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Elkattawy S, Younes I, Fichadiya H, Al-Nasseri A, Reddy A. A Case of Pyelonephritis in an Anuric Patient with End-Stage Renal Disease on Hemodialysis. Cureus 2021; 13:e15353. [PMID: 34239787 PMCID: PMC8244803 DOI: 10.7759/cureus.15353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 11/21/2022] Open
Abstract
Urinary tract infections are common sources of infections requiring antibiotic use worldwide. Chronic kidney disease (CKD) patients, especially those with minimal urine output are challenging when it comes to antibiotic stewardship given the scarcity of cases in the literature. It is further complicated by the fact that end-stage renal disease (ESRD) patients are found to have asymptomatic pyuria and its clinical significance for bacterial infection is yet to be determined. In this case, we report a patient who presented with non-specific symptoms including fever, cough, chills, diarrhea, nausea and was found to have left-sided perinephric stranding on CT scan of the abdomen. The patient also had a fever of 104.6 F which we attributed to left-sided pyelonephritis given the high sensitivity of such findings on CT scan. In this report, we explored the literature for the incidence and management of pyelonephritis in ESRD patients who are anuric.
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Affiliation(s)
- Sherif Elkattawy
- Internal Medicine, Rutgers New Jersey Medical School/Trinitas Regional Medical Center, Elizabeth, USA
| | - Islam Younes
- Internal Medicine, Trinitas Regional Medical Center, Elizabeth, USA
| | - Hardik Fichadiya
- Internal Medicine, Trinitas Regional Medical Center, Elizabeth, USA
| | - Abraheim Al-Nasseri
- Internal Medicine, St. George's University School of Medicine, Elizabeth, USA
| | - Aravinda Reddy
- Nephrology, Trinitas Regional Medical Center, Elizabeth, USA
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A nationwide cohort study suggests chronic hepatitis B virus infection increases the risk of end-stage renal disease among patients in Taiwan. Kidney Int 2014; 87:1030-8. [PMID: 25426815 DOI: 10.1038/ki.2014.363] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 08/25/2014] [Accepted: 09/11/2014] [Indexed: 02/06/2023]
Abstract
The association of chronic hepatitis B virus (HBV) infection with end-stage renal disease (ESRD) is unclear. To help clarify this we conducted a nationwide cohort study to measure the association by analyzing the claims data from the Taiwan National Health Insurance Research Database with ICD-9 codes used to identify diseases. We identified 17,758 adults who had chronic HBV infection and had not taken nucleos(t)ide analogs from 1999 to 2010 and randomly selected 71,032 matched controls without HBV in the same data set. The risk of ESRD was compared between these two cohorts. Cumulative incidences and hazard ratios were calculated after adjusting for competing mortality. The risk of ESRD was significantly higher in the HBV cohort (12-year cumulative incidence, 1.9%) than in the non-HBV cohort (0.49%) with a significant adjusted hazard ratio of 3.85. Multivariable stratified analysis further verified significant associations of ESRD with HBV in men of any age and women under the age of 60 years, but no significant association in women aged ⩾60 years. Thus, a large national cohort study indicates that untreated chronic HBV infection is associated with increased risk of ESRD. Hence, high-risk HBV-infected patients should have targeted monitoring for the development of ESRD.
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Abstract
Urinary tract infections in female patients are exceedingly common. One third of all women with an initial UTI demonstrate recurrence, and one third of those recurrences are in the first 6 months. The potential morbidity of RUTIs is high, especially in infants, the elderly, and pregnant patients. Uropathogenic bacteria reside in the rectal vault, colonize the vagina, and then ascend per the urethra into the bladder. These bacteria avidly adhere to uroepithelial cells using pili and can further ascend to the kidneys. Empiric treatment of an initial uncomplicated UTI is acceptable, but recurrences warrant a urine culture and possible radiographic evaluation. Fluoroquinolones are now first-line medications for UTIs, except in geographic areas where resistance to TMP-SMX is still low. Response to therapy should govern the need for additional treatment. Certain motivated patients with three or more UTIs per year should be considered for prophylaxis therapy.
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Affiliation(s)
- Sean P McLaughlin
- Division of Urology, Department of Surgery, University of North Carolina Hospitals, 2140 Bioinformatics Building, Campus Box 7235, Chapel Hill, NC 27599-7235, USA.
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Abstract
OBJECTIVES To first categorize a series of nephrectomies according to underlying pathology, as practised in a major general hospital in the north of Jordan, and then compare the results with published figures for Western countries. Also, to create standards for future evaluation of nephrectomies performed by laparoscopy. METHODS The hospital and pathological records of 423 consecutive nephrectomies performed at Princess Basma Teaching Hospital in the north of Jordan during the period of 1991 to 2000 were reviewed. RESULTS Benign disease led to surgery in 298 cases, of which 161 were secondary to infection-related conditions. Malignancy resulted in the removal of 125 kidneys. The rate of nephrectomy for benign conditions has declined during the last few years in comparison with that for malignant conditions. Patients operated on for benign diseases were younger [mean age, 38.4 years] than those with malignant tumours [mean age, 46.7 years]. CONCLUSIONS The mean age of patients undergoing surgery for benign and malignant disease was lower than in publications from Western countries. The frequency of nephrectomy performed for tuberculosis, hydatid disease, and xanthogranulomatous pyelonephritis is still higher than the rates published in Western countries. There is a remarkably low frequency of upper urothelial carcinoma compared with Western countries, probably due to environmental differences and genetic susceptibilities. Malignant renal tumours tend to affect people at a remarkably young age in Jordan, which is thought to be a reflection of the high proportion of young people. Nephrectomy for malignant disease had a higher rate of complications (16.8%) than for benign conditions [9.4%; p less than 0.0228]. The re-operation rate was 3.1% for all patients who underwent nephrectomy. The overall 30-day mortality rate was 0.9%. Both screening and education programmes are needed to decrease the rate of nephrectomy for preventable conditions.
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Affiliation(s)
- Ibrahim Fathi Ghalayini
- Faculty of Medicine, Jordan University of Science and Technology, Princess Basma Teaching Hospital, Irbid, Jordan.
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Abstract
Struvite calculi can be a debilitating affliction for which the cure is mainly surgical. If left untreated, infection-related calculi can cause failure to thrive, anemia, chronic renal insufficiency, renal failure and death. There has been much research aimed at non-surgical intervention and prevention of these calculi especially in this "non-invasive" era. The historic and current non-surgical treatment modalities of struvite calculi are discussed.
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Affiliation(s)
- B F Schwartz
- Department of Urology, University of California at San Francisco, USA
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Abstract
Nonobstructive, nonrefluxing pyelonephritis (or "simple" pyelonephritis) is not commonly associated with progressive renal scarring and global shrinkage. Although children are believed to be particularly susceptible to renal parenchymal scarring after simple pyelonephritis, progressive and global renal shrinkage remains an elusive clinical entity. We present such a case with close radiologic documentation.
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Affiliation(s)
- M H Hansen
- Department of Urology, Stanford University School of Medicine, and Lucile Salter Packard Children's Hospital at Stanford, California, USA
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Warren JW, Muncie HL, Hebel JR, Hall-Craggs M. Long-term urethral catheterization increases risk of chronic pyelonephritis and renal inflammation. J Am Geriatr Soc 1994; 42:1286-90. [PMID: 7983294 DOI: 10.1111/j.1532-5415.1994.tb06513.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To determine the prevalences of chronic pyelonephritis and chronic renal inflammation in elderly nursing home patients at the time of death and to assess correlation with urethral catheterization and other putative risk factors. DESIGN Prospective assessment of risk factors with the prevalences of chronic pyelonephritis and renal inflammation at autopsy. SETTING A 240-bed long-term care facility. PARTICIPANTS All residents > or = 65 years old who died and were autopsied during a 2-year period. MEASUREMENTS Antemortem assessment of risk factors for renal inflammation, including a search for any urethral catheterization in the person's life. Prospective assessment of urethral catheterization, catheter obstruction, and use of anti-inflammatory medications and urine cultures. Urinary tract pathology was assessed for gross and microscopic evidence of inflammation and urinary tract stones. RESULTS The duration of catheterization was significantly associated with increasing prevalence of bacteriuria, polymicrobial bacteriuria, chronic pyelonephritis, and chronic renal inflammation. The prevalence of chronic pyelonephritis at death was 10 percent (5/52) for patients catheterized > 90 days during their last year of life and zero (0/65) when catheterized < or = 90 days (P < 0.02; Fisher's exact test). Chronic pyelonephritis was significantly associated with renal stones and hydronephrosis. The prevalence of chronic renal inflammation without chronic pyelonephritis was significantly greater than that of chronic pyelonephritis: the prevalence was 43 percent (20/47) when catheterized > 90 days and 18 percent (12/65) when < or = 90 days (P < 0.05). Chronic renal inflammation was associated with hydronephrosis, ureteral dilatation, acute pyelonephritis and diastolic hypertension. CONCLUSION Chronic pyelonephritis and chronic renal inflammation are associated with long-term catheterization.
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Affiliation(s)
- J W Warren
- Department of Medicine, University of Maryland School of Medicine, Baltimore 21201
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Abstract
Forty-two of 371 patients (11.3%) entering a dialysis-transplant program had end-stage reflux nephropathy. Thirteen of these 371 patients were under 16 years of age, with 6 of them having reflux nephropathy. Most patients presented with severely impaired renal function, hypertension, and proteinuria. Documented urinary tract infections occurred in only 4 of the 18 male and 14 of the 24 female patients. Thirty-five patients had hypertension, which in 22 had not been detected before presentation. Five presented with accelerated hypertension. Eight of the 24 women presented during a pregnancy. Twenty-nine patients are still alive, 20 with a functioning renal transplant. Reflux nephropathy is an important cause of end-stage renal failure, particularly in younger people. All patients presenting with renal insufficiency and proteinuria, with or without urinary tract infections or hypertension, should have reflux nephropathy excluded.
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Affiliation(s)
- R R Bailey
- Department of Nephrology, Christchurch Hospital, New Zealand
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Abstract
In patients with apparent urinary tract infection, clinical presentation and results of physical examination and a few simple laboratory studies can identify patients who need urine culture and/or imaging studies and can guide initial therapy. A wide variety of effective antibiotics are available for various causes, and local patterns of microbial sensitivity and cost-effectiveness help govern drug selection. Response to therapy governs further treatment and follow-up. Exclusion of complicated infection and particular risk factors permits simplified but effective management of symptomatic recurrent infections.
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Affiliation(s)
- M Forland
- Office of the Medical Dean, University of Texas Medical School, San Antonio 78284
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Ganiats TG, Humphrey JB, Taras HL, Kaplan RM. Routine neonatal circumcision: a cost-utility analysis. Med Decis Making 1991; 11:282-93. [PMID: 1766331 DOI: 10.1177/0272989x9101100406] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A cost-utility analysis was performed to evaluate the relative importance of each of the various elements in the current circumcision debate. Elements used in the analysis included the cost of the procedure, the pain associated with the procedure, the risk of urinary tract infections, and the risk of penile cancer. The net, discounted lifetime dollar cost of routine circumcision is $102 per person, while the net, discounted lifetime health cost is 14 hours of healthy life. These results suggest that the financial and medical advantages and disadvantages of routine neonatal circumcision cancel each other and that factors other than cost or health outcomes must be used in decision making.
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Affiliation(s)
- T G Ganiats
- Department of Community of Family Medicine, University of California, San Diego School of Medicine, La Jolla 92093-0807
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Abstract
The vast majority of otherwise healthy adults with anatomically and functionally normal urinary tracts experience few untoward long-term consequences from symptomatic or asymptomatic UTIs. Effective early treatment of symptomatic infection rapidly curtails bacterial invasion and the resulting inflammatory response. Rarely, uncomplicated acute pyelonephritis causes suppuration and renal scarring. Urinary infections in patients with renal calculi, obstructed urinary tract, neurogenic bladder, or diabetes are frequently much more destructive and have ongoing sequelae. Strategies to treat both the infection and the complications are often necessary to alter this outcome.
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Affiliation(s)
- A R Ronald
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
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Abstract
Our current knowledge of the long-term outcome of uncomplicated urinary tract infections in women is based on a re-evaluation of the criteria for defining pyelonephritis at autopsy, careful description of the causes of renal disease among patients entering dialysis and transplant programs, long term observation of patients, and epidemiologic studies which have attempted to determine the association of bacteriuria with mortality. The weight of the evidence favors the conclusion that although urinary tract infections can produce severe impairment of renal function, this is rare in the absence of a major predisposing factor such as obstruction, calculus, reflux, abnormalities of the voiding mechanism or diabetes. The predisposing lesions, however, may go undetected until heralded by episodes of acute pyelonephritis or by renal failure. Unfortunately, urinary tract infections are so common that it is difficult to distinguish the population at greatest risk. The possible role of renal damage produced by autoimmune mechanisms following infection needs continued study.
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Affiliation(s)
- C M Kunin
- Department of Medicine, Ohio State University College of Medicine, Columbus 43210
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Abstract
Previous studies show that chronic pyelonephritis and end stage renal disease may follow acute pyelonephritis in children and adolescents when improperly or inadequately treated. Our study shows that there is a significant decrease in renal function following untreated acute bacterial pyelonephritis due to nephron loss. The acute inflammatory response is responsible for much of the renal damage, although damage from renal ischemia is an additional significant factor. The present study used a combination of an antibiotic and a xanthine oxidase inhibitor (allopurinol) as compared to antibiotic therapy alone begun 72 hours after infection. Both were successful in eradicating the infection rapidly, but did not entirely prevent renal damage. Treatment prior to 72 hours thus is important. It appears that the combined treatment, designed to eradicate the bacteria as well as reduce the post-ischemic reperfusion damage and the phagocytic burst of phagocytosis is ideal, as this combined treatment was effective in preventing almost all renal damage and loss of renal function.
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Affiliation(s)
- J A Roberts
- Department of Urology, Tulane University, New Orleans, Louisiana
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Roberts JA, Kaack MB, Baskin G, Korhonen TK, Svenson SB, Winberg J. P-fimbriae vaccines. II. Cross reactive protection against pyelonephritis. Pediatr Nephrol 1989; 3:391-6. [PMID: 2577147 DOI: 10.1007/bf00850213] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Protection against acute pyelonephritis was induced by immunization of baboons with purified P-fimbriae of Escherichia coli as vaccines. To test for cross-protective capacity of two different P-fimbriae vaccines we vaccinated baboons with P-fimbriae purified from either E. coli strain ER2 or strain JR1 and subsequently challenged the animals with E. coli strain JR1. All vaccinated animals showed elevated antibody titers to P-fimbriae from both of the E. coli strains used. Both vaccines tended to reduce the time of bacteriuria. They partially prevented pyelonephritis and protected against loss of renal function.
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Affiliation(s)
- J A Roberts
- Department of Urology, Delta Regional Primate Research Center, Covington, LA 70433
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Holmgren K, Danielson BG, Fellström B. Infection-induced urinary calculi and renal failure. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 1987; 21:219-23. [PMID: 3324303 DOI: 10.3109/00365598709180325] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
During 1974-1984 altogether 481 patients were treated for end-stage renal disease (ESRD). Eight patients, five women and three men, with chronic pyelonephritis as the primary cause of ESRD, had staghorn urinary calculi as a predisposing factor for renal failure. These eight patients were studied retrospectively concerning epidemiological and bacteriological aspects, the treatment of the stone disease, and the development of uraemia. Anatomical and metabolic abnormalities such as bladder outlet disturbances, primary hyperparathyroidism, phenacetin abuse or metabolic stone disease were found in six patients. The women had all been infected with Proteus mirabilis, whereas the men had been infected with various microorganisms. The average time taken for the development of ESRD, estimated from the first sign of renal impairment, was 7.4 +/- 2.9 (SD) years. Five patients had died before this study commenced. One of the patients still alive was on dialysis treatment. Two patients who were doing well without dialysis were stone free and had sterile urine after successful pyelolithotomy. It is concluded that the prevalence of infectious urinary calculi as a cause of uraemia in patients with ESRD is low. The time taken for uraemia to develop is short in these patients and they often have anatomical abnormalities. Proteus is commonly found in this group of patients. Patients with staghorn calculi, urinary tract infection and impairment of renal function are at risk of developing uraemia.
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Affiliation(s)
- K Holmgren
- Department of Urology, University Hospital, Uppsala, Sweden
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Huland H, Busch R. Pyelonephritic scarring in 213 patients with upper and lower urinary tract infections: long-term followup. J Urol 1984; 132:936-9. [PMID: 6492284 DOI: 10.1016/s0022-5347(17)49955-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Of 213 patients more than 3 years old with recurrent urinary tract infections new pyelonephritic scars formed only among those with a combination of urinary tract infection and vesicoureteral reflux. Of 61 patients with that combination new renal pyelonephritic scars developed in 7 (11.48 per cent) and severe clubbing in 2. Of 40 patients with vesicoureteral reflux who underwent an antireflux operation new scars formed in 5 and progressive renal damage occurred in 1. Most renal scars (58) were present at initial examination. Neither number of urinary tract infections, number of upper urinary tract infections localized by the bladder washout technique nor attacks of flank pain and fever were seen more often in patients who suffered new scars, and grade of reflux was not a factor. Patients in whom new scars developed during our prospective followup were younger than those who did not have new scars. However, new scars formed after an initial normal excretory urogram in only 1 patient with vesicoureteral reflux and urinary tract infection compared to 4 after an antireflux operation.
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Abstract
Immunopathologic responses to urinary Tamm-Horsfall protein in the development of chronic pyelonephritis were examined by four different approaches. First, in a rabbit model, tubulointerstitial nephritis developed in 64 of 102 rabbits injected intravenously with urine or rabbit Tamm-Horsfall protein as compared with only one of 17 rabbits in two control groups. Circulating cytotoxic lymphocytes plus immunoglobulin G (IgG) antibodies against Tamm-Horsfall protein were found in 51 percent of challenged (urine or Tamm-Horsfall protein) rabbits with tubulointerstitial nephritis as compared with only 8 percent of those without it (p less than 0.001). Second, in a porcine model of reflux nephropathy, 16 of 21 pigs with pyelographic findings indicative of reflux had elevated serum titers of anti-Tamm-Horsfall protein antibody as compared with 0 of 13 with normal pyelograms. Five of 10 refluxing pigs tested also had circulating lymphocytes that were cytotoxic in the presence of Tamm-Horsfall protein as compared with 0 of 13 with normal pyelograms. Third, in human studies, 12 of 49 patients with recurrent nephrolithiasis demonstrated abnormal elevations in anti-Tamm-Horsfall protein antibody; 13 of 49 had an abnormality in one of two assays of cell-mediated immunity to Tamm-Horsfall protein as compared with 0 of the normal control subjects. These abnormalities were not associated with overt obstruction or bacteriuria, but appeared to be more common in patients with recent onset and active recurrent nephrolithiasis. Lastly, an inhibitor of the binding reaction between human Tamm-Horsfall protein and its IgG antibody was detected in extracts of three uropathic coliforms. The inhibitors were partially purified by chromatographic means. Preliminary immunoautoradiographic studies revealed three or less protein-containing subunits of Escherichia coli that cross-reacted with anti-Tamm-Horsfall protein antibody. These studies suggest that autoimmune responses to Tamm-Horsfall protein may occur after exposure to Tamm-Horsfall protein by intravenous challenge, urinary reflux, or recurrent nephrolithiasis. This autoimmune response to Tamm-Horsfall protein may be the pathogenetic mechanism by which these factors, including bacteriuria, contribute to chronic pyelonephritis.
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Huland H, Busch R, Riebel T. Renal scarring after symptomatic and asymptomatic upper urinary tract infection: a prospective study. J Urol 1982; 128:682-5. [PMID: 7143583 DOI: 10.1016/s0022-5347(17)53133-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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