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Shimazu Y, Kanda J, Takakuwa T, Onda Y, Fukushima K, Hotta M, Fuchida SI, Uoshima N, Shimura Y, Tanaka H, Ohta K, Shibayama H, Kosugi S, Yagi H, Yoshihara S, Hosen N, Ito T, Shimazaki C, Matsumura I, Kuroda J, Takaori-Kondo A, Hino M. The impact of renal function on initial therapy in transplant-ineligible multiple myeloma patients. Ann Hematol 2024:10.1007/s00277-024-05934-2. [PMID: 39167179 DOI: 10.1007/s00277-024-05934-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 08/06/2024] [Indexed: 08/23/2024]
Abstract
The prognosis for multiple myeloma (MM) patients has improved with the advent of new drugs, but the prognosis with renal impairment (RI) is poor. The choice of treatment in such cases is critical, but there are no set criteria. We examined the impact of RI on initial therapy in transplant-ineligible MM patients. We selected symptomatic MM patients who met the following criteria: age ≥ 65 years, fit, and ineligible for transplantation from the database. We analyzed the impact of age, treatment, International Staging System (ISS) stage, karyotype abnormalities, performance status, and estimated glomerular filtration rate (GFR < 50 or ≥ 50 ml/min/1.73m2) on overall survival (OS). We also analyzed the OS by eGFR for each treatment. We selected 349 symptomatic MM patients. The regimens used were lenalidomide, bortezomib and dexamethasone (RVd), daratumumab, bortezomib, melphalan, and prednisolone (D-VMP), daratumumab, lenalidomide and dexamethasone (D-Rd) and daratumumab, bortezomib, and dexamethasone (D-Vd) in 184, 41, 74 and 50 patients, respectively. The median age was 74 years old; ISS stage was I/II/III in 85/112/131 patients; and 161 patients showed eGFR < 50. The OS was shorter with ISS stage III (p = 0.029) and eGFR < 50 (p < 0.001) by multivariate analysis. The OS under the RVd/D-Rd regimens were significantly shorter for patients with eGFR < 50, but OS under the D-VMP/D-Vd regimens were not significantly different between patients with eGFR < 50 and eGFR ≥ 50. The OS of the transplant-ineligible MM patients with higher ISS stage and RI was poor. Initial treatment with a D-VMP/D-Vd regimen might be less affected by RI.
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Affiliation(s)
- Yutaka Shimazu
- Department of Hematology, Graduate School of Medicine, Kyoto University, 54, Kawaramachi, Shogoin, Sakyoku, Kyoto, 606-8507, Japan.
- Department of Early Clinical Development, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Junya Kanda
- Department of Hematology, Graduate School of Medicine, Kyoto University, 54, Kawaramachi, Shogoin, Sakyoku, Kyoto, 606-8507, Japan
| | | | - Yoshiyuki Onda
- Department of Hematology, Japanese Red Cross Osaka Hospital, Osaka, Japan
| | - Kentaro Fukushima
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masaaki Hotta
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Shin-Ichi Fuchida
- Department of Hematology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Nobuhiko Uoshima
- Department of Hematology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
| | - Yuji Shimura
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hirokazu Tanaka
- Department of Hematology and Rheumatology, Kindai University Faculty of Medicine, Osaka, Japan
| | | | - Hirohiko Shibayama
- Department of Hematology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Satoru Kosugi
- Department of Internal Medicine (Hematology), Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Hideo Yagi
- Department of Hematology and Oncology, Nara Prefecture General Medical Center, Nara, Japan
| | - Satoshi Yoshihara
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya City, Japan
| | - Naoki Hosen
- Department of Hematology and Oncology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tomoki Ito
- First Department of Internal Medicine, Kansai Medical University, Hirakata, Japan
| | - Chihiro Shimazaki
- Department of Hematology, Japan Community Health Care Organization Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | - Itaru Matsumura
- Department of Hematology and Rheumatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Junya Kuroda
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akifumi Takaori-Kondo
- Department of Hematology, Graduate School of Medicine, Kyoto University, 54, Kawaramachi, Shogoin, Sakyoku, Kyoto, 606-8507, Japan
| | - Masayuki Hino
- Department of Hematology, Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
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Derudas D, Chiriu S. The Role of Monoclonal Antibodies in the Treatment of Myeloma Kidney Disease. Pharmaceuticals (Basel) 2024; 17:1029. [PMID: 39204135 PMCID: PMC11357053 DOI: 10.3390/ph17081029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/28/2024] [Accepted: 07/29/2024] [Indexed: 09/03/2024] Open
Abstract
Renal failure is one of the most important manifestations of multiple myeloma. It is caused by renal lesions such as cast nephropathy, immunoglobulin deposition disease, AL amyloidosis or other glomerular and/or tubular diseases, mostly due to the toxic effect of free light chains in serum. Renal failure can represent a clinical emergency and is associated with poor outcome in newly diagnosed and relapsed/refractory multiple myeloma patients. Although progression-free survival and overall survival have improved with the introduction of novel agents, renal failure remains a challenge for the treatment of patients with multiple myeloma. Monoclonal antibodies are a component of therapy for newly diagnosed and relapsed/refractory patients and, based on clinical trials and real-world experience, are also safe and effective for subjects with renal failure, even if they are on dialysis. Most of the data are on anti-CD38 and anti-SLAM7 antibodies, but new antibody-drug conjugates such as belantamab mafodotin and bispecific antibodies also appear to be effective in myeloma kidney disease. In the future, we will have to face some challenges, such as defining new criteria for renal response to treatment, defining specific trials for these difficult-to-treat patients and integrating different therapeutic options.
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Affiliation(s)
- Daniele Derudas
- S.C. di Ematologia e C.T.M.O. Ospedale Oncologico di Riferimento Regionale “A. Businco” ARNAS “G. Brotzu”, 09126 Cagliari, Italy;
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Wang C, Xiang S. Clinical effect of regional citrate anticoagulation continuous renal replacement therapy in three patients with hypercalcemic crisis. Int J Artif Organs 2024; 47:369-372. [PMID: 38869042 DOI: 10.1177/03913988241259963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
In this study, we investigated the effectiveness of regional citrate anticoagulation continuous renal replacement therapy (RCA-CRRT) in reducing blood calcium levels in three patients with hypercalcemia crisis caused by different etiologies. The sodium citrate chelation of calcium ions was utilized as an anticoagulant for treating severely affected patients. By adjusting the citrate anticoagulant dose and monitoring treatment indicators, RCA-CRRT parameters were actively modified to alleviate the hypercalcemia crisis and provide time for surgery or specialized treatment. Two patients experienced rapid and effective reductions in blood calcium levels, allowing for further treatment, while the third patient exhibited a repeated increase in blood calcium, which eventually decreased after parathyroid adenoma resection, leading to clinical discharge. Our findings suggest that RCA-CRRT can help alleviate hypercalcemia crisis, stabilize the patient's internal environment, and provide valuable time for clinical treatment in cases of various medical conditions causing abnormal blood calcium elevations.
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Affiliation(s)
- Chunyan Wang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Nursing Department, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Shilong Xiang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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Raab MS, Zamagni E, Manier S, Rodriguez‐Otero P, Schjesvold F, Broijl A. Difficult-to-treat patients with relapsed/refractory multiple myeloma: A review of clinical trial results. EJHAEM 2023; 4:1117-1131. [PMID: 38024633 PMCID: PMC10660429 DOI: 10.1002/jha2.743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/31/2023] [Accepted: 06/13/2023] [Indexed: 12/01/2023]
Abstract
Overall outcomes for multiple myeloma have improved due to the availability of new therapies, but patients with relapsed/refractory multiple myeloma harbouring certain factors continue to pose a therapeutic challenge. These challenging features include high-risk cytogenetics, renal impairment, patient characteristics such as age and frailty, and extramedullary disease. Prior refractory status and number of prior lines add further complexity to the treatment of these patients. While newer regimens are available and have suggested efficacy in these patient populations through subgroup analyses, differences in trial definitions and cut-offs make meaningful comparisons difficult. This review aims to examine the available clinical trial data for patients with high-risk cytogenetics, renal impairment, age and frailty and extramedullary disease.
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Affiliation(s)
- Marc S. Raab
- Heidelberg Myeloma Center, Department of Medicine VUniversity HospitalHeidelbergGermany
| | - Elena Zamagni
- Seragnoli Institute of HematologyBologna University School of MedicineBolognaItaly
| | - Salomon Manier
- Department of HematologyUniversity Hospital Center of LilleLilleFrance
| | | | - Fredrik Schjesvold
- Oslo Myeloma Center, Department of HaematologyOslo University Hospital, Oslo, Norway, and KG Jebsen Center for B Cell MalignanciesUniversity of OsloOsloNorway
| | - Annemiek Broijl
- Department of HematologyErasmus MC Cancer InstituteRotterdamThe Netherlands
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Dimopoulos MA, Mikhael J, Terpos E, Leleu X, Moreau P, Bladé J, Kim JS, Stockerl-Goldstein K, Richardson PG. An overview of treatment options for patients with relapsed/refractory multiple myeloma and renal impairment. Ther Adv Hematol 2022; 13:20406207221088458. [PMID: 35392438 PMCID: PMC8980434 DOI: 10.1177/20406207221088458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/02/2022] [Indexed: 11/16/2022] Open
Abstract
Renal impairment (RI) is a relatively common complication of multiple myeloma, which increases in frequency as disease becomes more advanced and recovery of renal function becomes less likely as patients progress through lines of therapy. Clinical trials in the relapsed/refractory multiple myeloma (RRMM) setting have not uniformly included patients with RI or robustly reported their outcomes. Here, we review existing data among patients with RI and RRMM across drug classes (including immunomodulatory agents, proteasome inhibitors, monoclonal antibodies, antibody-drug conjugates, chimeric antigen receptor T-cell therapies, and exportin-1 inhibitor) to provide an improved understanding of available treatment options for this important population. We highlight data from pivotal clinical trials, including data relating to renal response (as defined by the International Myeloma Working Group) and discuss real-world experiences in patients with RI, where applicable. Despite substantial advances in RRMM treatment, the presence of RI remains associated with reduced overall survival. Consistent inclusion of patients with RI, and uniform reporting of their outcomes, should be encouraged in future prospective trials of treatments for RRMM.
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Affiliation(s)
- Meletios A. Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Joseph Mikhael
- Applied Cancer Research and Drug Discovery Division at the Translational Genomics Research Institute (TGen), City of Hope Cancer Center, Phoenix, AZ, USA
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Xavier Leleu
- Service d’Hématologie et Thérapie Cellulaire, CHU and CIC Inserm 1402, Poitiers Cedex, France
| | | | - Joan Bladé
- Hospital Clínic de Barcelona/IDIBAPS, Barcelona, Spain
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Keith Stockerl-Goldstein
- Division of Oncology, Department of Medicine, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Paul G. Richardson
- Dana Farber Cancer Institute, 450 Brookline Avenue, 44 Binney St., Boston, MA 02115, USA
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Engels EA, Haber G, Hart A, Lynch CF, Li J, Pawlish KS, Qiao B, Yu KJ, Pfeiffer RM. Solid Organ Transplantation and Survival among Individuals with a History of Cancer. Cancer Epidemiol Biomarkers Prev 2021; 30:1312-1319. [PMID: 33926864 PMCID: PMC8254777 DOI: 10.1158/1055-9965.epi-21-0044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/17/2021] [Accepted: 04/14/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The success of immunotherapy highlights a possible role for immunity in controlling cancer during remission for patients with cancer in the general population. A prior cancer diagnosis is common among solid organ transplant candidates, and immunosuppressive medications administered to transplant recipients may increase recurrence risk. METHODS Using linked data from the United States solid organ transplant registry and 13 cancer registries, we compared overall and cancer-specific survival among patients with cancer who did versus did not receive subsequent transplantation. We used Cox regression in cohort and matched analyses, controlling for demographic factors, cancer stage, and time since cancer diagnosis. RESULTS The study included 10,524,326 patients with cancer, with 17 cancer types; 5,425 (0.05%) subsequently underwent solid organ transplantation. The median time from cancer diagnosis to transplantation was 5.7 years. Transplantation was associated with reduced overall survival for most cancers, especially cervical, testicular, and thyroid cancers [adjusted hazard ratios (aHR) for overall mortality, 3.43-4.88]. In contrast, transplantation was not associated with decreased cancer-specific survival for any cancer site, and we observed inverse associations for patients with breast cancer (aHRs for cancer-specific mortality, 0.65-0.67), non-Hodgkin lymphoma (0.50-0.51), and myeloma (0.39-0.42). CONCLUSIONS Among U.S. patients with cancer, subsequent organ transplantation was associated with reduced overall survival, likely due to end-stage organ disease and transplant-related complications. However, we did not observe adverse associations with cancer-specific survival, partly reflecting careful candidate selection. IMPACT These results do not demonstrate a detrimental effect of immunosuppression on cancer-specific survival and support current management strategies for transplant candidates with previous cancer diagnoses.
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Affiliation(s)
- Eric A Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland.
| | - Gregory Haber
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Allyson Hart
- Department of Medicine, Hennepin Healthcare, University of Minnesota, Minneapolis, Minnesota
| | - Charles F Lynch
- Department of Epidemiology, The University of Iowa, Iowa City, Iowa
| | - Jie Li
- Cancer Epidemiology Services, New Jersey Department of Health, Trenton, New Jersey
| | - Karen S Pawlish
- Cancer Epidemiology Services, New Jersey Department of Health, Trenton, New Jersey
| | - Baozhen Qiao
- Bureau of Cancer Epidemiology, New York State Department of Health, Albany, New York
| | - Kelly J Yu
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Ruth M Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
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Chen X, Luo X, Zu Y, Issa HA, Li L, Ye H, Yang T, Hu J, Wei L. Severe renal impairment as an adverse prognostic factor for survival in newly diagnosed multiple myeloma patients. J Clin Lab Anal 2020; 34:e23416. [PMID: 32710448 PMCID: PMC7521223 DOI: 10.1002/jcla.23416] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 12/22/2022] Open
Abstract
Background Renal impairment (RI) is associated with poor survival in newly diagnosed multiple myeloma (MM) patients. Renal function recovery has been one of the main therapeutic goals in those patients. Methods The records from 393 newly diagnosed MM patients in our hospital between January 2012 and December 2016 were retrospectively analyzed. RI was defined as an eGFR < 40 mL/min according to the novel IMWG criteria. RI patients were categorized based on their renal function at diagnosis: severe RI: eGFR < 30 mL/min, and mild RI: 30 mL/min ≤ eGFR <40 mL/min. We explored whether RI, and particularly severe RI, was an adverse prognostic factor for survival, and investigated the impact of renal function recovery on survival. Results Severe RI, hemoglobin <100 g/L, LDH ≥ 245 U/L, hyperuricemia, 1q21 amplification, and lack of novel agent treatment were associated with decreased overall survival (OS). Severe RI patients with renal response had a median OS of 27 months compared with 18 months for those patients without renal response (P = .030), but their median OS was still significantly lower than that for patients without severe RI, which was 51 months. In severe RI patients, the overall renal response rate in bortezomib‐based regimens was significantly higher than that in nonbortezomib‐based regimens. Conclusion Our results suggest that severe RI is an adverse prognostic factor for survival in newly diagnosed MM patients, restoration of renal function may improve survival, and bortezomib‐based regimens may be the preferred treatment in patients with severe RI.
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Affiliation(s)
- Xuduan Chen
- Department of Nephrology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Xiaofeng Luo
- Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yanping Zu
- Department of Nephrology, Fujian Provincial Hospital Jinshan Branch, Fuzhou, China
| | - Hajji Ally Issa
- Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Linlin Li
- Department of Nephrology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Hong Ye
- Department of Nephrology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ting Yang
- Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Jianda Hu
- Fujian Institute of Hematology, Fujian Provincial Key Laboratory on Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Lixin Wei
- Department of Nephrology, Fujian Medical University Union Hospital, Fuzhou, China
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Autologous Stem Cell Transplantation in Multiple Myeloma with Renal Failure: Friend or Foe? Stem Cells Int 2019; 2019:9401717. [PMID: 31781250 PMCID: PMC6875020 DOI: 10.1155/2019/9401717] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 09/22/2019] [Accepted: 09/30/2019] [Indexed: 12/22/2022] Open
Abstract
Autologous stem cell transplantation (ASCT) is a standard treatment for multiple myeloma (MM), but the clinical response and renal curative effect in MM patients with renal failure (RF) remain controversial. The myeloma kidney disease has different types, and most are due to the direct toxic effects of light chain. Although ASCT can effectively clear the light chain, the data of renal function improvement are still limited. We reviewed the published literatures, focusing on the prospective studies, the retrospective analysis studies, and the case reports. RF patients who received ASCT displayed a low survival rate (OS: HR 1.95, 95% CI 1.020 to 3.720; I2 = 64.9%, P = 0.014) and a shorter EFS/PFS (EFS/PFS: HR 1.53, 95% CI 1.090 to 2.140; I2 = 0%, P = 0.669). However, ASCT was feasible and could have the similar clinical response outcomes compared with the normal renal function (CR: OR 1.013, 95% CI 0.569 to 1.804; I2 = 48.5%, P = 0.101; PR: OR 1.013, 95% CI 0.342 to 1.226; I2 = 46.3%, P = 0.144). Moreover, MM with RF after ASCT had a good improvement of renal function and melphalan is still an important factor affecting the treatment of ASCT.
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Gameiro J, Jorge S, Lopes JA. Renal Involvement in Multiple Myeloma. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10312017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Multiple myeloma (MM) is a plasma cell disorder that represents almost 10% of haematologic malignancies. Renal impairment, one of the most common complications of MM that occurs in 20–50% of patients, can present in a variety of forms and is associated with increased mortality. Myeloma cast nephropathy is the most common cause of kidney disease in MM patients, presenting as acute kidney injury in the majority of patients. The recent introduction of new chemotherapy agents, autologous stem cell transplantation, and the development of novel techniques of light chain removal have been associated with improved renal and patient outcomes in MM patients. Nevertheless, dialysis-dependent patients with MM have higher mortality than other dialysis patients and may be considered for kidney transplantation only if sustained remission has been achieved and sustained for at least 3 years, bearing in mind the risk of disease recurrence.
The authors review the most frequent renal manifestations associated with MM, namely myeloma cast nephropathy, light-chain amyloidosis, and monoclonal immunoglobulin deposition disease, focussing on the therapeutic options for acute and chronic kidney disease.
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Affiliation(s)
- Joana Gameiro
- Service of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Sofia Jorge
- Service of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - José António Lopes
- Service of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
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Outcomes of newly diagnosed myeloma patients requiring dialysis: renal recovery, importance of rapid response and survival benefit. Blood Cancer J 2017. [PMID: 28622304 PMCID: PMC5520396 DOI: 10.1038/bcj.2017.49] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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