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Yang X, Xu Z, Zhang C, Cai Z, Zhang J. Metformin, beyond an insulin sensitizer, targeting heart and pancreatic β cells. Biochim Biophys Acta Mol Basis Dis 2016; 1863:1984-1990. [PMID: 27702625 DOI: 10.1016/j.bbadis.2016.09.019] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/17/2016] [Accepted: 09/27/2016] [Indexed: 12/22/2022]
Abstract
Metformin, a biguanide derivate, is known as the first-line antidiabetic agent for type 2 diabetes mellitus (T2DM) treatment. It reduces insulin resistance and decreases blood glucose concentration by inhibiting gluconeogenesis and suppressing hepatic glucose production with improved peripheral tissue insulin sensitivity. As an insulin sensitizer, metformin takes pleiotropic actions and exerts protective effects on multiple organs mainly in insulin-targeted tissues such as liver, muscle, and adipose tissues. Recent studies discover that metformin also plays essential roles in heart and pancreatic β cells - two important organs in metabolic regulation. Metformin not only protects T2DM patients from cardiovascular diseases and heart failure, but also restores insulin secretion activities and protects pancreatic β cells from lipotoxicity or glucotoxicity. Although accumulated evidence shed light on the metformin action, the precise mechanism of metformin is still under investigation. Further laboratory investigations and clinical trials are needed to pinpoint a map of metformin action. Based on recent findings, this review characterizes the beneficial role of metformin in cardiovascular diseases and pancreatic β cells.
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Affiliation(s)
- Xin Yang
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Metabolic Syndrome Research Center, Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Central South University, Changsha, Hunan 410011, China
| | - Zhipeng Xu
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Metabolic Syndrome Research Center, Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Central South University, Changsha, Hunan 410011, China
| | - Chunlan Zhang
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Metabolic Syndrome Research Center, Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Central South University, Changsha, Hunan 410011, China
| | - Zixin Cai
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Metabolic Syndrome Research Center, Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Central South University, Changsha, Hunan 410011, China
| | - Jingjing Zhang
- Department of Metabolism and Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; Metabolic Syndrome Research Center, Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Central South University, Changsha, Hunan 410011, China.
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Kalantar-Zadeh K, Kovesdy CP. Should Restrictions Be Relaxed for Metformin Use in Chronic Kidney Disease? No, We Should Never Again Compromise Safety! Diabetes Care 2016; 39:1281-6. [PMID: 27330129 PMCID: PMC4915554 DOI: 10.2337/dc15-2327] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Metformin is and has been considered as first-line therapy for type 2 diabetes for over a quarter of a century. Like other biguanides, metformin can cause a lactic acidosis that is exceptionally rare but fatal. The likelihood of metformin-associated lactic acidosis is substantially higher in patients with kidney impairment and also among those with seemingly normal kidney function who are at risk of acute kidney injury (AKI). Hence, regulatory agencies in many industrialized nations have maintained strict renal restrictions surrounding metformin. However, there have been millions of people exposed to metformin for many years, many of them with serum creatinine values at or close to 1.5 mg/dL with estimated glomerular filtration rates (eGFRs) much below 60 mL/min/1.73 m(2) who have not developed lactic acidosis. Thus, there clearly remains controversy in this area, and there has been heightened pressure to remove the renal restrictions of metformin. To provide a discussion on the pros and cons of relaxing the renal restrictions for metformin use, we provide a Point-Counterpoint. In the point narrative below, Drs. Kalantar-Zadeh and Kovesdy provide their argument that although there is little evidence of the potential benefits of metformin in kidney disease, just considering the sheer numbers of metformin users and the high fatality rate of its associated lactic acidosis, the most appropriate practice is to avoid metformin use in people with eGFR <45 mL/min/1.73 m(2) or in those who are at high risk of AKI irrespective of underlying eGFR. In the following counterpoint narrative, Drs. Bakris and Molitch argue that the data from a very large analysis demonstrate clearly that serum creatinine should be supplanted with eGFR as the criteria for metformin use and that the incidence of lactic acidosis is only elevated in those with a reduced eGFR who become dehydrated for various reasons or in those exposed to some toxin resulting in AKI. Otherwise the data clearly support the use of metformin under normal circumstances down to eGFR >30 mL/min/1.73 m(2)-William T. CefaluEditor in Chief, Diabetes Care.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, Division of Nephrology and Hypertension, School of Medicine, University of California, Irvine, Irvine, CA Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, CA VA Long Beach Healthcare System, Long Beach, CA
| | - Csaba P Kovesdy
- The University of Tennessee Health Science Center, Memphis, TN Memphis VA Medical Center, Memphis, TN
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Abstract
Lactic acidosis occurs when lactate production exceeds its metabolism. There are many possible causes of lactic acidosis, and in any given patient, several causes may coexist. This Attending Rounds presents a case in point. Metformin's role in the pathogenesis of lactic acidosis in patients with diabetes mellitus is complex, as the present case illustrates. The treatment of lactic acidosis is controversial, except for the imperative to remedy its underlying cause. The use of sodium bicarbonate to treat the often alarming metabolic derangements may be quite efficacious in that regard but is of questionable benefit to patients. Renal replacement therapies (RRTs) have particular appeal in this setting for a variety of reasons, but their effect on clinical outcomes is untested.
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Affiliation(s)
- Lawrence S Weisberg
- Division of Nephrology, Cooper Medical School of Rowan University, Cooper University Health Care, Camden, New Jersey
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Ramirez G, Morrison AD, Bittle PA. Clinical practice considerations and review of the literature for the Use of DPP-4 inhibitors in patients with type 2 diabetes and chronic kidney disease. Endocr Pract 2014; 19:1025-34. [PMID: 23757605 DOI: 10.4158/ep12306.ra] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Many commonly prescribed agents for the treatment of type 2 diabetes (T2DM) have important restrictions on use in patients with renal impairment. Prescribing information and published data on dipeptidyl peptidase-4 (DPP-4) inhibitors indicate that these agents are suitable for use in this patient population. However, a recent database analysis indicated prevalent underrecognition of renal impairment and limited awareness of prescription considerations associated with DPP-4 inhibitor use in patients with renal impairment. Thus, this article reviews recent literature on the safety, efficacy, pharmacokinetics, and clinical use of DPP-4 inhibitors in patients with renal impairment and T2DM. METHODS PubMed searches were conducted for literature describing the use of DPP-4 inhibitors in patients with renal impairment. RESULTS Most DPP-4 inhibitors are characterized by significant renal clearance. As a result, pharmacokinetics are measurably affected by the presence of renal impairment; plasma exposure of DPP-4 inhibitors and their metabolites may increase by up to sevenfold in severe impairment/end-stage renal disease. The exception in this case is linagliptin, which is eliminated predominantly via the hepatobiliary system. Our search identified several studies that evaluated specific doses of DPP-4 inhibitors in patients with renal impairment and reported positive safety and efficacy results. CONCLUSIONS Overall, DPP-4 inhibitors are an effective means of controlling blood glucose in patients with T2DM and renal impairment. Considering the restrictions associated with many other antihyperglycemic agents when used in patients with renal impairment, DPP-4 inhibitors should be a considered as a treatment option in this patient population.
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Papanas N, Maltezos E, Mikhailidis DP. Metformin and heart failure: never say never again. Expert Opin Pharmacother 2012; 13:1-8. [PMID: 22149365 DOI: 10.1517/14656566.2012.638283] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Metformin represents the cornerstone of treatment for type 2 diabetes mellitus. Traditionally, heart failure (HF) was considered a contraindication to its use. However, more recent evidence has shown that this should no longer be the case. Indeed, studies have demonstrated that metformin may even reduce the risk of incident HF and mortality in diabetic patients, while improving up to 2-year survival rates in those with HF. In addition, it appears to exert cardioprotective actions. Although longer follow-up data and more explicit information about the situation in patients with very advanced HF are needed, the cardiac safety of metformin has profound clinical implications and may be anticipated to further encourage its widespread use.
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Abstract
BACKGROUND The number of treatment options in the diabetes arena has grown dramatically in a short period of time, with a corresponding increase in the breadth and depth of literature from which physicians and diabetes organizations make evidence-based decisions. Thus, the purpose of this article is to provide an up-to-date review of the literature describing current treatment options and guidelines available for the management of type 2 diabetes and prevention of its complications. METHODS Pubmed searches were conducted for recent literature pertaining to the prevention of complications in type 2 diabetes. Comprehensive search terms were devised to identify articles describing micro- and macrovascular complications including nephropathy, neuropathy, retinopathy, and cardiovascular disease associated with type 2 diabetes. CONCLUSIONS The current body of literature demonstrates that a significant reduction in the incidence of diabetic complications is achievable with early initiation and long-term maintenance of controlled blood glucose and cardiovascular risk factors. Screening for diabetic complications should be initiated early and continued at regular intervals to ensure early pharmacological intervention.
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Friesecke S, Abel P, Roser M, Felix SB, Runge S. Outcome of severe lactic acidosis associated with metformin accumulation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R226. [PMID: 21171991 PMCID: PMC3220003 DOI: 10.1186/cc9376] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Revised: 07/14/2010] [Accepted: 12/20/2010] [Indexed: 01/31/2023]
Abstract
Introduction Metformin associated lactic acidosis (MALA) may complicate metformin therapy, particularly if metformin accumulates due to renal dysfunction. Profound lactic acidosis (LA) generally predicts poor outcome. We aimed to determine if MALA differs in outcome from LA of other origin (LAOO). Methods We conducted a retrospective analysis of all patients admitted with LA to our medical ICU of a tertiary referral center during a 5-year period. MALA patients and LAOO patients were compared with respect to parameters of acid-base balance, serum creatinine, hospital outcome, Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment (SOFA) score, using Pearson's Chi-square or the Mann-Whitney U-test. Results Of 197 patients admitted with LA, 10 had been diagnosed with MALA. With MALA, median arterial blood pH was significantly lower (6.78 [range 6.5 to 6.94]) and serum lactate significantly higher (18.7 ± 5.3 mmol/L) than with LAOO (pH 7.20 [range 6.46 to 7.35], mean serum lactate 11.2 ± 6.1 mmol/L). Overall mortality, however, was comparable (MALA 50%, LAOO 74%). Furthermore, survival of patients with arterial blood pH < 7.00 (N = 41) was significantly better (50% vs. 0%) if MALA (N = 10) was the underlying condition compared to LAOO (N = 31). Conclusions Compared to similarly severe lactic acidosis of other origin, the prognosis of MALA is significantly better. MALA should be considered in metformin-treated patients presenting with lactic acidosis.
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Affiliation(s)
- Sigrun Friesecke
- Department of Cardiology, Pneumology and Intensive Care Medicine, Ernst Moritz Arndt University, 17475 Greifswald, Germany.
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Abstract
Metformin has now been established as the drug of choice for the first-line management of type 2 diabetes mellitus. It reduces insulin resistance, improves glycaemic control, and can be safely combined with other classes of oral hypoglycaemic agents. Equally important, metformin has been shown to have a significant beneficial effect on cardiovascular morbidity. Moreover, this agent acts favourably on blood pressure, lipids, haemostasis and other features of the metabolic syndrome. Metformin also contributes to weight reduction and diabetes prevention.
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Abstract
As the diabetic population has significant morbidity and mortality from cardiovascular disease (CVD), much of its medical care focuses on CVD prevention and treatment. Some medications used to treat hyperglycemia may have beneficial effects on CV outcomes, others may have negative effects, while still others seem to have no direct effect. Although past epidemiological studies have shown a relationship between glycated hemoglobin levels and CV events in patients with type 2 diabetes, recent large randomized clinical trials (ACCORD, ADVANCE, and VADT) lasting 3.5 to 5.6 years have found that intensive glycemic control either has no impact on CV outcomes or even worsens them. Results of the 10-year follow-up of the UKPDS suggest that tight glycemic control of younger, newly diagnosed patients with type 2 diabetes may have CV benefits many years later. Because the pathogenesis of atherosclerosis spans decades, it may be that beneficial effects of tight glycemic control on CV outcomes are mainly in younger patients without established macrovascular disease. There is an emerging notion that tight glycemic control may be beneficial in primary prevention of CVD in younger patients with diabetes, but may become deleterious in older patients with established or subclinical CVD. Thus, while tight control may lessen microvascular disease, it may increase the risk of hypoglycemia and possibly of adverse CV events. In each patient, the goals of glycemic control need to be individualized based on age, overall prognosis, presence of macrovascular disease, and risk of hypoglycemia.
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Assessing the appropriate use of metformin in an inpatient setting and the effectiveness of two pharmacy-based measures to improve guideline adherence. Qual Manag Health Care 2009; 18:71-6. [PMID: 19148031 DOI: 10.1097/01.qmh.0000344595.48510.cb] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To demonstrate the level of compliance to metformin-prescribing guidelines and to evaluate the effectiveness of 2 pharmacy-based interventions. METHODS Retrospective chart review of all inpatients who had received at least 2 doses of metformin while hospitalized. Two cohorts of patients had chart audits-one group (group A) hospitalized between March and August of 2003 (487 patients) and one group (group B) hospitalized between August of 2005 and January of 2006 (370 patients). In December of 2003, the pharmacy inserted a safety alert in the electronic ordering system and mailed a printed safety alert to all clinical staff outlining the contraindications and precautions concerning metformin use. RESULTS More than two-thirds (69.3%) of the charts reviewed demonstrated that metformin was used in accordance with the prescribing guidelines. Surgical procedures, intravenous contrast use, and elevated serum creatinine levels accounted for the greatest percentage of guideline violations. The prescribing guidelines were violated 27.4% (47/137 charts) of the times in group A and 34.3% (40/146 charts) of the times in group B. CONCLUSIONS The significance of this study is that metformin is often given in spite of the presence of contraindications to its use. Two pharmacy interventions were ineffective in decreasing the guideline violation frequency in a group of patients who were prescribed the drug.
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Eurich DT, Tsuyuki RT, Majumdar SR, McAlister FA, Lewanczuk R, Shibata MC, Johnson JA. Metformin treatment in diabetes and heart failure: when academic equipoise meets clinical reality. Trials 2009; 10:12. [PMID: 19203392 PMCID: PMC2644685 DOI: 10.1186/1745-6215-10-12] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 02/09/2009] [Indexed: 11/10/2022] Open
Abstract
Objective Metformin has had a 'black box' contraindication in diabetic patients with heart failure (HF), but many believe it to be the treatment of choice in this setting. Therefore, we attempted to conduct a pilot study to evaluate the feasibility of undertaking a large randomized controlled trial with clinical endpoints. Study Design The pilot study was a randomized double blinded placebo controlled trial. Patients with HF and type 2 diabetes were screened in hospitals and HF clinics in Edmonton, Alberta, Canada (population ~1 million). Major exclusion criteria included the current use of insulin or high dose metformin, decreased renal function, or a glycosylated hemoglobin <7%. Patients were to be randomized to 1500 mg of metformin daily or matching placebo and followed for 6 months for a variety of functional outcomes, as well as clinical events. Results Fifty-eight patients were screened over a six month period and all were excluded. Because of futility with respect to enrollment, the pilot study was abandoned. The mean age of screened patients was 77 (SD 9) years and 57% were male. The main reasons for exclusion were: use of insulin therapy (n = 23; 40%), glycosylated hemoglobin <7% (n = 17; 29%) and current use of high dose metformin (n = 12; 21%). Overall, contraindicated metformin therapy was the most commonly prescribed oral antihyperglycemic agent (n = 27; 51%). On average, patients were receiving 1,706 mg (SD 488 mg) of metformin daily and 12 (44%) used only metformin. Conclusion Despite uncertainty in the scientific literature, there does not appear to be clinical uncertainty with regards to the safety or effectiveness of metformin in HF making a definitive randomized trial virtually impossible. Trial registration ClinicalTrials.gov Identifier: NCT00325910
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Affiliation(s)
- Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, Alberta, T6G 2G3, Canada.
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Papanas N, Monastiriotis C, Christakidis D, Maltezos E. Metformin and lactic acidosis in patients with type 2 diabetes--from pride and prejudice to sense and sensibility. Acta Clin Belg 2009; 64:42-8. [PMID: 19317240 DOI: 10.1179/acb.2009.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
AIM To present the cases of lactic acidosis encountered in our department among metformin-treated type 2 diabetic patients and to investigate the role of contraindications to metformin use. METHODS A survey of medical records of metformin-treated type 2 diabetic patients hospitalised for various medical conditions during the years 2004-2005 who exhibited elevated serum concentrations of lactic acid. RESULTS Seven metformin-treated type 2 diabetic patients were identified who were not attending our department and were hospitalised with elevated serum lactic acid levels (6 developed lactic acidosis). All patients had one or more contraindications to metformin use. Outcome was favourable in 6 patients, while 1 patient with hepatocellular carcinoma died of liver failure. CONCLUSIONS So far, metformin is one of the safest first-line oral hypoglycaemic agents. However, caution is needed to avoid patients with evident contraindications. This highlights the need for the practitioner to possess sound clinical judgement when prescribing metformin.
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Affiliation(s)
- N Papanas
- Second Department of Internal Medicine, Democritus University of Thrace, Greece.
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Runge S, Mayerle J, Warnke C, Robinson D, Roser M, Felix SB, Friesecke S. Metformin-associated lactic acidosis in patients with renal impairment solely due to drug accumulation? Diabetes Obes Metab 2008; 10:91-3. [PMID: 18095950 DOI: 10.1111/j.1463-1326.2006.00657.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
AIM We suspect that the life-threatening complication of metformin-associated lactic acidosis, solely due to drug accumulation following renal impairment, occurs more frequently than that previously reported and is not necessarily associated with other predisposing factors for lactic acidosis. METHODS During a period of 13 months, at a tertiary referral centre, the incidence of lactic acidosis of any aetiology was 12.8% [67 of 524 total intensive care unit (ICU) admissions]. Metformin-associated lactic acidosis solely as the result of drug accumulation was diagnosed in 6% of all the patients suffering from lactic acidosis (4 of 67 patients). RESULTS These patients presented with severe circulatory shock due to lactic acidosis. We could not identify any predisposing factor for lactic acidosis other than renal impairment. Intercurrent deterioration of diabetic nephropathy was suspected to be responsible for the accumulation of metformin followed by lactic acidosis, finally resulting in multiorgan failure. The diagnosis was supported by extensively elevated serum levels of metformin. Two patients died during ICU treatment. CONCLUSIONS Our data indicate that the incidence of metformin-associated lactic acidosis solely due to metformin accumulation is possible and underestimated. Symptoms of metformin-associated lactic acidosis are unspecific and physicians should be aware that metformin, if prescribed in patients with renal impairment, can cause fatal lactic acidosis due to drug accumulation.
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Affiliation(s)
- S Runge
- Department of Cardiology, Pneumology, and Intensive Care Medicine, Ernst Moritz Arndt University, Greifswald, Germany.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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