke Vol. 51, No. Suppl_1 ( 2020-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 51, No. Suppl_1 ( 2020-02)
    Abstract: On CT perfusion (CTP), cerebral blood flow 〈 30% than the contralateral hemisphere (CBF 〈 30) is considered a marker of infarct core. Our hypothesis is that CBF 〈 30 defines a reversible poor hemodynamic area rather than core and aimed to study CBF 〈 30 evolution over time, its relationship with leptomeningeal collateral circulation (CC) and outcome parameters. Methods: Retrospective analysis of a prospective database of acute ischemic strokes who underwent CTP on admission and immediately after endovascular thrombectomy (EVT). CC was graded on CT angiography (CTA) by the modified Tan scale (good CC: 2-3 grades). Complete recanalization was defined by modified Thrombolysis in Cerebral Ischemia ≥ 2B. Final infarct volume (FIV) was semi-automatically measured on 48-72h CT; ghost core was defined as: admission CBF 〈 30 - FIV 〉 10cc. Results: We included 494 patients; median time from onset to CT: 137 min (IQR 68-238). Median CBF 〈 30 volume on admission: 8 cc (0-28). With longer onset-to-CT times ischemic changes progressively increased on non-contrast CT (ASPECTS decay r=-0.21, p 〈 0.01), however CBF 〈 30 progressively decreased (r=-0.13, p 〈 0.01). 294 patients (60.6%) presented good CC. Good CC was associated with lower admission CBF 〈 30 (median CBF 〈 30 on good CC: 0 cc (0-12) vs 28.5 (7-57) on poor CC, p 〈 0.01). In recanalized patients (419, 84.8%), CBF 〈 30 virtually disappeared in CTP post-EVT (n=103) (median CBF 〈 30: 0ml (IQR 0) (88%= 0 cc) despite that most patients developed established infarcts (median FIV 16 (4-50), 59% FIV 〉 10cc)). Even in recanalized patients, baseline CBF 〈 30 only moderately correlates with FIV (r=0.55, p 〈 0.01). A ghost core was identified in 13.7% (34.5% if CT was performed 〈 90min from onset). 46.6% patients had good functional outcome (mRS 〈 3 at 3 months). A multivariate analysis of recanalized patients showed that CC (OR 0.43, CI 0.27-0.69, p 〈 0.01) but not CBF 〈 30 was an independent predictor of functional outcome. Conclusion: CBF 〈 30 represents an hemodynamic state rather than established infarct core, evolving over time inversely as it should physiologically (increase of infarct core over time). CBF 〈 30 should be considered as an outcome predictor but not used as exclusion criterion for EVT, especially in early time-windows.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.51.suppl_1.WP69
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2020
    detail.hit.zdb_id: 1467823-8
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