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1.
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2.

Objective

To evaluate the effects of sequential vaginal and sublingual misoprostol after a vaginal loading dose for second-trimester abortion.

Materials and methods

From January 2006 to December 2011, 173 women received an 800-μg vaginal loading dose of misoprostol. After the loading dose, 103 patients received 800 mg of misoprostol vaginally and 70 patients received 400 mg of misoprostol sublingually every 12 h until the delivery of the fetus.

Results

In the vaginal group, the average abortion time was 1.07 ± 1.29 days; that was 0.82 ± 0.66 days in the sublingual group. Sequential sublingual misoprostol after a vaginal loading dose of 800 mg with an administration interval of 12 h had a similar abortion rate and time to abortion. In addition, this protocol reduced unnecessary digital pelvic examinations and speculum examinations.

Conclusion

This sequential sublingual misoprostol regimen might be a suitable regimen for mid-trimester abortion.  相似文献   

3.

Study Objective

In the literature about primary dysmenorrhea (PD), either a pain gradient has been studied just in women with PD or pain was assessed as a binary variable (presence or absence). Accordingly, we decided to carry out a study in young women to determine possible factors associated with intense pain.

Design

A cross-sectional observational study.

Setting

A Spanish University in 2016.

Participants

A total of 306 women, aged 18-30 years.

Interventions

A questionnaire was filled in by the participants to assess associated factors with dysmenorrhoea.

Main Outcome Measures

Our outcome measure was the Andersch and Milsom scale (grade from 0 to 3). Definition: grade 0 (menstruation is not painful and daily activity is unaffected), grade 1 (menstruation is painful but seldom inhibits normal activity, analgesics are seldom required, and mild pain), grade 2 (daily activity affected, analgesics required and give relief so that absence from work or school is unusual, and moderate pain), and grade 3 (activity clearly inhibited, poor effect of analgesics, vegetative symptoms and severe pain).

Results

Factors significantly associated with more extreme pain: a higher menstrual flow (odds ratio [OR], 2.11; P < .001), a worse quality of life (OR, 0.97; P < .001) and use of medication for PD (OR, 8.22; P < .001).

Conclusion

We determined factors associated with extreme pain in PD in a novel way. Further studies are required to corroborate our results.  相似文献   

4.

Study Objective

Our aim was to assess incidence and risk factors for pelvic pain after pelvic mesh implantation.

Design

Retrospective study (Canadian Task Force classification II-2).

Setting

Single university hospital.

Patients

Women who have undergone surgery with pelvic mesh implant for treatment of pelvic floor disorders including prolapse and incontinence.

Interventions

Telephone interviews to assess pain, sexual function, and general health.

Measurements and Main Results

Pain was measured by the McGill Short-Form Pain Questionnaire for somatic pain, Neuropathic Pain Symptom Inventory for neuropathic pain, Pennebaker Inventory of Limbic Languidness for somatization, and Female Sexual Function Index (FSFI) for sexual health and dyspareunia. General health was assessed with the 12-item Short-Form Health Survey. Among 160 enrolled women, mean time since surgery was 20.8 ± 10.5 months, mean age was 62.1 ± 11.2 years, 93.8% were white, 86.3% were postmenopausal, and 3.1% were tobacco users. Types of mesh included midurethral sling for stress incontinence (78.8%), abdominal/robotic sacrocolpopexy (35.7%), transvaginal for prolapse (6.3%), and perirectal for fecal incontinence (1.9%), with 23.8% concomitant mesh implants for both prolapse and incontinence. Our main outcome, self-reported pelvic pain at least 1 year after surgery, was 15.6%. Women reporting pain were younger, with fibromyalgia, worse physical health, higher somatization, and lower surgery satisfaction (all p < .05). Current pelvic pain correlated with early postoperative pelvic pain (p < .001), fibromyalgia (p = .002), worse physical health (p = .003), and somatization (p = .003). Sexual function was suboptimal (mean FSFI, 16.2 ± 12.1). Only 54.0% were sexually active, with 19.0% of those reporting dyspareunia.

Conclusion

One in 6 women reported de novo pelvic pain after pelvic mesh implant surgery, with decreased sexual function. Risk factors included younger age, fibromyalgia, early postoperative pain, poorer physical health, and somatization. Understanding risk factors for pelvic pain after mesh implantation may improve patient selection.  相似文献   

5.

Objective

To compare the clinical efficacy, recurrence, complications and quality of life changes 3 years after Elevate-A/single incision mesh surgery anterior apical (SIM A) and sacrospinous ligament fixation (SSF) in the management of pelvic organ prolapse (POP).

Materials and methods

A prospective cohort study, 139 women, underwent transvaginal surgery for anterior and/or apical POP > stage 2, 69 patients had SIM A and 70 patients had SSF. The objective cure was defined as POP ≤ stage 1 anterior, apical according to POP-Q. Subjective cure is patient's negative feedback to question 2 and 3 of pelvic organ prolapse distress inventory 6 (POPDI-6). Patient's satisfaction was reported using validated quality of life questionnaires. Multi-channel urodynamic study was used to report any voiding problems related to the prolapse surgery 6 months after surgery.

Results

119 patients completed a minimum of 3 years follow-up. 89.8% is the overall prolapse correction success rate for SIM A and 73.3% for SSF group (p = 0.020), and 96.6% versus 73.4% at the anterior vaginal compartment respectively (p ≤ 0.001). Statistically significant difference was noticed in apical compartment with 98.3% with SIM A and 85.0% with SSF (p = 0.009). The subjective success rate, 86.4% in the SIM A and 70.0% in the SSF arm (p = 0.030) was significantly noted. Only, Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6) showed significant improvement. Operation time and intra-operative blood loss tend to be more with SIM A.

Conclusion

SIM A has better 3 years objective and subjective cure rate than SSF in the anterior and/or apical compartment prolapse.  相似文献   

6.

Study Objective

To determine whether vertical versus horizontal closure of the vaginal cuff during laparoscopic hysterectomy has an effect on postoperative vaginal length and pelvic organ prolapse.

Design

A prospective randomized controlled trial. Subjects were randomly assigned to vertical or horizontal vaginal cuff closure at the time of total laparoscopic hysterectomy. Pelvic organ prolapse quantization (POP-Q) tests were performed before surgery, 2 to 4 weeks after surgery, and 3 to 4 months after surgery (Canadian Task Force classification I).

Setting

An academic university-affiliated community hospital.

Patients

Patients undergoing laparoscopic or robotic-assisted laparoscopic total hysterectomy for benign or malignant disease, excluding those undergoing radical hysterectomy or concomitant pelvic floor procedure.

Interventions

Subjects were randomized into the vertical or horizontal vaginal cuff closure group. Total hysterectomy was completed with traditional laparoscopic techniques or with robotic assistance. A colpotomy ring was used in each subject. Vaginal cuff closure was performed with barbed suture in a running fashion according to the group assignment.

Measurements and Main Results

A total of 43 subjects were enrolled and randomized. One patient was excluded because the vaginal cuff was closed vaginally, 1 cancelled surgery, and 1 was completed without a uterine manipulator. The mean change in vaginal length was ?0.89 cm (standard deviation [SD] = 1.03) in the horizontal group and ?0.86 cm (SD = 1.19) in the vertical group (p = .57). POP-Q evaluation revealed no differences between groups and an overall trend toward improved POP-Q measurements. The average duration of vaginal cuff closure did not differ (p = .45), and there were no intraoperative complications related to vaginal cuff closure.

Conclusion

Horizontal and vertical laparoscopic closure of the vaginal cuff after laparoscopic hysterectomy results in similar changes in vaginal length and other POP-Q scores.  相似文献   

7.

Study Objective

Young age is a possible risk factor of endometriosis recurrence after surgery. However, the efficacy of postoperative medical treatment has not been well addressed in adolescents. The purpose of this study was to evaluate whether postoperative medical treatment is as effective in adolescents as it is in adults in the prevention of endometrioma recurrence.

Design

A retrospective cohort study.

Setting

Samsung Medical Center, Seoul, Korea.

Participants

This study included 176 reproductive-aged women who underwent conservative laparoscopic surgery for pathology-confirmed endometrioma. Women were classified into 2 groups according to age: adolescents (20 years of age and younger, n = 34; group I) and reproductive-aged women (aged 25-35 years, n = 142; group II).

Interventions

The same surgeon performed all of the surgeries for uniformity. Postoperatively, patients were treated monthly with a gonadotropin-releasing hormone agonist depot for 3-6 months, followed by cyclic oral contraceptives.

Main Outcome Measures

Endometrioma recurrence was determined using ultrasonography. The recurrence rate of endometrioma was compared between the 2 groups.

Results

During the treatment period (median, 41.0 months; range, 6-159 months), recurrence was noted in 8 cases (4.5%). After adjusting for confounders (which were statistically different between the groups), the cumulative proportion of recurrent endometriomas after 60 months was comparable between the 2 groups (5.3% in group I and 8.5% in group II).

Conclusion

Long-term postoperative medical treatment with cyclic oral contraceptives after a gonadotropin-releasing hormone agonist can be as effective in adolescents as it is in adults in the prevention of endometrioma recurrence.  相似文献   

8.

Study Objective

To compare immediate postpartum insertion of the contraceptive implant to placement at the 6-week postpartum visit among adolescent and young women.

Design

Non-blinded, randomized controlled trial.

Setting and Participants

Postpartum adolescents and young women ages 14-24 years who delivered at an academic tertiary care hospital serving rural and urban populations in North Carolina.

Interventions

Placement of an etonogestrel-releasing contraceptive implant before leaving the hospital postpartum, or at the 4-6 week postpartum visit.

Main Outcome Measures

Contraceptive implant use at 12 months postpartum.

Results

Ninety-six participants were randomized into the trial. Data regarding use at 12 months were available for 64 participants, 37 in the immediate group and 27 in the 6-week group. There was no difference in use at 12 months between the immediate group and the 6-week group (30 of 37, 81% vs 21 of 27, 78%; P = .75). At 3 months, the immediate group was more likely to have the implant in place (34 of 37, 92% vs 19 of 27, 70%; P = .02).

Conclusion

Placing the contraceptive implant in the immediate postpartum period results in a higher rate of use at 3 months postpartum and appears to have similar use rates at 12 months compared with 6-week postpartum placement. Providing contraceptive implants to adolescents before hospital discharge takes advantage of access to care, increases the likelihood of effective contraception in the early postpartum period, appears to have no adverse effects on breastfeeding, and might lead to increased utilization at 1 year postpartum.  相似文献   

9.

Study Objective

To evaluate the incidence of pelvic inflammatory disease (PID) in virgin women and investigate the clinical characteristics of the patients.

Design

Retrospective chart review and literature review.

Setting

Tertiary academic center.

Participants

Virgin women who were confirmed to have PID via surgery from 2002 to 2014.

Interventions

None.

Main Outcome Measures

The evaluation of medicosurgical history, clinical progress, surgical record, and pathologic reports.

Results

Of 122 patients diagnosed with PID via surgery, 5 women were virgins (4.1%). The median age was 21 years (range, 14-24 years), and all patients presented with abdominal pain. The median diameter of the pelvic abscess pocket on preoperative imaging was 4.5 cm (range, 2.6-15 cm). Only 1 case was preoperatively diagnosed as a tubo-ovarian abscess; the others were expected to be benign ovarian tumors, such as endometrioma and dermoid cysts. No possible source of infection was identified for any patient, except 1 who had a history of an appendectomy because of a ruptured appendix. The results of the histopathological analysis of the excisional biopsy performed during surgery in 4 cases were consistent with acute suppurative inflammation. After postoperative antibiotic use, the conditions of all patients stabilized, and they were discharged from the hospital on median postoperative day 9.

Conclusion

PID in virgin women is rare, but it should be considered in all women with abdominal pain, regardless of sexual history.  相似文献   

10.

Study Objective

To compare operative time in women stratified by body mass index (BMI) undergoing robotic-assisted sacrocolpopexy (RASC). Secondary objectives included characterizing perioperative characteristics and reoperation rates.

Design

Retrospective cohort study (Canadian Task Force classification II-2).

Setting

University-affiliated teaching hospital.

Patients

One hundred seventy-nine consecutive patients who underwent RASC by a single surgeon from 2009 through 2013.

Interventions

RASC.

Measurements and Main Results

Of 179 patients, 61 (34%) were normal weight (BMI < 25 kg/m2), 72 (40%) were overweight (BMI 25–30 kg/m2), and 46 (26%) were obese (BMI ≥ 30 kg/m2). Overweight patients were significantly older, more parous, more frequently postmenopausal, and more frequently underwent concomitant salpingo-oophorectomy. Median operative times were 202, 206, and 216 minutes in the normal-weight, overweight, and obese groups, respectively (p = .53).

Conclusion

Obese women undergoing RASC have similar operative time and procedural characteristics as normal-weight and overweight patients. Longer term outcomes are needed to ensure comparable surgical and anatomic success.  相似文献   

11.

Study Objective

To evaluate the outcomes of laparoscopic surgery for the treatment of adnexal pathology in older children and adolescents.

Design

A retrospective cohort review.

Setting

A tertiary academic center in Istanbul, Turkey.

Participants

Pediatric and adolescent patients aged between 9 and 19 years (n = 69) who underwent laparoscopic surgery for adnexal pathology from January 2005 through September 2015. The patients who were pregnant or with non-gynecologic pathology detected during surgery were excluded from the study.

Interventions

Patients were divided into 2 groups according to their age. Group 1 consisted of 31 patients aged between 9 and 16 years and group 2 included 38 patients aged between 17 and 19 years.

Main Outcome Measures

The indication for surgery, procedures performed, anesthesia time, length of hospital stay, pathology findings, and complication rates were evaluated.

Results

Ovarian cystectomy and adnexal detorsion with or without cystectomy were the most frequently performed. Ovary-sparing conservative surgery was possible for all patients, except those with gonadal dysgenesis and testicular feminization (n = 6), who underwent laparoscopic gonadectomy. The most common pathologic finding was mature cystic teratoma (30.2%), followed by benign paratubal cyst, and simple cysts of the ovary. Anesthesia time was shorter in group 2 (P = .018). The procedures performed, length of hospital stay, complication rate, and pathology findings were not significantly different between the 2 groups.

Conclusions

Laparoscopic surgery can be successfully performed as an efficient, safe, and well tolerated procedure for treating a wide variety of adnexal pathology among children and young adolescents without any significant variation between different age groups.  相似文献   

12.
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13.
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14.

Study Objective

The aim of this study was to document the change in ovarian conservation rate after ovarian torsion as a result of continuous quality improvement (CQI) measures, and to determine factors that contribute to this outcome.

Design

A retrospective, uncontrolled before-and-after study.

Setting

An academic children's hospital.

Participants

Female adolescents younger than 18 years with surgically confirmed ovarian torsion from April 1, 1988 to October 15, 2013; excluding cases from 2003 (intervention period).

Interventions

Implementation of CQI measures including educational programs, collaborative care pathways, and quality review with the goal of improving ovarian conservation.

Main Outcome Measures

Demographic characteristics, details on presentation, investigations, consultation, surgical intervention, surgical findings, pathology, postoperative course, and follow-up imaging.

Results

One hundred thirty-nine patients met inclusion criteria (42 pre-CQI cohort and 97 post-CQI cohort). Mean ages were 9.96 and 10.33 years, respectively. Ovarian conservation rates were 47.6% compared with 85.6%, respectively (P < .001). The following factors differed between cohorts: fever (P = .003), ultrasound completed (P = .001), time from first health care provider visit to imaging (P = .025), time from specialist consultation to surgery (P = .002), surgical start time within 1 hour of booking (P < .001), and gynecologist present in operating room (P < .001). A log-binomial regression model showed that gynecology presence in the operating room (relative risk [RR], 2.043) was associated with untwisting. Increasing time from specialist consultation to surgery (RR, 0.986 per hour) was inversely associated with untwisting. Fever at presentation was also inversely associated with untwisting (RR, 0.666).

Conclusion

The implementation of CQI measures was associated with a significant increase in ovarian conservation rate.  相似文献   

15.

Study Objective

To assess the safety and effectiveness of the Minerva Endometrial Ablation System for the treatment of heavy menstrual bleeding in premenopausal women.

Design

Multicenter, randomized, controlled, international study (Canadian Task Force classification I).

Setting

Thirteen academic and private medical centers.

Patients

Premenopausal women (n = 153) suffering from heavy menstrual bleeding (PALM-COEIN: E, O).

Intervention

Patients were treated using the Minerva Endometrial Ablation System or rollerball ablation.

Measurements and Main Results

At 1-year post-treatment, study success (alkaline hematin ≤80 mL) was observed in 93.1% of Minerva subjects and 80.4% of rollerball subjects with amenorrhea reported by 71.6% and 49% of subjects, respectively. The mean procedure times were 3.1 minutes for Minerva and 17.2 minutes for rollerball. There were no intraoperative adverse events and/or complications reported.

Conclusion

The results of this multicenter randomized controlled trial demonstrate that at the 12-month follow-up, the Minerva procedure produces statistically significantly higher rates of success, amenorrhea, and patient satisfaction as well as a shorter procedure time when compared with the historic criterion standard of rollerball ablation. Safety results were excellent and similar for both procedures.  相似文献   

16.

Study Objective

To assess the anatomic efficacy and safety of synthetic glue to fix prosthetic material in laparoscopic sacrocolpopexy.

Design

A 1-year follow-up in a prospective multicenter pilot study between November 2013 and November 2014 (Canadian Task Force Classification II-2).

Setting

An academic urogynecology research hospital.

Patients

Seventy consecutive patients with Pelvic Organ Prolapse Quantification stage ≥3 anterior and/or medial prolapse underwent laparoscopic sacrocolpopexy.

Interventions

All women underwent laparoscopic sacrocolpopexy with the same standardized technique using a synthetic surgical glue to fix anterior and posterior meshes.

Measurements and Main Results

Patients were followed up at 1 month and 1 year, with anatomic and functional assessment (Pelvic Floor Distress Inventory-20, Pelvic Floor Impact Questionnaire-7, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12). Anatomic success was defined as 1-year Pelvic Organ Prolapse Quantification stage ≤1. Sixty-six patients were included; the mean age was 56.7 ± 1.2 years. The mean operative time was 145 ± 5 minutes. The mean glue fixation time was less than 2 minutes for both anterior and posterior meshes. The 1-year anatomic success rate was 87.5% in the anterior compartment (Ba at ?2.3 cm, p < .0001) and 95.3% in the medial compartment (point C at ?6.1 cm, p < .0001). There were no intra- or postoperative complications and no cases of mesh exposure; 5 cases of mesh shrinkage (7.8%) were observed at 1 year. The postoperative urinary stress incontinence rate was 29.7% at 1 year. Eight patients (12.1%) underwent revision surgery with transobturator tape. All quality of life scores showed significant improvement (p < .0001) at 1 year.

Conclusion

Synthetic glue attachment of prosthetic material in laparoscopic sacrocolpopexy proved straightforward, safe, time-saving, and effective at 1 year. Prospective randomized studies will be needed to confirm the long-term benefit.  相似文献   

17.

Objective

To compare the efficacy and safety of carbetocin with those of oxytocin infusion in women with twin pregnancy undergoing elective cesarean delivery.

Material and methods

The present observational study conducted from January to December 2014 at a single center in Taiwan enrolled 64 women with twin pregnancy induced using in vitro fertilization–embryo transfer. The women were divided into a carbetocin group who received a single injection of 100 μg carbetocin (n = 25) and a control group who received a continuous intravenous infusion of 10 IU oxytocin in 500 mL 0.9% NaCl solution (125 mL/h) for 24 h (n = 39). Operative outcomes were compared between the groups.

Results

The mean estimated blood loss during surgery was lower in the carbetocin group compared with the control group (871 ± 305 and 922.8 ± 430 mL, respectively), but the difference was not significant (P = 0.06). There was also no significant difference in the drop in hemoglobin level between two groups. The mean operative time was significantly shorter in the carbetocin group compared with the control group (P = 0.001).

Conclusion

Carbetocin is as effective as oxytocin in preventing primary postpartum hemorrhage in infertile women with twin pregnancy undergoing elective cesarean delivery.  相似文献   

18.

Study Objective

The purpose of this study was to compare ovarian conservation rates and surgical approach in benign adnexal surgeries performed by surgeons vs gynecologists at a tertiary care institution.

Design

A retrospective cohort review.

Setting

Children's and adult tertiary care university-based hospital.

Participants

Patients 21 years of age and younger who underwent surgery for an adnexal mass from January 2003 through December 2013.

Interventions

Patient age, demographic characteristics, menarchal status, clinical symptoms, radiologic imaging, timing of surgery, surgeon specialty, mode of surgery, rate of ovarian conservation, and pathology were recorded. Patients were excluded if they had a uterine anomaly or pathology-proven malignancy.

Main Outcome Measures

The primary outcome was the rate of ovarian conservation relative to surgical specialty; secondary outcome was surgical approach relative to surgical specialty.

Results

Of 310 potential cases, 194 met inclusion criteria. Gynecologists were more likely than surgeons to conserve the ovary (80% vs 63%; odds ratio, 2.28; 95% confidence interval, 1.16-4.48). After adjusting for age, body mass index, mass size, and urgency of surgery, the difference was attenuated (adjusted odds ratio, 1.84; 95% confidence interval, 0.88-3.84). Surgeons and gynecologists performed minimally invasive surgery at similar rates (62% vs 50%; P = .11). A patient was more likely to receive surgery by a gynecologist if she was older (P < .001) and postmenarchal (P = .005).

Conclusion

Results of our study suggest that gynecologists are more likely to perform ovarian-conserving surgery. However, our sample size precluded precise estimates in our multivariable model. Educational efforts among all pediatric and gynecologic surgeons should emphasize ovarian conservation and fertility preservation whenever possible.  相似文献   

19.

Study Objective

Use of gonadotropin-releasing hormone agonists (GnRHa) to treat endometriosis can cause mood and vasomotor side effects. “Add-back therapy,” the combination of low-dose hormones, limits side effects but research is limited to adults. We sought to characterize quality of life (QOL) before treatment and to compare an add-back regimen of norethindrone acetate (NA) with conjugated estrogens (CEE) to NA alone for preventing side effects of GnRHa therapy in female adolescents with endometriosis.

Design

Twelve-month double-blind, placebo-controlled trial.

Setting

Pediatric Gynecology clinic in Boston, Massachusetts.

Participants

Fifty female adolescents (aged 15-22 years) with surgically confirmed endometriosis initiating treatment with GnRHa.

Interventions

Subjects were randomized to: NA (5 mg/d) with CEE (0.625 mg/d) or NA (5 mg/d) with placebo. All subjects received leuprolide acetate depot every 3 months.

Main Outcome Measures

The Short Form-36 v2 Health Survey, Beck Depression Inventory II, and Menopause Rating Scale were completed at repeated intervals.

Results

At baseline, subjects reported impaired physical health-related QOL compared with national norms (all P < .0001). Over 12 months, these Short Form-36 v2 scores improved (all P < .05). Subjects receiving NA with CEE showed greater improvements in the pain, vitality, and physical health subscales (Pbetween groups < .05) than those receiving NA alone, as well as better physical functioning (P < .05). There were no changes in depression or menopause-like symptoms in either group.

Conclusion

Female adolescents with endometriosis initiating GnRHa therapy have impaired QOL. Treatment with GnRHa combined with add-back therapy led to improved QOL, with no worsening of mood or menopausal side effects. NA with CEE was superior to NA alone for improving physical health-related QOL.  相似文献   

20.

Study Objective

To estimate long-acting reversible contraception (LARC) discontinuation rates. Secondary aims were to determine risk factors for discontinuation, describe reasons for discontinuation, evaluate complications related to placement, and estimate pregnancy rates after discontinuation.

Design

We conducted a retrospective cohort study of LARC method use through review of electronic medical record data.

Setting

Our program is housed in an academic primary care pediatric and adolescent clinic in Baltimore, Maryland.

Participants

One hundred sixty women ages 12-24 years who received an intrauterine device or subdermal implant through our program between December 10, 2012 and December 10, 2015.

Interventions

None.

Main Outcome Measures

Complications from LARC insertion, device discontinuation, reason(s) for discontinuation, pregnancies resulting from device failure, and occurrence of pregnancy within 1 year of discontinuation.

Results

Thirty-five women discontinued their LARC method. The 6-month discontinuation rate was 11.3% and the 12-month rate was 21.9%. Discontinuation was associated with history of sexually transmitted infection (adjusted hazard ratio, 3.21; 95% confidence interval, 1.49-6.90). The most common reason for discontinuation was bleeding for the implant and expulsion for the intrauterine device.

Conclusion

Our results support the safety and low discontinuation rates of LARC provision to adolescents and young adult women in a primary care setting. Discontinuation rates and reasons are consistent with those described in other studies.  相似文献   

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