1
|
Ranzil S, Ellery S, Walker DW, Vaillancourt C, Alfaidy N, Bonnin A, Borg A, Wallace EM, Ebeling PR, Erwich JJ, Murthi P. Disrupted placental serotonin synthetic pathway and increased placental serotonin: Potential implications in the pathogenesis of human fetal growth restriction. Placenta 2019; 84:74-83. [PMID: 31176514 PMCID: PMC6724713 DOI: 10.1016/j.placenta.2019.05.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 05/08/2019] [Accepted: 05/22/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Placental insufficiency contributes to altered maternal-fetal amino acid transfer, and thereby to poor fetal growth. An important placental function is the uptake of tryptophan and its metabolism to serotonin (5-HT) and kynurenine metabolites, which are essential for fetal development. We hypothesised that placental 5-HT content will be increased in pregnancies affected with fetal growth restriction (FGR). METHODS The components of the 5-HT synthetic pathway were determined in chorionic villus samples (CVS) from small-for gestation (SGA) and matched control collected at 10-12 weeks of human pregnancy; and in placentae from third trimester FGR and gestation-matched control pregnancies using the Fluidigm Biomarker array for mRNA expression, the activity of the enzyme TPH and 5-HT concentrations using an ELISA. RESULTS Gene expression for the rate limiting enzymes, TPH1 and TPH2; 5-HT transporter, SLC6A4; and 5-HT receptors HTR5A, HTR5B, HTR1D and HTR1E were detected in all CVS and third trimester placentae. No significant difference in mRNA was observed in SGA compared with control. Although there was no significant change in TPH1 mRNA, the mRNA of TPH2 and SLC6A4 was significantly decreased in FGR placentae (p < 0.05), while 5-HT receptor mRNA was significantly increased in FGR compared with control (p < 0.01). Placental TPH enzyme activity was significantly increased with a concomitant increase in the total placental 5-HT concentrations in FGR compared with control. CONCLUSION This study reports differential expression and activity of the key components of the 5-HT synthetic pathway associated with the pathogenesis of FGR. Further studies are required to elucidate the functional consequences of increased placental 5-HT in FGR pregnancies.
Collapse
Affiliation(s)
- Suveena Ranzil
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Stacey Ellery
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - David W Walker
- Royal Melbourne Institute of Technology University - Bundoora Campus, Melbourne, Victoria, Australia
| | - Cathy Vaillancourt
- INRS-Institut Armand-Frappier, Laval, QC, Canada; BioMed Research Centre, Laval, QC, Canada Center for Interdisciplinary Research on Well-Being, Health, Society and Environment, Universite du Quebec a Montreal, Montreal, QC, Canada
| | - Nadia Alfaidy
- Institut National de la Santé, et de la Recherche Médicale, Unité, 1036, Grenoble, France; Univ. Grenoble-Alpes, 38000, Grenoble, France; Commissariat à l'Energie Atomique (CEA), iRTSV- Biology of Cancer and infection, Grenoble, France
| | - Alexander Bonnin
- Zilkha Neurogenetic Institute, Keck School of Medicine of University of Southern California, USA
| | - Anthony Borg
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, Victoria, Australia
| | - Euan M Wallace
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Jan Jaap Erwich
- Department of Obstetrics and Gynecology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Padma Murthi
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia; Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, Victoria, Australia; Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Victoria, Australia.
| |
Collapse
|
2
|
Ranzil S, Walker DW, Borg AJ, Wallace EM, Ebeling PR, Murthi P. The relationship between the placental serotonin pathway and fetal growth restriction. Biochimie 2018; 161:80-87. [PMID: 30605696 DOI: 10.1016/j.biochi.2018.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 12/26/2018] [Indexed: 01/18/2023]
Abstract
Fetal growth restriction (FGR) is a complex disorder of human pregnancy that leads to poor health outcomes in offspring. These range from immediate risks such as perinatal morbidity and stillbirths, to long-term complications including severe neurodevelopmental problems. Despite its relatively high global prevalence, the aetiology of FGR and its complications is not currently well understood. We now know that serotonin (5-HT) is synthesised in the placenta and is crucial for early fetal forebrain development in mice. However, the contribution of a disrupted placental 5-HT synthetic pathway to the pathophysiology of placental insufficiency in FGR and its significant fetal neurodevelopmental complications are unclear.
Collapse
Affiliation(s)
- Suveena Ranzil
- Department of Obstetrics and Gynaecology, Monash University, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | | | - Anthony J Borg
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, Royal Women's Hospital, Parkville, Victoria, Australia
| | - Euan M Wallace
- Department of Obstetrics and Gynaecology, Monash University, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Clayton, Victoria, Australia
| | - Padma Murthi
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia; Department of Maternal-Fetal Medicine, Pregnancy Research Centre, Royal Women's Hospital, Parkville, Victoria, Australia; Department of Medicine, School of Clinical Sciences, Clayton, Victoria, Australia; Department of Obstetrics and Gynaecology, University of Melbourne, Royal Women's Hospital, Parkville, Victoria, Australia.
| |
Collapse
|
3
|
Gallardo Gaona J, Martínez Macías O, Acevedo Gallegos S, Velázquez Torres B, Ramírez Calvo J, Camarena Cabrera D. Propuesta clínica para el diagnóstico, la clasificación, el seguimiento y el manejo de la restricción del crecimiento intrauterino de origen placentario. PERINATOLOGÍA Y REPRODUCCIÓN HUMANA 2018. [DOI: 10.1016/j.rprh.2018.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
|
4
|
Velayo CL, Funamoto K, Silao JNI, Kimura Y, Nicolaides K. Evaluation of Abdominal Fetal Electrocardiography in Early Intrauterine Growth Restriction. Front Physiol 2017; 8:437. [PMID: 28694782 PMCID: PMC5483441 DOI: 10.3389/fphys.2017.00437] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 06/09/2017] [Indexed: 11/23/2022] Open
Abstract
Objectives: This descriptive study was performed to evaluate the capability of a non-invasive transabdominal electrocardiographic system to extract clear fetal electrocardiographic (FECG) measurements from intrauterine growth restricted (IUGR) fetuses and to assess whether abdominal FECG parameters can be developed as markers for evaluating the fetal cardiac status in IUGR. Methods: Transabdominal FECG was attempted in 20 controls and 15 IUGR singleton pregnancies at 20+0−33+6 weeks gestation. Standard ECG parameters were compared between the study groups and evaluated for their correlation. Accuracy for the prediction of IUGR by cut off values of the different FECG parameters was also determined. Results: Clear P-QRST complexes were recognized in all cases. In the IUGR fetuses, the QT and QTc intervals were significantly prolonged (p = 0.017 and p = 0.002, respectively). There was no correlation between ECG parameters and Doppler or other indices to predict IUGR. The generation of cut off values for detecting IUGR showed increasing sensitivities but decreasing specificities with the prolongation of ECG parameters. Conclusion: The study of fetal electrocardiophysiology is now feasible through a non-invasive transabdominal route. This study confirms the potential of FECG as a clinical screening tool to aid diagnosis and management of fetuses after key limitations are addressed. In the case of IUGR, both QT and QTc intervals were significantly prolonged and thus validate earlier study findings where both these parameters were found to be markers of diastolic dysfunction. This research is a useful prelude to a test of accuracy and Receiver Operating Characteristics (ROC) study.
Collapse
Affiliation(s)
- Clarissa L Velayo
- Department of Physiology, College of Medicine, University of the PhilippinesManila, Philippines
| | - Kiyoe Funamoto
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Tohoku UniversitySendai, Japan
| | - Joyceline Noemi I Silao
- Department of Obstetrics and Gynecology, Philippine General Hospital, University of the PhilippinesManila, Philippines
| | - Yoshitaka Kimura
- Department of Obstetrics and Gynecology, Graduate School of Medicine, Tohoku UniversitySendai, Japan
| | - Kypros Nicolaides
- Harris Birthright Research Centre, Kings College HospitalLondon, United Kingdom
| |
Collapse
|
5
|
Sharma D, Shastri S, Sharma P. Intrauterine Growth Restriction: Antenatal and Postnatal Aspects. Clin Med Insights Pediatr 2016; 10:67-83. [PMID: 27441006 PMCID: PMC4946587 DOI: 10.4137/cmped.s40070] [Citation(s) in RCA: 437] [Impact Index Per Article: 54.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 06/07/2016] [Accepted: 06/13/2016] [Indexed: 12/14/2022] Open
Abstract
Intrauterine growth restriction (IUGR), a condition that occurs due to various reasons, is an important cause of fetal and neonatal morbidity and mortality. It has been defined as a rate of fetal growth that is less than normal in light of the growth potential of that specific infant. Usually, IUGR and small for gestational age (SGA) are used interchangeably in literature, even though there exist minute differences between them. SGA has been defined as having birth weight less than two standard deviations below the mean or less than the 10th percentile of a population-specific birth weight for specific gestational age. These infants have many acute neonatal problems that include perinatal asphyxia, hypothermia, hypoglycemia, and polycythemia. The likely long-term complications that are prone to develop when IUGR infants grow up includes growth retardation, major and subtle neurodevelopmental handicaps, and developmental origin of health and disease. In this review, we have covered various antenatal and postnatal aspects of IUGR.
Collapse
Affiliation(s)
- Deepak Sharma
- Department of Neonatology, NEOCLINIC, TN Mishra Marg, Everest Vihar, Nirman Nagar, Jaipur, Rajasthan, India
| | - Sweta Shastri
- Department of Pathology, N.K.P Salve Medical College, Nagpur, Maharashtra, India
| | - Pradeep Sharma
- Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Jaipur, Rajasthan, India
| |
Collapse
|
6
|
Doppler for growth restriction: the association between the cerebroplacental ratio and a reduced interval to delivery. J Perinatol 2015; 35:332-7. [PMID: 25474558 DOI: 10.1038/jp.2014.211] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 09/30/2014] [Accepted: 10/02/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Evaluation of the cerebroplacental ratio (CPR) as an adjunct to umbilical artery Doppler (UA) to assess risk of delivery before 32 weeks and/or delivery within 2 weeks from diagnosis of fetal growth restriction (FGR). STUDY DESIGN In a cohort of fetuses with suspected FGR, UA Doppler was performed, and when abnormal the CPR was calculated (middle cerebral pulsatility index/umbilical artery pulsatility index). Doppler characteristics were used to determine three study groups: (1) normal UA, (2) abnormal UA with normal CPR and (3) abnormal UA with abnormal CPR. The primary outcomes were delivery before 32 weeks and delivery within 2 weeks. Adjusted odds ratio (aOR) with 95% confidence intervals (CIs) were calculated controlling for maternal age, chronic hypertension and tobacco use. We performed a linear regression analysis comparing the value of the CPR with the gestational age at delivery. Kaplan-Meier survival curve analysis with log-rank tests for probability was performed. RESULTS We included 154 patients: 91, 31 and 32 in Group 1, 2 and 3, respectively. Subjects in Group 3 had higher rates of the two primary outcomes: there was a fivefold increased risk (aOR=5.2 (95% CI=2.85-9.48)) for delivery before 32 weeks and over a fourfold increased risk for delivery within 2 weeks (aOR=4.76 (95% CI=2.32-9.76)) compared with those with a normal CPR (Group 1). In contrast, subjects in Group 2 (abnormal UA Doppler but normal CPR) had a similar rate of delivery before 32 weeks (aOR=1.16 (95% CI=0.55-2.48)) and within 2 weeks (aOR=1.07 (95% CI=0.43-2.69)). The median gestational age at delivery was 36, 36 and 29 weeks in Groups 1, 2 and 3, respectively (P<0.001). Linear regression analysis revealed a strong correlation between the value of the CPR and gestational age at delivery: R(2)=0.56, correlation coefficient=0.75. Kaplan-Meier analysis revealed a significantly decreased latency to delivery in Group 3, as opposed to Groups 1 and 2 (Cox-Mantel hazard ratio (HR) of Group 2 versus Group 1 HR=1.20 (95% CI=0.78-1.83) and Group 3 versus Group 1 HR=5.00 (95% CI=2.4-10.21)). CONCLUSION The CPR differentiates those fetuses with suspected growth restriction most at risk for delivery before 32 weeks and delivery within 2 weeks from those likely to have a more prolonged latency until delivery is required. In patients with suspected FGR and an abnormal UA, the CPR can be used to guide management decisions, such as maternal hospitalization and/or transport, aggressive fetal monitoring and antenatal corticosteroid administration.
Collapse
|
7
|
Regan J, Masters H, Warshak CR. Estimation of the growth rate in fetuses with an abnormal cerebroplacental ratio compared to those with suspected growth restriction without evidence of centralization of blood flow. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:837-842. [PMID: 25911717 DOI: 10.7863/ultra.34.5.837] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To evaluate the growth rate in fetuses with suspected growth restriction according to their Doppler characteristics. METHODS A retrospective cohort of fetuses with suspected growth restriction was identified. We reviewed umbilical artery and middle cerebral Doppler pulsatility indices and calculated the cerebroplacental ratio. Three study groups were determined: (1) normal umbilical artery Doppler findings; (2) abnormal umbilical artery findings with a normal cerebroplacental ratio; and (3) abnormal umbilical artery findings with an abnormal cerebroplacental ratio. The primary outcome was the growth rate as estimated by fetal biometry from serial sonographic evaluations. Analysis of the mean growth rate in each study group was performed by analysis of variance. In addition, linear regression analysis comparing the cerebroplacental ratio to the growth rate was performed. RESULTS Fetal growth restriction was suspected in 416 patients; 176 patients were included in this analysis: 113, 38, and 25 in groups 1, 2, and 3 respectively. The estimated mean (SD) growth rate in group 3 was significantly lower than in groups 1 and 2: 8.3 (4.4) versus 19.6 (6.0) and 18.6 (7.7) g/d, respectively (P < .001). Linear regression analysis revealed a strong correlation between the growth rate and cerebroplacental ratio (r = 0.76; R(2) = 0.58) as well as the birth weight and cerebroplacental ratio (r = 0.78; R(2) = 0.61). CONCLUSIONS In fetuses with suspected growth restriction and abnormal umbilical artery Doppler findings, an abnormal cerebroplacental ratio is strongly associated with reduced fetal growth. In contrast, if the cerebroplacental ratio is normal, even in the setting of abnormal umbilical artery Doppler findings, fetuses grow similarly to those with normal umbilical artery findings.
Collapse
Affiliation(s)
- Jodi Regan
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio USA.
| | - Heather Masters
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio USA
| | - Carri R Warshak
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio USA
| |
Collapse
|
8
|
Association between an abnormal cerebroplacental ratio and the development of severe pre-eclampsia. J Perinatol 2015; 35:322-7. [PMID: 25474554 DOI: 10.1038/jp.2014.210] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 10/02/2014] [Accepted: 10/06/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To study the association between the cerebroplacental ratio (CPR) and the development of pre-eclampsia. STUDY DESIGN Three study groups were determined: Group 1-normal umbilical artery (UA; referent), Group 2-abnormal UA and normal CPR and Group 3-abnormal UA and an abnormal CPR. The primary outcome was the development of severe pre-eclampsia. RESULTS We included 270 women. Women in Group 3 had significantly elevated rates of severe pre-eclampsia versus those in Group 1 and Group 2, 52.5% versus 5.1% and 15.4%, respectively, (P<0.01), adjusted odds ratio 4.14 (95% confidence interval, 2.59 to 6.61). Kaplan-Meier analysis revealed earlier delivery in women with pre-eclampsia in Group 3 versus Group 1, Cox-Mantel hazard ratio 2.39 (1.17 to 4.88), log rank P=0.01. CONCLUSION An abnormal CPR is associated with a higher rate severe pre-eclampsia with delivery at earlier gestational ages than with a normal UA or an abnormal UA, but normal CPR.
Collapse
|
9
|
Talmor A, Daemen A, Murdoch E, Missfelder-Lobos H, Timmerman D, Bourne T, Giussani DA, Lees C. Defining the relationship between fetal Doppler indices, abdominal circumference and growth rate in severe fetal growth restriction using functional linear discriminant analysis. J R Soc Interface 2013; 10:20130376. [PMID: 23966615 DOI: 10.1098/rsif.2013.0376] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The relationship between Doppler measurements, size and growth rate in fetal growth restriction has not been defined. We used functional linear discriminant analysis (FLDA) to investigate these parameters taking account of the difficulties inherent in exploring relationships between repeated observations from a small number of cases. In 40 fetuses with severe growth restriction, serial abdominal circumference (AC), umbilical, middle cerebral artery (MCA) and ductus venosus Doppler pulsatility index measurements were recorded. In 11 singleton fetuses with normal growth, umbilical artery pulsatility index only was measured. Data were expressed as z-scores in relation to gestation and analysed longitudinally using FLDA. In severe growth restriction, the Spearman correlation coefficients between umbilical artery pulsatility index and AC z-score, MCA pulsatility index and AC z-score and ductus venosus pulsatility index z-score and AC z-score were, respectively: -0.36, p = 4.4 × 10(-7); 0.70, p = 1.1 × 10(-17) and -0.50, p = 8.1 × 10(-4). No relationship was seen between Doppler parameters and growth rate. There was no relationship between umbilical artery pulsatility index and AC nor growth rate in normally grown fetuses. In severe fetal growth restriction, Doppler changes are related to absolute fetal AC size, not growth rate.
Collapse
Affiliation(s)
- Alon Talmor
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | | | | | | | | | | | | | | |
Collapse
|
10
|
|
11
|
Ott WJ. Development of a fetal risk assessment score for the prediction of neonatal outcome in the growth-restricted fetus. J Matern Fetal Neonatal Med 2012; 25:1941-4. [DOI: 10.3109/14767058.2012.679712] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
12
|
Mari G. Doppler ultrasonography in obstetrics: from the diagnosis of fetal anemia to the treatment of intrauterine growth-restricted fetuses. Am J Obstet Gynecol 2009; 200:613.e1-9. [PMID: 19200940 DOI: 10.1016/j.ajog.2008.10.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2008] [Revised: 08/11/2008] [Accepted: 10/30/2008] [Indexed: 10/21/2022]
Abstract
After the adoption of the use of umbilical artery and middle cerebral artery peak systolic velocity in high-risk pregnancies and in pregnancies that are at risk of having an anemic fetus, the main focus of Doppler ultrasonography in obstetrics today is intrauterine growth-restricted fetuses. What is most needed at this time are (1) training of sonographers and sonologists on how to perform a Doppler study, (2) an international classification of intrauterine growth-restricted fetuses, and (3) a study of the natural history of intrauterine growth-restricted fetuses that might contribute to a better understanding of the intrauterine growth-restriction process and to standard treatment of intrauterine growth-restricted fetuses. Future investigations, which would include randomized studies, could be designed from the results of such studies.
Collapse
|
13
|
Abstract
Intrauterine growth restriction (IUGR) secondary to placental insufficiency is a major cause of perinatal morbidity and mortality in the United States. Historically, Doppler changes occurring in IUGR fetuses play an important role in the diagnosis and management of these fetuses, and now, based on these changes, we have proposed a staging system for IUGR fetuses that demonstrates prognostic value. This manuscript also summarizes a practical classification for IUGR fetuses. We believe that future studies should differentiate among the different types of IUGR fetuses.
Collapse
Affiliation(s)
- Giancarlo Mari
- Department of Obstetrics and Gynecology, Wayne State University, 3990 John R. Box 163, Detroit, MI 48201, USA.
| | | |
Collapse
|
14
|
Mari G, Hanif F, Kruger M. Sequence of cardiovascular changes in IUGR in pregnancies with and without preeclampsia. Prenat Diagn 2008; 28:377-83. [DOI: 10.1002/pd.1990] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|