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Carnet Le Provost K, Kepp O, Kroemer G, Bezu L. Trial watch: local anesthetics in cancer therapy. Oncoimmunology 2024; 13:2308940. [PMID: 38504848 PMCID: PMC10950281 DOI: 10.1080/2162402x.2024.2308940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024] Open
Abstract
Preclinical evidence indicates potent antitumor properties of local anesthetics. Numerous underlying mechanisms explaining such anticancer effects have been identified, suggesting direct cytotoxic as well as indirect immunemediated effects that together reduce the proliferative, invasive and migratory potential of malignant cells. Although some retrospective and correlative studies support these findings, prospective randomized controlled trials have not yet fully confirmed the antineoplastic activity of local anesthetics, likely due to the intricate methodology required for mitigating confounding factors. This trial watch aims at compiling all published preclinical and clinical research, along with completed and ongoing trials, that explore the potential antitumor effects of local anesthetics.
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Affiliation(s)
- Killian Carnet Le Provost
- Equipe Labellisée Par La Ligue Contre Le Cancer, Université de Paris, Sorbonne Université, Centre de Recherche des Cordeliers, Institut Universitaire de France, Paris, France
- Metabolomics and Cell Biology Platforms, Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Oliver Kepp
- Equipe Labellisée Par La Ligue Contre Le Cancer, Université de Paris, Sorbonne Université, Centre de Recherche des Cordeliers, Institut Universitaire de France, Paris, France
- Metabolomics and Cell Biology Platforms, Gustave Roussy, Université Paris Saclay, Villejuif, France
| | - Guido Kroemer
- Equipe Labellisée Par La Ligue Contre Le Cancer, Université de Paris, Sorbonne Université, Centre de Recherche des Cordeliers, Institut Universitaire de France, Paris, France
- Metabolomics and Cell Biology Platforms, Gustave Roussy, Université Paris Saclay, Villejuif, France
- Pôle de Biologie, Hôpital européen Georges Pompidou, AP-HP, Paris, France
| | - Lucillia Bezu
- Equipe Labellisée Par La Ligue Contre Le Cancer, Université de Paris, Sorbonne Université, Centre de Recherche des Cordeliers, Institut Universitaire de France, Paris, France
- Metabolomics and Cell Biology Platforms, Gustave Roussy, Université Paris Saclay, Villejuif, France
- Gustave Roussy, Département Anesthésie, Chirurgie et Interventionnel, Villejuif, France
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Lu L, Sun Y, Ren Y, Zhao S, Hua Z. Effect of regional anesthesia and analgesia on long-term survival following abdominal cancer Surgery-A systematic review with meta-analysis. Heliyon 2023; 9:e20611. [PMID: 37842575 PMCID: PMC10570603 DOI: 10.1016/j.heliyon.2023.e20611] [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] [Received: 06/26/2023] [Revised: 09/23/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023] Open
Abstract
Background The impact of regional anesthesia and analgesia (RAA) on long-term survival following cancer surgery is a topic of debate. The aim of this study was to investigate the effects of perioperative RAA on long-term oncological outcomes in patients undergoing major abdominal cancer surgery. Methods The authors searched computerized databases and reference lists from inception to December 20, 2022. All studies that investigated the effects of perioperative RAA on long-term oncological outcomes following major abdominal cancer surgery were included. Using the inverse variance method with a random-effects model, hazard ratios (HR) and 95% confidence intervals (CI) were calculated. Results The systematic review included 51 retrospective studies, one prospective study, and three randomized controlled trials (RCTs), with a total of 95,046 patients. The results showed that perioperative RAA may improve long-term overall survival (HR: 0.85, 95% CI: 0.80 to 0.91, P = 0.00, I2 = 60.2%). However, there was no significant association between perioperative RAA and reduced cancer recurrence (HR: 0.98, 95% CI: 0.90 to 1.03, P = 0.31, I2 = 52.3%). When performing a pooled analysis of the data from the three RCTs, no statistically significant effect of RAA was found in either case. Conclusion The systematic review suggests perioperative RAA may improve long-term overall survival but does not appear to reduce cancer recurrence in patients undergoing major abdominal cancer surgery. The limited number of RCTs included in this study did not confirm this finding, highlighting the need for further RCTs to corroborate these results.
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Affiliation(s)
| | - Yanxia Sun
- Corresponding author. Beijing 100730, China.
| | - Yi Ren
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Siwen Zhao
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Zhen Hua
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
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Che X, Li T. Total versus inhaled intravenous anesthesia methods for prognosis of patients with lung, breast, or esophageal cancer: A cohort study. Front Surg 2023; 10:1155351. [PMID: 37114153 PMCID: PMC10126379 DOI: 10.3389/fsurg.2023.1155351] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/17/2023] [Indexed: 04/29/2023] Open
Abstract
Objective To explore the influences of total intravenous anesthesia (TIVA) and inhaled-intravenous anesthesia on the prognosis of patients with lung, breast, or esophageal cancer. Methods In this retrospective cohort study, patients with lung, breast, or esophageal cancer who underwent surgical treatments at Beijing Shijitan Hospital between January 2010 and December 2019 were included. The patients were categorized into the TIVA group and inhaled-intravenous anesthesia group, according to the anesthesia methods used for the patients for surgery of the primary cancer. The primary outcome of this study included overall survival (OS) and recurrence/metastasis. Results Totally, 336 patients were included in this study, 119 in the TIVA group and 217 in the inhaled-intravenous anesthesia group. The OS of patients in the TIVA group was higher than in the inhaled-intravenous anesthesia group (P = 0.042). There were no significant differences in the recurrence/metastasis-free survival between the two groups (P = 0.296). Inhaled-intravenous anesthesia (HR = 1.88, 95%CI: 1.15-3.07, P = 0.012), stage III cancer (HR = 5.88, 95%CI: 2.57-13.43, P < 0.001), and stage IV cancer (HR = 22.60, 95%CI: 8.97-56.95, P < 0.001) were independently associated with recurrence/ metastasis. Comorbidities (HR = 1.75, 95%CI: 1.05-2.92, P = 0.033), the use of ephedrine, noradrenaline or phenylephrine during surgery (HR = 2.12, 95%CI: 1.11-4.06, P = 0.024), stage II cancer (HR = 3.24, 95%CI: 1.08-9.68, P = 0.035), stage III cancer (HR = 7.60, 95%CI: 2.64-21.86, P < 0.001), and stage IV cancer (HR = 26.61, 95%CI: 8.57-82.64, P < 0.001) were independently associated with OS. Conclusion In patients with breast, lung, or esophageal cancer, TIVA is preferable than inhaled-intravenous anesthesia group for longer OS,, but TIVA was not associated with the recurrence/metastasis-free survival of patients.
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Affiliation(s)
- Xiangming Che
- Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Tianzuo Li
- Beijing Shijitan Hospital, Capital Medical University, Beijing, China
- Correspondence: Tianzuo Li
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Jiao R, Peng S, Wang L, Feng M, Li Y, Sun J, Liu D, Fu J, Feng C. Ultrasound-Guided Quadratus Lumborum Block Combined with General Anaesthesia or General Anaesthesia Alone for Laparoscopic Radical Gastrectomy for Gastric Adenocarcinoma: A Monocentric Retrospective Study. Int J Gen Med 2022; 15:7739-7750. [PMID: 36249896 PMCID: PMC9563320 DOI: 10.2147/ijgm.s382757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/23/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To investigate, in patients with gastric carcinoma undergoing laparoscopic radical gastrectomy, the effects of ultrasound-guided quadratus lumborum block (UG-QLB) combined with general anaesthesia (GA) on the postoperative recovery compared with GA alone. PATIENTS AND METHODS The retrospective study enrolled 231 patients with gastric carcinoma undergoing laparoscopic radical gastrectomy, including 119 patients who received UG-QLB combined with GA (Group QG), and 112 patients undergoing GA alone (Group GA). The primary endpoint was the postoperative 3-year recurrence-free survival (RFS). The secondary endpoints were the average visual analogue scale (VAS) scores within 48 h after surgery, the first time of postoperative ambulation, the first time of flatus, postoperative hospitalization, perioperative opioid requirement and adverse effects after surgery. RESULTS UG-QLB combined with GA did not affect the 3-year RFS in patients undergoing laparoscopic radical gastrectomy (HR 0.659, 95% CI 0.342-1.269, P=0.212). However, the VAS ranking analysis implicated that it could significantly alleviate the postoperative pain in laparoscopic radical gastrectomy patients (P<0.01). In addition, it dramatically facilitated the early recovery of postoperative ambulation and flatus, while shortening the duration of postoperative hospitalization (P<0.01). The most important was it could remarkably reduce the opioid consumption (P<0.01), which in the meanwhile, reduced the incidence of postoperative nausea and vomiting (PONV) (P=0.01). CONCLUSION Although UG-QLB combined with GA did not improve the 3-year RFS for patients with gastric carcinoma undergoing laparoscopic radical gastrectomy, it could provide satisfactory postoperative pain relief, reduce opioid consumption and adverse effects, which subsequently facilitates postoperative early rehabilitation.
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Affiliation(s)
- Ran Jiao
- Hospital of Shandong University, Jinan, 250100, People’s Republic of China
| | - Shuai Peng
- Department of Nursing, Yankuang New Journey General Hospital, Zoucheng, 273500, People’s Republic of China
| | - Lulu Wang
- Cheeloo College of Medicine, Shandong University, Jinan, 250102, People’s Republic of China
| | - Man Feng
- Department of Pathology, Affiliated Hospital of Shandong Academy of Medical Sciences, the Third Affiliated of Shandong First Medical University, Jinan, 250000, People’s Republic of China
| | - Youqin Li
- Cheeloo College of Medicine, Shandong University, Jinan, 250102, People’s Republic of China
| | - Jing Sun
- Cheeloo College of Medicine, Shandong University, Jinan, 250102, People’s Republic of China
| | - Dongyi Liu
- Department of Anaesthesiology, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250033, People’s Republic of China
| | - Jia Fu
- Department of Anaesthesiology, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250033, People’s Republic of China
| | - Chang Feng
- Department of Anaesthesiology, the Second Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250033, People’s Republic of China,Correspondence: Chang Feng, Department of Anaesthesiology, the Second Hospital, Cheeloo College of Medicine, Shandong University, 247 Bei Yuan Street, Jinan, 250033, People’s Republic of China, Tel +86-17660085521, Email
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Zhi X, Kuang X, Li J. The Impact of Perioperative Events on Cancer Recurrence and Metastasis in Patients after Radical Gastrectomy: A Review. Cancers (Basel) 2022; 14:cancers14143496. [PMID: 35884557 PMCID: PMC9319233 DOI: 10.3390/cancers14143496] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 02/04/2023] Open
Abstract
Radical gastrectomy is a mainstay therapy for patients with locally resectable gastric cancer (GC). GC patients who are candidates for radical gastrectomy will experience at least part of the following perioperative events: surgery, anesthesia, pain, intraoperative blood loss, allogeneic blood transfusion, postoperative complications, and their related anxiety, depression and stress response. Considerable clinical studies have shown that these perioperative events can promote recurrence and decrease the long-term survival of GC patients. The mechanisms include activation of neural signaling and the inflammatory response, suppression of antimetastatic immunity, increased release of cancer cells into circulation, and delayed adjuvant therapy, which are involved in every step of the invasion-metastasis cascade. Having appreciated these perioperative events and their influence on the risk of GC recurrence, we can now use this knowledge to find strategies that might substantially prevent the deleterious recurrence-promoting effects of perioperative events, potentially increasing cancer-free survival in GC patients.
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Affiliation(s)
- Xing Zhi
- Department of General Surgery, Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang 621000, China;
| | - Xiaohong Kuang
- Department of Hematology, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang 621000, China;
| | - Jian Li
- Department of General Surgery, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang 621000, China
- Correspondence: ; Tel.:+86-0816-2271901
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Hsu FK, Chang WK, Lin KJ, Chu TJ, Fang WL, Chang KY. Effect of epidural analgesia on cancer outcomes after gastric cancer resection: a single-centre cohort study in Taiwan. BMJ Open 2022; 12:e053050. [PMID: 35260453 PMCID: PMC8905940 DOI: 10.1136/bmjopen-2021-053050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
OBJECTIVE To investigate the influence of epidural anaesthesia and analgesia (EA) on cancer recurrence and overall survival after surgery for gastric cancer. STUDY DESIGN AND SETTING A retrospective study which involved patients with stage I-III gastric cancer undergoing curative resection in a medical centre from January 2012 to December 2017 and followed up until December 2019 through electronic medical chart review. Patient demographics, anaesthetic and surgical characteristics and pathologic features were also gathered. PRIMARY AND SECONDARY OUTCOME MEASURES The effects of EA on postoperative cancer recurrence and overall survival were evaluated using proportional hazards regression models with inverse probability of treatment weighting (IPTW). Multivariable Cox regression analyses were conducted for sensitivity analysis as well. RESULTS Among the 413 patients with median follow-up of 38.5 months (IQR: 22.1-59.7), 66 (16.0%) received EA after gastric cancer surgery. EA was not associated with greater cancer recurrence (IPTW-adjusted HR: 0.55, 95% CI: 0.27 to 1.13, p=0.102) or cancer specific (IPTW- adjusted HR: 0.53, 95% CI: 0.27 to 1.04, p=0.07) and all-cause mortality (IPTW-adjusted HR: 0.65, 95% CI: 0.37 to 1.16, p=0.143) after gastric cancer resections. For sensitivity analysis, multivariable Cox regression analysis also generated non-significant EA effects on cancer recurrence and survival after surgery. CONCLUSIONS There was no significant association between EA and cancer recurrence or overall survival in patients with stage I-III gastric cancer receiving surgical resection of primary tumour. Prospective study should be considered to elucidate the relationship between EA and cancer outcomes after gastric cancer surgery.
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Affiliation(s)
- Fu-Kai Hsu
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Kuei Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Kuan-Ju Lin
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tan-Ju Chu
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Liang Fang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Kuang-Yi Chang
- Department of Anesthesiology, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Zhang D, Jiang J, Liu J, Zhu T, Huang H, Zhou C. Effects of Perioperative Epidural Analgesia on Cancer Recurrence and Survival. Front Oncol 2022; 11:798435. [PMID: 35071003 PMCID: PMC8766638 DOI: 10.3389/fonc.2021.798435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 12/10/2021] [Indexed: 02/05/2023] Open
Abstract
Surgical resection is the main curative avenue for various cancers. Unfortunately, cancer recurrence following surgery is commonly seen, and typically results in refractory disease and death. Currently, there is no consensus whether perioperative epidural analgesia (EA), including intraoperative and postoperative epidural analgesia, is beneficial or harmful on cancer recurrence and survival. Although controversial, mounting evidence from both clinical and animal studies have reported perioperative EA can improve cancer recurrence and survival via many aspects, including modulating the immune/inflammation response and reducing the use of anesthetic agents like inhalation anesthetics and opioids, which are independent risk factors for cancer recurrence. However, these results depend on the cancer types, cancer staging, patients age, opioids use, and the duration of follow-up. This review will summarize the effects of perioperative EA on the oncological outcomes of patients after cancer surgery.
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Affiliation(s)
- Donghang Zhang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China.,Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Jingyao Jiang
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China.,Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Tao Zhu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
| | - Han Huang
- Department of Anesthesiology & Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second Hospital of Sichuan University, Chengdu, China
| | - Cheng Zhou
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Centre of Translational Medicine of Anesthesiology, West China Hospital of Sichuan University, Chengdu, China
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Dockrell L, Buggy DJ. The role of regional anaesthesia in the emerging subspecialty of onco-anaesthesia: a state-of-the-art review. Anaesthesia 2021; 76 Suppl 1:148-159. [PMID: 33426658 DOI: 10.1111/anae.15243] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2020] [Indexed: 01/07/2023]
Abstract
Cancer accounts for millions of deaths globally each year, predominantly due to recurrence and metastatic disease. The majority of patients with primary solid organ cancers require surgery, however, some degree of tumour dissemination related to surgery is inevitable. The surgical stress response and associated immunosuppression, pain, inflammation, tissue hypoxia and angiogenesis have all been implicated in promoting tumour survival, proliferation and recurrence. Regional anaesthesia was hypothesised to reduce the surgical stress response and immunosuppression, minimise the need for volatile anaesthesia and reduce pain and opioid requirements, thus mitigating pro-tumour pathways associated with the peri-operative period and improving long-term oncological outcomes. While some retrospective studies suggested an association between regional anaesthesia and reduced cancer recurrence, the first large randomised controlled trial on the effect of anaesthetic technique on cancer outcome found no significant difference between paravertebral regional anaesthesia and volatile anaesthesia with opioid analgesia in patients undergoing breast cancer surgery. Randomised controlled trials on the long-term oncological outcomes of regional anaesthesia in other tumour types are ongoing. The focus on how peri-operative interventions, especially regional anaesthesia, during cancer resection surgery, may enhance short-term recovery and perhaps influence long-term outcome has spawned the global emergence of the subspecialty of onco-anaesthesia. This review aims to discuss the most recent evidence on the use of regional anaesthesia in cancer surgery and the significance of its role in onco-anaesthesia.
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Affiliation(s)
- L Dockrell
- Division of Anaesthesiology and Peri-operative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Ireland
| | - D J Buggy
- Division of Anaesthesiology and Peri-operative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Ireland
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Influence of perioperative anaesthetic and analgesic interventions on oncological outcomes: a narrative review. Br J Anaesth 2019; 123:135-150. [PMID: 31255291 DOI: 10.1016/j.bja.2019.04.062] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/18/2019] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
Surgery is an important treatment modality for the majority of solid organ cancers. Unfortunately, cancer recurrence following surgery of curative intent is common, and typically results in refractory disease and patient death. Surgery and other perioperative interventions induce a biological state conducive to the survival and growth of residual cancer cells released from the primary tumour intraoperatively, which may influence the risk of a subsequent metastatic disease. Evidence is accumulating that anaesthetic and analgesic interventions could affect many of these pathophysiological processes, influencing risk of cancer recurrence in either a beneficial or detrimental way. Much of this evidence is from experimental in vitro and in vivo models, with clinical evidence largely limited to retrospective observational studies or post hoc analysis of RCTs originally designed to evaluate non-cancer outcomes. This narrative review summarises the current state of evidence regarding the potential effect of perioperative anaesthetic and analgesic interventions on cancer biology and clinical outcomes. Proving a causal link will require data from prospective RCTs with oncological outcomes as primary endpoints, a number of which will report in the coming years. Until then, there is insufficient evidence to recommend any particular anaesthetic or analgesic technique for patients undergoing tumour resection surgery on the basis that it might alter the risk of recurrence or metastasis.
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Pérez-González O, Cuéllar-Guzmán LF, Navarrete-Pacheco M, Ortiz-Martínez JJ, Williams WH, Cata JP. Impact of Regional Anesthesia on Gastroesophageal Cancer Surgery Outcomes. Anesth Analg 2018; 127:753-758. [DOI: 10.1213/ane.0000000000003602] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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