1
|
Hu FL, Chen HT, Guo FF, Yang M, Jiang X, Yu JH, Zhang FM, Xu GQ. Biliary microbiota and mucin 4 impact the calcification of cholesterol gallstones. Hepatobiliary Pancreat Dis Int 2021; 20:61-66. [PMID: 33341401 DOI: 10.1016/j.hbpd.2020.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 11/11/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cholesterol gallstones account for over 80% of gallstones, and the pathogenesis of gallstone formation involves genetic and environmental factors. However, data on the evolution of cholesterol gallstones with various densities are limited. This study aimed to determine the roles of microbiota and mucins on the formation of calcified cholesterol gallstones in patients with cholelithiasis. METHODS Paired gallbladder tissues and bile specimens were obtained from cholelithiasis patients who were categorized into the isodense group and calcified group according to the density of gallstones. The relative abundance of microbiota in gallbladder tissues was detected. Immunohistochemistry and enzyme-linked immunosorbent assay were performed to detect the expression levels of MUC1, MUC2, MUC3a, MUC3b, MUC4, MUC5ac and MUC5b in gallbladder tissues and bile. The correlation of microbiota abundance with MUC4 expression was evaluated by linear regression. RESULTS A total of 23 patients with gallbladder stones were included. The density of gallstones in the isodense group was significantly lower than that of the calcified group (34.20 ± 1.50 vs. 109.40 ± 3.84 HU, P < 0.0001). Compared to the isodense group, the calcified group showed a higher abundance of gram-positive bacteria at the fundus, in the body and neck of gallbladder tissues. The concentrations of MUC1, MUC2, MUC3a, MUC3b, MUC5ac and MUC5b in the epithelial cells of gallbladder tissues showed no difference between the two groups, while the concentrations of MUC4 were significantly higher in the calcified group than that in the isodense group at the fundus (15.49 ± 0.69 vs. 10.23 ± 0.54 ng/mL, P < 0.05), in the body (14.54 ± 0.94 vs. 11.87 ± 0.85 ng/mL, P < 0.05) as well as in the neck (14.77 ± 1.04 vs. 10.85 ± 0.72 ng/mL, P < 0.05) of gallbladder tissues. Moreover, the abundance of bacteria was positively correlated with the expression of MUC4 (r = 0.569, P < 0.05) in the calcified group. CONCLUSIONS This study showed the potential clinical relevance among biliary microbiota, mucins and calcified gallstones in patients with gallstones. Gram-positive microbiota and MUC4 may be positively associated with the calcification of cholesterol gallstones.
Collapse
Affiliation(s)
- Feng-Ling Hu
- Department of Gastroenterology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Hong-Tan Chen
- Department of Gastroenterology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Fang-Fang Guo
- Department of Gastroenterology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Ming Yang
- Department of Gastroenterology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xin Jiang
- Department of Gastroenterology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jing-Hua Yu
- Department of Gastroenterology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Fen-Ming Zhang
- Department of Gastroenterology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Guo-Qiang Xu
- Department of Gastroenterology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
| |
Collapse
|
2
|
Abstract
The majority of gallstone patients remain asymptomatic; however, interest toward the gallstone disease is continuing because of the high worldwide prevalence and management costs and the development of gallstone symptoms and complications. For cholesterol gallstone disease, moreover, a strong link exists between this disease and highly prevalent metabolic disorders such as obesity, dyslipidemia, type 2 diabetes, hyperinsulinemia, hypertriglyceridemia and the metabolic syndrome. Information on the natural history as well as the diagnostic, surgical (mainly laparoscopic cholecystectomy) and medical tools available to facilitate adequate management of cholelithiasis and its complications are, therefore, crucial to prevent the negative outcomes of gallstone disease. Moreover, some risk factors for gallstone disease are modifiable and some preventive strategies have become necessary to reduce the onset and the severity of complications.
Collapse
Affiliation(s)
- P Portincasa
- a Department of Biomedical Sciences and Human Oncology, Clinica Medica "A. Murri" , University of Bari Medical School , Bari , Italy
| | - A Di Ciaula
- b Division of Internal Medicine , Hospital of Bisceglie , Bisceglie , Italy
| | - O de Bari
- a Department of Biomedical Sciences and Human Oncology, Clinica Medica "A. Murri" , University of Bari Medical School , Bari , Italy
- d Department of Internal Medicine, Division of Gastroenterology and Hepatology , Saint Louis University School of Medicine , St. Louis , MO , USA
| | - G Garruti
- c Department of Emergency and Organ Transplants, Section of Endocrinology, Andrology and Metabolic Diseases , University of Bari Medical School , Bari , Italy
| | - V O Palmieri
- a Department of Biomedical Sciences and Human Oncology, Clinica Medica "A. Murri" , University of Bari Medical School , Bari , Italy
| | - D Q-H Wang
- d Department of Internal Medicine, Division of Gastroenterology and Hepatology , Saint Louis University School of Medicine , St. Louis , MO , USA
| |
Collapse
|
3
|
Abstract
Background To develop a method for systematic classification of gallbladder stones, analyze the clinical characteristics of each type of stone and provide a theoretical basis for the study of the formation mechanism of different types of gallbladder stones. Methodology A total of 807 consecutive patients with gallbladder stones were enrolled and their gallstones were studied. The material composition of gallbladder stones was analyzed using Fourier Transform Infrared spectroscopy and the distribution and microstructure of material components was observed with Scanning Electron Microscopy. The composition and distribution of elements were analyzed by an X-ray energy spectrometer. Gallbladder stones were classified accordingly, and then, gender, age, medical history and BMI of patients with each type of stone were analyzed. Principal Findings Gallbladder stones were classified into 8 types and more than ten subtypes, including cholesterol stones (297), pigment stones (217), calcium carbonate stones (139), phosphate stones (12), calcium stearate stones (9), protein stones (3), cystine stones (1) and mixed stones (129). Mixed stones were those stones with two or more than two kinds of material components and the content of each component was similar. A total of 11 subtypes of mixed stones were found in this study. Patients with cholesterol stones were mainly female between the ages of 30 and 50, with higher BMI and shorter medical history than patients with pigment stones (P<0.05), however, patients with pigment, calcium carbonate, phosphate stones were mainly male between the ages of 40 and 60. Conclusion The systematic classification of gallbladder stones indicates that different types of stones have different characteristics in terms of the microstructure, elemental composition and distribution, providing an important basis for the mechanistic study of gallbladder stones.
Collapse
Affiliation(s)
- Tie Qiao
- Laboratory of Gallbladder Diseases, Institute of Gallbladder Disease of Panyu, Panyu, Guangzhou, People's Republic of China
- Laboratory of Gallbladder Diseases, The Sixth People's Hospital of Nansha, Nansha, Guangzhou, People's Republic of China
- * E-mail:
| | - Rui-hong Ma
- Laboratory of Gallbladder Diseases, Institute of Gallbladder Disease of Panyu, Panyu, Guangzhou, People's Republic of China
- Laboratory of Gallbladder Diseases, The Sixth People's Hospital of Nansha, Nansha, Guangzhou, People's Republic of China
| | - Xiao-bing Luo
- Laboratory of Gallbladder Diseases, Institute of Gallbladder Disease of Panyu, Panyu, Guangzhou, People's Republic of China
- Laboratory of Gallbladder Diseases, The Sixth People's Hospital of Nansha, Nansha, Guangzhou, People's Republic of China
| | - Liu-qing Yang
- Laboratory of Gallbladder Diseases, Institute of Gallbladder Disease of Panyu, Panyu, Guangzhou, People's Republic of China
- Laboratory of Gallbladder Diseases, The Sixth People's Hospital of Nansha, Nansha, Guangzhou, People's Republic of China
| | - Zhen-liang Luo
- Laboratory of Gallbladder Diseases, Institute of Gallbladder Disease of Panyu, Panyu, Guangzhou, People's Republic of China
- Laboratory of Gallbladder Diseases, The Sixth People's Hospital of Nansha, Nansha, Guangzhou, People's Republic of China
| | - Pei-ming Zheng
- Laboratory of Gallbladder Diseases, Institute of Gallbladder Disease of Panyu, Panyu, Guangzhou, People's Republic of China
- Laboratory of Gallbladder Diseases, The Sixth People's Hospital of Nansha, Nansha, Guangzhou, People's Republic of China
| |
Collapse
|
4
|
Gallstones. Symptoms usually mean surgery. Mayo Clin Health Lett 2012; 30:1-3. [PMID: 23133852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
|
5
|
Il'chenko AA. [10 years of cholelithiasis classification (Central Scientific Research Institute of Gastroenterology): highlights of scientific and practical applications]. Eksp Klin Gastroenterol 2012:3-10. [PMID: 23402145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Clinical classification of cholelithiasisis presented, which includes 4 stages: stage without calculi, stage of formed gallstones, chronic calculous cholecystitis and complications. Sonographic description of main versions of biliary sludge, its causes and therapy efficacy are also given.
Collapse
|
6
|
Oudhoff JP, Timmermans DRM, Rietberg M, Knol DL, van der Wal G. The acceptability of waiting times for elective general surgery and the appropriateness of prioritising patients. BMC Health Serv Res 2007; 7:32. [PMID: 17328816 PMCID: PMC1847814 DOI: 10.1186/1472-6963-7-32] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2006] [Accepted: 02/28/2007] [Indexed: 11/29/2022] Open
Abstract
Background Problematic waiting lists in public health care threaten the equity and timeliness of care provision in several countries. This study assesses different stakeholders' views on the acceptability of waiting lists in health care, their preferences for priority care of patients, and their judgements on acceptable waiting times for surgical patients. Methods A questionnaire survey was conducted among 257 former patients (82 with varicose veins, 86 with inguinal hernia, and 89 with gallstones), 101 surgeons, 95 occupational physicians, and 65 GPs. Judgements on acceptable waiting times were assessed using vignettes of patients with varicose veins, inguinal hernia, and gallstones. Results Participants endorsed the prioritisation of patients based on clinical need, but not on ability to benefit. The groups had significantly different opinions (p < 0.05) on the use of non-clinical priority criteria and on the need for uniformity in the prioritisation process. Acceptable waiting times ranged between 2 and 25 weeks depending on the type of disorder (p < 0.001) and the severity of physical and psychosocial problems of patients (p < 0.001). Judgements were similar between the survey groups (p = 0.3) but responses varied considerably within each group depending on the individual's attitude towards waiting lists in health care (p < 0.001). Conclusion The explicit prioritisation of patients seems an accepted means for reducing the overall burden from waiting lists. The disagreement about appropriate prioritisation criteria and the need for uniformity, however, raises concern about equity when implementing prioritisation in daily practice. Single factor waiting time thresholds seem insufficient for securing timely care provision in the presence of long waiting lists as they do not account for the different consequences of waiting between patients.
Collapse
Affiliation(s)
- Jurriaan P Oudhoff
- Department of Public and Occupational Health, Institute for Research in Extramural Medicine, Free University Medical Centre, Amsterdam, The Netherlands
- Department of Primary Care & General Practice, University of Birmingham, Birmingham, UK
| | - Danielle RM Timmermans
- Department of Public and Occupational Health, Institute for Research in Extramural Medicine, Free University Medical Centre, Amsterdam, The Netherlands
| | - Martin Rietberg
- Department of Surgery, Deventer Hospital, Deventer, The Netherlands
| | - Dirk L Knol
- Department of Clinical Epidemiology and Biostatistics, Free University Medical Centre, Amsterdam, The Netherlands
| | - Gerrit van der Wal
- Department of Public and Occupational Health, Institute for Research in Extramural Medicine, Free University Medical Centre, Amsterdam, The Netherlands
| |
Collapse
|
7
|
Abstract
Gallstones are common in Western countries and Japan. Most gallstones are found in the gallbladder, but they sometimes pass through the cystic duct into extrahepatic and/or intrahepatic bile ducts to become bile-duct stones, causing conditions known as choledocholithiasis and hepatolithiasis. Some 10-15% of gallstone patients concomitantly suffer from bile-duct stones. Bile-duct stones can also be formed in the absence of gallbladder stones, and such primary bile-duct stones are more common in East Asian countries than in the Western world. Thus pathogenesis of primary and secondary bile-duct stones is unlikely to be similar. Furthermore, the gallbladder stones are primarily cholesterol or black-pigment stones, whereas most bile-duct stones are brown-pigment stones (calcium bilirubin stones). Thus, epidemiology, pathogenesis and classification of biliary stones are very likely to differ according to stone location (intrahepatic and/or extrahepatic bile duct).
Collapse
Affiliation(s)
- Susumu Tazuma
- Department of General Medicine and Clinical Pharmacotherapeutics, Hiroshima University Hospital and Graduate School of Biomedical Sciences, 1-2-3, Kasumi, Hiroshima 734-8551, Japan.
| |
Collapse
|
8
|
Ashok M, Nageshwar Reddy D, Jayanthi V, Kalkura SN, Vijayan V, Gokulakrishnan S, Nair KGM. Regional differences in constituents of gall stones. Trop Gastroenterol 2005; 26:73-5. [PMID: 16225049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The pathogenesis of pigment and mixed gall stone formation remains elusive. The elemental constituents of gall stones from southern states of Tamil Nadu, Kerala and Karnataka have been characterized. Our aim was to determine the elemental concentration of representative samples of pigment, mixed and cholesterol gall stones from Andhra Pradesh using proton-induced X-ray emission (PIXE) using a 3 MV horizontal pelletron accelerator. Pigment gall stones had significantly high concentrations of copper, iron and lead; chromium was absent. Except for iron all these elements were significantly low in cholesterol gall stones and intermediate levels were seen in mixed gall stones. Highest concentrations of chromium was seen in cholesterol and titanium in mixed gall stones respectively; latter similar to other southern states. Arsenic was distinctly absent in cholesterol and mixed gall stones. The study has identified differences in elemental components of the gall stones from Andhra Pradesh.
Collapse
Affiliation(s)
- M Ashok
- Crystal Growth Centre, Anna University & Stanley Medical College, Chennai
| | | | | | | | | | | | | |
Collapse
|
9
|
Tsunoda K, Shirai Y, Hatakeyama K. Prevalence of cholesterol gallstones positively correlates with per capita daily calorie intake. Hepatogastroenterology 2004; 51:1271-4. [PMID: 15362730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
BACKGROUND/AIMS Gallstone composition has changed over the past decades in East Asian countries with a prominent increase in the prevalence of cholesterol gallstones. This trend is possibly due to the westernization of dietary habits. This study was undertaken to delineate the changing trends in gallstone composition in Japan since the 1920s and to assess dietary influences on gallstone composition. METHODOLOGY Between 1971 and 1999, 1264 Japanese patients underwent cholecystectomy for gallstone disease in Niigata University Medical Hospital. Gallbladder stones retrieved from each patient were classified into four types by gross inspection of the cut surface and infrared spectroscopy: cholesterol stone, black pigment stone, brown pigment stone, and other stones. The literature was reviewed to find both changing trends in gallstone composition before 1971 and dietary changes since 1950 in Japan. RESULTS The prevalence of cholesterol gallstones among Japanese patients undergoing cholecystectomy increased steadily until the 1970s and declined thereafter (P<0.001). Among dietary factors, only per capita daily total calorie intake strongly correlated with cholesterol gallstone prevalence (r=0.93, P=0.02). CONCLUSIONS During the 20th century, the prevalence of cholesterol gallstones in the Japanese population increased steadily until the 1970s declining thereafter. Per capita daily total calorie intake appears to be the predominant dietary factor affecting cholesterol gallstone prevalence.
Collapse
Affiliation(s)
- Kazuhiko Tsunoda
- Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | | | | |
Collapse
|
10
|
|
11
|
Cetta F. [The classification of biliary calculi and the clinico-therapeutic implications]. Ann Ital Chir 1998; 69:701-8. [PMID: 10213940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
A new classification of gallstones is reported, which has interesting implications for diagnostic and therapeutic purposes. Gallstones have been divided according to "type" into the following categories: cholesterol (single, multiple), mixed, black pigment, brown pigment, combination and composite. In addition, gallstones primarily formed within the gallbladder have been distinguished from those initially formed in the common duct (before and after surgery) and within the intrahepatic ducts. Stone type and composition have been related to symptoms, on the basis of a new view, according to which gallstones are not a unique entity, but a heterogeneous disease including different entities, each of which has its own pathogenesis, clinical manifestations, biological behaviour and also deserves a different treatment. The proper treatment should be appropriate to the individual and his stones. Therapeutic guide-lines are suggested for each type of stones, in particular for stones complicated by cholangitis, pancreatitis, or for common duct stones concomitantly found with gallbladder stones. For the last group, techniques and therapeutic options preserving the function of the sphincter of Oddi are recommended. Suggestions are also reported concerning the treatment of various types of hepatolithiasis: primary, i.e. associated with cystic intrahepatic bile duct dilatation; post-surgical, i.e. occurring cranially to a biliary enteric anastomosis: secondary, i.e. associated with concomitant gallbladder and common duct stones.
Collapse
Affiliation(s)
- F Cetta
- Istituto di Clinica Chirurgica, Università di Siena
| |
Collapse
|
12
|
Abstract
BACKGROUND The role of ERCP in the management of choledocholithiasis in an era of minimally invasive therapy continues to be defined. METHODS We evaluated prospectively the pattern of liver test abnormalities and yield of cholangiography after presentation with illnesses suggesting choledocholithiasis. Ninety-four consecutive patients, all with liver test abnormalities (total bilirubin, alkaline phosphatase, AST, and ALT) at presentation, had serial determinations to within 24 hours of cholangiography and were divided into four groups based on their patterns of rise or fall of liver test results as well as presenting clinical syndrome. Group I: normalized liver tests; Group II: falling liver tests, and alkaline phosphatase falling greater than 50% of the difference between presentation value and upper limit of normal; Group III: alkaline phosphatase falling less than 50%; and Group IV: any liver test with increasing levels. Clinical syndromes included cholangitis, pancreatitis, combined cholangitis and pancreatitis, and biliary pain with abnormal liver tests. RESULTS Yields of choledocholithiasis were 13% (Group I), 50% (Group II), 67% (Group III), and 94% (Group IV). Yield by syndromes were 36% (biliary pancreatitis), 72% (biliary pain and abnormal liver tests), 87% (cholangitis), and 100% (cholangitis and pancreatitis). CONCLUSION The degree of decline in liver test levels is inversely related to the yield of cholangiography in symptomatic choledocholithiasis; the yield of ERCP in these patients (with normalized liver tests) is low and they do not require ERCP. Pre-ERCP estimates of the likelihood of choledocholithiasis can be made on the basis of the pattern of liver tests, and biliary pancreatitis patients with normalized liver tests do not require ERCP.
Collapse
Affiliation(s)
- A D Roston
- Division of Digestive Diseases, New York Hospital-Cornell Medical Center, New York, USA
| | | |
Collapse
|
13
|
Abstract
Cholesterol and brown pigment stones found in the common bile duct are often radiolucent and therefore indistinguishable. The purpose of this study was to define contact solvent systems able to dissolve both stone types. The influence of mucolytic agents on in vitro pigment stone dissolution was first determined. It was shown that dithioerythritol induced more rapid dissolution than N-acetylcysteine. Alternating treatment with an aqueous alkaline solvent (pH = 9.5), composed of sodium deoxycholate 50 mM, ethylenediaminetetraacetate 26 mM and dithioerythritol 50 mM, for 45 min, and an organic solvent methyl tert-butyl ether/dimethyl sulfoxide (90/10) for 15 min, was more effective for bilirubin, cholesterol, and fatty acid solubilization (p < 0.01) than using these solvents separately. The dissolution of brown stones was nearly completed within 9 h and that of mixed cholesterol stones was obtained within 3 h. We conclude that the alternating treatment described is very effective for the rapid in vitro dissolution of the two major stone types present in the bile ducts, and deserves further assessment in vivo.
Collapse
|
14
|
Tarasov VA. [The surgical aspects of biliary lithogenesis]. Voen Med Zh 1991:41-4. [PMID: 2042299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A clinic-morphological classification worked out by the author is made on the basis of the experience acquired during the surgical treatment of 680 patients with various forms of cholelithiasis and its complicated forms. The article discusses the peculiarities of surgical tactics depending on the mechanism of cholelith formation. The author makes a conclusion that cholecystectomy is an obligatory condition of treatment together with the drainage, reparative and recovery operations.
Collapse
|
15
|
Sugahara K, Matsumoto Y. Intrahepatic biliary lithiasis: its findings and current problems. Trop Gastroenterol 1989; 10:201-10. [PMID: 2697105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
|
16
|
Huang DH, Gao F, Guan WZ. [Polarizing microscopic studies of bile stones]. Zhonghua Wai Ke Za Zhi 1987; 25:336-8, 380. [PMID: 3691236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|
17
|
|
18
|
Madden JL. Primary and secondary common duct stones. Surg Gynecol Obstet 1970; 130:1091. [PMID: 5443618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
|
19
|
Madden JL, Vanderheyden L, Kandalaft S. The nature and surgical significance of common duct stones. Surg Gynecol Obstet 1968; 126:3-8. [PMID: 5634605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
|