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Respiratory Care Feb 2022Artificial airway suctioning is a key component of airway management and a core skill for clinicians charged with assuring airway patency. Suctioning of the artificial...
Artificial airway suctioning is a key component of airway management and a core skill for clinicians charged with assuring airway patency. Suctioning of the artificial airway is a common procedure performed worldwide on a daily basis. As such, it is imperative that clinicians are familiar with the most-effective and efficient methods to perform the procedure. We conducted a systematic review to assist in the development of evidence-based recommendations that pertain to the care of patients with artificial airways. From our systematic review, we developed guidelines and recommendations that addressed questions related to the indications, complications, timing, duration, and methods of artificial airway suctioning. By using a modified version of the RAND/UCLA Appropriateness Method, the following recommendations for suctioning were developed for neonatal, pediatric, and adult patients with an artificial airway: (1) breath sounds, visual secretions in the artificial airway, and a sawtooth pattern on the ventilator waveform are indicators for suctioning pediatric and adult patients, and an acute increase in airway resistance may be an indicator for suctioning in neonates; (2) as-needed only, rather than scheduled, suctioning is sufficient for neonatal and pediatric patients; (3) both closed and open suction systems may be used to safely and effectively remove secretions from the artificial airway of adult patients; (4) preoxygenation should be performed before suctioning in pediatric and adult patients; (5) the use of normal saline solution should generally be avoided during suctioning; (6) during open suctioning, sterile technique should be used; (7) suction catheters should occlude < 70% of the endotracheal tube lumen in neonates and < 50% in pediatric and adult patients, and suction pressure should be kept below -120 mm Hg in neonatal and pediatric patients and -200 mm Hg in adult patients; (8) suction should be applied for a maximum of 15 s per suctioning procedure; (9) deep suctioning should only be used when shallow suctioning is ineffective; (10) routine bronchoscopy for secretion removal is not recommended; and (11) devices used to clear endotracheal tubes may be used when airway resistance is increased due to secretion accumulation.
Topics: Adult; Airway Management; Child; Humans; Infant, Newborn; Intubation, Intratracheal; Respiration, Artificial; Suction; Ventilators, Mechanical
PubMed: 35078900
DOI: 10.4187/respcare.09548 -
Journal of Oral Rehabilitation Aug 2021Chin tuck against resistance (CTAR) exercise has been recently reported to be a new therapeutic exercise method that can help improve swallowing function in patients... (Review)
Review
BACKGROUND
Chin tuck against resistance (CTAR) exercise has been recently reported to be a new therapeutic exercise method that can help improve swallowing function in patients with dysphagia. However, due to the differences in exercise protocols, methods and the tools used across studies of CTAR exercise, an overall systematic review of these studies is necessary.
OBJECTIVE
The present study investigated the exercise protocols, methods and tools used in various studies of CTAR exercise and summarised their findings.
METHODS
We searched for studies related to CTAR exercise using electronic databases and selected nine articles for review. The articles were categorised on the basis of four criteria: study design and quality, training protocol, outcome measures and clinical effect.
RESULTS
Four articles reported that CTAR exercise not only helped activate the suprahyoid muscle in healthy adults, but also activated the sternocleidomastoid muscle less than Shaker exercise. In addition, five articles reported that CTAR exercise was effective in improving swallowing function and oral diet stage in the pharyngeal phase, including reduction of airway aspiration in patients with dysphagia after stroke.
CONCLUSIONS
CTAR exercise more selectively activates the suprahyoid muscle and is an effective therapeutic exercise for improving swallowing function in patients with dysphagia. Because it is less strenuous than Shaker exercise, it requires less physical burden and effort, allowing greater compliance.
Topics: Adult; Chin; Deglutition; Deglutition Disorders; Exercise Therapy; Humans; Resistance Training
PubMed: 33973284
DOI: 10.1111/joor.13181 -
The Cochrane Database of Systematic... Jan 2019Pneumonia is a lung infection that causes more deaths in children aged under five years than any other single cause. Chest physiotherapy is widely used as adjuvant...
BACKGROUND
Pneumonia is a lung infection that causes more deaths in children aged under five years than any other single cause. Chest physiotherapy is widely used as adjuvant treatment for pneumonia. Physiotherapy is thought to help remove inflammatory exudates, tracheobronchial secretions, and airway obstructions, and reduce airway resistance to improve breathing and enhance gas exchange. This is an update of a review published in 2013.
OBJECTIVES
To assess the effectiveness of chest physiotherapy with regard to time until clinical resolution in children (from birth to 18 years) of either gender with any type of pneumonia.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 1), which includes the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE (22 February 2018), Embase (22 February 2018), CINAHL (22 February 2018), LILACS (22 February 2018), Web of Science (22 February 2018), and PEDro (22 February 2018). We also searched clinical trials registers (ClinicalTrials.gov and WHO ICTRP) to identify planned, ongoing, and unpublished trials.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) that compared any type of chest physiotherapy with no chest physiotherapy for children with pneumonia.
DATA COLLECTION AND ANALYSIS
We used standard Cochrane methodological procedures. The primary outcomes of interest were mortality, duration of hospital stay, and time to clinical resolution. We used Review Manager 5 software to analyse data and GRADE to assess the quality of the evidence for each outcome.
MAIN RESULTS
We included three new RCTs for this update, for a total of six included RCTs involving 559 children aged from 29 days to 12 years with pneumonia who were treated as inpatients. Pneumonia severity was described as moderate in one trial, severe in two trials, and was not stated in three trials. The studies assessed five different interventions: effects of conventional chest physiotherapy (3 studies, 211 children), positive expiratory pressure (1 study, 72 children), continuous positive airway pressure (CPAP) (1 study, 94 children), bubble CPAP (bCPAP) (1 study, 225 children), and assisted autogenic drainage (1 studies, 29 children). The included studies were conducted in Bangladesh, Brazil, China, Egypt, and South Africa. The studies were overall at low risk of bias. Blinding of participants was not possible in most studies, but we considered that the outcomes were unlikely to be influenced by the lack of blinding.All included studies evaluated mortality. However, three studies assessed mortality as an outcome, and only one study of bCPAP reported that deaths occurred. Three deaths occurred in children in the physiotherapy group (N = 79) and 20 deaths in children in the control group (N = 146) (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.08 to 0.90; 559 children; low-quality evidence). It is uncertain whether chest physiotherapy techniques (bCPAP, assisted autogenic drainage, and conventional chest physiotherapy) reduced hospital stay duration (days) (mean difference (MD) 0.10, 95% CI -0.56 to 0.76; 4 studies; low-quality evidence).There was variation among clinical parameters used to define clinical resolution. Two small studies found no difference in resolution of fever between children in the physiotherapy (conventional chest physiotherapy and assisted autogenic drainage) and control groups. Of five studies that considered peripheral oxygen saturation levels, only two reported that use of chest physiotherapy (CPAP and conventional chest physiotherapy) showed a greater improvement in peripheral oxygen saturation levels. However, it was unclear whether respiratory rate (breaths/min) improved after conventional chest physiotherapy (MD -2.25, 95% CI -5.17 to 0.68; 2 studies, 122 children; low-quality evidence). Two studies assessed adverse events (number of events), but only one study reported any events (RR 1.28, 95% CI 0.98 to 1.67; 2 studies, 254 children; low-quality evidence).
AUTHORS' CONCLUSIONS
We could draw no reliable conclusions concerning the use of chest physiotherapy for children with pneumonia due to the small number of included trials with differing study characteristics and statistical presentation of data. Future studies should consider the following key points: appropriate sample size with adequate power to detect expected differences, standardisation of chest physiotherapy techniques, appropriate outcomes (such as duration of leukocytosis, and airway clearance), and adverse effects.
Topics: Child; Child, Preschool; Continuous Positive Airway Pressure; Drainage; Female; Humans; Infant; Infant, Newborn; Length of Stay; Male; Oxygen; Pneumonia; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Respiratory Rate; Respiratory Therapy
PubMed: 30601584
DOI: 10.1002/14651858.CD010277.pub3 -
Cureus Nov 2023Nasal congestion is a common issue stemming from various factors such as allergies and anatomical variations. Allergic rhinitis frequently leads to nasal congestion. The... (Review)
Review
Nasal congestion is a common issue stemming from various factors such as allergies and anatomical variations. Allergic rhinitis frequently leads to nasal congestion. The pathophysiology involves inflammation, swelling, and mucus production in the nasal mucosa. Multiple treatments are available, including oral phenylephrine, an over-the-counter or prescription option. However, the effectiveness and safety of phenylephrine have been subjects of debate. This systematic review aims to provide an updated perspective on the efficacy of oral phenylephrine versus placebo in addressing nasal congestion in adults. We conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, a systematic review involving searches on PubMed, Cochrane, and Scopus databases. Inclusion/exclusion criteria were defined to identify high-quality studies. The focus was on randomized controlled trials (RCTs) and case-control studies published in English between 1998 and 2023, involving adult populations. The interventions compared oral phenylephrine with placebo or standard care, with outcomes centering on changes in nasal congestion symptoms and nasal airway resistance. We identified four articles that met the criteria. These studies exhibited varied designs and populations. The findings consistently indicated that phenylephrine was not more effective than a placebo in relieving nasal congestion. This systematic review demonstrates that oral phenylephrine did not offer substantial relief from nasal congestion compared to a placebo in adults. The studies featured diverse designs, yet the prevailing conclusion was that phenylephrine's efficacy was limited. Safety assessments showed no life-threatening adverse events, with common side effects including headaches and mild discomfort. In summary, this systematic review indicates that oral phenylephrine is not significantly more effective than a placebo in alleviating nasal congestion in adults. Clinicians should explore alternative treatment options, considering the review's limitations. Additional research may be needed to clarify the role of oral phenylephrine in managing nasal congestion.
PubMed: 38125218
DOI: 10.7759/cureus.49074 -
The Cochrane Database of Systematic... Oct 2016Many treatments for the common cold exist and are sold over-the-counter. Nevertheless, evidence on the effectiveness and safety of nasal decongestants is limited. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Many treatments for the common cold exist and are sold over-the-counter. Nevertheless, evidence on the effectiveness and safety of nasal decongestants is limited.
OBJECTIVES
To assess the efficacy, and short- and long-term safety, of nasal decongestants used in monotherapy to alleviate symptoms of the common cold in adults and children.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 6, June 2016), which contains the Cochrane Acute Respiratory Infections (ARI) Specialised Register, MEDLINE (1946 to July 2016), Embase (2010 to 15 July 2016), CINAHL (1981 to 15 July 2016), LILACS (1982 to July 2016), Web of Science (1955 to July 2016) and clinical trials registers.
SELECTION CRITERIA
Randomised controlled trials (RCTs) and cluster-RCTs investigating the effectiveness and adverse effects of nasal decongestants compared with placebo for treating the common cold in adults and children. We excluded quasi-RCTs.
DATA COLLECTION AND ANALYSIS
Three review authors independently extracted and summarised data on subjective measures of nasal congestion, overall patient well-being score, objective measures of nasal airway resistance, adverse effects and general recovery. One review author acted as arbiter in cases of disagreement. We categorised trials as single and multi-dose and analysed data both separately and together. We also analysed studies using an oral or topical nasal decongestant separately and together.
MAIN RESULTS
We included 15 trials with 1838 participants. Fourteen studies included adult participants only (aged 18 years and over). In six studies the intervention was a single dose and in nine studies multiple doses were used. Nine studies used pseudoephedrine and three studies used oxymetazoline. Other decongestants included phenylpropanolamine, norephedrine and xylometazoline. Phenylpropanolamine (or norephedrine) is no longer available on the market therefore we did not include the results of these studies in the meta-analyses. Eleven studies used oral decongestants; four studies used topical decongestants.Participants were included after contracting the common cold. The duration of symptoms differed among studies; in 10 studies participants had symptoms for less than three days, in three studies symptoms were present for less than five days, one study counted the number of colds over one year, and one study experimentally induced the common cold. In the single-dose studies, the effectiveness of a nasal decongestant was measured on the same day, whereas the follow-up in multi-dose studies ranged between one and 10 days.Most studies were conducted in university settings (N = eight), six at a specific university common cold centre. Three studies were conducted at a university in collaboration with a hospital and two in a hospital only setting. In two studies the setting was unclear.There were large differences in the reporting of outcomes and the reporting of methods in most studies was limited. Therefore, we judged most studies to be at low or unclear risk of bias. Pooling was possible for a limited number of studies only; measures of effect are expressed as standardised mean differences (SMDs). A positive SMD represents an improvement in congestion. There is no defined minimal clinically important difference for measures of subjective improvement in nasal congestion, therefore we used the SMDs as a guide to assess whether an effect was small (0.2 to 0.49), moderate (0.5 to 0.79) or large (≥ 0.8).Single-dose decongestant versus placebo: 10 studies compared a single dose of nasal decongestant with placebo and their effectiveness was tested between 15 minutes and 10 hours after dosing. Seven of 10 studies reported subjective symptom scores for nasal congestion; none reported overall patient well-being. However, pooling was not possible due to the large diversity in the measurement and reporting of symptoms of congestion. Two studies recorded adverse events. Both studies used an oral decongestant and each of them showed that there was no statistical difference between the number of adverse events in the treatment group versus the placebo group.Multi-dose decongestant versus placebo: nine studies compared multiple doses of nasal decongestants with placebo, but only five reported on the primary outcome, subjective symptom scores for nasal congestion. Only one study used a topical decongestant; none reported overall patient well-being. Subjective measures of congestion were significantly better for the treatment group compared with placebo approximately three hours after the last dose (SMD 0.49, 95% confidence interval (CI) 0.07 to 0.92; P = 0.02; GRADE: low-quality evidence). However, the SMD of 0.49 only indicates a small clinical effect. Pooling was based on two studies, one oral and one topical, therefore we were unable to assess the effects of oral and topical decongestants separately. Seven studies reported adverse events (six oral and one topical decongestant); meta-analysis showed that there was no statistical difference between the number of adverse events in the treatment group (125 per 1000) compared to the placebo group (126 per 1000). The odds ratio (OR) for adverse events in the treatment group was 0.98 (95% CI 0.68 to 1.40; P = 0.90; GRADE: low-quality evidence). The results remained the same when we only considered studies using an oral decongestant (OR 0.95, 95% CI 0.65 to 1.39; P = 0.80; GRADE: low-quality evidence).
AUTHORS' CONCLUSIONS
We were unable to draw conclusions on the effectiveness of single-dose nasal decongestants due to the limited evidence available. For multiple doses of nasal decongestants, the current evidence suggests that these may have a small positive effect on subjective measures of nasal congestion in adults with the common cold. However, the clinical relevance of this small effect is unknown and there is insufficient good-quality evidence to draw any firm conclusions. Due to the small number of studies that used a topical nasal decongestant, we were also unable to draw conclusions on the effectiveness of oral versus topical decongestants. Nasal decongestants do not seem to increase the risk of adverse events in adults in the short term. The effectiveness and safety of nasal decongestants in children and the clinical relevance of their small effect in adults is yet to be determined.
Topics: Administration, Intranasal; Adult; Child; Common Cold; Humans; Imidazoles; Nasal Decongestants; Oxymetazoline; Phenylpropanolamine; Pseudoephedrine; Randomized Controlled Trials as Topic; Time Factors
PubMed: 27748955
DOI: 10.1002/14651858.CD009612.pub2 -
American Journal of Otolaryngology 2021Upper airway resistance syndrome (UARS) is a sleep related breathing disorder that was first described in 1993. This goal of this study is to determine the efficacy of... (Meta-Analysis)
Meta-Analysis
PURPOSE
Upper airway resistance syndrome (UARS) is a sleep related breathing disorder that was first described in 1993. This goal of this study is to determine the efficacy of surgical intervention for UARS.
MATERIALS AND METHODS
Systematic review of the literature and a case series of UARS patients at a large integrated healthcare system. Meta-analysis was performed.
RESULTS
For the systematic review, 971 abstracts were reviewed and 3 articles were included, yielding 49 subjects. All of the included studies were of level 3 or 4 evidence. Significant improvement in Epworth Sleepiness Scale (ESS) score was noted after surgery in two level 4 studies. No significant change in ESS was noted in one level 3 study. Our retrospective chart review of eleven UARS patients compared preoperative and postoperative ESS scores, as well as sleep study data. Patients underwent a variety of surgical procedures. Our findings show a significant improvement in mean ESS scores after surgery, from 11.0 (±3.5) to 7.0 (±4.8) with p = 0.01, though no difference in apnea hypopnea index (AHI) and respiratory disturbance index (RDI) were identified. Meta-analysis was performed on 2 studies from the systematic review and our cases series data. UARS surgery showed a mean change in ESS of -5.89 (95% CI, -8.29 to -3.50).
CONCLUSIONS
This systematic review, meta-analysis and retrospective case series indicate that surgery may improve ESS scores in patients with UARS. AHI and RDI are unlikely to be impacted by surgery.
Topics: Adult; Airway Resistance; Female; Humans; Male; Middle Aged; Otorhinolaryngologic Surgical Procedures; Retrospective Studies; Sleep Apnea Syndromes; Treatment Outcome
PubMed: 33831820
DOI: 10.1016/j.amjoto.2021.103011 -
The Laryngoscope Jan 2016Drug-induced sleep endoscopy (DISE) is used to determine surgical therapy for obstructive sleep apnea (OSA); however, the effects of anesthesia on the upper airway are... (Review)
Review
OBJECTIVES/HYPOTHESIS
Drug-induced sleep endoscopy (DISE) is used to determine surgical therapy for obstructive sleep apnea (OSA); however, the effects of anesthesia on the upper airway are poorly understood. Our aim was to systematically review existing literature on the effects of anesthetic agents on the upper airway.
DATA SOURCES
PubMed, CINAHL, EBM reviews and Scopus (all indexed years).
REVIEW METHODS
Inclusion criteria included English language articles containing original human data. Two investigators independently reviewed all articles for outcomes related to upper airway morphology, dynamics, neuromuscular response, and respiratory control.
RESULTS
The initial search yielded 180 abstracts; 56 articles were ultimately included (total population = 8,540). The anesthetic agents studied were: topical lidocaine, propofol, dexmedetomidine, midazolam, pentobarbital, sevoflurane, desflurane, ketamine, and opioids. Outcome measures were diverse and included imaging studies, genioglossus electromyography, endoscopic airway assessment, polysomnography, upper airway closing pressure, and clinical evidence of obstruction. All agents caused some degrees of airway collapse. Dexmedetomidine did not have dose-dependent effects when evaluated using cine magnetic resonance imaging, unlike sevoflurane, isoflurane, and propofol, and caused less dynamic collapse than propofol.
CONCLUSIONS
Studies assessing the effect of anesthesia on the upper airway in patients with and without OSA are limited, and few compare effects between agents. Medications with minimal effect on respiratory control (e.g., dexmedetomidine) may work best for DISE.
Topics: Airway Resistance; Analgesics, Opioid; Anesthetics; Humans; Larynx; Pharynx; Sleep Apnea, Obstructive
PubMed: 26198715
DOI: 10.1002/lary.25399 -
The Laryngoscope Jan 2022Nasal diseases are among the main motives for the early discontinuation of continuous positive airway pressure therapy and for long-term therapeutic compliance with... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Nasal diseases are among the main motives for the early discontinuation of continuous positive airway pressure therapy and for long-term therapeutic compliance with mandibular advancement device. Although our clinical experience leads us to the belief that recumbency impacts nasal airflow in some patient populations, there is no consensus regarding the magnitude of this effect and the specific group of patients who are the most affected by this condition. In this study, we conducted a meta-analysis to assess the effect of the recumbent position on nasal resistance and nasal airflow.
REVIEW METHODS
PubMed (Medline), Cochrane Library, EMBASE, Scopus, and SciELO databases were checked for relevant studies by two members of the YO-IFOS study group. The two authors extracted the data. The main outcome was expressed as the difference between nasal resistance and nasal airflow before and after recumbency.
RESULTS
Nine studies with a total population of 291 individuals were included in the meta-analysis for nasal resistance after recumbency. We found a statistically significant difference in nasal airway resistance of -0.18 Pa sec/cm as compared to before and after recumbency through rhinomanometry (RMM) analysis. A subgroup analysis revealed a variation of -0.20 Pa sec/cm for patients with snoring or sleep apnea and - 0.10 Pa sec/cm for healthy individuals. Regarding nasal airflow measured with RMM, three studies (n = 32) in asymptomatic controls revealed a statistically significant difference of 47.33 ml/sec.
CONCLUSIONS
Recumbency increases nasal resistance and diminishes nasal airflow. This finding is of utmost importance in snorers and sleep apnea patients. Laryngoscope, 132:6-16, 2022.
Topics: Airway Resistance; Humans; Nasal Cavity; Supine Position
PubMed: 33720430
DOI: 10.1002/lary.29509 -
Journal of Clinical Nursing Sep 2009This study aims to help nurses and nurse practitioners identify and manage paediatric patients with upper airway resistance syndrome. A review of upper airway resistance... (Review)
Review
AIMS
This study aims to help nurses and nurse practitioners identify and manage paediatric patients with upper airway resistance syndrome. A review of upper airway resistance syndrome is provided, including the signs and symptoms of upper airway resistance syndrome, criteria for diagnosis, recommendations for treatment and implications for nursing in paediatric primary care.
BACKGROUND
Nurses often encounter sleep-related problems in the paediatric primary care setting. Commonly, these problems are well known and include snoring and obstructive sleep apnoea. Upper airway resistance syndrome is a relatively new diagnosis among sleep-related breathing disorders with which nurses and nurse practitioners should be familiar. Upper airway resistance syndrome is characterised by incomplete obstruction of the airway during sleep, leading to increased respiratory efforts and frequent arousals despite normal oxygen saturations.
DESIGN
Systematic review.
METHOD
A review of the sleep literature identified articles regarding sleep and/or sleep-related breathing disorders and paediatrics, and upper airway resistance syndrome. Articles published since 2002 were prioritised; however, all articles describing upper airway resistance syndrome since 1993 were considered.
CONCLUSION
Timely recognition of sleep-disordered breathing is crucial to ensuring that patients receive effective and appropriate treatment. Upper airway resistance syndrome should be a part of the differential diagnosis when assessing a child with a sleep-related breathing disorder. RELEVANCE TO CLINICIAN PRACTICE: Nurses and nurse practitioners should become comfortable and skilled in performing a thorough sleep history and physical examination to help identify when a child should receive a sleep study or referral to a specialist.
Topics: Adolescent; Child; Child, Preschool; Humans; Pediatric Nursing; Sleep Apnea, Obstructive
PubMed: 19538557
DOI: 10.1111/j.1365-2702.2008.02772.x -
Cureus Jul 2023Airway suctioning is routinely performed in the majority of care circumstances, including acute care, subacute care, home-based settings, and long-term care. Using an... (Review)
Review
Airway suctioning is routinely performed in the majority of care circumstances, including acute care, subacute care, home-based settings, and long-term care. Using an artificial airway to suction the patient allows for the mobilization and evacuation of secretions. When a patient can't independently remove all of the secretions from their respiratory tract, suction is used. This can occur when the body produces excessive secretion or it is not eliminated quickly enough, causing the respiratory system's upper and lower respiratory secretions to accumulate. Airway blockage and inadequate breathing may result from this. Ultimately, this leads to a shortage of oxygen and carbon dioxide from the air, both of which are necessary for ideal cellular activity. Artificial airway suctioning is one of the most crucial components of airway care and a core competency for medical professionals trying to ensure airway patency. Artificial airway suctioning is a standard treatment carried out every day globally and is frequently done in both outpatient and inpatient patients. Therefore, specialists must know the safest and most efficient ways to perform surgery and any potential side effects. In ventilated infants and children, the removal of obstructive secretions by endotracheal suctioning is frequently done. It is unknown how suctioning affects the mechanics of breathing. This study used a prospective observational clinical design to examine the immediate impact of airway resistance in endotracheal suctioning, tidal volume, and dynamic lung regulation in mechanically ventilated adult patients and mechanically ventilated pediatric patients. The preparation, process, and indications for intraoperative fusion treatment in various circumstances are covered in this systematic review.
PubMed: 37641766
DOI: 10.7759/cureus.42579