A prospective study of shoulder pain in primary care: Prevalence of imaged pathology and response to guided diagnostic blocks

Background The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the su...

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Published inBMC musculoskeletal disorders Vol. 12; no. 1; p. 119
Main Authors Cadogan, Angela, Laslett, Mark, Hing, Wayne A, McNair, Peter J, Coates, Mark H
Format Journal Article
LanguageEnglish
Published London BioMed Central 28.05.2011
BioMed Central Ltd
BMC
Subjects
Acromioclavicular Joint - diagnostic imaging
Acromioclavicular Joint - pathology
Adolescent
Adult
Aged
Aged, 80 and over
Arthritis
Bursa, Synovial - diagnostic imaging
Bursa, Synovial - pathology
Care and treatment
Clinical decision making
Clinical diagnostics and imaging
Decision making
Diagnosis
Diagnostic imaging
Effusion
Epidemiology
Female
Humans
Injection
Internal Medicine
Joint Diseases - complications
Joint Diseases - diagnosis
Joint Diseases - diagnostic imaging
Joint Diseases - pathology
Joint Diseases - therapy
Magnetic Resonance Imaging
Male
Medical diagnosis
Medicine
Medicine & Public Health
Middle Aged
Nerve Block
New Zealand
NMR
Nuclear magnetic resonance
Odds Ratio
Orthopedics
Pain
Pain Measurement
Pathology
Predictive Value of Tests
Primary care
Primary Health Care
Prospective Studies
Rehabilitation
Research Article
Rheumatology
Rotator Cuff - diagnostic imaging
Rotator Cuff - pathology
Shoulder
Shoulder Fractures - complications
Shoulder Fractures - diagnosis
Shoulder Fractures - diagnostic imaging
Shoulder Fractures - pathology
Shoulder Fractures - therapy
Shoulder Joint - diagnostic imaging
Shoulder Joint - pathology
Shoulder pain
Shoulder Pain - diagnosis
Shoulder Pain - diagnostic imaging
Shoulder Pain - etiology
Shoulder Pain - pathology
Shoulder Pain - therapy
Sports Medicine
Systematic review
Tendon Injuries - complications
Tendon Injuries - diagnosis
Tendon Injuries - diagnostic imaging
Tendon Injuries - pathology
Tendon Injuries - therapy
Ultrasonic imaging
Ultrasonography
Ultrasound
X-rays
Young Adult
New Zealand
Pain Intensity
Rotator Cuff
Shoulder Pain
Rotator Cuff Tear
Lidocaine Hydrochloride
Online AccessGet full text
ISSN1471-2474
1471-2474
DOI10.1186/1471-2474-12-119

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Abstract Background The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ). Methods Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks. Results In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection ( p ≤ 0.05). Conclusions Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.
AbstractList The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ).BACKGROUNDThe prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ).Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks.METHODSConsecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks.In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05).RESULTSIn the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05).Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.CONCLUSIONSRotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.
The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ). Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks. In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05). Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.
BACKGROUND: The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ). METHODS: Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks. RESULTS: In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05). CONCLUSIONS: Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.
Background The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ). Methods Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks. Results In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p [less than] 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p [less than] 0.01) and an intact rotator cuff (OR 1.3; p [less than] 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p [less than or equal to] 0.05). Conclusions Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.
The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ). Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks. In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p [less than] 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p [less than] 0.01) and an intact rotator cuff (OR 1.3; p [less than] 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p [less than or equal to] 0.05). Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.
Background The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ). Methods Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks. Results In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection ( p ≤ 0.05). Conclusions Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.
Abstract Background The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ). Methods Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks. Results In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05). Conclusions Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.
ArticleNumber 119
Audience Academic
Author Cadogan, Angela
Hing, Wayne A
McNair, Peter J
Laslett, Mark
Coates, Mark H
AuthorAffiliation 1 Health & Rehabilitation Research Institute, AUT University, Akoranga Drive, Private Bag 92006, Northcote, Auckland, New Zealand
2 Physiosouth, Christchurch, New Zealand
3 Christchurch Radiology Group, Christchurch, New Zealand
AuthorAffiliation_xml – name: 3 Christchurch Radiology Group, Christchurch, New Zealand
– name: 1 Health & Rehabilitation Research Institute, AUT University, Akoranga Drive, Private Bag 92006, Northcote, Auckland, New Zealand
– name: 2 Physiosouth, Christchurch, New Zealand
Author_xml – sequence: 1
  givenname: Angela
  surname: Cadogan
  fullname: Cadogan, Angela
  email: acadogan@vodafone.co.nz
  organization: Health & Rehabilitation Research Institute, AUT University, Akoranga Drive
– sequence: 2
  givenname: Mark
  surname: Laslett
  fullname: Laslett, Mark
  organization: Health & Rehabilitation Research Institute, AUT University, Akoranga Drive
– sequence: 3
  givenname: Wayne A
  surname: Hing
  fullname: Hing, Wayne A
  organization: Health & Rehabilitation Research Institute, AUT University, Akoranga Drive
– sequence: 4
  givenname: Peter J
  surname: McNair
  fullname: McNair, Peter J
  organization: Health & Rehabilitation Research Institute, AUT University, Akoranga Drive
– sequence: 5
  givenname: Mark H
  surname: Coates
  fullname: Coates, Mark H
  organization: Christchurch Radiology Group
BackLink https://www.ncbi.nlm.nih.gov/pubmed/21619663$$D View this record in MEDLINE/PubMed
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Issue 1
Keywords Pain Intensity
Rotator Cuff
Shoulder Pain
Rotator Cuff Tear
Lidocaine Hydrochloride
Language English
License http://creativecommons.org/licenses/by/2.0
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Snippet Background The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains...
The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This...
Background The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains...
BACKGROUND: The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains...
Abstract Background The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms...
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SubjectTerms Acromioclavicular Joint - diagnostic imaging
Acromioclavicular Joint - pathology
Adolescent
Adult
Aged
Aged, 80 and over
Arthritis
Bursa, Synovial - diagnostic imaging
Bursa, Synovial - pathology
Care and treatment
Clinical decision making
Clinical diagnostics and imaging
Decision making
Diagnosis
Diagnostic imaging
Effusion
Epidemiology
Female
Humans
Injection
Internal Medicine
Joint Diseases - complications
Joint Diseases - diagnosis
Joint Diseases - diagnostic imaging
Joint Diseases - pathology
Joint Diseases - therapy
Magnetic Resonance Imaging
Male
Medical diagnosis
Medicine
Medicine & Public Health
Middle Aged
Nerve Block
New Zealand
NMR
Nuclear magnetic resonance
Odds Ratio
Orthopedics
Pain
Pain Measurement
Pathology
Predictive Value of Tests
Primary care
Primary Health Care
Prospective Studies
Rehabilitation
Research Article
Rheumatology
Rotator Cuff - diagnostic imaging
Rotator Cuff - pathology
Shoulder
Shoulder Fractures - complications
Shoulder Fractures - diagnosis
Shoulder Fractures - diagnostic imaging
Shoulder Fractures - pathology
Shoulder Fractures - therapy
Shoulder Joint - diagnostic imaging
Shoulder Joint - pathology
Shoulder pain
Shoulder Pain - diagnosis
Shoulder Pain - diagnostic imaging
Shoulder Pain - etiology
Shoulder Pain - pathology
Shoulder Pain - therapy
Sports Medicine
Systematic review
Tendon Injuries - complications
Tendon Injuries - diagnosis
Tendon Injuries - diagnostic imaging
Tendon Injuries - pathology
Tendon Injuries - therapy
Ultrasonic imaging
Ultrasonography
Ultrasound
X-rays
Young Adult
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Title A prospective study of shoulder pain in primary care: Prevalence of imaged pathology and response to guided diagnostic blocks
URI https://link.springer.com/article/10.1186/1471-2474-12-119
https://www.ncbi.nlm.nih.gov/pubmed/21619663
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https://www.proquest.com/docview/874481341
http://dx.doi.org/10.1186/1471-2474-12-119
https://pubmed.ncbi.nlm.nih.gov/PMC3127806
https://doaj.org/article/3ea457708cd64769837d351cb958acec
Volume 12
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