The document summarizes an evidence based project presentation on negative pressure wound therapy (NPWT) for diabetic foot ulcers (DFU). It includes objectives of the presentation, background information on evidence based nursing practice and DFUs. It also outlines the research question comparing NPWT to standard moist wound therapy for healing diabetic foot ulcers over 60 days. A literature review was conducted and findings from 5 systematic reviews showing NPWT increases healing rates for DFUs are summarized. National guidelines also support the use of NPWT for DFUs.

1. (NPWT)
(DFU)
Evidence Based Project
Group VIII
BSN-19S
Submitted by:
NRTM-4013: Nursing Research
Presented to: Ms. Summaira Nasir
April 27, 2022
Shifa College of Nursing,
Shifa Tameer-E-Milat University, H/8, Islamabad
Faisal Mahmood (0413) Aamina Riaz (0366)
Amna Bibi (003) Kinza Niazi (0379)
Nayab Fatima (0392)
Faisal Mahmood (0413) Aamina Riaz (0366)
Amna Bibi (003) Kinza Niazi (0379)
Nayab Fatima (0392)
1

2. Objectives
By the end of our 20 minutes presentation, learners will
be able to;
 Extrapolate Evidence based practice in context of nursing.
 Identify the significance of Evidence based nursing.
 Describe DFU & NPWT.
 Illustrate the mechanism of NPWT.
 Outline the significance of DFUs & NPWT.
 Identify the application of NPWT to practice.
 Interpret our PICOT question & components.
2

3. Objectives Cont..
 Appraise research methodology applied & systematic reviews.
 Relate case study's findings with literature's results.
 Discuss questionnaire & responses from clinical experts in SIH & QIH.
 Deduce EBN's criterias fulfillment based on findings.
 Formulate suggestions for implementation of NPWT.
 Summarize the whole sessions & pertinent points.
3

4. Evidence Based Nursing Practice
(EBNP)
"The conscientious, explicit and judicious use of current
best evidence in making decisions about the care of the
individual patient. It means integrating individual clinical
expertise with the best available external clinical evidence
from systematic research"(Sackett et al., 1996).
 It represents both an ideology & method.
 Ideology springs from ethical principle that every
patient deserves to be provided the best intervention
possible.
 Method is the way we go about findings & implementing those interventions.
4
EBP (Evidence
Based Practice)
Clinical
Expertise

5. Evidence Based Nursing
(EBN)
It is a practice through which nurses execute their clinical duties while utilizing the
current and valid research findings, clinical expertise, the client values &
preferences and the available resources to make a practice decision (International
council for Nurses,2012 Registered Nurses’ association of Ontario 2014)
 The inclusion of EBP in nursing provides nurses with the scientific research to
make well-founded decisions.
 Helps in cost containment, greater availability of information, and greater
consumer savvy about treatment and care options.
5

6. Significance of EBN
 It allows patients to have proactive role in their own healthcare as they can voice their
concerns, share their values and preferences
 Equips nurses with more knowledge on risks and benefits of certain diagnostic and
therapeutic measures
 EBN would lead to better patient outcome, reduction in morbidity and mortality and
better health indices.
 It would also reduce financial operational cost in healthcare of organizations as
expenditure on out-dated supplies/products for certain procedures may no longer be
needed
 Nurses can participate in multidisciplinary investigator-initiated research, contribute to
various aspects of research.
(Why Is Evidence-Based Practice in Nursing so Important?, 2021)
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7. Diabetic Foot Ulcers
(DFUs)
 Diabetic foot ulcers (DFUs) are complex, chronic wounds, which have a long-
term impact on the morbidity, mortality & quality of life. (Abetz et al., 2002)
 Are challenging to manage as they have significant
impact on healthcare economy.
 Adopting a proactive approach to management can
potentially reduce costs & improve patient outcomes.
 Using negative pressure wound therapy (NPWT) is an
example of how this can be achieved.
7
Diabetic Foot Ulcers
(Developed by Dr. Justin
Franson, DPM, 2021).

8. Negative Pressure Wound Therapy
(NPWT)
 An active therapy
 Controlled sub-atmospheric pressure
 Delivered through a sealed system & applied to
open wounds to help promote wound healing.
 Mc Callon, et al. found that VAC therapy and moist
dressing had a mean time of 22.8 and 42.8 days, respectively,
for therapy. Besides, in the VAC group, the mean of changes in the size of ulcers was three
weeks lesser than the moist dressing group (28.4% decreased vs. 9.5% increased).
8

9. Mechanism of NPWT
9
(MOA of NPWT, n. d.)

10. Significance of Topic
 In England, foot complications account for 20% of the total NHS spend
on diabetes care. approx. £650M/Year(Or £1 in every £150).
 In addition, are indirect costs to patient: negative effect on physical, psychological
& social well being with many patients unable to work.
 In a cross-sectional study in 2020 in Lahore, the prevalence of Diabetic Foot Ulcer
(DFU) in Lahore, Pakistan is 50.9%. Diabetes mellitus and poor knowledge of foot
care were the major risk factors for DFU. (Ejaz, Ahmad & Hanif, 2020)
 The majority (60-80%) of DFUs will heal, while 10-15% will remain active & 5-
24% will lead to amputation within a period of 6-18 months after the first
evaluation.
 DFUs precede upto 83% of major amputations & 96% of minor amputations.
 In individuals with diabetes & a lower extremity amputation, 55% will require
further amputation in <3 years.
10

11. Sig. of Topic Cont..
 Patient with DFUs experience pain, restricted mobility, exudate,
frustration, low self esteem & anxiety which leads to difficulty interaction among
nurse-patient and hinders quality of care being provided.
Two-thirds of DFUs take more than 12 months to heal, and the recurrence rate is
estimated to be 65% at 5 years after healing. Infection and gangrene resulting from
DFUs are the leading causes of amputation,and taken together, DFUs and
amputation dramatically increase mortality rates for patients with diabetes.
11

12. Research Question
In elderly diabetic patients with either stage II or stage III pressure ulcers,
Does negative pressure wound therapy lead to improve wound healing faster when
compared to standard moist wound therapy for 60 days.
12
Elderly diabetic patients with stage II or III pressure ulcers (P)
Negative pressure wound therapy (NPWT) (I)
Standard moist therapy (C)
Faster wound healing (O)
60 days (T)

13. Search Strategy
 A systematic search of databases selected based on their
relevance to wound care and peer reviewed status was conducted; specifically,
CINAHL, Cochrane CENTRAL, PubMed and the British Nursing Index were
searched.
Table 1. PICO Formulation
13
PICO Search Terms
Population Diabet* AND (foot OR heal) AND (ulcer OR wound)
Intervention Negative pressure* therapy OR vac
Comparison Any alternative treatment or no alternative treatment
Outcome Heal* OR improve* OR reduc*

14. Cont.. 14
• (Diabet* AND foot OR heel) AND (ulcer OR
wound) AND (negative pressure* therapy OR
vac) AND (heal* OR improve OR reduc*)
BNI
CINAHL
COCHRANE CENTRAL
• (Diabetes [MeSH] AND foot OR heel) AND
(ulcer [MeSH] OR wound) AND (negative
pressure* therapy OR vac) AND (heal* OR
improve OR reduc*)
PubMED

15. Literature Review
 5 Systematic reviews/Meta Analysis ( Reviewed > 50 studies from multiple
countries)
 Published between 2016-2021
 Literature received from PubMed,
Systematic reviews & IBR Approved.
15
Rating system for Hierarchy of Evidence
(Melnyk & Fineout-Overholt, 2015, p. 11).

16. Effectiveness of interventions to enhance healing of
chronic ulcers of the foot in diabetes: a systematic review
 Authors: F. L. Game, J. Apelqvist, C. Attinger, A. Hartemann, R. J. Hinchliffe, M.
Löndahl, P. E. Price & W. J. Jeffcoate.
 Publication Year: 2016
 Publisher: John Wiley & Sons, Ltd.
 Objective: to undertake a systematic review of the evidence supporting
interventions to enhance the healing of chronic ulcers of the foot in diabetes in order
both to inform protocols for routine care and to highlight areas, which should be
considered for further study.
 Studies included: David G Armstrong et al(2005) Southern Arizona
Arthur Tails, DPM et al(2009) Arizona, Nebraska and Texas.
WJ J effcoate et al(2009) UK
16

17. Cont...
 Method: Results based on a search of study design, patient group,
clinical problem and interventions of interest. Randomized controlled trials (RCT),
case–control studies, prospective and retrospective cohort studies and control before-
and-after and interrupted time series designs were included published between 2010-
2014 on EmBase & Medline.
 Results: The 2012 review included three studies of NPWT, two RCTs and a cohort
study. Two of the three were very small but reported significant benefits in both
healing rate and healing time. The second however, involving the randomization of
342 patients showed a reduced time to wound closure, an increased incidence of
healing by 16 weeks and a reduction in cross-sectional area by 8 weeks.
 Conclusions: The evidence to support the effectiveness or cost-effectiveness of
NPWT in the healing of chronic ulcers of the foot in diabetes is significant. Despite
widespread use, there have been no further good studies on the use of NPWT.
17

18. Evaluation of negative-pressure wound therapy for patients
with diabetic foot ulcers: systematic review
and meta-analysis
 Authors: Si Liu, Chao-zhu He, Yan-ting Cai, Qiu-ping Xing, Ying-zhen Guo,
Zhi-long Chen, Ji-liang Su & Li-ping Yang.
 Publication Date: 18 April, 2017
 Publisher: DovePress:Therapeutics and Clinical Risk Management
 Objective: To perform an updated systematic review and meta-analysis to assess the
clinical efficacy, safety, and cost-effectiveness of negative-pressure wound therapy
(NPWT) in the treatment of diabetic foot ulcers (DFUs).
 Studies Included: 5 studies from North America
2 studies from Italy
3 studies from Germany
1 study from UK
18
All studies were
RCTs conducted
between 2010-
2015)

19. Cont...
 Method: Searched the Cochrane Library, MEDLINE, EMBASE, Ovid,
and Chinese Biological Medicine databases up to June 30, 2016. Manaual
searching of reference list entries.
 Results: NPWT had a higher rate of complete healing of ulcers (relative risk,
1.48; 95% confidence interval [CI]: 1.24–1.76; P,0.001), shorter healing time and
greater reduction in ulcer area. A total of eleven randomized controlled trials,
which included a total of 1,044 patients were selected. Many analyses showed
that the NPWT was more cost-effective than standard dressing changes.
 Conclusions: These results indicate that NPWT is efficacious, safe, and cost-
effective in treating DFUs.
19

20. Negative pressure wound therapy for treating foot
wounds in people with diabetes mellitus (A systematic
Review)
 Authors: Zhenmi Liu, Jo C Dumville, Robert J Hinchliffe, Nicky Cullum, Fran
Game, Nikki Stubbs, Michael Sweeting & Frank Peinemann
 Publication Year: 2018
 Publisher: Willey & Sons Ltd.
 Objective: To assess the effects of negative pressure wound therapy compared with
standard care or other therapies in the treatment of foot wounds in people with DM in
any care setting.
 Studies Included: 11 RCTs
3 stduies from USA, 3 from India, 2 from China, 1 from Italy, 1
from Crotia & 1 from Turkey.
Published between 2005-2017.
20

21. Cont...
 Method: Searched the Cochrane Wounds Specialised Register; the
Cochrane Central Register of Controlled Trials (CENTRAL);Ovid MEDLINE (including In-
Process Citations);Ovid Embase and EBSCOCINAHL Plus.
 Results: Pooled data suggests NPWT may increase the number of healed wounds compared
with dressings. Data from three studies (441 participants) suggest that people allocated to
high-pressure NPWT may be at reduced risk of amputation. Ten studies compared NPWT
with dressings (two for amputation wounds and eight for foot ulcers in people with DM);
one study compared NPWT at 75 mmHg and 125mmHg for the treatment of foot ulcers. It is
uncertain whether the incidence of wound recurrence between groups. There is evidence to
suggest that NPWT may be effective in healing ulcers compared with wound dressings in
terms of the proportion of wounds healed and time to healing
 Conclusions: NPWT may be an effective treatment (including ulcer healing and
amputation) compared with dressings in terms of healing debrided foot ulcers and
postoperative amputation wounds in people with DM. The certainty of the evidence is
satisfactory, primarily due to the high levels of precision around estimates of effect.
21

22. The efficacy of negative pressure wound therapy for
diabetic foot ulcers: a systematised review
 Authors: Matthew Wynn & Smith Freeman
 Publication Year: 5 April, 2019
 Publisher: Journal of Tissue Viability
 Objective: To investigate the current state of knowledge on negative pressure wound
therapy (NPWT) used to treat diabetic foot ulceration (DFU), its clinical effectiveness
and any current issues in the research.
 Studies Included: 3 randomised controlled trials, 2
case series’, 1 non-controlled trial and 1 randomized case-control study.
From Germany, Canada, Spain, UK
Published between 2011 to 2017
22

23. Cont...
 Method: A systematic search of the British Nursing Index, CINAHL,
Cochrane Central and PubMed was undertaken. Only primary studies were included
and studies investigating a combination of NPWT and other therapies were excluded.
All the included studies were published in English.
 Results: It appears appropriate to use NPWT for the purpose of reducing wound
area. Granulation was present more often and developed more quickly in wounds
treated with NPWT. 0% incidence of amputation when NPWT was used. Notably,
the incidence of major amputations was reportedly higher than minor amputations
when advanced moist wound therapy was used.
 Conclusions: NPWT has the potential to reduce amputation incidences, increase
the rate of granulation formation, heal wounds faster and offer greater quality of
life for patients with DFU. These issues should be the focus of future research.
23

24. A systematic review and meta-analysis of efficacy and
safety of negative pressure wound therapy in the
treatment of diabetic foot ulcer
 Authors: Lin Chen, Shuang Zhang, Jun Da, Wencong Wu, Fei Ma, Chao Tang,
Guangzhou Li, Dejun Zhong & Bin Liao.
 Publication Year: Sep 24, 2021
 Publisher: Annals of Palliative Medicine
 Objective: To investigate the efficacy and safety of NPWT by literature search and
meta-analysis.
 Studies Included: 9 RCTs, including 943 participants published between 2013-
2020. Countries studied were India (4) , Pakistan (2), Germany, Poland & Iran.
24

25. Cont...
 Method: The databases of PubMed, Embase, Ovid, and Cochrane
library were selected as search platforms. The Cochrane Review Handbook was
used to assess the bias of the literatures.
 Results: NPWT patients also had a shorter granulation formation time, suggesting
that the wound healing was faster in patients with NPWT. The incidence of adverse
events (infection, pain, etc.) was reported in two studies, and there was no
significant difference between the two therapies (P>0.05), suggesting that NPWT
therapy was safe and reliable.
 Conclusions: The results showed that NPWT can effectively accelerate wound
healing, which is equally safe with general routine treatment. However, the negative
pressure value should be appropriately maintained and adjusted to avoid bleeding
tendency of the wound.
25

26. NICE Guidelines 2015
NPWT has now been included within the Diabetic Foot Problems:
Prevention and Management of Foot Problems in People With Diabetes Guidance.
 "Consider negative pressure wound therapy after surgical debridement for diabetic foot
ulcers on the advice of the multidisciplinary foot care services".
NPWT can be used for non-healing DFUs if wound is of >6 weeks with no progress in last 2
weeks.
 Factors include are:
 Comprehensive assessment
 Ability to achieve wound healing unless palliation of symptoms is the over all goal.
 Severity of wound
 Failure of wound to respond to other therapies.
(Recommendations | Diabetic Foot Problems: Prevention and Management | Guidance | NICE, 2015)
26

27. Survey of Project
27

28. Qutionnare Responses
28
Patient Preferences:
 Total patients interviewed = 17 (8 Males & 9 Females)
 All admitted in critical units of SIH.
Clinical Expertise:
 Total Participants = 20 (7 Females, 13Males)
Drs. 12 Males 9 from SIH & 3 from QIH.
RNs 8 5 from SIH & 3 from QIH.
Questions Responses
With adequate information provided about
both methods,
what method will you choose for DFU?
NPWT
88%(15)
8 M & 7 F
Moist Wound
Therapy
12 % (2 F)

29. Responses Cont..
29
Questions Responses
Do you believe NPWT can be used for diabetic foot
ulcers?
Yes
12(60%)
9 Drs & 3RNs
No
6(30%)
3 Drs & 3 RNs
Don't know
2(10%)
2RNs
Did you ever used/witnessed NPWT for diabetic
foot ulcers?
Yes 6(30%)
5 Drs & 1RN
No 14(70%)
7 Drs & 7 RNs
Is NPWT safe & reliable in treatment of diabetic
foot ulcers as compared to standard moist therapy?
Yes
12(60%)
9 Drs & 3RNs
No
6(30%)
3 Drs & 3 RNs
Don’t know
2(10%)
2RNs
Is it feasible to use it in SIH & other hospitals in
Islamabad?
Yes
15 (75%)
9 Drs & 3RNs
No
5 (20%)
3 Drs & 3 RNs
What are causes of not using NPWT for DFUs? Cost expense
5 (25%)
3 Drs & 2 RNs
Inadequate trained
staff
14 (70%)
9 Drs & 5 RNs
Lack of administ-
rative support
1 (5%)
1 RN
How can we make it more feasible? By raising awareness, educating pt. & more trained staff.
100% 12 Drs & 8 RNs.

30. Case Study

 Mr E with history of T2DM & peripheral artery disease.
 Amputation of Rt. first toe (2012)
 Presented with DFU( Self managed for 3 weeks)
 Initial assessment: 3cm x 2.2cm x 0.4cm deep
 Wound bed: 30% granulation/70% slough, High-medium exudate vol. malodour
 Dressing change: 3x weekly
30

31. CS Cont.…
 After 7 days of NPWT: Wound measured 2.7cm x 1.7 cm
 After 10 days: 70% granulation tissue/ 30% slough
 After 21 days: Epithelialization at the wound edge with lighter removable edge
 After 28 days: Wound measured 2cm x 1.7 cm
 NPWT discontinued after 28 days.
 Post NPWT, after 56 days, wound size measured
1.4cm x 0.8cm.
(Bowen, 2016)
31

32. Resources ( Financial, Logistics etc):
The results of the study show that NPWT is less
costly and more effective compared with Moist
wound therapy. In addition, NPWT reduces the
number of amputations and increases the number of
healed wounds, decreasing patients` and payers`
costs. “The expected costs per patient per year using
a NPWT treatment strategy ($5165 ± 3258) were
$4668 lower than those of a TWC treatment
strategy ($9833 ± 5861)”( Alipour et al., 2021).
Expertise ( Human resource):
Training can be given easily in short period of
time. Results from this therapy are high. "A single
session of NPWT dressing was applied in 84% (n =
320) patients, 8% (n = 31) patients needed two
sessions of NPWT dressing, 6% (n = 24) patients
had three sessions of NPWT dressing and only 1%
(n = 5) patients did not respond to NPWT
dressing" (Ur Rashid et al., 2020).
Socio-cultural acceptance:
This therapy is widely accepted in context of
socio-cultural settings, as it has been used in QIH
for the management of large surgical wounds &
there had been no objection to it. So, this can be
initiated in other hospitals as well for DFUs.
Quality of Evidence
The evidences we provided were
level I which is the highest quality
content & they supported use of
NPWT for management of DFUs &
advocated for positive outcomes.
EBN’s
Criterias

33. Recommendations
 It will be important to ensure that staff understand the new roles and have the
knowledge and tools to carry them out.
 Help reduce resistance to change by ensuring that staff understand the reasons for
change and agree that change is needed.
 To help staff accept the new bundle of practices fully, ensure that they understand
that those practices offer promising strategies for providing high-quality care for
patients.
 Identify and minimize practical barriers to using the new practices, such as
inadequate access to supplies.
 At all levels, engage staff to gain their support and buy-in to the improvement effort
and help tailor the practices in pressure ulcer prevention.
 Leaders & manager’s expressed support for improving pressure ulcer prevention
will reinforce its importance and thus increase the impetus among staff to adhere to
the new practices.

34. Conclusions
 All 5 systematic reviews demonstrated evidence &
supported idea that using NPWT is beneficial in faster healing
of DFUs compared to moist wound therapy.
 Clinical expertise also emphasized that this should be used in hospital &
community setting as a reliable therapy.
 The results from our project can be presented to clinical staff & management to
serve as a reinforcement about initiating NPWT for DFUs to help patient heal faster
& live a sustainable life.
 Future RCTs needed to be done in local settings to strengthen this initiative.
34

35. References
Abetz, L., Sutton, M., Brady, L., McNulty, P., &amp; Gagnon, D. (2002). The diabetic foot ulcer scale (DFS): A quality of life
instrument for use in clinical trials. Practical Diabetes International, 19(6), 167. https://doi.org/10.1002/pdi.356
Alipour, V., Rezapour , A., Arabloo, J., & Ebrahimi , M. (2021, February). Cost-Utility Analysis of Negative Pressure Wound
Therapy Compared With Traditional Wound Care in the Treatment of Diabetic Foot Ulcers in Iran.
Hmpgloballearningnetwork.com. Retrieved April 19, 2022, from
https://www.hmpgloballearningnetwork.com/site/wounds/original-research/cost-utility-analysis-negative-pressure-
wound-therapy-compared
Bowen G (2016, March 30) NICE guidance update supports use of negative pressure wound therapy for the diabetic foot.
The Diabetic Foot Journal 19 : 43–8
Ejaz, F., Ahmad, A., & Hanif, K. (2020). Prevalence of Diabetic Foot Ulcer in Lahore, Pakistan: A Cross Sectional Study.
Asian Journal of Allied Health Sciences (AJAHS), 3(4), 34-38. https://doi.org/10.52229/ajahs.v3i4.353
35

36. Cont..
Game, F. L., Apelqvist, J., Attinger, C., Hartemann, A., Hinchliffe, R. J., Löndahl, M., Price, P. E., & Jeffcoate,
W. J. (2016). Effectiveness of interventions to enhance healing of chronic ulcers of the foot in diabetes: a
systematic review. Diabetes/Metabolism Research and Reviews, 32, 154–168.
https://doi.org/10.1002/dmrr.2707
Liu, S., He, C. Z., Cai, Y. T., Xing, Q. P., Guo, Y. Z., Chen, Z. L., Su, J. L., & Yang, L. P. (2017). Evaluation of
negative-pressure wound therapy for patients with diabetic foot ulcers: systematic review and meta-
analysis. Therapeutics and Clinical Risk Management, Volume 13, 533–544.
https://doi.org/10.2147/tcrm.s131193
Liu, Z., Dumville, J. C., Hinchliffe, R. J., Cullum, N., Game, F., Stubbs, N., Sweeting, M., & Peinemann, F.
(2018). Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus.
Cochrane Database of Systematic Reviews, 2018(10). https://doi.org/10.1002/14651858.cd010318.pub3
Mc Callon SK, Knight CA, Valiulus JP, Cunningham MW, McCulloch JM, Farinas LP. Vacuum-assisted closure
versus saline-moistened gauze in the healing of postoperative diabetic foot wounds. Ostomy Wound
36

37. Cont.
Recommendations | Diabetic foot problems: prevention and management | Guidance | NICE. (2015, 26 augustus). NICE.Org.
Geraadpleegd op 17 april 2022, van https://www.nice.org.uk/guidance/ng19/chapter/recommendations
Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., &amp; Richardson, W. S. (1996). Evidence based medicine:
What it is and what it isn't. BMJ, 312(7023), 71–72. https://doi.org/10.1136/bmj.312.7023.71
Smith & Nephew UK. (n.d.). MOA of NPWT [Image]. Smith & Nephew. https://www.smith-nephew.com/es-
mx/uk/microsites/challenging-community-wounds/pico-celebrate/how-pico-works/
Melnyk, B.M. & Fineout-Overholt, E. (2015). "Box 1.3: Rating system for the hierarchy of evidence for intervention/treatment
questions" in Evidence-based practice in nursing & healthcare: A guide to best practice (3rd ed.) (pp. 11). Philadelphia, PA:
Wolters Kluwer Health.
Ur Rashid, H., Rashid, M., Ur Rehman Sarwar, S., Khan, I., Khan, N., & Bibi, N. (2020). Negative Pressure Wound Therapy
(NPWT): Our Experience in Pakistan With Locally Made Dressing. Cureus. https://doi.org/10.7759/cureus.9464
Why Is Evidence-Based Practice in Nursing so Important? (2021, 16 december). Eastern Illinois University. Geraadpleegd op
18 april 2022, van https://learnonline.eiu.edu/programs/rn-to-bsn/evidence-based-practice-important/
Wynn, M., & Freeman, S. (2019). The efficacy of negative pressure wound therapy for diabetic foot ulcers: A systematised
review. Journal of Tissue Viability, 28(3), 152–160. https://doi.org/10.1016/j.jtv.2019.04.001
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38. 38

39. 39

40. “Every great conversation, starts with a
good listener”, ‘Unknown’
40