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Ewald, Uwe
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Publications (10 of 64) Show all publications
Eriksson, L., Nga, N. T., Hoa, D. T., Duc, D. M., Bergström, A., Wallin, L., . . . Ekholm Selling, K. (2018). Secular trend, seasonality and effects of a community-based intervention on neonatal mortality: follow-up of a cluster-randomised trial in Quang Ninh province, Vietnam. Journal of Epidemiology and Community Health, 72(9), 776-782
Open this publication in new window or tab >>Secular trend, seasonality and effects of a community-based intervention on neonatal mortality: follow-up of a cluster-randomised trial in Quang Ninh province, Vietnam
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2018 (English)In: Journal of Epidemiology and Community Health, ISSN 0143-005X, E-ISSN 1470-2738, Vol. 72, no 9, p. 776-782Article in journal (Refereed) Published
Abstract [en]

Background: Little is know about whether the effects of community engagement interventions for child survival in low-income and middle-income settings are sustained. Seasonal variation and secular trend may blur the data. Neonatal mortality was reduced in a cluster-randomised trial in Vietnam where laywomen facilitated groups composed of local stakeholders employing a problem-solving approach for 3 years. In this analysis, we aim at disentangling the secular trend, the seasonal variation and the effect of the intervention on neonatal mortality during and after the trial.

Methods: In Quang Ninh province, 44 communes were allocated to intervention and 46 to control. Births and neonatal deaths were assessed in a baseline survey in 2005, monitored during the trial in 2008–2011 and followed up by a survey in 2014. Time series analyses were performed on monthly neonatal mortality data.

Results: There were 30 187 live births and 480 neonatal deaths. The intervention reduced the neonatal mortality from 19.1 to 11.6 per 1000 live births. The reduction was sustained 3 years after the trial. The control areas reached a similar level at the time of follow-up. Time series decomposition analysis revealed a downward trend in the intervention areas during the trial that was not found in the control areas. Neonatal mortality peaked in the hot and wet summers.

Conclusions: A community engagement intervention resulted in a lower neonatal mortality rate that was sustained but not further reduced after the end of the trial. When decomposing time series of neonatal mortality, a clear downward trend was demonstrated in intervention but not in control areas.

Trial registration number: ISRCTN44599712, Post-results.

National Category
Medical and Health Sciences
Research subject
International Health; Epidemiology; Pediatrics
Identifiers
urn:nbn:se:uu:diva-365036 (URN)10.1136/jech-2017-209252 (DOI)000445084200004 ()29764902 (PubMedID)
Funder
Swedish Research Council, 348-20136546
Available from: 2018-11-08 Created: 2018-11-08 Last updated: 2018-11-28Bibliographically approved
KC, A., Wrammert, J., Nelin, V., Clark, R., Ewald, U., Peterson, S. S. & Målqvist, M. (2017). Evaluation of Helping Babies Breathe Quality Improvement Cycle (HBB-QIC) on retention of neonatal resuscitation skills six months after training in Nepal. BMC Pediatrics, 17, Article ID 103.
Open this publication in new window or tab >>Evaluation of Helping Babies Breathe Quality Improvement Cycle (HBB-QIC) on retention of neonatal resuscitation skills six months after training in Nepal
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2017 (English)In: BMC Pediatrics, ISSN 1471-2431, E-ISSN 1471-2431, Vol. 17, article id 103Article in journal (Refereed) Published
Abstract [en]

Background: Each year 700,000 infants die due to intrapartum-related complications. Helping Babies Breathe (HBB) uses an algorithm to increase knowledge and improve skills on neonatal resuscitation. Implementation of HBB in low-resource clinical settings has shown to reduce intrapartum stillbirths and first-day neonatal mortality. However, there is a lack of evidence on the effect of different HBB implementation strategies to improve and sustain the clinical competency of health workers on bag-and-mask ventilation. This study was conducted to evaluate the impact of multi-faceted implementation strategy for HBB as quality improvement cycle (HBB-QIC) on retention of neonatal resuscitation skills in a tertiary hospital of Nepal.

Methods: A Time series design was applied. The multi-faceted intervention for HBB-QIC included training, daily bag-and-mask skill checks, preparation for resuscitation before every birth, self-evaluation and peer review on neonatal resuscitation skills and weekly review meetings. Knowledge and skills were assessed through questionnaires, skill checklists, and Objective Structured Clinical Examinations (OSCE) before implementation of the HBB-QIC, immediately after HBB training, and again at six months. Means were compared using paired t-tests, and associations between skill retention and HBB-QIC components were analyzed using logistic regression analysis.

Results: 137 health workers were enrolled in the study. Knowledge scores were higher immediately following the HBB training, 16.4  1.4 compared to 12.8  1.6 before (out of 17), and the knowledge was retained six months after the training (16.5  1.1). Bag-and-mask skills improved immediately after the training and were retained six months after the training. The retention of bag-and-mask skills was associated with daily bag-and-mask skill checks, preparation for resuscitation before every birth, use of a self-evaluation checklist, and attendance at weekly review meetings. The implementation strategies with the highest association to skill retention were daily bag-and-mask skill checks (RR-5.1, 95% CI 1.9-13.5) and use of self-evaluation checklists after every delivery (RR-3.8, 95% CI 1.4-9.7).

Conclusions: Health workers who practiced bag-and-mask skills, prepared for resuscitation before every birth, used self-evaluation checklists and attended weekly review meetings retained their neonatal resuscitation skills. Further studies are required to evaluate HBB-QIC in primary care settings, where the number of deliveries is gradually increasing.

Keywords
Neonatal resuscitation, Helping Babies Breathe, retention of skills, multi-faceted implementation strategy, quality improvement cycle, Nepal
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-267918 (URN)10.1186/s12887-017-0853-5 (DOI)000398776700001 ()
Funder
Swedish Society of Medicine
Available from: 2015-11-29 Created: 2015-11-29 Last updated: 2017-12-01Bibliographically approved
Ewald, U. (2017). Family-Centered Care: More than a Good Feeling?. Neonatology, 112(3), 301-302
Open this publication in new window or tab >>Family-Centered Care: More than a Good Feeling?
2017 (English)In: Neonatology, ISSN 1661-7800, E-ISSN 1661-7819, Vol. 112, no 3, p. 301-302Article in journal, Meeting abstract (Other academic) Published
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-346845 (URN)000412791900028 ()
Available from: 2018-03-27 Created: 2018-03-27 Last updated: 2018-03-27Bibliographically approved
Wrammert, J., KC, A., Ewald, U. & Målqvist, M. (2017). Improved postnatal care is needed to maintain gains in neonatal survival after the implementation of the Helping Babies Breathe initiative. Acta Paediatrica, 106(8), 1280-1285
Open this publication in new window or tab >>Improved postnatal care is needed to maintain gains in neonatal survival after the implementation of the Helping Babies Breathe initiative
2017 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 106, no 8, p. 1280-1285Article in journal (Refereed) Published
Abstract [en]

Aim Helping Babies Breathe (HBB) is a neonatal resuscitation protocol proven to reduce intrapartum-related mortality in low-income settings. The aim of this study was to describe the timing and causes of neonatal in-hospital deaths before and after HBB training at a maternity health facility in Nepal.

Methods A prospective cohort study was conducted at the facility between July 2012 and September 2013. All 137 staff, including medical doctors and midwives, were trained in January 2013. The causes of 299 neonatal deaths and the day of death, up to 27 days, were collected before and after the training course.

Results Deaths caused by intrapartum-related complications were reduced from 51% to 33%.  Preterm infants survived for more days (p<0.01) during the neonatal period, but overall in-hospital neonatal mortality was unchanged (p=0.46) after training. The survival rates linked to complications of infection, congenital anomalies and other causes were unaffected by the intervention.

Conclusion The continuum of postnatal care for newborn infants needs to be strengthened after Helping Babies Breathe training, in order to maintain the gains in neonatal survival on the day of delivery. Additional interventions in the postnatal period are therefore required to increase neonatal survival at facilities in low-income settings.

Keywords
cause of death, low-income settings, neonatal resuscitation, perinatal mortality, postnatal
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-316710 (URN)10.1111/apa.13835 (DOI)000405233800012 ()28316097 (PubMedID)
Funder
Swedish Research Council
Available from: 2017-03-06 Created: 2017-03-06 Last updated: 2018-02-20Bibliographically approved
Raiskila, S., Axelin, A., Toome, L., Caballero, S., Tandberg, B. S., Montirosso, R., . . . Lehtonen, L. (2017). Parents' presence and parent-infant closeness in 11 neonatal intensive care units in six European countries vary between and within the countries. Acta Paediatrica, 106(6), 878-888
Open this publication in new window or tab >>Parents' presence and parent-infant closeness in 11 neonatal intensive care units in six European countries vary between and within the countries
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2017 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 106, no 6, p. 878-888Article in journal (Refereed) Published
Abstract [en]

Aim: Little is known about the amount of physical parent-infant closeness in neonatal intensive care units (NICUs), and this study explored that issue in six European countries.

Methods: The parents of 328 preterm infants were recruited in 11 NICUs in Finland, Estonia, Sweden, Norway, Italy and Spain. They filled in daily diaries about how much time they spent in the NICU, in skin-to-skin contact (SSC) and holding their babies in the first two weeks of their hospitalisation.

Results: The parents' NICU presence varied from a median of 3.3 (minimum 0.7-maximum 6.7) to 22.3 (18.7-24.0) hours per day (p < 0.001), SSC varied from 0.3 (0-1.4) to 6.6 (2.2-19.5) hours per day (p < 0.001) and holding varied from 0 (0-1.5) to 3.2 (0-7.4) hours per day (p < 0.001). Longer SSC was associated with singleton babies and more highly educated mothers. Holding the baby for longer was associated with gestational age. The most important factor supporting parent-infant closeness was the opportunity to stay overnight in the NICU. Having other children and the distance from home to the hospital had no impact on parent-infant closeness.

Conclusion: Parents spent more time in NICUs if they could stay overnight, underlining the importance that these facilities play in establishing parent-infant closeness.

Keywords
Family-centred care, Kangaroo care, Preterm infants, Single-family room parent-infant closeness, Skin-to-skin care
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-324221 (URN)10.1111/apa.13798 (DOI)000401011500007 ()28235152 (PubMedID)
Available from: 2017-06-20 Created: 2017-06-20 Last updated: 2017-06-20Bibliographically approved
Wrammert, J., Zetterlund, C., KC, A., Ewald, U. & Målqvist, M. (2017). Resuscitation practices of low and normal birth weight infants in Nepal: an observational study using video camera recordings. Global Health Action, 10(1), Article ID 1322372.
Open this publication in new window or tab >>Resuscitation practices of low and normal birth weight infants in Nepal: an observational study using video camera recordings
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2017 (English)In: Global Health Action, ISSN 1654-9716, E-ISSN 1654-9880, Vol. 10, no 1, article id 1322372Article in journal (Other academic) Published
Abstract [en]

Background: The global burden of stillbirth and neonatal deaths remains achallenge in low-income countries. Training in neonatal resuscitation canreduce intrapartum stillbirth and early neonatal mortality. Previous resultsdemonstrate that infants who previously would have been registered asstillbirths are successfully resuscitated after such training, suggesting thatthere is a process of selection for resuscitation that needs to be explored.

Objective: To compare neonatal resuscitation of low birth weight andnormal birth weight infants born at a facility in a low-income setting.

Methods: Motion-triggered video cameras were installed above theresuscitation tables at a maternity health facility during an interventionstudy (ISRCTN97846009) employing the Helping Babies Breatheresuscitation protocol in Kathmandu, Nepal. Recordings were analysed,noting crying, stimulation, ventilation, suctioning and oxygenadministration during resuscitation. Birth weight, Apgar scores and sex ofthe infant were retrieved from matched hospital registers. The results wereanalysed by chi-square and logistic regression.

Results: A total of 2253 resuscitation cases were recorded. Low birthweight infants in need of resuscitation had higher odds of receivingventilation (aOR 1.73), and lower odds of receiving suctioning (aOR 0.53)after adjustment for the Helping Babies Breathe intervention, sex of theinfant and place of resuscitation within the facility. The rate of stimulationand administration of oxygen was the same in both groups.

Conclusions: Low birth weight was associated with more ventilation andless suctioning during neonatal resuscitation in a low-income setting. Asventilation is the most important intervention when the infant does notinitiate breathing after birth, low birth weight was not a predictor for thedecision to withhold resuscitation. Frequent routine use of suctioning of thelower airways continues to be a problem in the studied context, even afterthe introduction of the Helping Babies Breathe protocol.

Place, publisher, year, edition, pages
Taylor & Francis, 2017
Keywords
neonatal resuscitation, low birth weight, guideline adherence, video recording, low-income population
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-316720 (URN)10.1080/16549716.2017.1322372 (DOI)000402549800001 ()
Available from: 2017-03-06 Created: 2017-03-06 Last updated: 2017-08-16Bibliographically approved
KC, A., Bergström, A., Chaulagain, D., Brunell, O., Ewald, U., Gurung, A., . . . Målqvist, M. (2017). Scaling up quality improvement intervention for perinatal care in Nepal (NePeriQIP); study protocol of a cluster randomised trial. BMJ global health, 2(3), Article ID e000497.
Open this publication in new window or tab >>Scaling up quality improvement intervention for perinatal care in Nepal (NePeriQIP); study protocol of a cluster randomised trial
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2017 (English)In: BMJ global health, Vol. 2, no 3, article id e000497Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: Nepal Perinatal Quality Improvement Project (NePeriQIP) intends to scale up a quality improvement (QI) intervention for perinatal care according to WHO/National guidelines in hospitals of Nepal using the existing health system structures. The intervention builds on previous research on the implementation of Helping Babies Breathe-quality improvement cycle in a tertiary healthcare setting in Nepal. The objective of this study is to evaluate the effect of this scaled-up intervention on perinatal health outcomes.

METHODS/DESIGN: Cluster-randomised controlled trial using a stepped wedged design with 3 months delay between wedges will be conducted in 12 public hospitals with a total annual delivery rate of 60 000. Each wedge will consist of 3 hospitals. Impact will be evaluated on intrapartum-related mortality (primary outcome), overall neonatal mortality and morbidity and health worker's performance on neonatal care (secondary outcomes). A process evaluation and a cost-effectiveness analysis will be performed to understand the functionality of the intervention and to further guide health system investments will also be performed.

DISCUSSION: In contexts where resources are limited, there is a need to find scalable and sustainable implementation strategies for improved care delivery. The proposed study will add to the scarce evidence base on how to scale up interventions within existing health systems. If successful, the NePeriQIP model can provide a replicable solution in similar settings where support and investment from the health system is poor, and national governments have made a global pledge to reduce perinatal mortality.

TRIAL REGISTRATION NUMBER: ISRCTN30829654.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:uu:diva-332595 (URN)10.1136/bmjgh-2017-000497 (DOI)29071130 (PubMedID)
Available from: 2017-10-30 Created: 2017-10-30 Last updated: 2019-03-28Bibliographically approved
Malmström, B., Nohlert, E., Ewald, U. & Widarsson, M. (2017). Simulation-based team training improved the self-assessed ability of physicians, nurses and midwives to perform neonatal resuscitation. Acta Paediatrica, 106(8), 1273-1279
Open this publication in new window or tab >>Simulation-based team training improved the self-assessed ability of physicians, nurses and midwives to perform neonatal resuscitation
2017 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 106, no 8, p. 1273-1279Article in journal (Refereed) Published
Abstract [en]

Aim: The use of simulation-based team training in neonatal resuscitation has increased in Sweden during the last decade, but no formal evaluation of this training method has been performed. This study evaluated the effect of simulation-based team training on the self-assessed ability of personnel to perform neonatal resuscitation. Methods: We evaluated a full-day simulation-based team training course in neonatal resuscitation, by administering a questionnaire to 110 physicians, nurses and midwives before and after the training period. The questionnaire focused on four important domains: communication, leadership, confidence and technical skills. The study was carried out in Sweden from 2005 to 2007. Results: The response rate was 84%. Improvements in the participants self-assessed ability to perform neonatal resuscitation were seen in all four domains after training (p < 0.001). Professionally inexperienced personnel showed a significant improvement in the technical skills domain compared to experienced personnel (p = 0.001). No differences were seen between professions or time since training in any of the four domains. Personnel with less previous experience with neonatal resuscitation showed improved confidence (p = 0.007) and technical skills (p = 0.003). Conclusion: A full-day course on simulation-based team training with video-supported debriefing improved the participants' self-assessed ability to perform neonatal resuscitation.

Place, publisher, year, edition, pages
WILEY, 2017
Keywords
Behavioural skills, Multiprofessional team training, Neonatal resuscitation program, Simulation-based training, Video-assisted debriefing
National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-329898 (URN)10.1111/apa.13861 (DOI)000405233800011 ()28370414 (PubMedID)
Available from: 2018-02-20 Created: 2018-02-20 Last updated: 2018-03-28Bibliographically approved
Kc, A., Wrammert, J., Clark, R. B., Ewald, U. & Målqvist, M. (2016). Inadequate fetal heart rate monitoring and poor use of partogram associated with intrapartum stillbirth: a case-referent study in Nepal. BMC Pregnancy and Childbirth, 16, Article ID 233.
Open this publication in new window or tab >>Inadequate fetal heart rate monitoring and poor use of partogram associated with intrapartum stillbirth: a case-referent study in Nepal
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2016 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 16, article id 233Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Newborns are at the greatest risk for dying during the intrapartum period, including labor and delivery, and the first day of life. Fetal heart rate monitoring (FHRM) and partogram use to track labor progress are evidence-based techniques that can help to identify maternal and fetal risk factors so that these can be addressed early. The objective of this study was to assess health worker adherence to protocols for FHRM and partogram use during the intrapartum period, and to assess the association between adherence and intrapartum stillbirth in a tertiary hospital of Nepal.

METHODS: A case-referent study was conducted over a 15-month period. Cases included all intrapartum stillbirths, while 20 % of women with live births were randomly selected on admission to make up the referent population. The frequency of FHRM and the use of partogram were measured and their association to intrapartum stillbirth was assessed using logistic regression analysis.

RESULTS: During the study period, 4,476 women with live births were enrolled as referents and 136 with intrapartum stillbirths as cases. FHRM every 30 min was only completed in one-fourth of the deliveries, and labor progress was monitored using a partogram in just over half. With decreasing frequency of FHRM, there was an increased risk of intrapartum stillbirth; FHRM at intervals of more than 30 min resulted in a four-fold risk increase for intrapartum stillbirth (aOR 4.17, 95 % CI 2.0-8.7), and the likelihood of intrapartum stillbirth increased seven times if FHRM was performed less than every hour or not at all (aOR 7.38, 95 % CI 3.5-15.4). Additionally, there was a three-fold increased risk of intrapartum stillbirth if the partogram was not used (aOR 3.31, 95 % CI 2.0-5.4).

CONCLUSION: The adherence to FHRM and partogram use was inadequate for monitoring intrapartum progress in a tertiary hospital of Nepal. There was an increased risk of intrapartum stillbirth when fetal heart rate was inadequately monitored and when the progress of labor was not monitored using a partogram. Further exploration is required in order to determine and understand the barriers to adherence; and further, to develop tools, techniques and interventions to prevent intrapartum stillbirth.

CLINICAL TRIAL REGISTRATION: ISRCTN97846009 .

Keywords
Intrapartum stillbirth; Fetal heart rate monitoring; Partogram; Clinical adherence; Nepal
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:uu:diva-302498 (URN)10.1186/s12884-016-1034-5 (DOI)000381606100002 ()27542350 (PubMedID)
External cooperation:
Available from: 2016-09-05 Created: 2016-09-05 Last updated: 2017-11-21Bibliographically approved
K.C, A., Wrammert, J., Ewald, U., Clark, R., Gautam, J., Baral, G., . . . Målqvist, M. (2016). Incidence of intrapartum stillbirth and associated risk factors in tertiary care setting of Nepal: a case-control study. Reproductive Health, 12, Article ID 103.
Open this publication in new window or tab >>Incidence of intrapartum stillbirth and associated risk factors in tertiary care setting of Nepal: a case-control study
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2016 (English)In: Reproductive Health, ISSN 1742-4755, E-ISSN 1742-4755, Vol. 12, article id 103Article in journal (Refereed) Published
Abstract [en]

Background: Each year, 1.2 million intrapartum stillbirths occur globally. In Nepal, about 50% of the total number of stillbirths occur during the intrapartum period. An understanding of the risk factors associated with intrapartum stillbirth will facilitate the development of preventative strategies to reduce the burden of death. This study was conducted in a tertiary-care setting with the aim to identify the risk factors associated with intrapartum stillbirth.

Methods: A case-control study was completed from July 2012 to September 2013. All women who had an intrapartum stillbirth during the study period were included as cases, and 20% of women with live births were randomly selected on admission to make up the referent population. Information from the clinical records of case and referent women was retrieved. In addition, interviews were completed with each woman on their demographic and obstetric history.

Results: During the study period, 4,476 women with live births were enrolled as referents and 136 women with intrapartum stillbirths as cases.  The following factors were found to increase the risk for intrapartum stillbirth: poor familial wealth quintile (Adj OR 1.8, 95% CI-1.1-3.4); less maternal education (Adj OR, 3.2 95% CI-1.8-5.5); lack of antenatal care (Adj OR, 4.8 95% CI 3.2-7.2); antepartum hemorrhage (Adj OR 2.1, 95% CI 1.1-4.2); multiple births (Adj. OR-3.0, 95% CI- 1.9-5.4); obstetric complication during the labor period (Adj. OR 4.5, 95% CI-2.9-6.9); lack of fetal heart rate monitoring per protocol (Adj. OR-1.9, 95% CI 1.5-2.4); no partogram use (Adj. OR-2.1, 95% CI 1.1-4.1); small weight for gestational age (Adj. OR-1.8, 95% CI-1.2-1.7); premature birth (Adj. OR-5.4, 95% CI 3.5-8.2); and being born premature and with small weight for gestational age (Adj. OR-9.0, 95% CI 7.3-15.5).

Conclusion: Inadequate Fetal heart rate monitoring and partogram use are risk factors associated with intrapartum stillbirth and increasing the adherence to the interventions that can reduce the risk of intrapartum stillbirth. Preterm birth and small weight for gestational age were the factors that had the highest risk for intrapartum stillbirth, which indicates that adequate antenatal care can improve the health and growth of the baby and prevent premature death.

Keywords
intrapartum stillbirth, fetal heart rate monitoring, partogram, risk factor, Nepal
National Category
Pediatrics Obstetrics, Gynecology and Reproductive Medicine
Research subject
Pediatrics; Obstetrics and Gynaecology
Identifiers
urn:nbn:se:uu:diva-267392 (URN)10.1186/s12978-016-0226-9 (DOI)000382735400001 ()
Funder
Swedish Society of Medicine
Available from: 2015-11-21 Created: 2015-11-21 Last updated: 2017-12-01Bibliographically approved
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