scholarly journals A review on health-care acquired infections of the hospital staff during routine patient’s delivery service

2021 ◽  
Vol 25 (9) ◽  
pp. 1581-1586
Author(s):  
A.A. Enaigbe ◽  
C.C. Irodi
Keyword(s):  
Health Care ◽  
Health Care Professionals ◽  
Adverse Drug Events ◽  
Care Delivery ◽  
Educational Interventions ◽  
World Health ◽  
Infection Prevention And Control ◽  
Medical Attention ◽  
And Control ◽  
The Impact

The health-care acquired infections (HCAIs) occur world-wide among persons undergoing medical attention in health institutions and result in unexpected long-term stay, disability and financial loses. The most predominant infections are catheter associated urinary tract, central line associated, surgical site and ventilator associated pneumonia infections. The patients are prone to infections during hospitalization from varied environmental sources, hands of health-care professionals, medical equipment and other infected patients. The frequent factors affecting patients on admission are improper hand hygiene, contact with infected patients, adverse drug events and surgical complications. Patients under health-care delivery can acquire infection disseminated from food, water, aerosols and hospital wastes. The application of personal protective equipment, routine educational interventions are common approaches that can help stop HCAIs and save lives, decrease death rate and health delivery expenses. In buttressing this, the World Health Organization (WHO) enunciated guidelines to enhance hand washing practices, infection prevention and control programme, monitored use of antibiotics and its resistance. The other measures included global adoption of efficient surveillance system and the impact of relevant stakeholders in health sectors needed to prevent and control hospital acquired infections.

scholarly journals The experience of European hospital-based health care workers on following infection prevention and control procedures for COVID-19

2020 ◽  
Author(s):  
Denise van Hout ◽  
Paul Hutchinson ◽  
Marta Wanat ◽  
Caitlin Pilbeam ◽  
Herman Goossens ◽  
...  
Keyword(s):  
Health Care ◽  
Health Care Workers ◽  
Prevention And Control ◽  
Infection Prevention ◽  
Infection Risk ◽  
Infection Prevention And Control ◽  
Emotional Wellbeing ◽  
Care Workers ◽  
And Control ◽  
The Impact

ABSTRACTBackgroundWorking under pandemic conditions exposes health care workers (HCWs) to infection risk and psychological strain. Protecting the physical and psychological health of HCWs is a key priority. This study assessed the perceptions of European hospital HCWs of local infection prevention and control (IPC) procedures during the COVID-19 pandemic and the impact on their emotional wellbeing.MethodsWe performed two rounds of an international cross-sectional survey, between 31 March and 17 April 2020 via existing research networks (round 1), and between 14 May and 31 August 2020 via online convenience sampling (round 2). Main outcome measures were (1) behavioural determinants of HCW adherence with IPC procedures, (2) WHO-5 Well-Being Index, a validated scale of 0-100 reflecting emotional wellbeing. The WHO-5 was interpreted as a score below or above 50 points, a cut-off score used in previous literature to screen for depression.Results2,289 HCWs (round 1: n=190, round 2: n=2,099) from 40 countries in Europe participated. Mean age of respondents was 42 (±11) years, 66% were female, 47% and 39% were medical doctors and nurses, respectively. 74% (n=1699) of HCWs were directly treating patients with COVID-19, of which 32% (n=527) reported they were fearful of caring for these patients. HCWs reported high levels of concern about COVID-19 infection risk to themselves (71%) and their family (82%) as a result of their job. 40% of HCWs considered that getting infected with COVID-19 was not within their control. This was more common among junior than senior HCWs (46% versus 38%, P value <.01). Sufficient COVID-19-specific IPC training, confidence in PPE use and institutional trust were positively associated with the feeling that becoming infected with COVID-19 was within their control. Female HCWs were more likely than males to report a WHO-5 score below 50 points (aOR 1.5 (95% confidence interval (CI) 1.2-1.8).ConclusionsIn Europe, the COVID-19 pandemic has had a differential impact on those providing direct COVID-19 patient care, junior staff and women. Health facilities must be aware of these differential impacts, build trust and provide tailored support for this vital workforce during the current COVID-19 pandemic.

scholarly journals Spectrum of genetic disorders and the impact on health care delivery: an introduction

1999 ◽  
Vol 5 (6) ◽  
pp. 1188-1195
Author(s):  
v El Hazmi
Keyword(s):  
Health Care ◽  
Health Care Delivery ◽  
Care Delivery ◽  
Genetic Disorders ◽  
Single Gene ◽  
Medical Attention ◽  
World Population ◽  
Symptomatic Therapy ◽  
Specialist Care ◽  
The Impact

Until recently, infectious diseases and malnutrition-related disorders constituted the major cause of ill health and mortality in the world population. However, advances in treatment of such disorders and increased understanding of the molecular basis of heredity have led to genetically transmitted conditions becoming a major cause of morbidity and mortality. Several disorders, including chromosomal [Down syndrome, Turner syndrome], single-gene [sickle-cell disease, thalassaemia, glucose-6-phosphate dehydrogenase deficiency, haemophilia, inborn errors of metabolism]and multifactorial disorders [coronary artery disease, arteriosclerosis, diabetes mellitus, hypertension, obesity]are common and becoming increasingly important. As there is no agreed-upon definitive cure with acceptable risk, these disorders are a significant burden on the health care delivery system. This is because the chronic nature of genetic diseases requires lifelong medical attention, expensive supportive and symptomatic therapy and specialist care. This review outlines the genetic disorders, their impact on health care delivery systems and the general framework required to prevent and control these disorders

scholarly journals Knowledge, attitude and preventive practices regarding tuberculosis care and control among health care professionals at TB centres: implications for TB control efforts

2020 ◽  
Vol 7 (6) ◽  
pp. 2318
Author(s):  
K. M. Jaiswal ◽  
Lohit S. Vaishnao ◽  
Sujata Dudhgaonkar ◽  
Latesh Raghte ◽  
Mahek S. Kewalramani ◽  
...  
Keyword(s):  
Health Care ◽  
Traditional Medicine ◽  
Health Care Professionals ◽  
World Health ◽  
Average Score ◽  
Global Public Health ◽  
Attitudes And Practices ◽  
Preventive Practices ◽  
Paramedical Staff ◽  
And Control

Background: Tuberculosis (TB) ranks as the leading cause of death from infectious disease. The World Health Organization (WHO) has considered TB a global public health disaster since 1993. Four factors affect non-adherence to treatment-the patient, healthcare systems, pharmaco-therapeutics and the key persons, health care professional (HCP). So, the study was conducted to evaluate knowledge, attitudes and practices regarding TB care and control in HCPs working in TB units.Methods: This was a cross-sectional, observational, questionnaire-based study conducted in all the HCPs working for the TB care and control.Results: The responses to the questions of knowledge were variable indicating incompleteness of information, facts, understanding related to TB in HCPs. HCPs show very strong positive attitude for finding every new case of TB is essential. The HCPs disagree to some statements like traditional or alternative medicine assists in wellbeing of TB patients. Practice competency was low with average score 2.32 out of 6, doctors having higher score of 4.62 followed by nurses, lab-technicians, pharmacist and activist with score of 2.57, 1.66, 1.5, 1.25 respectively.  The activist are the key persons in the national tuberculosis program, exhibited the least score in this study indicates they do not have much orientation about the practice of TB treatment. Specific deficiencies existed for some knowledge statements of HCWs on TB. There was disagreement in attitudes regarding stigma and traditional medicine, and practice competencies were poor. Improvement in aspect of KAP of HCPs on TB will help India achieve the goal of End TB.Conclusions: Specific deficiencies existed for some knowledge statements of TB in paramedical staff as compared to doctor participants. There was disagreement in attitudes regarding stigma and traditional medicine, and practice competencies were poor in activists. Improvement in knowledge, attitude and practices of TB in paramedical staff by conducting CME, Workshop, training sessions will help India to achieve the goal of End TB.

scholarly journals Hospital knowledge and practice of doctors and nurses regarding hand hygiene in a survey

2020 ◽  
pp. 119-132
Keyword(s):  
Health Care ◽  
Hand Hygiene ◽  
Health Care Professionals ◽  
Scientific Evidence ◽  
Health Care Facilities ◽  
World Health ◽  
The Difference ◽  
Health Organization ◽  
Healthcare Associated ◽  
The Impact

INTRODUCTION. The guidelines issued by the World Health Organization (WHO) in 2009 regarding hand hygiene (HH) in health care provided health care professionals with scientific evidence that argued that HH principles should be respected when dealing with patients. Despite the passage of years and strenuous attempts to introduce these recommendations to the Polish health care facilities for the prevention of healthcare-associated infections (HAI), these principles are still not being implemented in an optimal way for the patient’s safety. OBJECTIVE OF WORK. The aim was to examine the views and attitudes of physicians (L) and nurses (P) towards the WHO rules of hand hygiene. MATERIAL AND METHODS. The study was performed by means of a diagnostic survey using a questionnaire of our own design; random sampling was used. The study involved 231 LP: 173 (74.9%) women, 58 (25.1%) men, including 93 (40.3%) doctors and 138 (59.7%) nurses. The study was conducted in a multiprofile hospital in Małopolska in 2017. The difference between what the respondents think (their views) and what they do in reality (what attitudes they display) was examined in relation to WHO principles, such as wearing natural short nails and jewelry on their hands. RESULTS. Negative practice of observing these HH principles in relation to views was detected (R = -0.014, p<0.05, R2 = 0.016). Respondents supported the view that the ring could affect HAI and rarely used it in practice, the practice was positive (R = 0.298, p <0.001, R2 = 0.085). Women strongly emphasized the view that wearing long nails has an impact on HAI spread, but in practice they often declared keeping long nails, practice was negative (R = -0.241, p <0.01, R2 = 0.054). In response to the question about the impact of nail painting on the spread of HAI, this view was poorly represented, in practice some of them wore painted nails, the practice was negative (R = -0.226, p <0.01, R2 = 0.045). CONCLUSION. Despite high support for the principles of hand hygiene, in practice, these principles were not always respected, the impact on the practice was negative in areas such as: general adherence to the HH principles, wearing long and painted nails. The compatibility of views with practice was detected in relation to wearing a wedding ring.

“Stories Take Your Role Away From You”: Understanding the Impact on Health Care Professionals of Viewing Digital Stories of Pediatric and Adolescent/Young Adult Oncology Patients

2017 ◽  
Vol 34 (4) ◽  
pp. 261-271 ◽  
Author(s):  
Catherine M. Laing ◽  
Nancy J. Moules ◽  
Andrew Estefan ◽  
Mike Lang
Keyword(s):  
Health Care ◽  
Young Adult ◽  
Health Care Providers ◽  
Health Care Professionals ◽  
Care Delivery ◽  
Healthcare Delivery ◽  
Care Providers ◽  
Oncology Patients ◽  
Digital Stories ◽  
The Impact

The purpose of this philosophical hermeneutic study was to understand the effects on health care providers (HCPs) of watching digital stories made by (past and present) pediatric and adolescent/young adult (AYA) oncology patients. Twelve HCPs participated in a focus group where they watched digital stories made by pediatric/AYA oncology patients and participated in a discussion related to the impact the stories had on them personally and professionally. Findings from this research revealed that HCPs found digital stories to be powerful, therapeutic, and educational tools. Health care providers described uses for digital stories ranging from education of newly diagnosed families to training of new staff. Digital stories, we conclude, can be an efficient and effective way through which to understand the patient experience, implications from which can range from more efficient patient care delivery to decision making. Recommendations for incorporating digital storytelling into healthcare delivery are offered.

scholarly journals The Impact of COVID-19 on Patient Safety: A Survey of Acute-Care Registered Nurses in New Jersey

2021 ◽  
Vol 1 (S1) ◽  
pp. s54-s55
Author(s):  
Monika Pogorzelska-Maziarz ◽  
Mary Lou Manning ◽  
Angela Gerolamo ◽  
Mary Johansen ◽  
Irina Grafova ◽  
...  
Keyword(s):  
Patient Safety ◽  
New Jersey ◽  
Registered Nurses ◽  
Acute Care ◽  
Prevention And Control ◽  
Infection Prevention ◽  
Care Delivery ◽  
Infection Prevention And Control ◽  
And Control ◽  
The Impact

Background: As the world grapples with the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), it is important to consider the full impact of coronavirus disease 2019 (COVID-19) on healthcare delivery. Evidence from outbreaks of novel H1N1 and Ebola indicates that response to these types of outbreaks requires extraordinary resources, which are diverted from routine infection prevention and control activities. However, little is known about the impact of COVID-19 on adherence to patient safety protocols in hospitals, including infection prevention and control activities. We have described the reports of acute-care registered nurses (RNs) in adhering to patient safety protocols while delivering care to COVID-19 patients. Methods: In October 2020, we conducted a cross-sectional electronic survey of all active RNs in the state of New Jersey who provided direct patient care in a New Jersey hospital in an emergency or adult inpatient unit during the onset of the COVID-19 pandemic. Results: More than 3,027 RNs participated in the survey, for a 15% response rate based on number of eligible RNs. Moreover, 15% of respondents reported that they tested positive for COVID-19 during the initial peak of COVID-19 in New Jersey (March–June 2020). Most RNs reported that the number of patients they were assigned during the first peak of the pandemic affected their ability to adhere to patient safety protocols (eg, deep-vein thrombosis screening, central-line bundles, pressure ulcer prevention). In open-ended responses, they shared that being understaffed, the extra time it took for downing and doffing of PPE, the lack of access to ancillary staff (ie nursing assistants, runners), and the need to cluster care affected the quality of care. A nurse working in the intensive care unit (ICU) lamented, “We were sometimes given 4–5 ICU patients who were very sick and required a lot of care. Shortcuts had to be taken to prioritize the most important needs. Sometimes IVs remained longer than desired. Foleys remained in longer. To avoid PPE shortages, we didn’t go into the rooms nearly as much as we normally would, [and] things got missed.” Feelings of being overwhelmed and helpless permeated the nurses’ comments. Conclusions: When caring for COVID-19 patients, frontline nurses struggled with adherence to necessary patient safety protocols, which ultimately disrupted care delivery. Future research should quantify the extent to which the COVID-19 pandemic affected care delivery, including adherence to patient safety protocols among frontline providers.Funding: NoDisclosures: None

scholarly journals Consult, Negotiate, and Involve: Evaluation of an Advanced Communication Skills Program for Health Care Professionals

2018 ◽  
Vol 35 (4) ◽  
pp. 296-307 ◽  
Author(s):  
Jane Coad ◽  
Joanna Smith ◽  
David Pontin ◽  
Faith Gibson
Keyword(s):  
Health Care ◽  
Young People ◽  
Communication Skills ◽  
Health Professionals ◽  
Health Care Professionals ◽  
Cancer Education ◽  
Care Delivery ◽  
Skills Training ◽  
Communication Skills Training ◽  
The Impact

Effective communication is central to children, young people, and their families’ experiences of health care. Most patient complaints in developed health care systems result from ineffective communication, including inadequate information provision, not feeling listened to, failure to value patients concerns, and patients not feeling involved in care decisions. Advanced communication skills training is now embedded within cancer care policy in the United Kingdom and now features prominently within cancer education in many countries. Here, we share findings from a research evaluation of an advanced communication skills training program dedicated to health professionals caring for children and young people with cancer. We evaluated participants’ (n = 59) perceptions of the program, impact on their skills, knowledge, competence, and confidence. An appreciative inquiry design was adopted; data included interviews, precourse-postcourse evaluations, e-mail blog survey, and 360-degree reflective work records. The framework approach underpinned data analysis and triangulation of data sets. Key findings highlighted good and poor practice in health professionals’ engagement with children, young people, and their families; the purpose of communicating effectively was not always consistent with collaborative working. Attending a program helped participants expand their knowledge of communication theories and strategies. Participants valued using simulated scenarios to develop their skills and were keen to use their new skills to enhance care delivery. Our emphasis within this evaluation, however, remained on what was communicated, when and how, rather than to what effect. The impact of programs such as these must now be evaluated in terms of patient benefit.

scholarly journals Overcoming fragmentation and waste in health care systems in Africa: Collaboration of health care professionals with pastoral caregivers

2014 ◽  
Vol 70 (2) ◽  
Author(s):  
Emem Agbiji ◽  
Christina Landman
Keyword(s):  
Health Care ◽  
Health Care Professionals ◽  
Hospital Care ◽  
Care Delivery ◽  
Health Care Systems ◽  
Medical Model ◽  
World Health ◽  
African Countries ◽  
Care Systems ◽  
Health Care Delivery Systems

This article explores the possibility and limits of collaboration between medical professionals and pastoral caregivers with a view to overcoming fragmentation and waste in the African hospital care sector. It argues that the quality of health and health care in many African countries is poor. Therefore, a purposeful reform of health care delivery systems in Africa is necessary. Building on the World Health Organization’s statement that the medical model that focuses on medicine and surgery and ignores the factors of belief and faith in healing is no longer satisfactory, it further argues that the medical model (including the bio-psychosocial model) is not sufficient for holistic hospital care; it therefore needs to accommodate complementary approaches (such as pastoral care) and include these as collaborative treatments. The connection of collaboration with quality, value, relationships and the ending of life implies that collaboration is an ethical process of reflection – which could have a legal implication.

scholarly journals Knowledge, attitude and practice of Nepali medical and dental practitioners on infection control during Covid-19 Pandemic

2020 ◽  
Vol 10 (2) ◽  
pp. 29-35
Author(s):  
Asal Acharya ◽  
Pratistha Thapa ◽  
Rabindra Man Shrestha ◽  
Sujita Shrestha ◽  
Alka Gupta
Keyword(s):  
Health Care ◽  
Infection Control ◽  
Health Care Professionals ◽  
Prevention And Control ◽  
Infection Prevention ◽  
Infection Prevention And Control ◽  
Attitude And Practice ◽  
Dental Practitioners ◽  
And Control ◽  
Knowledge Attitude And Practice

Introduction: Coronavirus Disease 2019 (COVID-19) has been declared a global public health emergency which is affecting people across the world. Health care professionals and their working environment are in close by vicinity to the patient. The chance of cross-contamination and spread of infection is high if proper infection control measures are not taken. Hence, the aim of this study was to assess the knowledge, attitude and practice (KAP) of Nepali medical and dental practitioners on infection control during the COVID-2019 pandemic. Materials and Method: A self administered questionnaire was formulated and circulated online among health care practitioners. Questionnaire consisted of questions on knowledge, attitude and practice regarding infection control on COVID-19 pandemic. A scoring criteria was set, giving score 1 to the correct answer and score 0 to the incorrect answer. Total scores were calculated and levels of knowledge, attitude and practice were assessed. Mean scores for medical and dental practitioners were also assessed and compared. Result: Total 80% of the total participants had not received training on infection prevention and control practices specifically for COVID-19. Only 19.3%, 4.7%, 9.5% participants scored maximum scores for knowledge, attitude and practice, respectively. Majority of the participants (around 80%) had good attitude towards infection control regarding COVID-19 pandemic. Conclusion: There is a need for specific training on infection prevention and control on COVID-19 for Nepali health care professionals. Supply of personal protective equipment materials required for infection control against COVID-19 in health care facility should improve to combat against this pandemic.

scholarly journals Infection prevention and control (IPC) at a Lassa fever treatment center before and after the implementation of an intensive IPC program

2020 ◽  
Vol 3 (3) ◽  
pp. 213-216
Author(s):  
Olayinka Stephen Ilesanmi ◽  
Oladele Olufemi Ayodeji ◽  
Ayobami A. Bakare ◽  
Nelson Adedosu ◽  
Anthonia Adeagbo ◽  
...  
Keyword(s):  
Health Care ◽  
World Health Organization ◽  
Prevention And Control ◽  
Infection Prevention ◽  
Lassa Fever ◽  
Medical Centre ◽  
World Health ◽  
Infection Prevention And Control ◽  
Health Organization ◽  
And Control

Background: Infection prevention and control (IPC) programs are important to control the Lassa Fever (LF) outbreak. We reported IPC's status at the Federal Medical Centre, Owo, southwest Nigeria, before and after implementing the IPC program during a surge in the LF outbreak. Methods: We conducted a longitudinal observational study among five health care professionals at the Federal Medical Centre, Owo, between February 2019 and May 2019 using the IPC Assessment Framework (IPCAF). The tool has eight core components with a score of 0-100 per component and provided a baseline assessment of the IPC program and evaluation after three months. We interviewed relevant unit heads and IPC committee members in the first phase. In the second phase, we designed and implemented the IPC program, and in the third phase, we conducted a repeat interview similar to the first phase. The program initiated included training healthcare workers and providing relevant IPC items according to identified gaps and available funding. Results: We interviewed five health care professionals, two female nurses, and three male doctors responsible for organizing and implementing IPC activities at the Federal Medical Centre, Owo, with an in-depth understanding of IPC activities.  The overall IPC level score increased from 318.5 at baseline to 545 at three months later. IPC improvements were reported in all the components, with IPC education and training [baseline (20), final (70)], IPC guidelines [baseline (50), final (92.5)] and monitoring/audits of IPC practices and feedback [baseline (40), final (82.5)] recording the highest improvements. Healthcare-associated infection [baseline (10), final (25)], and built environment, materials, and equipment for IPC [baseline (43.5), final (55)] had the least improvement. Poor motivation to adopt recommended changes among hospital staff were major issues preventing improvements. Conclusion: Promotion of IPC program and activities should be implemented at the Federal Medical Centre, Owo.   References World Health Organization, WHO. Lassa fever. Available from: https://www.who.int/health-topics/lassa-fever/#tab=tab_1. [Accessed on 11 October 2020] Nigeria Centre for Disease Control. Lassa fever. Available from: https://ncdc.gov.ng/diseases/factsheet/47. [Accessed on 11 October 2020]. World Health Organization, WHO. Lassa fever. Available from: https://www.who.int/news-room/fact-sheets/detail/lassa-fever. [Accessed on 11 October 2020]. Ijarotimi IT, Ilesanmi OS, Aderinwale A, Abiodun-Adewusi O, Okon IM. Knowledge of Lassa fever and use of infection prevention and control facilities among health care workers during Lassa fever outbreak in Ondo state, Nigeria. Pan Afr Med J. 2018; 30:1-13. https://doi.org/10.11604/pamj.2018.30.56.13125 Mateer EJ, Huang C, Shehu NY, Paessler S. Lassa fever–induced sensorineural hearing loss: A neglected public health and social burden. PLoS Negl Trop Dis. 2018;12(2):1-11. https://doi.org/10.1371/journal.pntd.0006187 Ijarotimi I., Oladejo J., Nasidi A, Jegede O. Lassa fever in the State Specialist Hospital Akure, Nigeria: Case report, Contact tracing and outcome of hospital contacts. Int J Infect Trop Dis. 2016;3(1):20-28. https://doi.org/10.14194/ijitd.3.1.4 Ireye F, Ejiyere H, Aigbiremolen AO, Famiyesin OE, Rowland-Udoh EA, Ogeyemhe CO, Okudo I, Onimisi AB. Knowledge, attitude and infection prevention and control practices regarding Lassa fever among healthcare workers in Edo State, Nigeria. Int J Prev Treat. 2019;8(1):21-27. https://doi.org/10.5923/j.ijpt.20190801.03 World Health Organization. Infection prevention and control assessment framework at the facility level. 2018; 2016:1-15. Available from: https://www.who.int/infection-prevention/tools/core-components/IPCAF-facility.PDF?ua=1 [Accessed on 11 October 2020]. World Health Organization, WHO. Communicable disease surveillance and response systems - Guide to monitoring and evaluating. Epidemic and pandemic alert and response. Published online 2006:90. doi: rr5305a1 [pii] Ousman K, Kabego L, Talisuna A, Diaz J, Mbuyi J, Houndjo B, et al. The impact of Infection Prevention and control (IPC) bundle implementation on IPC compliance during the Ebola virus outbreak in Mbandaka/Democratic Republic of the Congo: A before and after design. BMJ Open. 2019;9(9):1-6. https://doi.org/10.1136/bmjopen-2019-029717 Nzinga J, Mbindyo P, Mbaabu L, Warira A, English M. Documenting the experiences of health workers expected to implement guidelines during an intervention study in Kenyan hospitals. Implement Sci. 2009;4(1):1-9. https://doi.org/10.1186/1748-5908-4-44. Ataiyero Y, Dyson J, Graham M. Barriers to hand hygiene practices among health care workers in sub-Saharan African countries: A narrative review. Am J Infect Control. 2019 May;47(5):565-573. https://doi.org/10.1016/j.ajic.2018.09.014. Gilbert GL, Kerridge I. The politics and ethics of hospital infection prevention and control: a qualitative case study of senior clinicians’ perceptions of professional and cultural factors that influence doctors’ attitudes and practices in a large Australian hospital. BMC Health Serv Res. 2019; 19(212). https://doi.org/1186/s12913-019-4044-y.  

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