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Kim NH, Kang JH, Kim HJ. Differences in the Impact of Obesity and Metabolic Unhealthiness on the Risk of Gallbladder Polyp. Yonsei Med J 2023; 64:658-664. [PMID: 37880846 PMCID: PMC10613762 DOI: 10.3349/ymj.2023.0182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/23/2023] [Accepted: 07/28/2023] [Indexed: 10/27/2023] Open
Abstract
PURPOSE Differences in the impact of obesity and metabolic health status on the risk of gallbladder polyp (GBP) remain uncertain. Herein, we aimed to compare the risk of GBP ≥5 mm among individuals with different phenotypes based on obesity and metabolic health status. MATERIALS AND METHODS A cohort of 253485 asymptomatic adults who underwent abdominal ultrasonography screening were categorized into the following four groups according to obesity and metabolic health status: 1) metabolically healthy non-obese (MHNO), 2) metabolically unhealthy and non-obese (MUNO), 3) metabolically healthy but obese (MHO), and 4) metabolically unhealthy obese (MUO). RESULTS The prevalences of GBP ≥5 mm were 2.4%, 3.1%, 3.7%, and 4.0% in the MHNO, MUNO, MHO, and MUO groups, respectively. The multivariable-adjusted odds ratio (OR) values for prevalence of GBP ≥5 mm by comparing the MUNO, MHO, and MUO with the MHNO group were 1.11 [95% confidence interval (CI), 1.04-1.19], 1.30 (95% CI, 1.15-1.47), and 1.37 (95% CI, 1.28-1.45), respectively. The risk of GBP ≥5 mm in the MHO group was significantly higher than that in the MUNO group, but not significantly different from that in the MUO group. CONCLUSION Obesity and metabolic unhealthiness appear to be independent risk factors for the prevalence of GBP, and the impact of obesity is greater than that of metabolic unhealthiness, suggesting that maintaining both normal weight and metabolic health may help reduce the risk of GBP.
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Affiliation(s)
- Nam Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Hun Kang
- Department of Radiology, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea.
| | - Hong Joo Kim
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Analysis of risk factors for gallbladder polyp formation - A retrospective study based on serial ultrasounds. Eur J Gastroenterol Hepatol 2020; 32:1154-1159. [PMID: 32541237 DOI: 10.1097/meg.0000000000001814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM To evaluate gallbladder polyp (GBP) formation related risk factors based on serial ultrasounds (US). METHODS Risk factors related GBP formation were retrospectively investigated among participants, who had US reexamination and interval >180 days in 5 years. After groups were divided based on US, we compared final data and initial data in GBP new incidence group. Then compared the data in GBP new incidence group and GBP(-) group. RESULTS Overall 20 447 participants were recruited, including 18 243 in GBP (-) group and 2204 in GBP group. The mean diameters of polyps were 0.455 ± 0.198 mm in initial and 0.420 ± 0.180 mm in final examination. GBP new incidence group included 797 participants. Percentage of GBP new incidence participants was higher than GBP resolved (36.16% vs. 11.71%). Participants in middle age were more likely have GBP size increase or new incidence, and participants in old age (≥60 years old) were with GBP size decrease or resolved. In GBP new incidence group, participants in final US showed higher FBG, higher LDL, lower HDL, higher ALT and higher AST than initial US. Compared with GBP (-) group and, same risk factors, in addition with age, were shown in GBP new incidence group, Logistic regression analysis show that higher LDL, lower HDL and higher AST were risk factors for GBP formation. CONCLUSION Participants in middle age were more likely to have GBP new incidence. Higher LDL, lower HDL and higher AST were independently risk factors for GBP formation.
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Zhao X, Zheng H, Shan S, Wang K, Zhang M, Xie S, Liu C. Association between the non-HDL-cholesterol-to-HDL-cholesterol ratio and the risk of gallbladder polyp formation among men: a retrospective cohort study. Lipids Health Dis 2020; 19:146. [PMID: 32576257 PMCID: PMC7313103 DOI: 10.1186/s12944-020-01322-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 06/12/2020] [Indexed: 12/30/2022] Open
Abstract
Background Dyslipidaemia and male sex are associated with gallbladder polyp (GBP) formation. However, the potential relation between the non-high-density lipoprotein-cholesterol-to-high-density lipoprotein-cholesterol (non-HDL-c/HDL-c) ratio and GBPs in men is unclear. Methods A total of 1866 eligible subjects were selected for this retrospective cohort study from Wuhan Union Hospital between April 1, 2013, and November 30, 2014. Clinical and laboratory data of subjects were collected. Patients with GBPs or cholecystectomy at baseline, with missing data for baseline lipid profiles, following abdominal ultrasonography or taking lipid-lowering drugs were excluded. The patients were divided into five groups based on their non-HDL-c/HDL-c ratios, and descriptive analyses of the baseline data were performed. A Cox proportional hazards model was applied to estimate the relationship between the non-HDL-c/HDL-c ratio and GBPs. Results After a median follow-up of 1 year, 7.34% (n = 137) of the subjects developed GBPs. Compared with subjects without GBPs, those who developed GBPs after follow-up had significantly higher triglyceride (TG) levels and non-HDL-c/HDL-c ratios. The prevalence of GBPs showed a linearity increment with age, peaked in the 30–39 years group, 40–49 years group and 50–59 years group, and then declined slightly. The results of univariate analysis showed that the non-HDL-c/HDL-c ratio (hazard ratio (HR) = 1.29, 95% confidence interval (CI), 1.05–1.60, P = 0.0159) was positively correlated with GBPs. In the fully adjusted Cox regression model, the HRs were 2.24 for quintile 2 (95% CI: 1.13–4.44, P = 0.0203), 1.50 for quintile 3 (95% CI: 0.73–3.10, P = 0.269), 2.52 for quintile 4 (95% CI: 1.26–5.01, P = 0.0087) and 2.13 for quintile 5 (95% CI: 1.04–4.37, P = 0.0397). No interaction was found among the subgroups. Conclusions A higher non-HDL-c/HDL-c ratio is independently related to a higher risk of GBP formation in Chinese men. Further research is needed to investigate whether this association exists in different regions and races.
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Affiliation(s)
- Xiaofang Zhao
- Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Huabo Zheng
- Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shengshuai Shan
- Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Kun Wang
- Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Meng Zhang
- Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Songpu Xie
- Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Chengyun Liu
- Department of Geriatrics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China. .,The First People's Hospital of Jiangxia District, Wuhan City & Union Jiangnan Hospital, HUST, Wuhan, 430200, China.
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Bong J, Kang HW, Cho H, Nam JH, Jang DK, Kim JH, Lee JK, Lim YJ, Koh MS, Lee JH. Vegetarianism as a protective factor for asymptomatic colonic diverticulosis in Asians: a retrospective cross-sectional and case-control study. Intest Res 2019; 18:121-129. [PMID: 31661949 PMCID: PMC7000646 DOI: 10.5217/ir.2019.00106] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/01/2019] [Indexed: 02/07/2023] Open
Abstract
Background/Aims Dietary fiber intake is considered a protective factor for diverticular disease such as diverticulitis. However, evidence for an inverse connection between dietary fiber consumption and asymptomatic colonic diverticulosis is lacking. Specifically, few studies have investigated this subject in Asians with different presentations of diverticulosis. Therefore, we assessed the protective effects of a vegetarian diet for asymptomatic colonic diverticulosis in Buddhist monks who are obligatory vegetarians for spiritual reasons compared with the general population. Methods A retrospective, cross-sectional, case-control study was conducted in age- and sex-matched Buddhist monks and the general population who underwent colonoscopy for screening at a Korean health promotion center from August 2005 to June 2018. We compared the prevalence of asymptomatic diverticulosis between the 2 groups using a self-administered questionnaire. Results In this study, a total of 1,316 individuals were included (Buddhist monks of 658 and general population of 658) with a mean age of 52.6±9.5 years. The prevalence of asymptomatic diverticulosis in Buddhist monks was lower compared with the general population (6.7% [44/658] vs. 10.8% [71/658], P=0.008). Buddhist monks had a higher rate of high body mass index (BMI) and metabolic syndrome. By a multivariate regression analysis model, a nonvegetarian diet (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.21–2.72, P=0.004), old age (OR, 4.53; 95% CI, 1.36–15.12; P=0.014), male sex (OR, 1.91; 95% CI, 1.28–2.85; P=0.002), and a high BMI (OR, 1.50; 95% CI, 1.01–2.23; P=0.047) were independent predictors of asymptomatic diverticulosis. Moreover, a nonvegetarian diet was associated with both right-sided and left-sided diverticulosis. Conclusions A nonvegetarian diet may increase a risk of asymptomatic colonic diverticulosis in Asians.
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Affiliation(s)
- Jihun Bong
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Hyoun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Hyeki Cho
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Ji Hyung Nam
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jae Hak Kim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Yun Jeong Lim
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Moon-Soo Koh
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jin Ho Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
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Yamin Z, Xuesong B, Guibin Y, Liwei L, Fei L. Risk factors of gallbladder polyps formation in East Asian population: A meta-analysis and systematic review. Asian J Surg 2019; 43:52-59. [PMID: 31109764 DOI: 10.1016/j.asjsur.2019.03.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 02/21/2019] [Accepted: 03/20/2019] [Indexed: 02/07/2023] Open
Abstract
To perform Meta-analysis to identify risk factors associated with gallbladder polyps (GBP) formation in east Asian population. Three English electronic bibliographic databases includes PubMed, Embase and Medline, with reviewed researches from 1986 to 2017. All possible risk factors of GBP formation were recorded. Meta-analyses were performed by Review Manager Software. Pooled odds ratios (OR) or the mean difference (MD) were used to determine risk factors. Sixteen studies and 227021 people were recruited, including 17261 people with GBP and 209760 without GBP. For categorical variables evaluated by OR test., risk factors of GBP formation were male gender (OR, 1.63; 95%CI, 1.42-1.87) and positive HBsAg. GBP formation were not correlated with age <50 years old, hypertension, DM, BMI ≥ 25kg/m2, smoking, drinking, HDL decrease, TC increase, TG increase, fatty liver and GBS. For continuous variables evaluated by MD test, risk factors of GBP formation were DBP (MD, 1.08; 95%CI, 0.15-2.02), mean BMI (MD,0.19; 95%CI,0.02-0.35), waist circumference (MD,1.780; 95%CI, 0.17,3.40), mean LDL (MD,0.89; 95%CI,0.03-1.75), mean HDL (MD,-1.87; 95%CI,-3.21 to -0.52). GBP formation were not correlated with mean age, SBP, mean TC, mean TG, ASL and ALT. In conclusion, risk factors of gallbladder polyp formation included male gender, higher BMI, higher waist circumference, higher DBP, higher LDL, lower HDL and positive HBsAg in east Asian population. GBP formation was not correlated with age, hypertension, DM, smoking, drinking, fatty liver, GBS, TC, TG, SBP, ASL and ALT. The mechanism of Dyslipidemias causing GBP needs deeper study in future.
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Affiliation(s)
- Zheng Yamin
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Bai Xuesong
- Xuanwu Hospital, The First Clinical Medical College, Capital Medical University, Beijing, China
| | - Yao Guibin
- Xuanwu Hospital, The First Clinical Medical College, Capital Medical University, Beijing, China
| | - Liu Liwei
- Xuanwu Hospital, The First Clinical Medical College, Capital Medical University, Beijing, China
| | - Li Fei
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Liu HW, Chen CY. Ovo-lactovegetarian diet as a possible protective factor against gallbladder polyps in Taiwan: A cross-sectional study. Tzu Chi Med J 2019; 31:29-34. [PMID: 30692829 PMCID: PMC6334569 DOI: 10.4103/tcmj.tcmj_16_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective Gallbladder polyps (GBPs) are an increasingly common incidental finding and 3% to 8% of GBPs become malignant. A poor prognosis is expected in patients with gallbladder cancer. No studies have considered the relationship between diet and the development of GBPs in the Taiwanese population. The objective of this study was to investigate whether a vegetarian diet protects against GBP development. Materials and Methods This cross-sectional study included 11,717 individuals who received a health checkup at Taipei Tzu Chi Hospital (New Taipei City, Taiwan) between October 2011 and October 2016. All individuals completed questionnaires that collected data about their characteristics, dietary patterns, and lifestyle. Physical examinations were conducted, and blood chemistry tests were performed. The presence of GBPs was determined using ultrasonography. We subsequently evaluated the association between diet and GBP prevalence using multivariate analysis. Results The prevalence of GBPs for the entire group was 8.3%. GBPs were significantly less common in the vegetarian groups (vegans 9.0%, ovo-lacto vegetarians 7.5%, and semi-vegetarians 7.2%) compared with the omnivore group (9.6%) (P = 0.002). Step-wise logistic regression revealed that an ovo-lacto vegetarian diet was a possible protective factor (odds ratio = 0.83, P = 0.015). Conclusions The study findings showed a strong negative association between an ovo-lacto vegetarian diet and GBP occurrence.
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Affiliation(s)
- Hao-Wen Liu
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Cheng-Yu Chen
- Department of Family Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
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Metabolic status and lifestyle factors associated with gallbladder polyps: a covariance structure analysis. BMC Gastroenterol 2018; 18:159. [PMID: 30382815 PMCID: PMC6211420 DOI: 10.1186/s12876-018-0882-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023] Open
Abstract
Background Gallbladder Polyps (GBP) are highly prevalent in China; however, the etiology of GBP has not been clearly defined. This study explored the associations between lifestyle factors and GBP and whether it mediated by metabolic factors or not. Methods A total of 487 newly diagnosed GBP cases and 502 healthy controls were involved in this study. A questionnaire was used to investigate the socio-demographic characteristics and lifestyle factors. Food Intake Frequencies Questionnaire was used to obtain the food intake frequencies of seven food categories. Blood was tested for lipid profiles, fasting blood glucose and blood urine acid. A Covariance Structure Analysis was used in the analysis to explore the possible pathways between socio-demographic characteristics, lifestyle factors, metabolic factor and GBP. Results The Covariance Structure Analysis showed that a higher BMI and elevated triglyceride level mediated the association between age and GBP. Lifestyle factors (smoking and drinking) and higher intake frequencies of fatty food (meat and viscera) also linked to higher BMI and higher triglyceride level, respectively, which were associated with GBP. Conclusion In conclusion, age and lifestyle factors might be indirectly related with GBP through BMI and the triglyceride pathway.
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Kim HJ, Kim Y, Kim S, Chin HJ, Lee H, Lee JP, Kim DK, Oh KH, Joo KW, Kim YS, Nah DY, Shin SJ, Kim KS, Park JY, Yoo KD. Age, sex, and the association of chronic kidney disease with all-cause mortality in Buddhist priests: An analysis of the standardized mortality ratio from the Korean Buddhist priests cohort. Medicine (Baltimore) 2018; 97:e13099. [PMID: 30407320 PMCID: PMC6250507 DOI: 10.1097/md.0000000000013099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/08/2018] [Indexed: 12/27/2022] Open
Abstract
Buddhist priests lead a unique lifestyle, practicing asceticism, with a vegetarian diet. Such behavior may have an impact on clinical outcomes. Hence, we explored the mortality among Korean Buddhist priests as compared with the general population.This study is a single-center, retrospective study. Among the 3867 Buddhist priests who visited Dongguk University Gyeongju Hospital between January 2000 and February 2016, 3639 subjects were available for mortality data from Statistics Korea. Standardized mortality ratio (SMR) was computed for all causes of death and compared with the general population using national statistics in Korea. Information regarding end-stage renal disease (ESRD) was investigated from the Korean Society of Nephrology registry. Among the 3639 patients, the baseline laboratory results were obtained in 724 patients. Chronic kidney disease (CKD) was defined as dipstick proteinuria ≥1 or an estimated glomerular filtration rate <60 mL/min/1.73 m.The mean age was 50.0 ± 12.5 years, and 51.0% were men. During the follow-up period for 31.1 ± 35.6 months, 55 (7.6%) patients died. During the follow-up period, 3 (0.4%) and 23 (3.2%) patients developed ESRD and urinary stone, respectively. The SMR for all causes of death was 0.76 (95% confidence interval [CI] 0.57-0.99; men 0.91, 95% CI 0.65-1.23; women 0.52, 95% CI 0.28-0.87). Among 724 patients, 74 (10.2%) patients had CKD. The SMR for non-CKD patients (0.61, 95% CI 0.43-0.85) was significantly lower than the general population. Female and patients older than 50 years (0.74, 95% CI 0.55-0.98) had a significantly lower SMR. In the Cox proportional hazards model with adjustment, older age (adjusted HR 1.04, 95% CI 1.10-1.07) and presence of CKD (adjusted HR 2.55, 95% CI 1.07-6.06) were independently associated with increased all-cause mortality.Buddhist priests and especially Buddhist priests without CKD showed a significantly lower mortality compared with the general population.
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Affiliation(s)
- Hyo Jin Kim
- Department of Internal Medicine, Dongguk University College of Medicine
- Department of Internal Medicine, Dongguk University Gyeongju Hospital, Gyeongsangbuk-do
| | - Yunmi Kim
- Department of Internal Medicine, Dongguk University College of Medicine
- Department of Internal Medicine, Dongguk University Gyeongju Hospital, Gyeongsangbuk-do
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University Hospital
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University Hospital
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University Hospital
| | - Deuk-Young Nah
- Department of Internal Medicine, Dongguk University College of Medicine
- Department of Internal Medicine, Dongguk University Gyeongju Hospital, Gyeongsangbuk-do
| | - Sung Joon Shin
- Department of Internal Medicine, Dongguk University College of Medicine
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Gyeonggi-do, Republic of Korea
| | - Kyung Soo Kim
- Department of Internal Medicine, Dongguk University College of Medicine
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Gyeonggi-do, Republic of Korea
| | - Jae Yoon Park
- Department of Internal Medicine, Dongguk University College of Medicine
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Gyeonggi-do, Republic of Korea
| | - Kyung Don Yoo
- Department of Internal Medicine, Dongguk University College of Medicine
- Department of Internal Medicine, Dongguk University Gyeongju Hospital, Gyeongsangbuk-do
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Paik WH. [Risk Factors of Gallbladder Polyp]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2015; 66:249-250. [PMID: 26913297 DOI: 10.4166/kjg.2015.66.5.249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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