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Nursing Open Nov 2022Pressure injuries (PIs) are one of the most common complications related to immobility, especially in hospitalized patients, which lead to increased morbidity, infection... (Meta-Analysis)
Meta-Analysis Review
AIM
Pressure injuries (PIs) are one of the most common complications related to immobility, especially in hospitalized patients, which lead to increased morbidity, infection and overall decreased quality of life. Arginine supplementation may prevent the development of PIs. This study has summarized the findings of studies on the effect of arginine supplementation on PI healing.
DESIGN
Systematic review and meta-analysis.
METHODS
This study was conducted on online electronic databases including PubMed, Scopus, Web of Science, Google Scholar and Embase to identify relevant clinical trial studies up to September 2020. The pooled effect size of arginine supplement effects on PI was evaluated with standard mean difference (SMD) with 95% confidence interval (CI).
RESULTS
Eight studies met the inclusion criteria for this meta-analysis with 196 patients. PIs were significantly improved with Arginine supplementation (SMD: -0.6; CI 95%: -0.9 to -0.3, I : 72.5%, p = .001). Subgroup analysis showed that administering Arginine supplement more than 15 g/day had more beneficial effects on the healing of PIs (SMD: -2.8; CI 95%: -4.08 to -1.52, I : 54.7%, p = .138).
CONCLUSIONS
Our findings suggest that the administration of Arginine supplement in patients with PIs can accelerate the healing of this type of ulcer. Arginine is a supplement, and primary treatment is still needed to optimize PI healing. Therefore, arginine supplementation in addition to primary treatment seems to be an appropriate approach for the healing of PIs. Further well-designed studies are necessary to prevent the development of PIs compared to their primary treatment.
Topics: Humans; Arginine; Dietary Supplements; Enteral Nutrition; Quality of Life; Wound Healing; Pressure Ulcer
PubMed: 34170617
DOI: 10.1002/nop2.974 -
Children (Basel, Switzerland) Nov 2021Pediatric palliative care (PPC) is a set of actions aimed at children who suffer from a severe or life-threatening disease to alleviate the symptoms of the disease and... (Review)
Review
Pediatric palliative care (PPC) is a set of actions aimed at children who suffer from a severe or life-threatening disease to alleviate the symptoms of the disease and improve the quality of life of both the child and his/her family. One of the tools used to control symptoms is physiotherapy; however, its application in the child population has not been thoroughly studied. The main objective of this study was to gather, analyze, and critically evaluate the available scientific evidence on physiotherapy in children who require palliative care through a systematic review of the studies published in the last 10 years in the following databases: PubMed, Cochrane Library, PEDro, CINAHL, and Scopus. Of a total of 622 studies, the inclusion criteria were only met by seven articles, which were focused on the relationship between physiotherapy and PPC. This study analyzed: (1) the main pathologies treated, with a predominance of cerebral palsy and cancer; (2) the interventions applied, such as respiratory physiotherapy, neurological physiotherapy, therapeutic massage, and virtual reality; (3) the effects achieved in the child and his/her family, highlighting the control of symptoms and the improvement of the quality of life; and (4) the knowledge of the physiotherapists on PPC, observing that most of the professionals had not received training in this scope. The findings of this review indicate a lack of an adequate evidence foundation for physiotherapy in PPC.
PubMed: 34828756
DOI: 10.3390/children8111043 -
Journal of Pain and Symptom Management May 2021Children with cancer and their families have complex needs related to symptoms, decision-making, care planning, and psychosocial impact extending across the illness...
CONTEXT
Children with cancer and their families have complex needs related to symptoms, decision-making, care planning, and psychosocial impact extending across the illness trajectory, which for some includes end of life. Whether specialty pediatric palliative care (SPPC) is associated with improved outcomes for children with cancer and their families is unknown.
OBJECTIVE
We conducted a systematic review following PRISMA guidelines to investigate outcomes associated with SPPC in pediatric oncology with a focus on intervention delivery, collaboration, and alignment with National Quality Forum domains.
METHODS
We searched PubMed, Embase, Scopus, Web of Science, and CINAHL databases from inception until April 2020 and reviewed references manually. Eligible articles were published in English, involved pediatric patients aged 0-18 years with cancer, and contained original data regarding patient and family illness and end-of-life experiences, including symptom management, communication, decision-making, quality of life, satisfaction, and healthcare utilization.
RESULTS
We screened 6682 article abstracts and 82 full-text articles; 32 studies met inclusion criteria, representing 15,635 unique children with cancer and 342 parents. Generally, children with cancer who received SPPC had improved symptom burden, pain control, and quality of life with decreased intensive procedures, increased completion of advance care planning and resuscitation status documentation, and fewer end-of-life intensive care stays with higher likelihood of dying at home. Family impact included satisfaction with SPPC and perception of improved communication.
CONCLUSION
SPPC may improve illness experiences for children with cancer and their families. Multisite studies utilizing comparative effectiveness approaches and validated metrics may support further advancement of the field.
Topics: Child; Hospice and Palliative Care Nursing; Humans; Neoplasms; Palliative Care; Quality of Life; Terminal Care
PubMed: 33348034
DOI: 10.1016/j.jpainsymman.2020.12.003 -
The Cochrane Database of Systematic... Nov 2022Eczema and food allergy are common health conditions that usually begin in early childhood and often occur in the same people. They can be associated with an impaired... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Eczema and food allergy are common health conditions that usually begin in early childhood and often occur in the same people. They can be associated with an impaired skin barrier in early infancy. It is unclear whether trying to prevent or reverse an impaired skin barrier soon after birth is effective for preventing eczema or food allergy.
OBJECTIVES
Primary objective To assess the effects of skin care interventions such as emollients for primary prevention of eczema and food allergy in infants. Secondary objective To identify features of study populations such as age, hereditary risk, and adherence to interventions that are associated with the greatest treatment benefit or harm for both eczema and food allergy.
SEARCH METHODS
We performed an updated search of the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase in September 2021. We searched two trials registers in July 2021. We checked the reference lists of included studies and relevant systematic reviews, and scanned conference proceedings to identify further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA: We included RCTs of skin care interventions that could potentially enhance skin barrier function, reduce dryness, or reduce subclinical inflammation in healthy term (> 37 weeks) infants (≤ 12 months) without pre-existing eczema, food allergy, or other skin condition. Eligible comparisons were standard care in the locality or no treatment. Types of skin care interventions could include moisturisers/emollients; bathing products; advice regarding reducing soap exposure and bathing frequency; and use of water softeners. No minimum follow-up was required.
DATA COLLECTION AND ANALYSIS
This is a prospective individual participant data (IPD) meta-analysis. We used standard Cochrane methodological procedures, and primary analyses used the IPD dataset. Primary outcomes were cumulative incidence of eczema and cumulative incidence of immunoglobulin (Ig)E-mediated food allergy by one to three years, both measured at the closest available time point to two years. Secondary outcomes included adverse events during the intervention period; eczema severity (clinician-assessed); parent report of eczema severity; time to onset of eczema; parent report of immediate food allergy; and allergic sensitisation to food or inhalant allergen.
MAIN RESULTS
We identified 33 RCTs comprising 25,827 participants. Of these, 17 studies randomising 5823 participants reported information on one or more outcomes specified in this review. We included 11 studies, randomising 5217 participants, in one or more meta-analyses (range 2 to 9 studies per individual meta-analysis), with 10 of these studies providing IPD; the remaining 6 studies were included in the narrative results only. Most studies were conducted at children's hospitals. Twenty-five studies, including all those contributing data to meta-analyses, randomised newborns up to age three weeks to receive a skin care intervention or standard infant skin care. Eight of the 11 studies contributing to meta-analyses recruited infants at high risk of developing eczema or food allergy, although the definition of high risk varied between studies. Durations of intervention and follow-up ranged from 24 hours to three years. All interventions were compared against no skin care intervention or local standard care. Of the 17 studies that reported information on our prespecified outcomes, 13 assessed emollients. We assessed most of the evidence in the review as low certainty and had some concerns about risk of bias. A rating of some concerns was most often due to lack of blinding of outcome assessors or significant missing data, which could have impacted outcome measurement but was judged unlikely to have done so. We assessed the evidence for the primary food allergy outcome as high risk of bias due to the inclusion of only one trial, where findings varied based on different assumptions about missing data. Skin care interventions during infancy probably do not change the risk of eczema by one to three years of age (risk ratio (RR) 1.03, 95% confidence interval (CI) 0.81 to 1.31; risk difference 5 more cases per 1000 infants, 95% CI 28 less to 47 more; moderate-certainty evidence; 3075 participants, 7 trials) or time to onset of eczema (hazard ratio 0.86, 95% CI 0.65 to 1.14; moderate-certainty evidence; 3349 participants, 9 trials). Skin care interventions during infancy may increase the risk of IgE-mediated food allergy by one to three years of age (RR 2.53, 95% CI 0.99 to 6.49; low-certainty evidence; 976 participants, 1 trial) but may not change risk of allergic sensitisation to a food allergen by age one to three years (RR 1.05, 95% CI 0.64 to 1.71; low-certainty evidence; 1794 participants, 3 trials). Skin care interventions during infancy may slightly increase risk of parent report of immediate reaction to a common food allergen at two years (RR 1.27, 95% CI 1.00 to 1.61; low-certainty evidence; 1171 participants, 1 trial); however, this was only seen for cow's milk, and may be unreliable due to over-reporting of milk allergy in infants. Skin care interventions during infancy probably increase risk of skin infection over the intervention period (RR 1.33, 95% CI 1.01 to 1.75; risk difference 17 more cases per 1000 infants, 95% CI one more to 38 more; moderate-certainty evidence; 2728 participants, 6 trials) and may increase the risk of infant slippage over the intervention period (RR 1.42, 95% CI 0.67 to 2.99; low-certainty evidence; 2538 participants, 4 trials) and stinging/allergic reactions to moisturisers (RR 2.24, 95% 0.67 to 7.43; low-certainty evidence; 343 participants, 4 trials), although CIs for slippages and stinging/allergic reactions were wide and include the possibility of no effect or reduced risk. Preplanned subgroup analyses showed that the effects of interventions were not influenced by age, duration of intervention, hereditary risk, filaggrin (FLG) mutation, chromosome 11 intergenic variant rs2212434, or classification of intervention type for risk of developing eczema. We could not evaluate these effects on risk of food allergy. Evidence was insufficient to show whether adherence to interventions influenced the relationship between skin care interventions and eczema or food allergy development.
AUTHORS' CONCLUSIONS
Based on low- to moderate-certainty evidence, skin care interventions such as emollients during the first year of life in healthy infants are probably not effective for preventing eczema; may increase risk of food allergy; and probably increase risk of skin infection. Further study is needed to understand whether different approaches to infant skin care might prevent eczema or food allergy.
Topics: Female; Animals; Cattle; Emollients; Eczema; Food Hypersensitivity; Milk Hypersensitivity; Allergens
PubMed: 36373988
DOI: 10.1002/14651858.CD013534.pub3 -
Women's Health (London, England) 2022To synthesize and integrate current international knowledge regarding nursing strategies for the provision of emotional and practical support to the mothers of preterm... (Meta-Analysis)
Meta-Analysis
Nurses' strategies to provide emotional and practical support to the mothers of preterm infants in the neonatal intensive care unit: A systematic review and meta-analysis.
AIM
To synthesize and integrate current international knowledge regarding nursing strategies for the provision of emotional and practical support to the mothers of preterm infants in the neonatal intensive care unit.
METHODS
A systematic review and meta-analysis was undertaken. Four English-language databases including EMBASE, PubMed (including MEDLINE), Scopus, and Web of Science were searched from January 2010 to October 2021. Original quantitative studies that were written in English and focused on nursing strategies for the provision of emotional and practical support to the mothers of preterm infants in the neonatal intensive care unit were included. Eligibility assessment, data extraction, and methodological quality appraisal were conducted independently by the review authors. A narrative synthesis of the review results and a meta-analysis were performed.
RESULTS
Twenty studies that were published from 2010 to 2021 were included in the review. Three categories concerning the review aims were identified: 'nursing strategies related to mothers' emotions and infant-mother attachment', 'nursing strategies related to mothers' empowerment', and 'nursing strategies related to mothers' participation in care process and support'. Eight interventional studies that reported mothers' stress as the study outcome were entered into the meta-analysis. Interventions consisted of the educational programme, spiritual care, telenursing, parent support programme, skin-to-skin care, and guided family centred care. Significantly lower maternal stress was found in the intervention group compared with that of the control group (: -1.06; 95% confidence interval: -1.64, -0.49; Z = 3.62, < 0.001).
CONCLUSION
This review identified and highlighted key nursing strategies used to provide emotional and practical support to the mothers of preterm infants in the neonatal intensive care unit. They included family centred care, skin-to-skin care, parent support and education programmes, interpersonal psychotherapy, spiritual care, newborn individualized developmental care and assessment programme, and telenursing.
Topics: Emotions; Female; Humans; Infant; Infant, Newborn; Infant, Premature; Intensive Care Units, Neonatal; Mothers; Nurses
PubMed: 35735784
DOI: 10.1177/17455057221104674 -
The Cochrane Database of Systematic... Jun 2023Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately... (Review)
Review
BACKGROUND
Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title.
OBJECTIVES
To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music.
SEARCH METHODS
For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update. We also searched reference lists and contacted researchers via electronic list-serves. We incorporated 76 new studies into the review. SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis. DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes. MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I = 92%, considerable heterogeneity), based on very low-certainty evidence. In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements.
AUTHORS' CONCLUSIONS
Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.
Topics: Humans; Acute Pain; Blood Specimen Collection; Pain Management; Pain, Procedural; Systematic Reviews as Topic; Infant, Newborn; Infant; Child, Preschool
PubMed: 37314064
DOI: 10.1002/14651858.CD006275.pub4 -
Pediatric Physical Therapy : the... Jul 2022To conduct a systematic review and meta-analysis on the effect of motor intervention on motor function of infants and toddlers with cerebral palsy (CP). (Meta-Analysis)
Meta-Analysis
PURPOSE
To conduct a systematic review and meta-analysis on the effect of motor intervention on motor function of infants and toddlers with cerebral palsy (CP).
METHODS
Four databases were searched for randomized controlled trials (RCTs) of motor interventions for children with or at high risk of CP younger than 36 months. Studies were excluded if less than 50% of children developed CP.
RESULTS
Eleven RCTs included 363 children; 85% diagnosed with CP. Very low-quality evidence supports that: (1) task-specific motor training was more effective than standard care for improving motor function (small effect), (2) constraint-induced movement therapy (CIMT) may be more effective than bimanual play or massage for improving function of the more affected hand (moderate effect), and high-intensity treadmill training is no more effective than low-intensity for improving walking.
CONCLUSIONS
Very low-quality evidence supports that task-specific motor training and CIMT may improve motor function of infants and toddlers with CP.The Supplemental Digital Content Video Abstract is available at: http://links.lww.com/PPT/A382 .
Topics: Cerebral Palsy; Child, Preschool; Hand; Humans; Infant; Massage; Physical Therapy Modalities; Walking
PubMed: 35671383
DOI: 10.1097/PEP.0000000000000914 -
European Journal of Cancer (Oxford,... May 2020Children with cancer often undergo long treatment trajectories involving repeated needle procedures that potentially cause pain and distress. As part of a comprehensive...
BACKGROUND
Children with cancer often undergo long treatment trajectories involving repeated needle procedures that potentially cause pain and distress. As part of a comprehensive effort to develop clinical practice guidelines (CPGs) to address pain prevention and management in children with cancer, we aimed to provide recommendations on the pharmacological and psychological management of procedure-related pain and distress.
METHODS
Of the international inter-disciplinary CPG development panel (44 individuals), two working groups including 13 healthcare professionals focused on procedural pain and distress. Grading of Recommendations Assessment, Development and Evaluation methodology was used, including the use of systematic literature reviews to inform recommendations and the use of evidence to decision frameworks. At an in-person meeting in February 2018, the guideline panel discussed these frameworks and formulated recommendations which were then discussed with a patient-parent panel consisting of 4 survivors and 5 parents.
RESULTS
The systematic reviews led to the inclusion of 48 randomised controlled trials (total number of participants = 2271). Quality of evidence supporting the recommendations ranged from very low to moderate. Strong recommendations were made for the use of topical anesthetics in all needle procedures, for offering deep sedation (DS)/general anesthesia (GA) to all children undergoing lumbar puncture, for the use of DS/ GA in major procedures in children of all ages, for the use of hypnosis in all needle procedures and for the use of active distraction in all needle procedures.
CONCLUSION
In this CPG, an evidence-based approach to manage procedure-related pain and distress in children with cancer is presented. As children with cancer often undergo repeated needle procedures during treatment, prevention and alleviation of procedure-related pain and distress is of the utmost importance to increase quality of life in these children and their families.
Topics: Age Factors; Antineoplastic Agents; Child; Evidence-Based Medicine; Humans; Injections; Medical Oncology; Needles; Neoplasms; Pain, Procedural; Quality of Life; Randomized Controlled Trials as Topic; Stress, Psychological
PubMed: 32302949
DOI: 10.1016/j.ejca.2020.02.039 -
Medicine Jan 2020Sedoanalgesia secondary iatrogenic withdrawal syndrome (IWS) in paediatric intensive units is frequent and its assessment is complex. Therapies are heterogeneous, and...
BACKGROUND
Sedoanalgesia secondary iatrogenic withdrawal syndrome (IWS) in paediatric intensive units is frequent and its assessment is complex. Therapies are heterogeneous, and there is currently no gold standard method for diagnosis. In addition, the assessment scales validated in children are scarce. This paper aims to identify and describe both the paediatric diagnostic and assessment tools for the IWS and the treatments for the IWS in critically ill paediatric patients.
METHODS
A systematic review was conducted according to the PRISMA guidelines. This review included descriptive and observational studies published since 2000 that analyzed paediatric scales for the evaluation of the iatrogenic withdrawal syndrome and its treatments. The eligibility criteria included neonates, newborns, infants, pre-schoolers, and adolescents, up to age 18, who were admitted to the paediatric intensive care units with continuous infusion of hypnotics and/or opioid analgesics, and who presented signs or symptoms of deprivation related to withdrawal and prolonged infusion of sedoanalgesia.
RESULTS
Three assessment scales were identified: Withdrawal Assessment Tool-1, Sophia Observation Withdrawal Symptoms, and Opioid and Benzodiazepine Withdrawal Score. Dexmedetomidine, methadone and clonidine were revealed as options for the treatment and prevention of the iatrogenic withdrawal syndrome. Finally, the use of phenobarbital suppressed symptoms of deprivation that are resistant to other drugs.
CONCLUSIONS
The reviewed scales facilitate the assessment of the iatrogenic withdrawal syndrome and have a high diagnostic quality. However, its clinical use is very rare. The treatments identified in this review prevent and effectively treat this syndrome. The use of validated iatrogenic withdrawal syndrome assessment scales in paediatrics clinical practice facilitates assessment, have a high diagnostic quality, and should be encouraged, also ensuring nurses' training in their usage.
Topics: Child; Humans; Iatrogenic Disease; Intensive Care Units, Pediatric; Substance Withdrawal Syndrome
PubMed: 32000360
DOI: 10.1097/MD.0000000000018502