TREATMENT OF POSTOPERATIVE NAUSEA AND VOMITING THAT IS ALREADY ESTABLISHED DURING THE POST-ANESTHESIA CARE UNIT: A VIGNETTE-BASED SURVEY OF ANESTHESIOLOGISTS
Main Article Content
Keywords
Postoperative nausea and vomiting (PONV), Antiemetic therapy, Post-anesthesia care unit (PACU), Clinical practice patterns, Vignette-based survey.
Abstract
Background: Postoperative nausea and vomiting (PONV) is one of the most uncomfortable adverse effects of patients undergoing surgery and is one of the primary factors influencing their satisfaction with the anesthesia services. Although much attention has been paid to the prevention of PONV, there is little information on the treatment of proven PONV within a regular clinical scenario.
Methods: A questionnaire with five hypothetical clinical vignettes was dispatched to 300 anesthesiologists who were randomly chosen to provide an insight into the treatment measures of established PONV based in the post-anesthesia care unit (PACU). Vignettes involved a description of an ambulatory surgical patient who experienced PONV due to the administration of different prophylactic regimens. The respondents were requested to specify their first and second preference of treatment, both pharmacologic and non-pharmacologic. Such demographic and practice characteristics were also gathered.
Findings: The survey was filled out by seventy-six anesthesiologists. The most commonly chosen first line treatment was 5-HT3 receptor antagonist (50%), when none had been used as prophylaxis. Even though majority of the respondents said that they had switched to another pharmacologic class due to prophylaxis failure, a significant number of respondents repeated dosing of 5-HT3 antagonists. Pharmacologic (18 agents) and non-pharmacologic (12 interventions) treatments were reported in wide range, which means that there was a significant variation in practices patterns.
Conclusions: The therapy of established PONV is still less uniform and does not always follow the recommendations of the consensus. The results noted here emphasize the necessity of standardized treatment recommendations, better clinical decision-making, and additional clinical trials dedicated to the most effective way of managing PONV once it occurs.
References
1. Kindler CH, Harms C, Amsler F, Ihde-Scholl T, Scheidegger D: The visual analog scale allows effective measurement of preoper- ative anxiety and detection of patients' anesthetic concerns. Anesth Analg 2000, 90:706-712.
2. Macario A, Weinger M, Carney S, Kim A: Which clinical anesthe- sia outcomes are important to avoid? The perspective of patients. Anesth Analg 1999, 89:652-658.
3. Macario A, Weinger M, Truong P, Lee M: Which clinical anesthe- sia outcomes are both common and important to avoid? The perspective of a panel of expert anesthesiologists. Anesth Analg 1999, 88:1085-1091.
4. Apfel CC, Korttila K, Abdalla M, Kerger H, Turan A, Vedder I, Zernak C, Danner K, Jokela R, Pocock SJ, Trenkler S, Kredel M, Biedler A, Sessler DI, Roewer N, IMPACT Investigators: A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004, 350:2441-2451.
5. White PF, Hamza MA, Recart A, Coleman JE, Macaluso AR, Cox L, Jaffer O, Song D, Rohrich R: Optimal timing of acustimulation for antiemetic prophylaxis as an adjunct to ondansetron in patients undergoing plastic surgery. Anesth Analg 2005, 100:367-372.
6. Henzi I, Walder B, Tramer MR: Metoclopramide in the preven- tion of postoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled stud- ies. Br J Anaesth 1999, 83:761-771.
7. Kranke P, Morin AM, Roewer N, Wulf H, Eberhart LH: The efficacy and safety of transdermal scopolamine for the prevention of postoperative nausea and vomiting: a quantitative system- atic review. Anesth Analg 2002, 95:133-143.
8. Habib AS, El-Moalem HE, Gan TJ: The efficacy of the 5-HT3 receptor antagonists combined with droperidol for PONV prophylaxis is similar to their combination with dexametha- sone. A meta-analysis of randomized controlled trials. Can J Anaesth 2004, 51:311-319.
9. Macario A, Chung A, Weinger MB: Variation in practice patterns of anesthesiologists in California for prophylaxis of postoper- ative nausea and vomiting. J Clin Anesth 2001, 13:353-360.
10. Kazemi-Kjellberg F, Henzi I, Tramer MR: Treatment of estab- lished postoperative nausea and vomiting: a quantitative sys- tematic review. BMC Anesthesiol 2001, 1:2.
11. Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, Kovac A, Philip BK, Sessler DI, Temo J, Tramer MR, Watcha M: Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003, 97:62-71.
12. Peabody JW, Luck J, Glassman P, Jain S, Hansen J, Spell M, Lee M: Measuring the quality of physician practice by using clinical vignettes: a prospective validation study. Ann Intern Med 2004, 141:771-780.
13. Colenda CC, Rapp SR, Leist JC, Poses RM: Clinical variables influ- encing treatment decisions for agitated dementia patients: survey of physician judgments. J Am Geriatr Soc 1996, 44:1375-1379.
14. Sriram TG, Chandrashekar CR, Isaac MK, Srinivasa Murthy R, Kishore Kumar KV, Moily S, Shanmugham V: Development of case vignettes to assess the mental health training of primary care medical officers. Acta Psychiatr Scand 1990, 82:174-177.
15. Glassman PA, Kravitz RL, Petersen LP, Rolph JE: Differences in clin- ical decision making between internists and cardiologists. Arch Intern Med 1997, 157:506-512.
16. Newcombe RG: Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 1998, 17:857-872.
17. Ashton CM, Petersen NJ, Souchek J, Menke TJ, Yu HJ, Pietz K, Eigen- brodt ML, Barbour G, Kizer KW, Wray NP: Geographic variations in utilization rates in Veterans Affairs hospitals and clinics. N Engl J Med 1999, 340:32-39.
18. O'Connor GT, Quinton HB, Traven ND, Ramunno LD, Dodds TA, Marciniak TA, Wennberg JE: Geographic variation in the treat- ment of acute myocardial infarction: the Cooperative Cardi- ovascular Project. JAMA 1999, 281:627-633.
19. Wennberg J, Gittelsohn : Small area variations in health care delivery. Science 1973, 182:1102-1108.
20. Cohen MM, Rose DK, Yee DA: Changing anesthesiologists' practice patterns. Can it be done? Anesthesiology 1996, 85:260-269.
21. Overdyk FJ, Harvey SC, Baldwin D, Rust P, Multani M, Marcell J: Indi- vidualized outcome feedback produces voluntary antiemetic prescribing practice changes. J Clin Anesth 1999, 11:17-23.
22. Tramer MR, Moore RA, Reynolds DJ, McQuay HJ: A quantitative systematic review of ondansetron in treatment of estab- lished postoperative nausea and vomiting. BMJ 1997, 314:1088-1092.
23. Claybon L: Single dose intravenous ondansetron for the 24- hour treatment of postoperative nausea and vomiting. Anaes- thesia 1994, 49(Suppl):24-29.
24. Scuderi PE, James RL, Harris L, Mims GR: Antiemetic prophylaxis does not improve outcomes after outpatient surgery when compared to symptomatic treatment. Anesthesiology 1999, b90:360-371.
25. Candiotti KA, Birnbach DJ, Lubarsky DA, Nhuch F, Kamat A, Koch WH, Nikoloff M, Wu L, Andrews D: The impact of pharmacoge- nomics on postoperative nausea and vomiting: do CYP2D6 allele copy number and polymorphisms affect the success or failure of ondansetron prophylaxis? Anesthesiology 2005, 102:543-549.
26. Habib AS, Gan TJ: The effectiveness of rescue antiemetics after failure of prophylaxis with ondansetron or droperidol: a pre- liminary report. J Clin Anesth 2005, 17:62-65.
27. Kovac AL, O'Connor TA, Pearman MH, Kekoler LJ, Edmondson D, Baughman VL, Angel JJ, Campbell C, Jense HG, Mingus M, Shahvari MB, Creed MR: Efficacy of repeat intravenous dosing of ondansetron in controlling postoperative nausea and vomit- ing: a randomized, double-blind, placebo-controlled multi- center trial. J Clin Anesth 1999, 11:453-459.
28. Joris JL, Poth NJ, Djamadar AM, Sessler DI, Hamoir EE, Defechereux TR, Meurisse MR, Lamy ML: Supplemental oxygen does not reduce postoperative nausea and vomiting after thyroidec- tomy. Br J Anaesth 2003, 91:857-861.
29. Greif R, Laciny S, Rapf B, Hickle RS, Sessler DI: Supplemental oxy- gen reduces the incidence of postoperative nausea and vom- iting. Anesthesiology 1999, 91:1246-1252.
30. Anderson LA, Gross JB: Aromatherapy with peppermint, iso- propyl alcohol, or placebo is equally effective in relieving postoperative nausea. J Perianesth Nurs 2004, 19:29-35.
31. Coloma M, White PF, Ogunnaike BO, Markowitz SD, Brown PM, Lee AQ, Berrisford SB, Wakefield CA, Issioui T, Jones SB, Jones DB: Comparison of acustimulation and ondansetron for the treatment of established postoperative nausea and vomit- ing. Anesthesiology 2002, 97:1387-1392.
32. Lee A, Gin T, Lau AS, Ng FF: A comparison of patients' and health care professionals' preferences for symptoms during immediate postoperative recovery and the management of postoperative nausea and vomiting. Anesth Analg 2005, 100:87-93.
33. Macario A, Dexter F, Lubarsky D: Meta-analysis of trials compar- ing postoperative recovery after anesthesia with sevoflurane or desflurane. Am J Health Syst Pharm 2005, 62:63-68.
34. Apfel CC, Roewer N, Korttila K: How to study postoperative nausea and vomiting. Acta Anaesthesiol Scand 2002, 46:921-928.
35. Burmeister LF: Principles of successful sample surveys. Anesthe- siology 2003, 99:1251-1252. compared to symptomatic treatment. Anesthesiology 1999, 90:360-371.
36. Candiotti KA, Birnbach DJ, Lubarsky DA, Nhuch F, Kamat A, Koch WH, Nikoloff M, Wu L, Andrews D: The impact of pharmacoge- nomics on postoperative nausea and vomiting: do CYP2D6 allele copy number and polymorphisms affect the success or failure of ondansetron prophylaxis? Anesthesiology 2005, 102:543-549.
37. Habib AS, Gan TJ: The effectiveness of rescue antiemetics after failure of prophylaxis with ondansetron or droperidol: a pre- liminary report. J Clin Anesth 2005, 17:62-65.
38. Kovac AL, O'Connor TA, Pearman MH, Kekoler LJ, Edmondson D, Baughman VL, Angel JJ, Campbell C, Jense HG, Mingus M, Shahvari MB, Creed MR: Efficacy of repeat intravenous dosing of ondansetron in controlling postoperative nausea and vomit- ing: a randomized, double-blind, placebo-controlled multi- center trial. J Clin Anesth 1999, 11:453-459.
39. Joris JL, Poth NJ, Djamadar AM, Sessler DI, Hamoir EE, Defechereux TR, Meurisse MR, Lamy ML: Supplemental oxygen does not reduce postoperative nausea and vomiting after thyroidec- tomy. Br J Anaesth 2003, 91:857-861.
40. Greif R, Laciny S, Rapf B, Hickle RS, Sessler DI: Supplemental oxy- gen reduces the incidence of postoperative nausea and vom- iting. Anesthesiology 1999, 91:1246-1252.
41. Anderson LA, Gross JB: Aromatherapy with peppermint, iso- propyl alcohol, or placebo is equally effective in relieving postoperative nausea. J Perianesth Nurs 2004, 19:29-35.
42. Coloma M, White PF, Ogunnaike BO, Markowitz SD, Brown PM, Lee AQ, Berrisford SB, Wakefield CA, Issioui T, Jones SB, Jones DB: Comparison of acustimulation and ondansetron for the treatment of established postoperative nausea and vomit- ing. Anesthesiology 2002, 97:1387-1392.
43. Lee A, Gin T, Lau AS, Ng FF: A comparison of patients' and health care professionals' preferences for symptoms during immediate postoperative recovery and the management of postoperative nausea and vomiting. Anesth Analg 2005, 100:87-93.
44. Macario A, Dexter F, Lubarsky D: Meta-analysis of trials compar- ing postoperative recovery after anesthesia with sevoflurane or desflurane. Am J Health Syst Pharm 2005, 62:63-68.
45. Apfel CC, Roewer N, Korttila K: How to study postoperative nausea and vomiting. Acta Anaesthesiol Scand 2002, 46:921-928.
46. Burmeister LF: Principles of successful sample surveys. Anesthe- siology 2003, 99:1251-1252.
2. Macario A, Weinger M, Carney S, Kim A: Which clinical anesthe- sia outcomes are important to avoid? The perspective of patients. Anesth Analg 1999, 89:652-658.
3. Macario A, Weinger M, Truong P, Lee M: Which clinical anesthe- sia outcomes are both common and important to avoid? The perspective of a panel of expert anesthesiologists. Anesth Analg 1999, 88:1085-1091.
4. Apfel CC, Korttila K, Abdalla M, Kerger H, Turan A, Vedder I, Zernak C, Danner K, Jokela R, Pocock SJ, Trenkler S, Kredel M, Biedler A, Sessler DI, Roewer N, IMPACT Investigators: A factorial trial of six interventions for the prevention of postoperative nausea and vomiting. N Engl J Med 2004, 350:2441-2451.
5. White PF, Hamza MA, Recart A, Coleman JE, Macaluso AR, Cox L, Jaffer O, Song D, Rohrich R: Optimal timing of acustimulation for antiemetic prophylaxis as an adjunct to ondansetron in patients undergoing plastic surgery. Anesth Analg 2005, 100:367-372.
6. Henzi I, Walder B, Tramer MR: Metoclopramide in the preven- tion of postoperative nausea and vomiting: a quantitative systematic review of randomized, placebo-controlled stud- ies. Br J Anaesth 1999, 83:761-771.
7. Kranke P, Morin AM, Roewer N, Wulf H, Eberhart LH: The efficacy and safety of transdermal scopolamine for the prevention of postoperative nausea and vomiting: a quantitative system- atic review. Anesth Analg 2002, 95:133-143.
8. Habib AS, El-Moalem HE, Gan TJ: The efficacy of the 5-HT3 receptor antagonists combined with droperidol for PONV prophylaxis is similar to their combination with dexametha- sone. A meta-analysis of randomized controlled trials. Can J Anaesth 2004, 51:311-319.
9. Macario A, Chung A, Weinger MB: Variation in practice patterns of anesthesiologists in California for prophylaxis of postoper- ative nausea and vomiting. J Clin Anesth 2001, 13:353-360.
10. Kazemi-Kjellberg F, Henzi I, Tramer MR: Treatment of estab- lished postoperative nausea and vomiting: a quantitative sys- tematic review. BMC Anesthesiol 2001, 1:2.
11. Gan TJ, Meyer T, Apfel CC, Chung F, Davis PJ, Eubanks S, Kovac A, Philip BK, Sessler DI, Temo J, Tramer MR, Watcha M: Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003, 97:62-71.
12. Peabody JW, Luck J, Glassman P, Jain S, Hansen J, Spell M, Lee M: Measuring the quality of physician practice by using clinical vignettes: a prospective validation study. Ann Intern Med 2004, 141:771-780.
13. Colenda CC, Rapp SR, Leist JC, Poses RM: Clinical variables influ- encing treatment decisions for agitated dementia patients: survey of physician judgments. J Am Geriatr Soc 1996, 44:1375-1379.
14. Sriram TG, Chandrashekar CR, Isaac MK, Srinivasa Murthy R, Kishore Kumar KV, Moily S, Shanmugham V: Development of case vignettes to assess the mental health training of primary care medical officers. Acta Psychiatr Scand 1990, 82:174-177.
15. Glassman PA, Kravitz RL, Petersen LP, Rolph JE: Differences in clin- ical decision making between internists and cardiologists. Arch Intern Med 1997, 157:506-512.
16. Newcombe RG: Two-sided confidence intervals for the single proportion: comparison of seven methods. Stat Med 1998, 17:857-872.
17. Ashton CM, Petersen NJ, Souchek J, Menke TJ, Yu HJ, Pietz K, Eigen- brodt ML, Barbour G, Kizer KW, Wray NP: Geographic variations in utilization rates in Veterans Affairs hospitals and clinics. N Engl J Med 1999, 340:32-39.
18. O'Connor GT, Quinton HB, Traven ND, Ramunno LD, Dodds TA, Marciniak TA, Wennberg JE: Geographic variation in the treat- ment of acute myocardial infarction: the Cooperative Cardi- ovascular Project. JAMA 1999, 281:627-633.
19. Wennberg J, Gittelsohn : Small area variations in health care delivery. Science 1973, 182:1102-1108.
20. Cohen MM, Rose DK, Yee DA: Changing anesthesiologists' practice patterns. Can it be done? Anesthesiology 1996, 85:260-269.
21. Overdyk FJ, Harvey SC, Baldwin D, Rust P, Multani M, Marcell J: Indi- vidualized outcome feedback produces voluntary antiemetic prescribing practice changes. J Clin Anesth 1999, 11:17-23.
22. Tramer MR, Moore RA, Reynolds DJ, McQuay HJ: A quantitative systematic review of ondansetron in treatment of estab- lished postoperative nausea and vomiting. BMJ 1997, 314:1088-1092.
23. Claybon L: Single dose intravenous ondansetron for the 24- hour treatment of postoperative nausea and vomiting. Anaes- thesia 1994, 49(Suppl):24-29.
24. Scuderi PE, James RL, Harris L, Mims GR: Antiemetic prophylaxis does not improve outcomes after outpatient surgery when compared to symptomatic treatment. Anesthesiology 1999, b90:360-371.
25. Candiotti KA, Birnbach DJ, Lubarsky DA, Nhuch F, Kamat A, Koch WH, Nikoloff M, Wu L, Andrews D: The impact of pharmacoge- nomics on postoperative nausea and vomiting: do CYP2D6 allele copy number and polymorphisms affect the success or failure of ondansetron prophylaxis? Anesthesiology 2005, 102:543-549.
26. Habib AS, Gan TJ: The effectiveness of rescue antiemetics after failure of prophylaxis with ondansetron or droperidol: a pre- liminary report. J Clin Anesth 2005, 17:62-65.
27. Kovac AL, O'Connor TA, Pearman MH, Kekoler LJ, Edmondson D, Baughman VL, Angel JJ, Campbell C, Jense HG, Mingus M, Shahvari MB, Creed MR: Efficacy of repeat intravenous dosing of ondansetron in controlling postoperative nausea and vomit- ing: a randomized, double-blind, placebo-controlled multi- center trial. J Clin Anesth 1999, 11:453-459.
28. Joris JL, Poth NJ, Djamadar AM, Sessler DI, Hamoir EE, Defechereux TR, Meurisse MR, Lamy ML: Supplemental oxygen does not reduce postoperative nausea and vomiting after thyroidec- tomy. Br J Anaesth 2003, 91:857-861.
29. Greif R, Laciny S, Rapf B, Hickle RS, Sessler DI: Supplemental oxy- gen reduces the incidence of postoperative nausea and vom- iting. Anesthesiology 1999, 91:1246-1252.
30. Anderson LA, Gross JB: Aromatherapy with peppermint, iso- propyl alcohol, or placebo is equally effective in relieving postoperative nausea. J Perianesth Nurs 2004, 19:29-35.
31. Coloma M, White PF, Ogunnaike BO, Markowitz SD, Brown PM, Lee AQ, Berrisford SB, Wakefield CA, Issioui T, Jones SB, Jones DB: Comparison of acustimulation and ondansetron for the treatment of established postoperative nausea and vomit- ing. Anesthesiology 2002, 97:1387-1392.
32. Lee A, Gin T, Lau AS, Ng FF: A comparison of patients' and health care professionals' preferences for symptoms during immediate postoperative recovery and the management of postoperative nausea and vomiting. Anesth Analg 2005, 100:87-93.
33. Macario A, Dexter F, Lubarsky D: Meta-analysis of trials compar- ing postoperative recovery after anesthesia with sevoflurane or desflurane. Am J Health Syst Pharm 2005, 62:63-68.
34. Apfel CC, Roewer N, Korttila K: How to study postoperative nausea and vomiting. Acta Anaesthesiol Scand 2002, 46:921-928.
35. Burmeister LF: Principles of successful sample surveys. Anesthe- siology 2003, 99:1251-1252. compared to symptomatic treatment. Anesthesiology 1999, 90:360-371.
36. Candiotti KA, Birnbach DJ, Lubarsky DA, Nhuch F, Kamat A, Koch WH, Nikoloff M, Wu L, Andrews D: The impact of pharmacoge- nomics on postoperative nausea and vomiting: do CYP2D6 allele copy number and polymorphisms affect the success or failure of ondansetron prophylaxis? Anesthesiology 2005, 102:543-549.
37. Habib AS, Gan TJ: The effectiveness of rescue antiemetics after failure of prophylaxis with ondansetron or droperidol: a pre- liminary report. J Clin Anesth 2005, 17:62-65.
38. Kovac AL, O'Connor TA, Pearman MH, Kekoler LJ, Edmondson D, Baughman VL, Angel JJ, Campbell C, Jense HG, Mingus M, Shahvari MB, Creed MR: Efficacy of repeat intravenous dosing of ondansetron in controlling postoperative nausea and vomit- ing: a randomized, double-blind, placebo-controlled multi- center trial. J Clin Anesth 1999, 11:453-459.
39. Joris JL, Poth NJ, Djamadar AM, Sessler DI, Hamoir EE, Defechereux TR, Meurisse MR, Lamy ML: Supplemental oxygen does not reduce postoperative nausea and vomiting after thyroidec- tomy. Br J Anaesth 2003, 91:857-861.
40. Greif R, Laciny S, Rapf B, Hickle RS, Sessler DI: Supplemental oxy- gen reduces the incidence of postoperative nausea and vom- iting. Anesthesiology 1999, 91:1246-1252.
41. Anderson LA, Gross JB: Aromatherapy with peppermint, iso- propyl alcohol, or placebo is equally effective in relieving postoperative nausea. J Perianesth Nurs 2004, 19:29-35.
42. Coloma M, White PF, Ogunnaike BO, Markowitz SD, Brown PM, Lee AQ, Berrisford SB, Wakefield CA, Issioui T, Jones SB, Jones DB: Comparison of acustimulation and ondansetron for the treatment of established postoperative nausea and vomit- ing. Anesthesiology 2002, 97:1387-1392.
43. Lee A, Gin T, Lau AS, Ng FF: A comparison of patients' and health care professionals' preferences for symptoms during immediate postoperative recovery and the management of postoperative nausea and vomiting. Anesth Analg 2005, 100:87-93.
44. Macario A, Dexter F, Lubarsky D: Meta-analysis of trials compar- ing postoperative recovery after anesthesia with sevoflurane or desflurane. Am J Health Syst Pharm 2005, 62:63-68.
45. Apfel CC, Roewer N, Korttila K: How to study postoperative nausea and vomiting. Acta Anaesthesiol Scand 2002, 46:921-928.
46. Burmeister LF: Principles of successful sample surveys. Anesthe- siology 2003, 99:1251-1252.
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Dec 09, 2020
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Dr.Smithasri. Uppalapati. (2020). TREATMENT OF POSTOPERATIVE NAUSEA AND VOMITING THAT IS ALREADY ESTABLISHED DURING THE POST-ANESTHESIA CARE UNIT: A VIGNETTE-BASED SURVEY OF ANESTHESIOLOGISTS. Journal of Population Therapeutics and Clinical Pharmacology, 27(4), 287-296. https://doi.org/10.53555/hzz00f10
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Author Biography
Dr.Smithasri. Uppalapati
Assistant Professor, Department of Anesthesia, Sri Lakshmi Narayana Institute of Medical Science, Pondicherry, India.
How to Cite
Dr.Smithasri. Uppalapati. (2020). TREATMENT OF POSTOPERATIVE NAUSEA AND VOMITING THAT IS ALREADY ESTABLISHED DURING THE POST-ANESTHESIA CARE UNIT: A VIGNETTE-BASED SURVEY OF ANESTHESIOLOGISTS. Journal of Population Therapeutics and Clinical Pharmacology, 27(4), 287-296. https://doi.org/10.53555/hzz00f10
