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{{Short description|Medical branch dealing of cancer in adolescent and young adults}}
'''[[Adolescence|Adolescent]] and [[Youth|young adult]] oncology (AYA)''' is a branch of medicine that deals with the prevention, diagnosis, and treatment of cancer in AYA patients aged 13-30. Studies have continuously shown that while pediatric cancer survival rates have gone up, the survival rate for adolescents and young adults has remained stagnant. While many clinical trials exist for adults with cancer and children with cancer, AYAs underutilize clinical trials.<ref>{{Cite journal|last=Tai|first=Eric|last2=Buchanan|first2=Natasha|last3=Eliman|first3=Dena|last4=Westervelt|first4=Lauren|last5=Beaupin|first5=Lynda|last6=Lawvere|first6=Silvana|last7=Bleyer|first7=Archie|date=2014-6|title=Understanding and Addressing the Lack of Clinical Trial Enrollment Among Adolescents With Cancer|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6074033/|journal=Pediatrics|volume=133|issue=Suppl 3|pages=S98–S103|doi=10.1542/peds.2014-0122D|issn=0031-4005|pmc=6074033|pmid=24918214}}</ref><ref>{{Cite journal|last=Bleyer|first=Archie|last2=Tai|first2=Eric|last3=Siegel|first3=Stuart|date=2018-8|title=Role of clinical trials in survival progress of American adolescents and young adults with cancer—and lack thereof|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6077840/|journal=Pediatric blood & cancer|volume=65|issue=8|pages=e27074|doi=10.1002/pbc.27074|issn=1545-5009|pmc=6077840|pmid=29667766}}</ref> Most pediatric clinical trials serve patients up to age 21.<ref>{{Cite book|last=Chisholm|first=Julia|url=https://books.google.com/books?id=kWBODwAAQBAJ&pg=PA44&lpg=PA44&dq=aya+environments&source=bl&ots=hgU17eSwtB&sig=ACfU3U00-_QXMl9VsytK_TPxywICm7Gu3g&hl=en&sa=X&ved=2ahUKEwivgv-FkuTpAhUZH80KHdi9AG8Q6AEwAnoECAkQAQ#v=onepage&q=aya%20environments&f=false|title=A Practical Approach to the Care of Adolescents and Young Adults with Cancer|last2=Hough|first2=Rachael|last3=Soanes|first3=Louise|date=2018-02-27|publisher=Springer|isbn=978-3-319-66173-5|language=en}}</ref> Additionally, AYAs face problems that adults and children rarely see including college concerns, fertility, and sense of aloneness.<ref>{{Cite book|last=Forum|first=National Cancer Policy|url=https://www.ncbi.nlm.nih.gov/books/NBK179872/|title=PSYCHOSOCIAL ASPECTS OF AYA CANCER DIAGNOSIS AND TREATMENT|last2=Services|first2=Board on Health Care|last3=Workshop|first3=A. Livestrong and Institute of Medicine|last4=Medicine|first4=Institute of|date=2014-01-10|publisher=National Academies Press (US)|language=en}}</ref> Studies have often shown that treating young adults with the same protocols used in pediatrics is more effective than adult oriented treatments.<ref>{{Cite web|date=2019-02-25|title=Childhood Leukemia Treatment Also Effective for Young Adults - National Cancer Institute|url=https://www.cancer.gov/news-events/cancer-currents-blog/2019/aya-leukemia-pediatric-regimen-effective|access-date=2020-06-02|website=www.cancer.gov|language=en}}</ref>
{{Use mdy dates|date=August 2023}}
'''Adolescent and young adult oncology''' is a branch of medicine that deals with the prevention, diagnosis, and treatment of [[Cancer in adolescents and young adults|cancer in adolescent and young adult]] (AYA) patients aged 16–40. Studies have continuously shown that while pediatric cancer survival rates have gone up, the survival rate for [[Adolescence|adolescents]] and [[young adult]]s has remained stagnant. While many clinical trials exist for adults with cancer and children with cancer, AYAs underutilize [[clinical trial]]s.<ref>{{Cite journal|last1=Tai|first1=Eric|last2=Buchanan|first2=Natasha|last3=Eliman|first3=Dena|last4=Westervelt|first4=Lauren|last5=Beaupin|first5=Lynda|last6=Lawvere|first6=Silvana|last7=Bleyer|first7=Archie|date=June 2014|title=Understanding and Addressing the Lack of Clinical Trial Enrollment Among Adolescents With Cancer|journal=Pediatrics|volume=133|issue=Suppl 3|pages=S98–S103|doi=10.1542/peds.2014-0122D|issn=0031-4005|pmc=6074033|pmid=24918214}}</ref><ref>{{Cite journal|last1=Bleyer|first1=Archie|last2=Tai|first2=Eric|last3=Siegel|first3=Stuart|date=August 2018|title=Role of clinical trials in survival progress of American adolescents and young adults with cancer—and lack thereof|journal=Pediatric Blood & Cancer|volume=65|issue=8|pages=e27074|doi=10.1002/pbc.27074|issn=1545-5009|pmc=6077840|pmid=29667766}}</ref> Most pediatric clinical trials serve patients up to age 21.<ref>{{Cite book|last1=Chisholm|first1=Julia|url=https://books.google.com/books?id=kWBODwAAQBAJ&pg=PA44|title=A Practical Approach to the Care of Adolescents and Young Adults with Cancer|last2=Hough|first2=Rachael|last3=Soanes|first3=Louise|date=2018-02-27|publisher=Springer|isbn=978-3-319-66173-5|language=en|access-date=2020-06-02|archive-date=2020-07-09|archive-url=https://web.archive.org/web/20200709225337/https://books.google.com/books?id=kWBODwAAQBAJ&pg=PA44&lpg=PA44&dq=aya+environments|url-status=live}}</ref> Additionally, AYAs face problems that adults and children rarely see including college concerns, [[fertility]], and sense of aloneness.<ref>{{Cite book|url=https://www.ncbi.nlm.nih.gov/books/NBK179872/|title=Psychosocial Aspects Of Aya Cancer Diagnosis And Treatment|author=((Nass, Sharyl J; Patlak, Margie, [[Rapporteurs]]; National Cancer Policy Forum; Board on Health Care Services; A Livestrong and Institute of Medicine Workshop; Institute of Medicine))|date=2014-01-10|publisher=National Academies Press (US)|language=en|access-date=2020-06-02|archive-date=2017-01-18|archive-url=https://web.archive.org/web/20170118125353/https://www.ncbi.nlm.nih.gov/books/NBK179872/|url-status=live}}</ref> Studies have often shown that treating young adults with the same protocols used in pediatrics is more effective than adult oriented treatments.<ref>{{Cite web|date=2019-02-25|title=Childhood Leukemia Treatment Also Effective for Young Adults|url=https://www.cancer.gov/news-events/cancer-currents-blog/2019/aya-leukemia-pediatric-regimen-effective|access-date=2020-06-02|website=National Cancer Institute|language=en|archive-date=2020-07-09|archive-url=https://web.archive.org/web/20200709174829/https://www.cancer.gov/news-events/cancer-currents-blog/2019/aya-leukemia-pediatric-regimen-effective|url-status=live}}</ref>


In countries like the United States and the United Kingdom, specialized AYA units have started to be built in children's and adult hospitals to cater to the need of these age groups. AYA wards are designed to be bright and welcoming with many games and televisions to keep patients busy.<ref>{{Cite web|date=2019-12-19|title=How A Space For Young People Can provide Relief During Cancer Treatment|url=https://teencanceramerica.org/community-stories/teen-young-adults/how-a-space-for-young-people-can-provide-relief-during-cancer-treatment/|access-date=2020-06-02|website=Teen Cancer America|language=en-US}}</ref> The need for these spaces come from the findings that AYAs tend to prefer pediatric wards than adult wards, but do not like to be treated like children.<ref>{{Cite journal|last=Sadeghi|first=Narges|last2=Abdeyazdan|first2=Zahra|last3=Motaghi|first3=Minoo|last4=Rad|first4=Marzieh Ziaei|last5=Torkan|first5=Behnaz|date=2012|title=Satisfaction levels about hospital wards’ environment among adolescents hospitalized in adult wards vs. pediatric ones|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3733288/|journal=Iranian Journal of Nursing and Midwifery Research|volume=17|issue=6|pages=430–433|issn=1735-9066|pmc=3733288|pmid=23922584}}</ref>
In countries like the US and the UK, specialized AYA units have started to be built in children's and adult hospitals to cater to the need of these age groups. AYA wards are designed to be bright and welcoming with many games and televisions to keep patients busy.<ref>{{Cite web|date=2019-12-19|title=How A Space For Young People Can provide Relief During Cancer Treatment|url=https://teencanceramerica.org/community-stories/teen-young-adults/how-a-space-for-young-people-can-provide-relief-during-cancer-treatment/|access-date=2020-06-02|website=Teen Cancer America|language=en-US|archive-date=2020-09-26|archive-url=https://web.archive.org/web/20200926052803/https://teencanceramerica.org/community-stories/teen-young-adults/how-a-space-for-young-people-can-provide-relief-during-cancer-treatment/|url-status=live}}</ref> The need for these spaces come from the findings that AYAs tend to prefer pediatric wards over adult wards, but do not like to be treated like children.<ref>{{Cite journal|last1=Sadeghi|first1=Narges|last2=Abdeyazdan|first2=Zahra|last3=Motaghi|first3=Minoo|last4=Rad|first4=Marzieh Ziaei|last5=Torkan|first5=Behnaz|date=2012|title=Satisfaction levels about hospital wards' environment among adolescents hospitalized in adult wards vs. pediatric ones|journal=Iranian Journal of Nursing and Midwifery Research|volume=17|issue=6|pages=430–433|issn=1735-9066|pmc=3733288|pmid=23922584}}</ref>


AYA teams are usually made up of specialists that specialize in both pediatric and adult medicine.
AYA teams are usually made up of specialists that specialize in both [[Pediatrics|pediatric]] and [[Oncology|adult medicine]] due to the fact that people under 21 tend to do better under pediatric care.<ref>{{Cite web|title=Teens Do Better Here|url=https://www.seattlechildrens.org/about/stories/teens-do-better-here/|access-date=2020-11-25|website=Seattle Children's Hospital|language=en}}</ref>


== United States ==
== United States ==
Internationally, different countries tend to treat the AYA age group in different environments. Most AYA treatment centers in the United States are within larger children's hospitals. The organization, Teen Cancer America was created to establish more AYA wards in hospitals across the United States, and currently there are about 21 hospitals in the U.S. affiliated with Teen Cancer America,<ref>{{Cite web|title=Teen Cancer America - Our Work|url=https://teencanceramerica.org/our-work/|access-date=2020-06-02|website=Teen Cancer America|language=en-US}}</ref> and many more with AYA programs. The American Academy of Pediatrics' opinion is that children should be under the care of pediatrician until they deem not necessary, and children's hospitals in America are increasingly treating older patients well into their twenties as a part of AYA and other adult programs.<ref>{{Cite journal|last=Hardin|first=Amy Peykoff|last2=Hackell|first2=Jesse M.|last3=Medicine|first3=Committee on Practice and Ambulatory|date=2017-09-01|title=Age Limit of Pediatrics|url=https://pediatrics.aappublications.org/content/140/3/e20172151|journal=Pediatrics|language=en|volume=140|issue=3|doi=10.1542/peds.2017-2151|issn=0031-4005|pmid=28827380}}</ref>
Internationally, different countries tend to treat the AYA age group in different environments. Most AYA treatment centers in the US are within larger [[children's hospital]]s. The organization, Teen Cancer America was created to establish more AYA wards in hospitals across the US, and currently there are about 21 hospitals affiliated with Teen Cancer America,<ref>{{Cite web|title=Teen Cancer America Our Work|url=https://teencanceramerica.org/our-work/|access-date=2020-06-02|website=Teen Cancer America|language=en-US|archive-date=2020-05-13|archive-url=https://web.archive.org/web/20200513101434/https://teencanceramerica.org/our-work/|url-status=live}}</ref> and many more with AYA programs. The [[American Academy of Pediatrics|American Academy of Pediatrics']] opinion is that children should be under the care of a pediatrician until they deem not necessary, and children's hospitals in the US are increasingly treating older patients well into their twenties as a part of AYA and other adult programs.<ref>{{Cite journal|last1=Hardin|first1=Amy Peykoff|last2=Hackell|first2=Jesse M.|last3=Medicine|first3=Committee on Practice and Ambulatory|s2cid=31354886|date=2017-09-01|title=Age Limit of Pediatrics|url=https://pediatrics.aappublications.org/content/140/3/e20172151|journal=Pediatrics|language=en|volume=140|issue=3|pages=e20172151|doi=10.1542/peds.2017-2151|issn=0031-4005|pmid=28827380|doi-access=free|access-date=2020-06-03|archive-date=2020-02-13|archive-url=https://web.archive.org/web/20200213043903/https://pediatrics.aappublications.org/content/140/3/e20172151|url-status=live}}</ref>


== United Kingdom ==
== United Kingdom ==
{{Main|Teenage Cancer Trust}}
{{Main|Teenage Cancer Trust}}
The UK is seen to be one of the pioneers of AYA cancer care at its hospitals. Teenage Cancer Trust is a cancer care and support charity in the UK that exists to improve the cancer experience of young people aged 13–24. Founded in 1990, the charity's key service is providing specialist teenage units in NHS hospitals. It also trains and funds staff who are teenage cancer specialists.<ref>{{Cite web|last=|first=|date=2014-08-29|title=History|url=https://www.teenagecancertrust.org/about-us/our-story/history|url-status=live|archive-url=|archive-date=|access-date=2020-06-03|website=www.teenagecancertrust.org|language=en}}</ref> The units are dedicated areas for teenage and young adult patients, who are involved in their concept and creation. Medical facilities on the units are equipped with computers, TVs, game consoles, and bright colored design. The UK has over 28 units in children's hospitals and adult hospitals dedicated to AYAs aged 13-24.<ref>{{Cite web|title=Our specialist cancer units|url=https://www.teenagecancertrust.org/get-help/how-we-can-help/our-units|access-date=2020-06-03|website=www.teenagecancertrust.org|language=en}}</ref><ref>{{Cite journal|last=Taylor|first=Rachel M|last2=Fern|first2=Lorna A|last3=Barber|first3=Julie|last4=Alvarez-Galvez|first4=Javier|last5=Feltbower|first5=Richard|last6=Morris|first6=Stephen|last7=Hooker|first7=Louise|last8=McCabe|first8=Martin G|last9=Gibson|first9=Faith|last10=Raine|first10=Rosalind|last11=Stark|first11=Dan P|date=2019-04-20|title=Description of the BRIGHTLIGHT cohort: the evaluation of teenage and young adult cancer services in England|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500338/|journal=BMJ Open|volume=9|issue=4|doi=10.1136/bmjopen-2018-027797|issn=2044-6055|pmc=6500338|pmid=31005941}}</ref>
The UK is seen to be one of the pioneers of AYA cancer care at its hospitals. Teenage Cancer Trust is a cancer care and support charity in the UK that exists to improve the cancer experience of young people aged 13–24.<ref>{{Cite book|last1=Bleyer|first1=Archie W.|url=https://books.google.com/books?id=pXgDooG8SEsC&pg=PA509|title=Cancer in Adolescents and Young Adults|last2=Barr|first2=Ronald Duncan|date=2007-09-23|publisher=Springer Science & Business Media|isbn=978-3-540-68152-6|language=en|access-date=2020-06-06|archive-date=2020-08-04|archive-url=https://web.archive.org/web/20200804173854/https://books.google.com/books?id=pXgDooG8SEsC&pg=PA509&lpg=PA509&dq=age+21+mexico+pediatrics|url-status=live}}</ref> Founded in 1990, the charity's key service is providing specialist teenage units in [[National Health Service|NHS hospitals]]. It also trains and funds staff who are teenage cancer specialists.<ref>{{Cite web|last=|first=|date=2014-08-29|title=History|url=https://www.teenagecancertrust.org/about-us/our-story/history|url-status=live|archive-url=https://web.archive.org/web/20200611062813/https://www.teenagecancertrust.org/about-us/our-story/history|archive-date=2020-06-11|access-date=2020-06-03|website=Teenage Cancer Trust|language=en}}</ref> The units are dedicated areas for teenage and young adult patients, who are involved in their concept and creation. Medical facilities on the units are equipped with computers, TVs, game consoles, and bright colored design. The UK has over 28 units in children's hospitals and [[Hospital|adult hospitals]] dedicated to AYAs aged 13–24.<ref>{{Cite web|title=Our specialist cancer units|url=https://www.teenagecancertrust.org/get-help/how-we-can-help/our-units|access-date=2020-06-03|website=Teenage Cancer Trust|language=en|archive-date=2020-06-22|archive-url=https://web.archive.org/web/20200622031448/https://www.teenagecancertrust.org/get-help/how-we-can-help/our-units|url-status=live}}</ref><ref>{{Cite journal |last1=Taylor |first1=Rachel M |last2=Fern |first2=Lorna A |last3=Barber |first3=Julie |last4=Alvarez-Galvez |first4=Javier |last5=Feltbower |first5=Richard |last6=Morris |first6=Stephen |last7=Hooker |first7=Louise |last8=McCabe |first8=Martin G |last9=Gibson |first9=Faith |author-link9=Faith Gibson |last10=Raine |first10=Rosalind |last11=Stark |first11=Dan P |date=2019-04-20 |title=Description of the Brightlight cohort: the evaluation of teenage and young adult cancer services in England |journal=BMJ Open |volume=9 |issue=4 |pages=e027797 |doi=10.1136/bmjopen-2018-027797 |issn=2044-6055 |pmc=6500338 |pmid=31005941}}</ref>


== See also ==
== See also ==

* [[Adolescence|Adolescent]]
* [[Teenage Cancer Trust]]
* [[Teenage Cancer Trust]]
* [[Childhood cancer|Pediatric oncology]]
* [[Childhood cancer]]


== References ==
== References ==
Line 22: Line 22:


== External links ==
== External links ==
* [https://teencanceramerica.org/ Teen Cancer America]
* [https://www.teenagecancertrust.org/ Teenage Cancer Trust]
* [https://www.canteen.org.au/ Canteen]


[[Category:Oncology]]
* https://teencanceramerica.org/
[[Category:Young adult]]
* https://www.teenagecancertrust.org/
[[Category:Adolescent medicine]]
* https://www.canteen.org.au/

Latest revision as of 18:46, 9 May 2024

Adolescent and young adult oncology is a branch of medicine that deals with the prevention, diagnosis, and treatment of cancer in adolescent and young adult (AYA) patients aged 16–40. Studies have continuously shown that while pediatric cancer survival rates have gone up, the survival rate for adolescents and young adults has remained stagnant. While many clinical trials exist for adults with cancer and children with cancer, AYAs underutilize clinical trials.[1][2] Most pediatric clinical trials serve patients up to age 21.[3] Additionally, AYAs face problems that adults and children rarely see including college concerns, fertility, and sense of aloneness.[4] Studies have often shown that treating young adults with the same protocols used in pediatrics is more effective than adult oriented treatments.[5]

In countries like the US and the UK, specialized AYA units have started to be built in children's and adult hospitals to cater to the need of these age groups. AYA wards are designed to be bright and welcoming with many games and televisions to keep patients busy.[6] The need for these spaces come from the findings that AYAs tend to prefer pediatric wards over adult wards, but do not like to be treated like children.[7]

AYA teams are usually made up of specialists that specialize in both pediatric and adult medicine due to the fact that people under 21 tend to do better under pediatric care.[8]

United States

[edit]

Internationally, different countries tend to treat the AYA age group in different environments. Most AYA treatment centers in the US are within larger children's hospitals. The organization, Teen Cancer America was created to establish more AYA wards in hospitals across the US, and currently there are about 21 hospitals affiliated with Teen Cancer America,[9] and many more with AYA programs. The American Academy of Pediatrics' opinion is that children should be under the care of a pediatrician until they deem not necessary, and children's hospitals in the US are increasingly treating older patients well into their twenties as a part of AYA and other adult programs.[10]

United Kingdom

[edit]

The UK is seen to be one of the pioneers of AYA cancer care at its hospitals. Teenage Cancer Trust is a cancer care and support charity in the UK that exists to improve the cancer experience of young people aged 13–24.[11] Founded in 1990, the charity's key service is providing specialist teenage units in NHS hospitals. It also trains and funds staff who are teenage cancer specialists.[12] The units are dedicated areas for teenage and young adult patients, who are involved in their concept and creation. Medical facilities on the units are equipped with computers, TVs, game consoles, and bright colored design. The UK has over 28 units in children's hospitals and adult hospitals dedicated to AYAs aged 13–24.[13][14]

See also

[edit]

References

[edit]
  1. ^ Tai, Eric; Buchanan, Natasha; Eliman, Dena; Westervelt, Lauren; Beaupin, Lynda; Lawvere, Silvana; Bleyer, Archie (June 2014). "Understanding and Addressing the Lack of Clinical Trial Enrollment Among Adolescents With Cancer". Pediatrics. 133 (Suppl 3): S98–S103. doi:10.1542/peds.2014-0122D. ISSN 0031-4005. PMC 6074033. PMID 24918214.
  2. ^ Bleyer, Archie; Tai, Eric; Siegel, Stuart (August 2018). "Role of clinical trials in survival progress of American adolescents and young adults with cancer—and lack thereof". Pediatric Blood & Cancer. 65 (8): e27074. doi:10.1002/pbc.27074. ISSN 1545-5009. PMC 6077840. PMID 29667766.
  3. ^ Chisholm, Julia; Hough, Rachael; Soanes, Louise (February 27, 2018). A Practical Approach to the Care of Adolescents and Young Adults with Cancer. Springer. ISBN 978-3-319-66173-5. Archived from the original on July 9, 2020. Retrieved June 2, 2020.
  4. ^ Nass, Sharyl J; Patlak, Margie, Rapporteurs; National Cancer Policy Forum; Board on Health Care Services; A Livestrong and Institute of Medicine Workshop; Institute of Medicine (January 10, 2014). Psychosocial Aspects Of Aya Cancer Diagnosis And Treatment. National Academies Press (US). Archived from the original on January 18, 2017. Retrieved June 2, 2020.
  5. ^ "Childhood Leukemia Treatment Also Effective for Young Adults". National Cancer Institute. February 25, 2019. Archived from the original on July 9, 2020. Retrieved June 2, 2020.
  6. ^ "How A Space For Young People Can provide Relief During Cancer Treatment". Teen Cancer America. December 19, 2019. Archived from the original on September 26, 2020. Retrieved June 2, 2020.
  7. ^ Sadeghi, Narges; Abdeyazdan, Zahra; Motaghi, Minoo; Rad, Marzieh Ziaei; Torkan, Behnaz (2012). "Satisfaction levels about hospital wards' environment among adolescents hospitalized in adult wards vs. pediatric ones". Iranian Journal of Nursing and Midwifery Research. 17 (6): 430–433. ISSN 1735-9066. PMC 3733288. PMID 23922584.
  8. ^ "Teens Do Better Here". Seattle Children's Hospital. Retrieved November 25, 2020.
  9. ^ "Teen Cancer America – Our Work". Teen Cancer America. Archived from the original on May 13, 2020. Retrieved June 2, 2020.
  10. ^ Hardin, Amy Peykoff; Hackell, Jesse M.; Medicine, Committee on Practice and Ambulatory (September 1, 2017). "Age Limit of Pediatrics". Pediatrics. 140 (3): e20172151. doi:10.1542/peds.2017-2151. ISSN 0031-4005. PMID 28827380. S2CID 31354886. Archived from the original on February 13, 2020. Retrieved June 3, 2020.
  11. ^ Bleyer, Archie W.; Barr, Ronald Duncan (September 23, 2007). Cancer in Adolescents and Young Adults. Springer Science & Business Media. ISBN 978-3-540-68152-6. Archived from the original on August 4, 2020. Retrieved June 6, 2020.
  12. ^ "History". Teenage Cancer Trust. August 29, 2014. Archived from the original on June 11, 2020. Retrieved June 3, 2020.
  13. ^ "Our specialist cancer units". Teenage Cancer Trust. Archived from the original on June 22, 2020. Retrieved June 3, 2020.
  14. ^ Taylor, Rachel M; Fern, Lorna A; Barber, Julie; Alvarez-Galvez, Javier; Feltbower, Richard; Morris, Stephen; Hooker, Louise; McCabe, Martin G; Gibson, Faith; Raine, Rosalind; Stark, Dan P (April 20, 2019). "Description of the Brightlight cohort: the evaluation of teenage and young adult cancer services in England". BMJ Open. 9 (4): e027797. doi:10.1136/bmjopen-2018-027797. ISSN 2044-6055. PMC 6500338. PMID 31005941.
[edit]