Treatment of hydrocephalus in adults by placement of an open ventricular shunt

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Object. Ventricular shunt placement is the neurosurgical procedure most frequently associated with complications. Over the years, it has been a growing concern that the performance of most shunting devices does not conform to physiological parameters. An open ventriculoperitoneal (VP) bypass with a peritoneal catheter for which the cross-sectional internal diameter was 0.51 mm as a distinctive element for flow resistance was evaluated for use in the treatment of adult patients with hydrocephalus.

Methods. During a 2-year period, open shunts were surgically implanted in 54 adults with hydrocephalus; conventional shunts were implanted in 80 matched controls. Periodic evaluations were performed using neuroimaging studies and measures of clinical status. All patients were followed from 12 to 36 months, 18.5 ± 4 months for patients with the open shunt and 19.1 ± 8.1 months for controls (mean ± standard deviation). The device continued to function in 50 patients with the open shunt (93%) and in 49 controls (61%; p < 0.001). The Evans index in patients with the open shunt was 0.33 ± 0.09 throughout the follow up. No cases of infection, overdrainage, or slit ventricles were observed; the index in controls was 0.28 ± 0.08; 60% of them developed slit ventricles. During the follow-up period occlusion occurred in four patients with the open shunt (7%) and in 31 controls (39%; p < 0.001).

Conclusions. The daily cerebrospinal fluid (CSF) drainage through the open VP shunt is close to 500 ml of uninterrupted flow propelled by the hydrokinetic force generated by the combination of ventricular pressure and siphoning effect. It complies with hydrokinetic parameters imposed by a bypass connection between the ventricular and peritoneal cavities as well as with the physiological archetype of continuous flow and drainage according to CSF production. The open shunt is simple, inexpensive, and an effective treatment for hydrocephalus in adults.

Article Information

Address reprint requests to: Julio Sotelo, M.D., Instituto Nacional de Neurología y Neurocirugía, Insurgentes Sur 3877, 14269 Mexico City, Mexico. email: jsotelo@servidor.unam.mx.

© AANS, except where prohibited by US copyright law.

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Figures

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    Graph showing data generated in the laboratory that illustrate the flow characteristics, in units of hydrokinetic force, of the open VP shunt equipped with a 0.51-mm ID peritoneal catheter under varying intraventricular and hydrostatic pressure combinations meant to represent the spectrum between the supine and the erect posture. For instance, if the patient's posture is reclined approximately 45° he or she would have 8 cm H2O of IVP plus 30 cm of gravity effect (38 UHF), resulting in a flow rate of 25.5 ml/hour through the shunt.

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    Axial T2-weighted magnetic resonance images obtained in a patient with hydrocephalus. Left: Image obtained before surgery, demonstrating enlarged ventricles. Center: Eight months after surgical implantation of the open VP shunt, brain compliance was adequate and the ventricle size was normal (Evans index 0.32). Right: Twenty-six months after surgery the ventricle size remains normal.

References

  • 1.

    Aschoff AKremer PBenesch Cet al: Shunt-technology and overdrainage. A critical review of hydrostatic, programmable and variable-resistance-valves and flow-reducing devices. Eur J Pediatr Surg 1 (Suppl 1):49501991Aschoff A Kremer P Benesch C et al: Shunt-technology and overdrainage. A critical review of hydrostatic programmable and variable-resistance-valves and flow-reducing devices. Eur J Pediatr Surg 1 (Suppl 1):49–50 1991

    • Search Google Scholar
    • Export Citation
  • 2.

    Aschoff AKremer PHashemi Bet al: The scientific history of hydrocephalus and its treatment. Neurosurg Rev 22:67951999Aschoff A Kremer P Hashemi B et al: The scientific history of hydrocephalus and its treatment. Neurosurg Rev 22:67–95 1999

    • Search Google Scholar
    • Export Citation
  • 3.

    Bergsneider MPeacock WJMazziotta JCet al: Beneficial effect of siphoning in treatment of adult hydrocephalus. Arch Neurol 56:122412291999Bergsneider M Peacock WJ Mazziotta JC et al: Beneficial effect of siphoning in treatment of adult hydrocephalus. Arch Neurol 56:1224–1229 1999

    • Search Google Scholar
    • Export Citation
  • 4.

    Boch ALHermelin ÉSainte-Rose Cet al: Mechanical dysfunction of ventriculoperitoneal shunts caused by calcification of the silicone rubber catheter. J Neurosurg 88:9759821998Boch AL Hermelin É Sainte-Rose C et al: Mechanical dysfunction of ventriculoperitoneal shunts caused by calcification of the silicone rubber catheter. J Neurosurg 88:975–982 1998

    • Search Google Scholar
    • Export Citation
  • 5.

    Boon AJWTans JTJDelwel EJet al: Does CSF outflow resistance predict the response to shunting in patients with normal pressure hydrocephalus? Acta Neurochir Suppl 71:3313331998Boon AJW Tans JTJ Delwel EJ et al: Does CSF outflow resistance predict the response to shunting in patients with normal pressure hydrocephalus? Acta Neurochir Suppl 71:331–333 1998

    • Search Google Scholar
    • Export Citation
  • 6.

    Borgbjerg BMGjerris FAlbeck MJet al: Frequency and causes of shunt revisions in different cerebrospinal fluid shunt types. Acta Neurochir 136:1891941995Borgbjerg BM Gjerris F Albeck MJ et al: Frequency and causes of shunt revisions in different cerebrospinal fluid shunt types. Acta Neurochir 136:189–194 1995

    • Search Google Scholar
    • Export Citation
  • 7.

    Borgbjerg BMGjerris FAlbeck MJet al: Risk of infection after cerebrospinal fluid shunt: an analysis of 884 first-time shunts. Acta Neurochir 136:171995Borgbjerg BM Gjerris F Albeck MJ et al: Risk of infection after cerebrospinal fluid shunt: an analysis of 884 first-time shunts. Acta Neurochir 136:1–7 1995

    • Search Google Scholar
    • Export Citation
  • 8.

    Bradbury MWB: Anatomy and physiology of cerebrospinal fluid in Schurr PHPolkey CE (eds): Hydrocephalus. New York: Oxford1993 pp 1947Bradbury MWB: Anatomy and physiology of cerebrospinal fluid in Schurr PH Polkey CE (eds): Hydrocephalus. New York: Oxford 1993 pp 19–47

    • Search Google Scholar
    • Export Citation
  • 9.

    Cardoso ERRowan JOGalbraith S: Analysis of the cerebrospinal fluid pulse wave in intracranial pressure. J Neurosurg 59:8178211983Cardoso ER Rowan JO Galbraith S: Analysis of the cerebrospinal fluid pulse wave in intracranial pressure. J Neurosurg 59:817–821 1983

    • Search Google Scholar
    • Export Citation
  • 10.

    Casey ATKimmings EJKleinlugtebeld ADet al: The long-term outlook for hydrocephalus in childhood. A ten-year cohort study of 155 patients. Pediatr Neurosurg 27:63701997Casey AT Kimmings EJ Kleinlugtebeld AD et al: The long-term outlook for hydrocephalus in childhood. A ten-year cohort study of 155 patients. Pediatr Neurosurg 27:63–70 1997

    • Search Google Scholar
    • Export Citation
  • 11.

    Cuetter ACGarcia-Bobadilla JGuerra LGet al: Neurocysticercosis: focus on intraventricular disease. Clin Infect Dis 24:1571641997Cuetter AC Garcia-Bobadilla J Guerra LG et al: Neurocysticercosis: focus on intraventricular disease. Clin Infect Dis 24:157–164 1997

    • Search Google Scholar
    • Export Citation
  • 12.

    Czosnyka MCzosnyka ZWhitehouse Het al: Hydrodynamic properties of hydrocephalus shunts: United Kingdom shunt evaluation laboratory. J Neurol Neurosurg Psychiatry 62:43501997Czosnyka M Czosnyka Z Whitehouse H et al: Hydrodynamic properties of hydrocephalus shunts: United Kingdom shunt evaluation laboratory. J Neurol Neurosurg Psychiatry 62:43–50 1997

    • Search Google Scholar
    • Export Citation
  • 13.

    Czosnyka ZCzosnyka MRichards Het al: Hydrodynamic properties of hydrocephalus shunts. Acta Neurochir 71 (Suppl):3343391998Czosnyka Z Czosnyka M Richards H et al: Hydrodynamic properties of hydrocephalus shunts. Acta Neurochir 71 (Suppl):334–339 1998

    • Search Google Scholar
    • Export Citation
  • 14.

    Czosnyka ZCzosnyka MRichards HKet al: Posture-related overdrainage: comparison of the performance of 10 hydrocephalus shunts in vitro. Neurosurgery 42:3273341998Czosnyka Z Czosnyka M Richards HK et al: Posture-related overdrainage: comparison of the performance of 10 hydrocephalus shunts in vitro. Neurosurgery 42:327–334 1998

    • Search Google Scholar
    • Export Citation
  • 15.

    Decq PBarat JLDuplessis Eet al: Shunt failure in adult hydrocephalus: flow-controlled shunt versus differential pressure shunts—a cooperative study in 289 patients. Surg Neurol 43:3333391995Decq P Barat JL Duplessis E et al: Shunt failure in adult hydrocephalus: flow-controlled shunt versus differential pressure shunts—a cooperative study in 289 patients. Surg Neurol 43:333–339 1995

    • Search Google Scholar
    • Export Citation
  • 16.

    Del Bigio MR: Epidemiology and direct economic impact of hydrocephalus: a community based study. Can J Neurol Sci 25:1231261998Del Bigio MR: Epidemiology and direct economic impact of hydrocephalus: a community based study. Can J Neurol Sci 25:123–126 1998

    • Search Google Scholar
    • Export Citation
  • 17.

    Drake JMSainte-Rose C: The Shunt Book. Cambridge, MA: Blackwell1995Drake JM Sainte-Rose C: The Shunt Book. Cambridge MA: Blackwell 1995

    • Search Google Scholar
    • Export Citation
  • 18.

    Faulhauer KSchmitz P: Overdrainage phenomena in shunt treated hydrocephalus. Acta Neurochir 45:891011978Faulhauer K Schmitz P: Overdrainage phenomena in shunt treated hydrocephalus. Acta Neurochir 45:89–101 1978

    • Search Google Scholar
    • Export Citation
  • 19.

    Feldman ZKanter MJRobertson CSet al: Effect of head elevation on intracranial pressure, cerebral perfusion pressure, and cerebral blood flow in head-injured patients. J Neurosurg 76:2072111992Feldman Z Kanter MJ Robertson CS et al: Effect of head elevation on intracranial pressure cerebral perfusion pressure and cerebral blood flow in head-injured patients. J Neurosurg 76:207–211 1992

    • Search Google Scholar
    • Export Citation
  • 20.

    Fishman RA: Cerebrospinal Fluid in Diseases of the Nervous Systemed 2. Philadelphia: WB Saunders1992 pp 2342Fishman RA: Cerebrospinal Fluid in Diseases of the Nervous System ed 2. Philadelphia: WB Saunders 1992 pp 23–42

    • Search Google Scholar
    • Export Citation
  • 21.

    Foltz EL: Hydrocephalus: slit ventricles, shunt obstructions, and third ventricle shunts: a clinical study. Surg Neurol 40:1191241993Foltz EL: Hydrocephalus: slit ventricles shunt obstructions and third ventricle shunts: a clinical study. Surg Neurol 40:119–124 1993

    • Search Google Scholar
    • Export Citation
  • 22.

    Foltz ELBlanks JP: Symptomatic low intracranial pressure in shunted hydrocephalus. J Neurosurg 68:4014081988Foltz EL Blanks JP: Symptomatic low intracranial pressure in shunted hydrocephalus. J Neurosurg 68:401–408 1988

    • Search Google Scholar
    • Export Citation
  • 23.

    Fried AShapiro KTakei Fet al: A laboratory model of shunt-dependent hydrocephalus. Development and biomechanical characterization. J Neurosurg 66:7347401987Fried A Shapiro K Takei F et al: A laboratory model of shunt-dependent hydrocephalus. Development and biomechanical characterization. J Neurosurg 66:734–740 1987

    • Search Google Scholar
    • Export Citation
  • 24.

    Greenberg MS: Handbook of Neurosurgeryed 4. Lakeland, FL: Greenberg Graphics1997 pp 571592Greenberg MS: Handbook of Neurosurgery ed 4. Lakeland FL: Greenberg Graphics 1997 pp 571–592

    • Search Google Scholar
    • Export Citation
  • 25.

    Horton DPollay M: Fluid flow performance of a new siphon-control device for ventricular shunts. J Neurosurg 72:9269321990Horton D Pollay M: Fluid flow performance of a new siphon-control device for ventricular shunts. J Neurosurg 72:926–932 1990

    • Search Google Scholar
    • Export Citation
  • 26.

    Kang JKLee IW: Long-term follow-up of shunting therapy. Childs Nerv Syst 15:7117171999Kang JK Lee IW: Long-term follow-up of shunting therapy. Childs Nerv Syst 15:711–717 1999

    • Search Google Scholar
    • Export Citation
  • 27.

    Kestle JMilner RDrake J: The shunt design trial: variation in surgical experience did not influence shunt survival. Pediatr Neurosurg 30:2832871999Kestle J Milner R Drake J: The shunt design trial: variation in surgical experience did not influence shunt survival. Pediatr Neurosurg 30:283–287 1999

    • Search Google Scholar
    • Export Citation
  • 28.

    Ketyi I: Biofilms produced by Pseudomonas aeruginosa and by staphylococcus aureus on model medical devices. Acta Microbiol Immunol Hung 42:2212271995Ketyi I: Biofilms produced by Pseudomonas aeruginosa and by staphylococcus aureus on model medical devices. Acta Microbiol Immunol Hung 42:221–227 1995

    • Search Google Scholar
    • Export Citation
  • 29.

    Lee EJHung YCChang CHet al: Cerebral blood flow velocity and vasomotor reactivity before and after shunting surgery in patients with normal pressure hydrocephalus. Acta Neurochir 140:5996051998Lee EJ Hung YC Chang CH et al: Cerebral blood flow velocity and vasomotor reactivity before and after shunting surgery in patients with normal pressure hydrocephalus. Acta Neurochir 140:599–605 1998

    • Search Google Scholar
    • Export Citation
  • 30.

    Lundberg FTegenfeldt JOMontelius Let al: Protein depositions on one hydrocephalus shunt and on fifteen temporary ventricular catheters. Acta Neurochir 139:7347421997Lundberg F Tegenfeldt JO Montelius L et al: Protein depositions on one hydrocephalus shunt and on fifteen temporary ventricular catheters. Acta Neurochir 139:734–742 1997

    • Search Google Scholar
    • Export Citation
  • 31.

    Magnaes B: Body position and cerebrospinal fluid pressure in Wood JH (ed): Neurobiology of Cerebrospinal Fluid. New York: Plenum Press1983 Vol 2 pp 629642Magnaes B: Body position and cerebrospinal fluid pressure in Wood JH (ed): Neurobiology of Cerebrospinal Fluid. New York: Plenum Press 1983 Vol 2 pp 629–642

    • Search Google Scholar
    • Export Citation
  • 32.

    Magram GLiakos AM: The CSF accumulator: its role in the central nervous system and implications for advancing hydrocephalus shunt technology. Pediatr Neurosurg 26:2362461997Magram G Liakos AM: The CSF accumulator: its role in the central nervous system and implications for advancing hydrocephalus shunt technology. Pediatr Neurosurg 26:236–246 1997

    • Search Google Scholar
    • Export Citation
  • 33.

    McComb JG: Recent research into the nature of the cerebrospinal fluid formation and absorption. J Neurosurg 59:3693831983McComb JG: Recent research into the nature of the cerebrospinal fluid formation and absorption. J Neurosurg 59:369–383 1983

    • Search Google Scholar
    • Export Citation
  • 34.

    McCullough DCFox JL: Negative intracranial pressure hydrocephalus in adults with shunts and its relationship to the production of subdural hematoma. J Neurosurg 40:3723751974McCullough DC Fox JL: Negative intracranial pressure hydrocephalus in adults with shunts and its relationship to the production of subdural hematoma. J Neurosurg 40:372–375 1974

    • Search Google Scholar
    • Export Citation
  • 35.

    Portnoy HDSchulte RRFox JL: Anti-siphon and reversible occlusion valves for shunting in hydrocephalus and preventing post-shunt subdural hematomas. J Neurosurg 38:7297381973Portnoy HD Schulte RR Fox JL: Anti-siphon and reversible occlusion valves for shunting in hydrocephalus and preventing post-shunt subdural hematomas. J Neurosurg 38:729–738 1973

    • Search Google Scholar
    • Export Citation
  • 36.

    Pudenz RH: The surgical treatment of hydrocephalus—an historical review. Surg Neurol 15:15261981Pudenz RH: The surgical treatment of hydrocephalus—an historical review. Surg Neurol 15:15–26 1981

    • Search Google Scholar
    • Export Citation
  • 37.

    Pudenz RHFoltz EL: Hydrocephalus: overdrainage by ventricular shunts. A review and recommendations. Surg Neurol 35:2002121991Pudenz RH Foltz EL: Hydrocephalus: overdrainage by ventricular shunts. A review and recommendations. Surg Neurol 35:200–212 1991

    • Search Google Scholar
    • Export Citation
  • 38.

    Punt J: Principles of CSF diversion and alternative treatments in Schurr PHPolkey CE (eds): Hydrocephalus. New York: Oxford1993 pp 139160Punt J: Principles of CSF diversion and alternative treatments in Schurr PH Polkey CE (eds): Hydrocephalus. New York: Oxford 1993 pp 139–160

    • Search Google Scholar
    • Export Citation
  • 39.

    Rekate HOlivero W: Current concepts of CSF production and absorption in Scott RM (ed): Hydrocephalus. Baltimore: Williams & Wilkins1990 Vol 3 pp 1122Rekate H Olivero W: Current concepts of CSF production and absorption in Scott RM (ed): Hydrocephalus. Baltimore: Williams & Wilkins 1990 Vol 3 pp 11–22

    • Search Google Scholar
    • Export Citation
  • 40.

    Renier DLacombe JPierre-Kahn Aet al: Factors causing acute shunt infection. Computer analysis of 1174 operations. J Neurosurg 61:107210781984Renier D Lacombe J Pierre-Kahn A et al: Factors causing acute shunt infection. Computer analysis of 1174 operations. J Neurosurg 61:1072–1078 1984

    • Search Google Scholar
    • Export Citation
  • 41.

    Rubalcava MASotelo J: Differences between ventricular and lumbar cerebrospinal fluid in hydrocephalus secondary to cysticercosis. Neurosurgery 37:6686721995Rubalcava MA Sotelo J: Differences between ventricular and lumbar cerebrospinal fluid in hydrocephalus secondary to cysticercosis. Neurosurgery 37:668–672 1995

    • Search Google Scholar
    • Export Citation
  • 42.

    Sainte-Rose CHooven MDHirsch JF: A new approach in the treatment of hydrocephalus. J Neurosurg 66:2132261987Sainte-Rose C Hooven MD Hirsch JF: A new approach in the treatment of hydrocephalus. J Neurosurg 66:213–226 1987

    • Search Google Scholar
    • Export Citation
  • 43.

    Sakamoto HKitano SNishikawa Met al: Clinical significance of ventricular size in shunted-hydrocephalic children. Acta Neurochir Suppl 71:3573591998Sakamoto H Kitano S Nishikawa M et al: Clinical significance of ventricular size in shunted-hydrocephalic children. Acta Neurochir Suppl 71:357–359 1998

    • Search Google Scholar
    • Export Citation
  • 44.

    Sgouros SMalluci CWalsh ARet al: Long-term complications of hydrocephalus. Pediatr Neurosurg 23:1271321995Sgouros S Malluci C Walsh AR et al: Long-term complications of hydrocephalus. Pediatr Neurosurg 23:127–132 1995

    • Search Google Scholar
    • Export Citation
  • 45.

    Sotelo J: A new ventriculoperitoneal shunt for treatment of hydrocephalus. Experimental results. RBM Eur J Biomed Eng 15:2572621993Sotelo J: A new ventriculoperitoneal shunt for treatment of hydrocephalus. Experimental results. RBM Eur J Biomed Eng 15:257–262 1993

    • Search Google Scholar
    • Export Citation
  • 46.

    Sotelo J: Shunts: which one, and why? Surg Neurol 49:12131998Sotelo J: Shunts: which one and why? Surg Neurol 49:12–13 1998

  • 47.

    Sotelo J: Update: the new ventriculoperitoneal shunt at the Institute of Neurology of Mexico. Surg Neurol 46:19201996Sotelo J: Update: the new ventriculoperitoneal shunt at the Institute of Neurology of Mexico. Surg Neurol 46:19–20 1996

    • Search Google Scholar
    • Export Citation
  • 48.

    Sotelo JDel Brutto OH: Brain cysticercosis. Arch Med Res 31:3142000Sotelo J Del Brutto OH: Brain cysticercosis. Arch Med Res 31:3–14 2000

    • Search Google Scholar
    • Export Citation
  • 49.

    Sotelo JMarin C: Hydrocephalus secondary to cysticercotic arachnoiditis. A long-term follow-up review of 92 cases. J Neurosurg 66:6866891987Sotelo J Marin C: Hydrocephalus secondary to cysticercotic arachnoiditis. A long-term follow-up review of 92 cases. J Neurosurg 66:686–689 1987

    • Search Google Scholar
    • Export Citation
  • 50.

    Sotelo JRubalcava MAGómez-Llata S: A new shunt for hydrocephalus that relies on CSF production rather than on ventricular pressure. Initial clinical experiences. Surg Neurol 43:3243321995Sotelo J Rubalcava MA Gómez-Llata S: A new shunt for hydrocephalus that relies on CSF production rather than on ventricular pressure. Initial clinical experiences. Surg Neurol 43:324–332 1995

    • Search Google Scholar
    • Export Citation
  • 51.

    Tanaka AKimura MNakayama Yet al: Cerebral blood flow and autoregulation in normal pressure hydrocephalus. Neurosurgery 40:116111671997Tanaka A Kimura M Nakayama Y et al: Cerebral blood flow and autoregulation in normal pressure hydrocephalus. Neurosurgery 40:1161–1167 1997

    • Search Google Scholar
    • Export Citation
  • 52.

    Toledo EEynan NShalit M: Intracranial hypotension—an iatrogenic complication of vacuum drainage systems. Acta Neurochir 52:55591980Toledo E Eynan N Shalit M: Intracranial hypotension—an iatrogenic complication of vacuum drainage systems. Acta Neurochir 52:55–59 1980

    • Search Google Scholar
    • Export Citation
  • 53.

    Trost HA: Is there a reasonable differential indication for different hydrocephalus shunt systems? Childs Nerv Syst 11:1891921995Trost HA: Is there a reasonable differential indication for different hydrocephalus shunt systems? Childs Nerv Syst 11:189–192 1995

    • Search Google Scholar
    • Export Citation
  • 54.

    Tuli SDrake JLawless Jet al: Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg 92:31382000Tuli S Drake J Lawless J et al: Risk factors for repeated cerebrospinal shunt failures in pediatric patients with hydrocephalus. J Neurosurg 92:31–38 2000

    • Search Google Scholar
    • Export Citation
  • 55.

    Turner MS: The treatment of hydrocephalus: a brief guide to shunt selection. Surg Neurol 43:3143231995Turner MS: The treatment of hydrocephalus: a brief guide to shunt selection. Surg Neurol 43:314–323 1995

    • Search Google Scholar
    • Export Citation
  • 56.

    Yoshihara MTsunoda ASato Ket al: Differential diagnosis of NPH and brain atrophy assessed by measurement of intracranial and ventricular CSF volume with 3D FASE MRI. Acta Neurochir Suppl 71:3713741998Yoshihara M Tsunoda A Sato K et al: Differential diagnosis of NPH and brain atrophy assessed by measurement of intracranial and ventricular CSF volume with 3D FASE MRI. Acta Neurochir Suppl 71:371–374 1998

    • Search Google Scholar
    • Export Citation
  • 57.

    Zentner JGilsbach JFelder T: Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 129 patients. Neurosurg Rev 18:1691721995Zentner J Gilsbach J Felder T: Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 129 patients. Neurosurg Rev 18:169–172 1995

    • Search Google Scholar
    • Export Citation

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