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Rai S, Sharma P, Nepal A, Poudel S, Guerra Y. Acute Pancreatitis Caused by Pegylated (PEG)-Asparaginase Associated With Severe Hypertriglyceridemia. Cureus 2024; 16:e62448. [PMID: 39011188 PMCID: PMC11248515 DOI: 10.7759/cureus.62448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2024] [Indexed: 07/17/2024] Open
Abstract
Pegylated (PEG)-asparaginase is used during the induction and intensification phases of treatment for B-cell acute lymphoblastic leukemia (B-ALL). It works by depleting the external sources of asparagine, causing the death of lymphoblasts. It has several adverse effects, including pancreatitis and hypertriglyceridemia; however, the simultaneous occurrence of both is uncommon. We present the case of an 18-year-old man with B-ALL who developed acute epigastric pain radiating to the back and non-bloody, non-bilious emesis following treatment with PEG-asparaginase. He was diagnosed with acute interstitial pancreatitis and severe hypertriglyceridemia. Conservative management was used for the pancreatitis, while hypertriglyceridemia was treated with an insulin infusion. Pancreatic toxicity and hypertriglyceridemia can necessitate the discontinuation of PEG-asparaginase, limiting treatment options and potentially increasing the risk of relapse. Therefore, further studies are needed to identify the factors contributing to hypertriglyceridemia and pancreatitis, aiding clinicians in monitoring and prevention.
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Affiliation(s)
- Sumina Rai
- Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Prabhat Sharma
- Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Anamika Nepal
- Internal Medicine, Shankarapur Hospital, Kathmandu, NPL
| | - Sajana Poudel
- Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
| | - Yannis Guerra
- Endocrinology, Diabetes and Metabolism, John H. Stroger, Jr. Hospital of Cook County, Chicago, USA
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Silvano J, Marques N, Tavares I, Ferreira I. Severe L-asparaginase-induced Hypertriglyceridaemia Treated with Plasmapheresis. Eur J Case Rep Intern Med 2021; 8:002342. [PMID: 33768080 DOI: 10.12890/2021_002342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 02/02/2021] [Indexed: 12/15/2022] Open
Abstract
L-asparaginase is used for the treatment of acute lymphoblastic leukaemia. Hypertriglyceridaemia is a side effect and associated with potentially fatal complications, including acute pancreatitis. Plasmapheresis may have a role in treatment when triglycerides are >2000 mg/dl. We report the case of a 39-year-old woman treated with L-asparaginase for acute lymphoblastic leukaemia, who developed severe hypertriglyceridaemia (6560 mg/dl) and acute pancreatitis. Intravenous insulin infusion was started, along with fenofibrate and atorvastatin administration, and platelet transfusion. Plasmapheresis was carried out leading to a frank decline in serum triglyceride levels (366 mg/dl), a decrease in pancreatic enzymes and clinical improvement. The diagnosis of pancreatitis secondary to L-asparaginase should lead to immediate drug withdrawal, and plasmapheresis should be considered when serum triglyceride values exceed 2000 mg/dl. In our case, there was a 95% triglyceride removal rate. This response illustrates the strong effectiveness of early treatment with plasmapheresis in severe and symptomatic hypertriglyceridaemia associated with L-asparaginase. LEARNING POINTS Pancreatitis following L-asparaginase-induced hypertriglyceridaemia is a severe and potentially reversible condition in both adults and children treated for acute lymphoblastic leukaemia.Early plasmapheresis is more effective to rapidly decrease serum triglycerides.
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Affiliation(s)
- José Silvano
- Nephrology Department, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Nidia Marques
- Nephrology Department, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Isabel Tavares
- Nephrology Department, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Ines Ferreira
- Nephrology Department, Centro Hospitalar e Universitário de São João, Porto, Portugal
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Lau KM, Saunders IM, Goodman A. Pegaspargase-induced hypertriglyceridemia in a patient with acute lymphoblastic leukemia. J Oncol Pharm Pract 2019; 26:193-199. [PMID: 30823860 DOI: 10.1177/1078155219833438] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Pegaspargase, a long acting formulation of L-asparaginase, is an asparagine specific enzyme that selectively kills leukemic cells by depleting plasma asparagine. Pegaspargase is FDA approved for the first-line treatment of adult acute lymphoblastic leukemia and is a critical component of numerous multi-chemotherapeutic regimens. Pegaspargase is associated with well-described toxicities including hypersensitivity reactions, hepatotoxicity, and thrombosis. However, hypertriglyceridemia is a much rarer complication of pegaspargase and has only been described in a limited number of reports. We present a case of severe hypertriglyceridemia after a single dose of pegaspargase. The patient was re-challenged with pegaspargase and again developed hypertriglyceridemia which was complicated by pancreatitis. Here, we summarize published reports and a literature review describing the incidence of pegaspargase-induced hypertriglyceridemia in common acute lymphoblastic leukemia protocols.
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Affiliation(s)
- Kimberly M Lau
- Department of Pharmacy, University of California San Diego, La Jolla, CA, USA
| | - Ila M Saunders
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA
| | - Aaron Goodman
- Division of Blood and Marrow Transplantation, Department of Medicine, University of California San Diego, La Jolla, CA, USA
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Schmiegelow K, Müller K, Mogensen SS, Mogensen PR, Wolthers BO, Stoltze UK, Tuckuviene R, Frandsen T. Non-infectious chemotherapy-associated acute toxicities during childhood acute lymphoblastic leukemia therapy. F1000Res 2017; 6:444. [PMID: 28413626 PMCID: PMC5389408 DOI: 10.12688/f1000research.10768.1] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2017] [Indexed: 01/19/2023] Open
Abstract
During chemotherapy for childhood acute lymphoblastic leukemia, all organs can be affected by severe acute side effects, the most common being opportunistic infections, mucositis, central or peripheral neuropathy (or both), bone toxicities (including osteonecrosis), thromboembolism, sinusoidal obstruction syndrome, endocrinopathies (especially steroid-induced adrenal insufficiency and hyperglycemia), high-dose methotrexate-induced nephrotoxicity, asparaginase-associated hypersensitivity, pancreatitis, and hyperlipidemia. Few of the non-infectious acute toxicities are associated with clinically useful risk factors, and across study groups there has been wide diversity in toxicity definitions, capture strategies, and reporting, thus hampering meaningful comparisons of toxicity incidences for different leukemia protocols. Since treatment of acute lymphoblastic leukemia now yields 5-year overall survival rates above 90%, there is a need for strategies for assessing the burden of toxicities in the overall evaluation of anti-leukemic therapy programs.
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Affiliation(s)
- Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Müller
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Signe Sloth Mogensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Pernille Rudebeck Mogensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Diabetes and Metabolism, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Benjamin Ole Wolthers
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ulrik Kristoffer Stoltze
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ruta Tuckuviene
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Thomas Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
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Raja RA, Schmiegelow K, Sørensen DN, Frandsen TL. Asparaginase-associated pancreatitis is not predicted by hypertriglyceridemia or pancreatic enzyme levels in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2017; 64:32-38. [PMID: 27555294 DOI: 10.1002/pbc.26183] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/04/2016] [Accepted: 07/07/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND l-Asparaginase is an important drug for treatment of childhood acute lymphoblastic leukemia (ALL), but is associated with serious toxicities, including pancreatitis and hypertriglyceridemia (HTG). Asparaginase-associated pancreatitis (AAP) is a common reason for stopping asparaginase treatment. The aim of this study was to explore if HTG or early elevations in pancreatic enzymes were associated with the subsequent development of AAP. METHOD Children (1.0-17.9 years) diagnosed with ALL, treated with asparaginase for 30 weeks, according to the NOPHO ALL2008 protocol at the University Hospital Rigshospitalet, Copenhagen, Denmark, were eligible. Pancreatic enzymes, triglycerides, and cholesterol were measured regularly. RESULTS Thirty-one patients were included. Seven patients were diagnosed with AAP. HTG was most evident when PEG-asparaginase and dexamethasone were administered concomitantly. Overall, there was no significant difference in triglyceride levels in patients who experienced AAP and patients who did not. An increase in triglyceride levels during concomitant dexamethasone therapy in delayed intensification was significantly associated with an increase in pancreas-specific amylase levels two weeks later (P = 0.005). CONCLUSIONS AAP does not seem to be associated with HTG. Continuous monitoring of pancreas enzymes does not predict AAP.
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Affiliation(s)
- Raheel Altaf Raja
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ditte Nørbo Sørensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
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Galindo RJ, Yoon J, Devoe C, Myers AK. PEG-asparaginase induced severe hypertriglyceridemia. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 60:173-7. [DOI: 10.1590/2359-3997000000068] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/14/2015] [Indexed: 01/19/2023]
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Kothari J, Thomas A, Goldstone A. Pseudohyponatraemia due to L-asparaginase-associated dyslipidaemia in T-cell lymphoblastic lymphoma. BMJ Case Rep 2014; 2014:bcr-2013-202829. [PMID: 24686801 DOI: 10.1136/bcr-2013-202829] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Mittal N, Llanos-Chea A, Dighe D, Giordano L. A Teenaged Patient with Severe Asparaginase-Induced Hypertriglyceridemia Safely Re-Challenged During Primary and Relapse Therapy for Acute Lymphoblastic Leukemia. J Adolesc Young Adult Oncol 2014. [DOI: 10.1089/jayao.2013.0037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Nupur Mittal
- Division of Pediatric Hematology/Oncology, University of Illinois at Chicago, Chicago, Illinois
| | - Alejandro Llanos-Chea
- Department of Pediatrics, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois
| | - Dipti Dighe
- Department of Pediatrics, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois
| | - Lisa Giordano
- Department of Pediatrics, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois
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Raja RA, Schmiegelow K, Frandsen TL. Asparaginase-associated pancreatitis in children. Br J Haematol 2012; 159:18-27. [PMID: 22909259 DOI: 10.1111/bjh.12016] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
l-asparaginase has been an element in the treatment for acute lymphoblastic leukaemia (ALL) and non-Hodgkin lymphoma since the late 1960s and remains an essential component of their combination chemotherapy. Among the major toxicities associated with l-asparaginase therapy are pancreatitis, allergic reactions, thrombotic events, hepatotoxicity and hyperlipidaemia. Acute pancreatitis is one of the most common reasons for stopping treatment with l-asparaginase. Short-term complications of asparaginase-associated pancreatitis include development of pseudocysts and pancreatic necrosis. Long-term complications include chronic pancreatitis and diabetes. The pathophysiology of asparaginase-associated pancreatitis remains to be uncovered. Individual clinical and genetic risk factors have been identified, but they are only weak predictors of pancreatitis. This review explores the definition, possible risk factors, treatment and complications of asparaginase-associated pancreatitis.
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Affiliation(s)
- Raheel Altaf Raja
- The Department of Paediatrics and Adolescent Medicine, the University Hospital Rigshospitalet, Copenhagen, Denmark
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Tan M, Wai D, Chng CL, Hwang W. Acarbose is an effective treatment for severe hypertriglyceridemia secondary to l-asparaginase and dexamethasone. Leuk Lymphoma 2012; 53:1245-6. [PMID: 22149169 DOI: 10.3109/10428194.2011.647312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Seah J, Lin K, Tai D, Lim ST, Chan A. Conservative Management of L-Asparaginase-Induced Hypertriglyceridemia in an Adult Patient: A Case Report and Review of the Literature. ACTA ACUST UNITED AC 2012; 35:596-8. [DOI: 10.1159/000342690] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Berrueco R, Rives S, López-García VS, Catalá A, Toll T, Estella J. Very high hypertriglyceridemia induced: is plasmapheresis needed? Pediatr Blood Cancer 2011; 57:532. [PMID: 21618412 DOI: 10.1002/pbc.23177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 03/31/2011] [Indexed: 01/19/2023]
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Stefanutti C, Di Giacomo S, Labbadia G. Timing clinical events in the treatment of pancreatitis and hypertriglyceridemia with therapeutic plasmapheresis. Transfus Apher Sci 2011; 45:3-7. [PMID: 21723786 DOI: 10.1016/j.transci.2011.06.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hyperlipidemic pancreatitis (HP) is caused by severe hypertriglyceridemia (SHTG). Evidence of SHTG refractoriness to standard medical treatment but not to therapeutic apheresis has increased in the last years. METHODS Described is the timing of clinical events and the sequence of therapeutic plasma-exchange (TPE) procedures to treat pancreatitis due to SHTG in a male patient, Caucasian, aged 49years, referred to emergency for severe epigastric pain. There was no history of alcohol consumption, a pre-existing mild hyperlipidemia was treated with diet alone, and biliary imaging was normal. Physical examination revealed epigastric tenderness. Laboratory investigation revealed marked hypertriglyceridemia (11,355mg/dL; range: 30-150), and hypercholesterolemia (941mg/dL; range: 80-200). Serum amylase (Amy) and lipase (Lip) were increased: 160UI/L (range: 20-100) and 175UI/L (range: 13-60), respectively. A computerized tomography (CT) scan of the abdomen revealed a picture compatible with acute pancreatic phlogosis. It was diagnosed as "acute secondary pancreatitis (AP) and SHTG". RESULTS The patient was successfully submitted to three sessions of TPE in emergency. He was released from hospital after 13 days of hospitalization. The levels of lipids and lipoproteins in his plasma were as follows: triglycerides (TG) 185mg/dL; total cholesterol (TC) 179mg/dL; HDL-cholesterol (HDLC) 22mg/dL; LDL-cholesterol (LDLC) 120mg/dL. CONCLUSIONS The decision to submit the patient with clinical evidence of HP caused by SHTG to apheresis was correct. The improvement in the clinical picture was fast and the recovery was complete.
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Affiliation(s)
- C Stefanutti
- Therapeutic Plasmapheresis Unit - Department of Clinical and Medical Therapy, University of Rome La Sapienza - Umberto I Hospital, 155, V.le del Policlinico, I-00161 (EU) Rome, Italy.
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Cohen H, Bielorai B, Harats D, Toren A, Pinhas-Hamiel O. Conservative treatment of L-asparaginase-associated lipid abnormalities in children with acute lymphoblastic leukemia. Pediatr Blood Cancer 2010; 54:703-6. [PMID: 20063421 DOI: 10.1002/pbc.22305] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the incidence and clinical consequences of asparaginase-associated lipid abnormalities in children with acute lymphoblastic leukemia (ALL). METHODS Sixty-five newly diagnosed children and adolescents aged 0.4-21 years with ALL or lymphoblastic lymphoma were retrospectively evaluated for lipid abnormalities. They were treated according to the ALLIC-BFM 2002 protocol between 2002 and 2005. Fasting cholesterol levels were measured in all patients and triglycerides (TG) in 42/65 patients. RESULTS Prior to treatment, mean cholesterol level was 149 +/- 50 mg/dl, and increased to maximal level 274 +/- 124 mg/dl during treatment. Mean TG level during treatment was 459 +/- 526 mg/dl (range 54-3,009). Twelve patients (28%) had TG levels <200 mg/dl, 18 (43%) had 200-400 mg/dl, 3 (7%) had 400-600 mg/dl, 4 (10%) between 600 and 1,000 mg/dl, and 5 (12%) patients had >1,000 mg/dl. No association was found between TG levels and age or gender. One of the 12 patients with TG >400 mg/dl developed left saggital sinus thrombosis and left frontal lobe infarct. TG level at the time of the event was 2,640 mg/dl. None of the five patients with TG levels >1,000 mg/dl developed pancreatitis. Children with TG levels between 400 and 600 mg/dl were treated by fasting. Fibrates and heparin were added to those with levels >600 mg/dl. Lipid abnormalities normalized in all children upon completion of asparaginase treatment. CONCLUSIONS Abnormalities of lipid profile in children with ALL during asparaginase therapy are relatively common. We recommend measuring TG before and during asparaginase treatment. Initiation of conservative treatment could prevent further increase of TG and decrease the risk of potential complications.
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Affiliation(s)
- Hofit Cohen
- The Bert W. Strassburger Lipid Center, Sheba Medical Center, Tel-Hashomer, Israel.
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Stefanutti C. Italian Multicenter Study on Low-Density Lipoprotein Apheresis: Retrospective Analysis (2007). Ther Apher Dial 2010; 14:79-86. [DOI: 10.1111/j.1744-9987.2009.00704.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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