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Sleep Breathing Disorders in Heart Failure. Cardiol Clin 2022; 40:183-189. [DOI: 10.1016/j.ccl.2021.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Floras JS. The 2021 Carl Ludwig Lecture. Unsympathetic autonomic regulation in heart failure: patient-inspired insights. Am J Physiol Regul Integr Comp Physiol 2021; 321:R338-R351. [PMID: 34259047 DOI: 10.1152/ajpregu.00143.2021] [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] [Indexed: 01/08/2023]
Abstract
Defined as a structural or functional cardiac abnormality accompanied by symptoms, signs, or biomarkers of altered ventricular pressures or volumes, heart failure also is a state of autonomic disequilibrium. A large body of evidence affirms that autonomic disturbances are intrinsic to heart failure; basal or stimulated sympathetic nerve firing or neural norepinephrine (NE) release more often than not exceed homeostatic need, such that an initially adaptive adrenergic or vagal reflex response becomes maladaptive. The magnitude of such maladaptation predicts prognosis. This Ludwig lecture develops two theses: the elucidation and judiciously targeted amelioration of maladaptive autonomic disturbances offers opportunities to complement contemporary guideline-based heart failure therapy, and serendipitous single-participant insights, acquired in the course of experimental protocols with entirely different intent, can generate novel insight, inform mechanisms, and launch entirely new research directions. I précis six elements of our current synthesis of the causes and consequences of maladaptive sympathetic disequilibrium in heart failure, shaped by patient-inspired epiphanies: arterial baroreceptor reflex modulation, excitation stimulated by increased cardiac filling pressure, paradoxical muscle sympathetic activation as a peripheral neurogenic constraint on exercise capacity, renal sympathetic restraint of natriuresis, coexisting sleep apnea, and augmented chemoreceptor reflex sensitivity and then conclude by envisaging translational therapeutic opportunities.
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Affiliation(s)
- John S Floras
- University Health Network and Sinai Health Division of Cardiology, Toronto General Hospital Research Institute and Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Tamisier R, Damy T, Bailly S, Davy JM, Verbraecken J, Lavergne F, Palot A, Goutorbe F, d'Ortho MP, Pépin JL. Adaptive servo ventilation for sleep apnoea in heart failure: the FACE study 3-month data. Thorax 2021; 77:178-185. [PMID: 34230094 PMCID: PMC8762030 DOI: 10.1136/thoraxjnl-2021-217205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/18/2021] [Indexed: 11/29/2022]
Abstract
Rationale Adaptive servo ventilation (ASV) is contraindicated in patients with systolic heart failure (HF) who have a left ventricular ejection fraction (LVEF) below 45% and predominant central sleep apnoea (CSA). However, the effects of ASV in other HF subgroups have not been clearly defined. Objective The European, multicentre, prospective, observational cohort trial, FACE, evaluated the effects of ASV therapy on morbidity and mortality in patients with HF with sleep-disordered breathing (SDB); 3-month outcomes in patient subgroups defined using latent class analysis (LCA) are presented. Methods Consecutive patients with HF with predominant CSA (±obstructive sleep apnoea) indicated for ASV were included from 2009 to 2018; the non-ASV group included patients who refused/were noncompliant with ASV. The primary endpoint was time to composite first event (all-cause death, lifesaving cardiovascular intervention or unplanned hospitalisation for worsening of chronic HF). Measurements and main results Baseline assessments were performed in 503 patients, and 482 underwent 3-month follow-up. LCA identified six discrete patient clusters characterised by variations in LVEF, SDB type, age, comorbidities and ASV acceptance. The 3- month rate of primary outcome events was significantly higher in cluster 1 patients (predominantly men, low LVEF, severe HF, CSA; 13.9% vs 1.5%–5% in other clusters, p<0.01). Conclusion For the first time, our data identified homogeneous patient clusters representing clinically relevant subgroups relating to SDB management in patients with HF with different ASV usage, each with a different prognosis. This may improve patient phenotyping in clinical practice and allow individualisation of therapy.
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Affiliation(s)
- Renaud Tamisier
- Université Grenoble Alpes, Laboratoire HP2 Inserm U1300, CHU Grenoble Alpes, Grenoble, France
| | - Thibaud Damy
- Hopital Henri Mondor, Creteil, Île-de-France, France.,Cardiology Department, French Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Assistance Publique - Hôpitaux de Paris, Paris, France.,UFR Médecine, Université Paris-Est Créteil, Paris, France
| | - Sebastien Bailly
- Université Grenoble Alpes, Laboratoire HP2 Inserm U1300, CHU Grenoble Alpes, Grenoble, France
| | - Jean-Marc Davy
- CHU Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Johan Verbraecken
- Multidisciplinary Sleep Disorders Centre, University Hospital Antwerp, Antwerp, Belgium.,University of Antwerp, Antwerp, Belgium
| | | | - Alain Palot
- Hopital Saint Joseph, Marseille, Provence-Alpes-Côte d'Azur, France
| | | | - Marie-Pia d'Ortho
- Hôpital Bichat Claude-Bernard, Paris, Île-de-France, France.,Université de Paris, Neurodiderot, INSERM, Paris, France
| | - Jean Louis Pépin
- Université Grenoble Alpes, Laboratoire HP2 Inserm U1300, CHU Grenoble Alpes, Grenoble, France
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Studnicka M, Baumgartner B, Bolitschek J, Doberer D, Eber E, Eckmayr J, Hartl S, Hesse P, Jaksch P, Kink E, Kneussl M, Lamprecht B, Olschewski H, Pfleger A, Pohl W, Prior C, Puelacher C, Renner A, Steflitsch W, Stelzmüller I, Täubl H, Vonbank K, Wagner M, Wantke F, Wass R. [Masterplan 2025 of the Austrian Society of Pneumology (ASP)-the expected burden and management of respiratory diseases in Austria]. Wien Klin Wochenschr 2020; 132:89-113. [PMID: 32990821 DOI: 10.1007/s00508-020-01722-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Scientific Members of the Austrian Society of Pneumology describe the expected development in respiratory health and provide guidance towards patient-oriented and cost-efficient respiratory care in Austria.Methods: In November 2017, respiratory care providers (physicians, nurses, physiotherapists) together with patient's advocacy groups and experts in health development, collaborated in workshops on: respiratory health and the environment, bronchial asthma and allergy, COPD, pediatric respiratory disease, respiratory infections, sleep disorders, interventional pneumology, thoracic oncology and orphan diseases.Results: Respiratory disease is extremely prevalent and driven by ill-health behavior, i.e. cigarette smoking, over-eating and physical inactivity. For the majority of respiratory diseases increased prevalence, but decreased hospitalizations are expected.The following measures should be implemented to deal with future challenges:1. Screening and case-finding should be implemented for lung cancer and COPD.2. E-health solutions (telemedicine, personal apps) should be used to facilitate patient management.3. Regional differences in respiratory care should be reduced through E‑health and harmonization of health insurance benefits across Austria.4. Patient education and awareness, to reduce respiratory health illiteracy should be increased, which is essential for sleep disorders but relevant also for other respiratory diseases.5. Respiratory care should be inter-professional, provided via disease-specific boards beyond lung cancer (for ILDs, sleep, allergy)6. Programs for outpatient's pulmonary rehabilitation can have a major impact on respiratory health.7. Increased understanding of molecular pathways will drive personalized medicine, targeted therapy (for asthma, lung cancer) and subsequently health care costs.
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Affiliation(s)
- Michael Studnicka
- Landeskrankenhaus Salzburg, Universitätsklinik für Pneumologie/Lungenheilkunde, Müllner Hauptstraße 48, 5020, Salzburg, Österreich. .,Paracelsus Medical University, Salzburg, Österreich.
| | - Bernhard Baumgartner
- Abteilung für Pulmologie, Salzkammergut-Klinikum Vöcklabruck, Vöcklabruck, Österreich
| | - Josef Bolitschek
- Abteilung für Pneumologie, Ordensklinikum Linz GmbH Elisabethinen, Linz, Österreich
| | - Daniel Doberer
- Klin. Abteilung für Pulmologie, Medizinische Universität Wien, Wien, Österreich
| | - Ernst Eber
- Univ.-Klinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Josef Eckmayr
- Abteilung für Lungenkrankheiten, Klinikum Wels-Grieskirchen, Wels, Österreich
| | - Sylvia Hartl
- 2. Interne Lungenabteilung, Otto Wagner-Spital, Wien, Österreich
| | - Peter Hesse
- Ordination Dr. Judith & Dr. Peter Hesse, Schwechat, Österreich
| | - Peter Jaksch
- Klin. Abteilung für Thoraxchirurgie, Medizinische Universität Wien, Wien, Österreich
| | - Eveline Kink
- Lungenabteilung, LKH Graz II - Standort Enzenbach, Gratwein-Straßengel, Österreich
| | - Meinhard Kneussl
- ehem. 2. Medizinische Abteilung mit Pneumologie, Wilhelminenspital Wien, Wien, Österreich
| | - Bernd Lamprecht
- Klinik für Lungenheilkunde, Kepler Universitätsklinikum, Linz, Österreich
| | - Horst Olschewski
- Klinische Abteilung für Pulmonologie, LKH-Univ. Klinikum Graz, Graz, Österreich
| | - Andreas Pfleger
- Univ.-Klinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Wolfgang Pohl
- Abteilung für Atmungs- und Lungenerkrankungen, Krankenhaus Hietzing, Wien, Österreich
| | - Christian Prior
- Ordination Univ.-Prof. Dr. Christian Prior, Innsbruck, Österreich
| | | | - Andreas Renner
- Abteilung für Atmungs- und Lungenerkrankungen, Krankenhaus Hietzing, Wien, Österreich
| | - Wolfgang Steflitsch
- Wahlarzt-Ordination für Lungenheilkunde, Ollersbach bei Neulengbach, Österreich
| | | | - Helmut Täubl
- Standort Natters, Pulmologie, LKH Hochzirl-Natters, Natters, Österreich
| | - Karin Vonbank
- Klin. Abteilung für Pulmologie, Medizinische Universität Wien, Wien, Österreich
| | - Marlies Wagner
- Univ.-Klinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Felix Wantke
- FAZ Floridsdorfer Allergiezentrum GmbH, Wien, Österreich
| | - Romana Wass
- Klinik für Lungenheilkunde, Kepler Universitätsklinikum, Linz, Österreich
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Keir DA, Duffin J, Badrov MB, Alba AC, Floras JS. Hypercapnia During Wakefulness Attenuates Ventricular Ectopy: Observations in a Young Man With Heart Failure With Reduced Ejection Fraction. Circ Heart Fail 2020; 13:e006837. [PMID: 32493059 DOI: 10.1161/circheartfailure.119.006837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniel A Keir
- University Health Network and Mount Sinai Hospital Division of Cardiology and Department of Medicine, University of Toronto, and the Toronto General Research Institute, Toronto, ON, Canada (D.A.K., M.B.B., A.C.A., J.S.F)
| | - James Duffin
- Departments of Anaesthesia and Physiology (J.D.), University of Toronto, ON, Canada
- Thornhill Research, Inc, Toronto, ON, Canada (J.D.)
| | - Mark B Badrov
- University Health Network and Mount Sinai Hospital Division of Cardiology and Department of Medicine, University of Toronto, and the Toronto General Research Institute, Toronto, ON, Canada (D.A.K., M.B.B., A.C.A., J.S.F)
| | - Ana Carolina Alba
- University Health Network and Mount Sinai Hospital Division of Cardiology and Department of Medicine, University of Toronto, and the Toronto General Research Institute, Toronto, ON, Canada (D.A.K., M.B.B., A.C.A., J.S.F)
| | - John S Floras
- University Health Network and Mount Sinai Hospital Division of Cardiology and Department of Medicine, University of Toronto, and the Toronto General Research Institute, Toronto, ON, Canada (D.A.K., M.B.B., A.C.A., J.S.F)
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Inami T, Kasai T, Yumino D, Perger E, Alshaer H, Hummel R, Lyons OD, Floras JS, Bradley TD. Relationship of stroke volume to different patterns of Cheyne-Stokes respiration in heart failure. Sleep 2020; 42:5341673. [PMID: 30946471 DOI: 10.1093/sleep/zsy262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/20/2018] [Indexed: 12/16/2022] Open
Abstract
STUDY OBJECTIVES In patients with heart failure (HF) and reduced left ventricular ejection fraction (HFrEF), stroke volume (SV) falls during hyperpnea of Cheyne-Stokes respiration with central sleep apnea (CSR-CSA). We have identified two distinct patterns of hyperpnea: positive, in which end-expiratory lung volume (EELV) remains at or above functional residual capacity (FRC), and negative, in which EELV falls below FRC. The increase in expiratory intrathoracic pressure generated by the latter should have effects on the heart analogous to external chest compression. To test the hypotheses that in HFrEF patients, CSR-CSA with the negative pattern has an auto-resuscitation effect such that compared with the positive pattern, it is associated with a smaller fall in SV and a smaller increase in cardiac workload (product of heart rate and systolic blood pressure). METHODS In 15 consecutive HFrEF patients with CSR-CSA during polysomnography, hemodynamic data derived from digital photoplethysmography during positive and negative hyperpneas were compared. RESULTS Compared to the positive, negative hyperpneas were accompanied by reductions in the maximum and mean relative fall in SV of 30% (p = 0.002) and 10% (p = 0.031), respectively, and by reductions in the degree of increases in heart rate and rate pressure product during hyperpnea of 46% (p < 0.001) and 13% (p = 0.007), respectively. CONCLUSIONS Our findings suggest the novel concept that the negative pattern of CSR-CSA may constitute a form of auto-resuscitation that acts as a compensatory mechanism to maintain SV in patients with severe HF.
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Affiliation(s)
- Toru Inami
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada
| | - Takatoshi Kasai
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada
| | - Dai Yumino
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada
| | - Elisa Perger
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada
| | - Hisham Alshaer
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Richard Hummel
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Owen D Lyons
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada.,Department of Medicine of Women's College Hospital, Toronto, ON, Canada
| | - John S Floras
- Department of Medicine of the University Health Network Toronto General Hospital and Mt. Sinai Health System, Toronto, ON, Canada
| | - T Douglas Bradley
- Sleep Research Laboratory of the University Health Network Toronto Rehabilitation Institute, Toronto, ON, Canada.,Centre for Sleep Medicine and Circadian Biology of the University of Toronto, Toronto, ON, Canada.,Department of Medicine of the University Health Network Toronto General Hospital and Mt. Sinai Health System, Toronto, ON, Canada
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Abstract
Synchronization of molecular, metabolic, and cardiovascular circadian oscillations is fundamental to human health. Sleep-disordered breathing, which disrupts such temporal congruence, elicits hemodynamic, autonomic, chemical, and inflammatory disturbances with acute and long-term consequences for heart, brain, and circulatory and metabolic function. Sleep apnea afflicts a substantial proportion of adult men and women but is more prevalent in those with established cardiovascular diseases and especially fluid-retaining states. Despite the experimental, epidemiological, observational, and interventional evidence assembled in support of these concepts, this substantial body of work has had relatively modest pragmatic impact, thus far, on the discipline of cardiology. Contemporary estimates of cardiovascular risk still are derived typically from data acquired during wakefulness. The impact of sleep-related breathing disorders rarely is entered into such calculations or integrated into diagnostic disease-specific algorithms or therapeutic recommendations. Reasons for this include absence of apnea-related symptoms in most with cardiovascular disease, impediments to efficient diagnosis at the population level, debate as to target, suboptimal therapies, difficulties mounting large randomized trials of sleep-specific interventions, and the challenging results of those few prospective cardiovascular outcome trials that have been completed and reported. The objectives of this review are to delineate the bidirectional interrelationship between sleep-disordered breathing and cardiovascular disease, consider the findings and implications of observational and randomized trials of treatment, frame the current state of clinical equipoise, identify principal current controversies and potential paths to their resolution, and anticipate future directions.
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Affiliation(s)
- John S Floras
- From the University Health Network and Sinai Health System Division of Cardiology, Department of Medicine, University of Toronto, Ontario, Canada.
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Abstract
Sleep disordered breathing (SDB), which causes sleep deprivation, intermittent hypoxia, and negative intrathoracic pressure swings, can be accompanied by other harmful pathophysiologies relating to cardiovascular diseases (CVD), including sudden death, atrial fibrillation, stroke, and coronary artery disease leading to heart failure. Continuous positive airway pressure (CPAP) therapy for SDB has been reported to provide favorable effects such as lowered systemic blood pressure and improved endothelial function. However, in recent randomized controlled trials, CPAP has failed to demonstrate its beneficial prognostic impact on the primary or secondary setting of CVD. In this review article, we describe the characteristics of SDB complicated with CVD, the prognostic impacts of SDB in CVD, and the beneficial effects of CPAP on CVD.
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Affiliation(s)
- Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University.,Department of Advanced Cardiac Therapeutics, Fukushima Medical University
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Murata A, Kasai T. Treatment of central sleep apnea in patients with heart failure: Now and future. World J Respirol 2019; 9:1-7. [DOI: 10.5320/wjr.v9.i1.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 12/13/2018] [Accepted: 01/05/2019] [Indexed: 02/06/2023] Open
Abstract
Heart failure (HF) is known to be associated with sleep-disordered breathing (SDB). In addition to disturbing patients’ sleep, SDB is also associated with a deterioration in the cardiac function and an increased mortality and morbidity. Central sleep apnea (CSA), typically characterized by Cheyne-Stokes breathing (CSB), is increasingly found in patients with HF compared to the general population. An important pathogenetic factor of CSA seen in HF patients is an instability in the control of the respiratory system, characterized by both hypocapnia and increased chemosensitivity. Sympathetic overactivation, pulmonary congestion and increased chemosensitivity associated with HF stimulate the pulmonary vagal irritant receptor, resulting in chronic hyperventilation and hypocapnia. Additionally, the repetitive apnea and arousal cycles induce cyclic sympathetic activation, which may worsen the cardiac prognosis. Correcting CSB may improve both patient’s quality of life and HF syndrome itself. However, a treatment for HF in patients also experiencing CSA is yet to be found. In fact, conflicting results from numerous clinical studies investigating sleep apnea with HF guide to a troubling question, that is whether (or not) sleep apnea should be treated in patients with HF? This editorial attempts to both collect the current evidence about randomized control trials investigating CSA in patients with HF and highlight the effect of specific CSA treatments on cardiovascular endpoints.
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Affiliation(s)
- Azusa Murata
- Department of Cardiovascular Medicine, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Takatoshi Kasai
- Department of Cardiovascular Medicine, Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo 113-8421, Japan
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Linz D, Baumert M, Catcheside P, Floras J, Sanders P, Lévy P, Cowie MR, Doug McEvoy R. Assessment and interpretation of sleep disordered breathing severity in cardiology: Clinical implications and perspectives. Int J Cardiol 2018; 271:281-288. [DOI: 10.1016/j.ijcard.2018.04.076] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 04/14/2018] [Accepted: 04/17/2018] [Indexed: 10/28/2022]
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Floras JS. Ambulatory Apnea Monitoring in Heart Failure. J Am Coll Cardiol 2017; 70:1365-1367. [DOI: 10.1016/j.jacc.2017.07.761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 07/28/2017] [Indexed: 11/25/2022]
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