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Wetzel B, Mylonas G, Puntus T, Prager F, Bernhart C, Amon M. LIPEMIA RETINALIS DURING CHEMOTHERAPY WITH ADJUNCTIVE GLUCOCORTICOID TREATMENT IN A PATIENT WITH COLON CARCINOMA. Retin Cases Brief Rep 2021; 15:450-452. [PMID: 30074937 PMCID: PMC8219080 DOI: 10.1097/icb.0000000000000814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this report is to describe a case of lipemia retinalis due to decompensating hyperlipidemia that occurred during chemotherapy in a patient with metastatic colon carcinoma. METHODS Retrospective case report. RESULTS A 55-year-old non-insulin-dependent diabetic man with well-controlled hyperlipidemia presented himself with temporarily blurred vision in both eyes occurring during chemotherapy. He was found to have lipemia retinalis in his both eyes. Blood tests revealed elevated cholesterol and triglyceride levels exceeding 8,200 mg/dL. He received six cycles of FOLFIRI/bevacizumab and accompanying dexamethasone because of colon cancer with pulmonary metastases. Lipemia retinalis had resolved after a 6-week follow-up when chemotherapy was finished, and the patients' triglyceride and glucose levels decreased to normal values. CONCLUSION Lipemia retinalis associated with visual impairment may occur during chemotherapy under accompanying treatment with dexamethasone. Even if patients with hyperlipidemia are metabolically well-controlled with oral medication, treatment with dexamethasone can potentially lead to decompensation of hyperlipidemia causing secondary lipemia retinalis.
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Affiliation(s)
- Barbara Wetzel
- Department of Ophthalmology, Academic Teaching Hospital of St. John of God, Vienna, Austria
- Sigmund Freud University Vienna, Campus Prater, Vienna, Austria; and
| | - Georgios Mylonas
- Department of Ophthalmology, Academic Teaching Hospital of St. John of God, Vienna, Austria
- Sigmund Freud University Vienna, Campus Prater, Vienna, Austria; and
| | - Thomas Puntus
- Department of Internal Medicine, Academic Teaching Hospital of St. John of God, Vienna, Austria
| | - Franz Prager
- Department of Ophthalmology, Academic Teaching Hospital of St. John of God, Vienna, Austria
- Sigmund Freud University Vienna, Campus Prater, Vienna, Austria; and
| | - Clemens Bernhart
- Department of Ophthalmology, Academic Teaching Hospital of St. John of God, Vienna, Austria
- Sigmund Freud University Vienna, Campus Prater, Vienna, Austria; and
| | - Michael Amon
- Department of Ophthalmology, Academic Teaching Hospital of St. John of God, Vienna, Austria
- Sigmund Freud University Vienna, Campus Prater, Vienna, Austria; and
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Dineen R, Stewart PM, Sherlock M. Factors impacting on the action of glucocorticoids in patients receiving glucocorticoid therapy. Clin Endocrinol (Oxf) 2019; 90:3-14. [PMID: 30120786 DOI: 10.1111/cen.13837] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 07/27/2018] [Accepted: 08/15/2018] [Indexed: 01/16/2023]
Abstract
Glucocorticoids (GCs) are steroid hormones, which are essential for life. They are secreted by the adrenal cortex under the control of the hypothalamic-pituitary-adrenal (HPA) axis. Glucocorticoids are essential for the normal function of most organ systems and, in both, excess and deficiency can lead to significant adverse consequences. Adrenal insufficiency (AI) is a rare, life-threatening disorder characterized by insufficient production of corticosteroid hormones. Primary AI is defined by the inability of the adrenal cortex to produce sufficient amounts of glucocorticoids and/or mineralocorticoids despite normal or increased adrenocorticotropin hormone (ACTH). Secondary AI is adrenal hypofunction due to insufficient amount of ACTH produced by the pituitary gland. Conventional treatment of both primary and secondary adrenal insufficiencies involves lifelong glucocorticoid replacement therapy. The role of cortisol deficiency and the impact of hydrocortisone replacement on morbidity and mortality in this patient group are under increasing scrutiny. Established glucocorticoid replacement regimens do not completely mirror endogenous hormonal production, and their monitoring to ensure optimum therapy is hampered by the lack of reliable biomarkers of hormone sufficiency. A further confounding issue is the tissue-specific regulation of glucocorticoid through the two isozymes of 11β-hydroxysteroid dehydrogenase (11β-HSD) with research focusing on the role of this prereceptor regulation in the development of adverse metabolic features in patients. This review defines the factors influencing glucocorticoid action in patients with adrenal insufficiency receiving glucocorticoid therapy.
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Affiliation(s)
- Rosemary Dineen
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Paul M Stewart
- Department of Endocrinology, University of Leeds, Leeds, UK
| | - Mark Sherlock
- Academic Department of Endocrinology, Beaumont Hospital and the Royal College of Surgeons in Ireland, Dublin, Ireland
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Werumeus Buning J, Dimova LG, Perton FG, Tietge UJF, van Beek AP, Dullaart RPF. Downregulation of cholesteryl ester transfer protein by glucocorticoids: a randomised study on HDL. Eur J Clin Invest 2017; 47:494-503. [PMID: 28542805 DOI: 10.1111/eci.12770] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 05/20/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND High density lipoprotein (HDL) cholesterol is not decreased in hypercortisolism despite high triglycerides, which may be ascribed to effects on the cholesteryl ester transfer protein (CETP) pathway. We explored if CETP mRNA expression is modulated by glucocorticoid treatment in vitro. Effects of doubling the hydrocortisone (HCT) replacement dose on plasma CETP activity, and HDL characteristics were tested in patients with secondary adrenal insufficiency. MATERIALS AND METHODS Human THP-1 macrophages were incubated with corticosterone in vitro in the presence or absence of a liver X receptor (LXR) agonist, followed by determination of CETP mRNA levels by quantitative real-time PCR. In addition, a randomised double-blind cross-over study was performed in 47 patients with secondary adrenal insufficiency (university medical setting; 10 weeks exposure to a higher HCT dose (0·4-0·6 mg/kg body weight) vs. 10 weeks of a lower HCT dose (0·2-0·3 mg/kg body weight). RESULTS Corticosterone dose dependently decreased CETP mRNA in THP-1 macrophages. Corticosterone also decreased CETP mRNA expression after LXR pretreatment. In patients, CETP activity decreased with doubling of the HCT dose (P = 0·049), coinciding with an increase in HDL cholesterol, apolipoprotein A-I and the HDL cholesterol/apolipoprotein A-I ratio (reflecting HDL size; P < 0·01 for each). The increase in the HDL cholesterol/apolipoprotein A-I ratio was correlated with the decrease in plasma CETP activity (r = -0·442, P = 0·002). CONCLUSION Glucocorticoids downregulate CETP gene expression in a human macrophage cell system. In line, a higher glucocorticoid replacement dose decreases plasma CETP activity in patients, thereby contributing to higher HDL cholesterol and an increase in estimated HDL size.
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Affiliation(s)
- Jorien Werumeus Buning
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Lidya G Dimova
- Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, Groningen, the Netherlands
| | - Frank G Perton
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,Laboratory Center, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Uwe J F Tietge
- Department of Pediatrics, Center for Liver, Digestive, and Metabolic Diseases, Groningen, the Netherlands
| | - André P van Beek
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Robin P F Dullaart
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Buitenwerf E, Kerstens MN, Links TP, Kema IP, Dullaart RPF. High-density lipoproteins and adrenal steroidogenesis: A population-based study. J Clin Lipidol 2017; 11:469-476. [PMID: 28502504 DOI: 10.1016/j.jacl.2016.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/02/2016] [Accepted: 12/29/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cholesterol trafficked within plasma lipoproteins, in particular high-density lipoproteins (HDL), may represent an important source of cholesterol that is required for adrenal steroidogenesis. Based on a urinary gas chromatography method, compromised adrenal function has been suggested in men but not in women with (genetically determined) low plasma HDL-cholesterol (HDL-C). OBJECTIVE The objective of the article was to examine the extent to which glucocorticoid production relates to HDL-C in a population-based cohort. METHODS A total of 240 subjects (120 men and 120 women, aged 20-79 years) without relevant comorbidities were recruited from the general population. Glucocorticoid metabolites were measured by gas chromatography with tandem mass spectrometric detection in 24-hour urine collections to estimate total glucocorticoid production (TGP). Fasting plasma (apo)lipoproteins were assayed by routine methods. RESULTS TGP was not decreased but tended to be increased in subjects with low HDL-C (NCEP-ATPIII criteria; P = .094). In univariate analysis, TPG was correlated inversely with HDL-C (r = -0.353, P < .001) and apoA-I (r = -0.263, P = .01). Multivariable linear regression analysis demonstrated that TGP was still inversely related to HDL-C (β = -0.145, P = .019) or alternatively to low HDL-C (β = -0.129, P = .013) taking age, sex, current smoking, and other metabolic syndrome components into account. CONCLUSION In this population-based study, urinary glucocorticoid metabolite excretion was inversely associated with HDL-C. We found no evidence for an attenuated adrenal function in men and women with low HDL-C.
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Affiliation(s)
- Edward Buitenwerf
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Michiel N Kerstens
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thera P Links
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ido P Kema
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Robin P F Dullaart
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Quinkler M, Beuschlein F, Hahner S, Meyer G, Schöfl C, Stalla GK. Adrenal cortical insufficiency--a life threatening illness with multiple etiologies. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 110:882-8. [PMID: 24529304 DOI: 10.3238/arztebl.2013.0882] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 08/06/2013] [Accepted: 08/06/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND The clinical signs of adrenal cortical insufficiency (incidence, ca. 25 per million per year; prevalence, ca. 400 per million) are nonspecific, and misdiagnoses are therefore common. Glucocorticoid substitution therapy has been in use for 50 years but is not a wholly adequate treatment. Our understanding of this disease remains incomplete in many ways. METHOD We selectively searched the Medline database for publications on adrenal cortical insufficiency, with particular attention to studies from the year 2000 onward (search terms: "adrenal insufficiency" or "Addison's disease" or "hypopituitarism"). RESULTS Hydrocortisone substitution therapy is often given in doses of 10-25 mg/day, timed according to the circadian rhythm. Gastrointestinal and other, febrile infections account for 30-50% of life-threatening adrenocortical crises. Such crises affect 8 of 100 persons with adrenal cortical insufficiency per year and must be treated by the immediate administration of glucocorticoids and fluids. When persons with adrenal cortical insufficiency are acutely ill or are otherwise under unusual stress, they may need additional amounts of hydrocortisone, often in the range of 5-10 mg but occasionally as high as 200 mg. The sustained administration of excessive amounts of steroid can shorten patients lives by several years. Inappropriate substitution therapy can cause other major medical conditions, such as metabolic syndrome and osteoporosis. CONCLUSION Important measures for the prevention of adrenocortical crises include improved care by treating physicians, education of patients and their families, the provision of emergency identifying documents, and the prescription of glucocorticoid emergency kits.
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Affiliation(s)
- Marcus Quinkler
- Department of Endocrinology and Metabolic Diseases, Charité Campus Mitte, Charité Universitätsmedizin Berlin
| | - Felix Beuschlein
- Endocrine Research Unit, Medizinische Klinik - Campus Innenstadt, Klinikum der Ludwig-Maximilian-Universität München
| | - Stefanie Hahner
- Department of Internal Medicine I, Universitätsklinikum Würzburg, Department of Endocrinology
| | - Gesine Meyer
- Department of Internal Medicine, Division of Endocrinology, Johann Wolfgang Goethe-University, Frankfurt am Main/Germany
| | - Christof Schöfl
- Department of Medicine 1 - Gastroenterology, Pneumology and Endocrinology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg
| | - Günter K Stalla
- Department of Clinical Neuroendocrinology, Max Planck Institute of Psychiatry, Munich
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Lieu FK, Lin CY, Wang PS, Jian CY, Yeh YH, Chen YA, Wang KL, Lin YC, Chang LL, Wang GJ, Wang SW. Effect of swimming on the production of aldosterone in rats. PLoS One 2014; 9:e87080. [PMID: 25289701 PMCID: PMC4188567 DOI: 10.1371/journal.pone.0087080] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Accepted: 12/18/2013] [Indexed: 01/09/2023] Open
Abstract
It has been demonstrated that exercise is one of the stresses known to increase the aldosterone secretion. Both potassium and angiotensin II (Ang II) levels are shown to be correlated with aldosterone production during exercise, but the mechanism is still unclear. In an in vivo study, male rats were catheterized via right jugular vein (RJV), and divided into four groups namely water immersion, swimming, lactate infusion (13 mg/kg/min) and pyruvate infusion (13 mg/kg/min) groups. Each group was treated for 10 min. Blood samples were collected at 0, 10, 15, 30, 60 and 120 min from RJV after administration. In an in vitro study, rat zona glomerulosa (ZG) cells were challenged by lactate (1–10 mM) in the presence or absence of Ang II (10−8 M) for 60 min. The levels of aldosterone in plasma and medium were measured by radioimmunoassay. Cell lysates were analyzed by immunoblotting assay. After exercise and lactate infusion, plasma levels of aldosterone and lactate were significantly higher than those in the control group. Swimming for 10 min significantly increased the plasma Ang II levels in male rats. Administration of lactate plus Ang II significantly increased aldosterone production and enhanced protein expression of steroidogenic acute regulatory protein (StAR) in ZG cells. These results demonstrated that acute exercise led to the increase of both aldosterone and Ang II secretion, which is associated with lactate action on ZG cells and might be dependent on the activity of renin-angiotensin system.
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Affiliation(s)
- Fu-Kong Lieu
- Department of Rehabilitation, Cheng Hsin General Hospital, Taipei, Taiwan, ROC
| | - Chih-Yung Lin
- Department of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Paulus S. Wang
- Department of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Graduate Institute of Basic Medical Science, College of Medicine, China Medical University, and Medical Center of Aging Research, China Medical University Hospital, Taichung, Taiwan, ROC
- Department of Biotechnology, College of Health Science, Asia University, Taichung, Taiwan, ROC
- Department of Medical Research and Education, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Cai-Yun Jian
- Department of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yung-Hsing Yeh
- Department of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yi-An Chen
- Department of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Kai-Lee Wang
- Department of Physiology, School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
| | - Yi-Chun Lin
- Department of Rehabilitation, Cheng Hsin General Hospital, Taipei, Taiwan, ROC
| | - Ling-Ling Chang
- Department of Chemical Engineering, College of Engineering, Chinese Culture University, Taipei, Taiwan, ROC
| | - Guei-Jane Wang
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan, ROC
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, ROC
- Department of Health and Nutrition Biotechnology, Asia University, Taichung, Taiwan, ROC
| | - Shyi-Wu Wang
- Department of Physiology and Pharmacology, College of Medicine, Chang-Gung University, Taoyuan, Taiwan, ROC
- * E-mail:
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Ragnarsson O, Nyström HF, Johannsson G. Glucocorticoid replacement therapy is independently associated with reduced bone mineral density in women with hypopituitarism. Clin Endocrinol (Oxf) 2012; 76:246-52. [PMID: 21767286 DOI: 10.1111/j.1365-2265.2011.04174.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Patients with hypopituitarism have adverse cardiovascular morbidity and reduced bone mineral density (BMD). The objective of this study was to analyse the effects of glucocorticoid (GC) replacement on cardiovascular risk factors and BMD in patients with hypopituitarism. DESIGN, PATIENTS AND METHODS This was a cross-sectional study on 365 patients with hypopituitarism. Two-hundred and four patients (56%) were ACTH insufficient (ACTHins), receiving a mean ± SD hydrocortisone equivalent (HCeq) dose of 20·5 ± 5·8 mg/day. The difference in BMD and cardiovascular risk profile between ACTH sufficient (ACTHsuff) and ACTHins patients, before commencement of GH replacement, was analysed by multiple linear and logistic regression. RESULTS ACTHins was independently associated with lower fasting glucose but not other cardiovascular risk factors. The mean HCeq dose per kg body weight was 15% higher in ACTHins women than in ACTHins men (P = 0·009). In women, ACTHins was independently associated with decreased BMD at the lumbar spine (P = 0·002) and femoral neck (P = 0·006) and the presence of osteopenia (P = 0·004). BMD was not different between ACTHins and ACTHsuff men. CONCLUSION The current average HCeq dose of approximately 20 mg per day is not associated with an adverse metabolic profile, as compared with ACTHsuff patients with hypopituitarism. GC replacement in ACTHins women is independently associated with reduced BMD and higher prevalence of osteopenia.
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Affiliation(s)
- Oskar Ragnarsson
- Department of Endocrinology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Göteborg, Sweden.
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Quinkler M, Hahner S. What is the best long-term management strategy for patients with primary adrenal insufficiency? Clin Endocrinol (Oxf) 2012; 76:21-5. [PMID: 21585418 DOI: 10.1111/j.1365-2265.2011.04103.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Primary adrenal insufficiency is treated with glucocorticoid and mineralocorticoid replacement therapy. Recent data revealed that health-related quality of life in adrenal insufficiency is impaired in many patients and that patients with adrenal insufficiency are also threatened by an increased mortality and morbidity. This may be caused by inadequate glucocortiocid therapy and adrenal crisis. Therefore, the optimization of hormone replacement therapy remains one of the most challenging tasks in endocrinology because it is largely based on clinical grounds because of the lack of objective assessment tools. This article provides answers to the important daily clinical questions, such as correct dose finding, dose adaptation in special situations, e g, pregnancy, improvement of quality of life and measures for protection from adrenal crisis. Other important aspects discussed are side effects of glucocortiocid replacement therapy and interactions with other drugs.
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Affiliation(s)
- Marcus Quinkler
- Clinical Endocrinology, Charité Campus Mitte, Charité University Medicine Berlin, Berlin, Germany.
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van Beek AP, Wolffenbuttel BHR, Runge E, Trainer PJ, Jönsson PJ, Koltowska-Häggström M. The pituitary gland and age-dependent regulation of body composition. J Clin Endocrinol Metab 2010; 95:3664-74. [PMID: 20484487 DOI: 10.1210/jc.2009-2506] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT The prevalence of obesity is increased in hypopituitarism. In the general population, body mass index (BMI) and waist circumference increase with advancing age. It remains uncertain whether age-related changes in pituitary function contribute to the changes in body composition associated with advancing years. OBJECTIVE Our objective was to study the relationship between pituitary function, body composition, and age in a large cohort of patients with hypopituitarism and a matched reference population. DESIGN, SETTING, AND PARTICIPANTS A total of 3632 GH-deficient adults with hypopituitarism, adequately replaced with all pituitary hormones except for GH, from the prospective KIMS database (Pfizer International Metabolic Database) were included in present analysis. A random sample of the general population (3427 subjects) was used as reference. Patients and controls were grouped by gender in five age cohorts of 10 yr from 28 yr onward. MAIN OUTCOME MEASURES Differences in BMI and waist circumference were evaluated. RESULTS Patients had a significantly higher BMI and waist circumference than controls, with larger differences at younger age. With advancing age, an increase in BMI and waist circumference was seen in controls but was virtually absent in the patients with adult-onset GH deficiency and hypopituitarism. CONCLUSION Patients with hypopituitarism have more excess body fat than age-matched controls, especially in the youngest age groups. The normal increase in fat mass with advancing age is not seen in adult-onset GH-deficient hypopituitarism, suggesting a potential role for the normal pituitary gland as an age-dependent regulator of body composition in adult life.
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Affiliation(s)
- André P van Beek
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, De Brug 4.069, AA 31, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
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Dullaart RPF. Comment on high HDL-cholesterol in women with rheumatoid arthritis on low-dose glucocorticoid therapy. Eur J Clin Invest 2009; 39:533. [PMID: 19490063 DOI: 10.1111/j.1365-2362.2009.02142.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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