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Parillo M, Mallio CA, Van der Molen AJ, Rovira À, Ramalho J, Ramalho M, Gianolio E, Karst U, Radbruch A, Stroomberg G, Clement O, Dekkers IA, Nederveen AJ, Quattrocchi CC. Skin Toxicity After Exposure to Gadolinium-Based Contrast Agents in Normal Renal Function, Using Clinical Approved Doses: Current Status of Preclinical and Clinical Studies. Invest Radiol 2023; 58:530-538. [PMID: 37185158 DOI: 10.1097/rli.0000000000000973] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVES The aim of this study was to summarize the current preclinical and clinical evidence on the association between exposure to gadolinium (Gd) compounds and skin toxicity in a setting similar to clinical practice. MATERIALS AND METHODS A search of MEDLINE and PubMed references from January 2000 to December 2022 was performed using keywords related to gadolinium deposition and its effects on the skin, such as "gadolinium," "gadolinium-based contrast agents," "skin," "deposition," and "toxicity." In addition, cross-referencing was added when appropriate. For preclinical in vitro studies, we included all the studies that analyzed the response of human dermal fibroblasts to exposure to various gadolinium compounds. For preclinical animal studies and clinical studies, we included only those that analyzed animals or patients with preserved renal function (estimated glomerular filtration rate >30 mL/min/1.73 m 2 ), using a dosage of gadolinium-based contrast agents (GBCAs) similar to that commonly applied (0.1 mmol/kg). RESULTS Forty studies were selected. Preclinical findings suggest that Gd compounds can produce profibrotic responses in the skin in vitro, through the activation and proliferation of dermal fibroblasts and promoting their myofibroblast differentiation. Gadolinium influences the process of collagen production and the collagen content of skin, by increasing the levels of matrix metalloproteinase-1 and tissue inhibitor of metalloproteinase-1. Preclinical animal studies show that Gd can deposit in the skin with higher concentrations when linear GBCAs are applied. However, these deposits decrease over time and are not associated with obvious macroscopic or histological modifications. The clinical relevance of GBCAs in inducing small fiber neuropathy remains to be determined. Clinical studies show that Gd is detectable in the skin and hair of subjects with normal renal function in higher concentrations after intravenous administration of linear compared with macrocyclic GBCA. However, these deposits decrease over time and are not associated with cutaneous or histological modifications. Also, subclinical dermal involvement related to linear GBCA exposure may be detectable on brain MRI. There is no conclusive evidence to support a causal relationship between GBCA administration at the clinical dose and cutaneous manifestations in patients with normal renal function. CONCLUSIONS Gadolinium can produce profibrotic responses in the skin, especially acting on fibroblasts, as shown by preclinical in vitro studies. Gadolinium deposits are detectable in the skin even in subjects with normal renal function with higher concentrations when linear GBCAs are used, as confirmed by both preclinical animal and human studies. There is no proof to date of a cause-effect relationship between GBCA administration at clinical doses and cutaneous consequences in patients with normal renal function. Multiple factors, yet to be determined, should be considered for sporadic patients with normal renal function who develop clinical skin manifestations temporally related to GBCA administration.
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Affiliation(s)
- Marco Parillo
- From the Unit of Diagnostic Imaging and Interventional Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Carlo A Mallio
- From the Unit of Diagnostic Imaging and Interventional Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Aart J Van der Molen
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Àlex Rovira
- Section of Neuroradiology, Department of Radiology, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joana Ramalho
- Department of Neuroradiology, Centro Hospitalar Universitário de Lisboa Central, Lisbon
| | - Miguel Ramalho
- Department of Radiology, Hospital Garcia de Orta, EPE, Almada, Portugal
| | - Eliana Gianolio
- Department of Molecular Biotechnologies and Health Science, University of Turin, Turin, Italy
| | - Uwe Karst
- Institute of Inorganic and Analytical Chemistry, University of Münster, Münster
| | - Alexander Radbruch
- Department of Neuroradiology, University Hospital Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Gerard Stroomberg
- RIWA-Rijn-Association of River Water Works, Nieuwegein, the Netherlands
| | - Olivier Clement
- Université de Paris, AP-HP, Hôpital Européen Georges Pompidou, DMU Imagina, Service de Radiologie, Paris, France
| | - Ilona A Dekkers
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Aart J Nederveen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Davies J, Siebenhandl-Wolff P, Tranquart F, Jones P, Evans P. Gadolinium: pharmacokinetics and toxicity in humans and laboratory animals following contrast agent administration. Arch Toxicol 2022; 96:403-429. [PMID: 34997254 PMCID: PMC8837552 DOI: 10.1007/s00204-021-03189-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/02/2021] [Indexed: 12/12/2022]
Abstract
Gadolinium-based contrast agents (GBCAs) have transformed magnetic resonance imaging (MRI) by facilitating the use of contrast-enhanced MRI to allow vital clinical diagnosis in a plethora of disease that would otherwise remain undetected. Although over 500 million doses have been administered worldwide, scientific research has documented the retention of gadolinium in tissues, long after exposure, and the discovery of a GBCA-associated disease termed nephrogenic systemic fibrosis, found in patients with impaired renal function. An understanding of the pharmacokinetics in humans and animals alike are pivotal to the understanding of the distribution and excretion of gadolinium and GBCAs, and ultimately their potential retention. This has been well studied in humans and more so in animals, and recently there has been a particular focus on potential toxicities associated with multiple GBCA administration. The purpose of this review is to highlight what is currently known in the literature regarding the pharmacokinetics of gadolinium in humans and animals, and any toxicity associated with GBCA use.
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Affiliation(s)
- Julie Davies
- GE Healthcare, Pollards Wood, Nightingales Lane, Chalfont St. Giles, UK.
| | | | | | - Paul Jones
- GE Healthcare, Pollards Wood, Nightingales Lane, Chalfont St. Giles, UK
| | - Paul Evans
- GE Healthcare, Pollards Wood, Nightingales Lane, Chalfont St. Giles, UK
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Do QN, Lenkinski RE, Tircso G, Kovacs Z. How the Chemical Properties of GBCAs Influence Their Safety Profiles In Vivo. Molecules 2021; 27:58. [PMID: 35011290 PMCID: PMC8746842 DOI: 10.3390/molecules27010058] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/18/2021] [Accepted: 12/22/2021] [Indexed: 01/21/2023] Open
Abstract
The extracellular class of gadolinium-based contrast agents (GBCAs) is an essential tool for clinical diagnosis and disease management. In order to better understand the issues associated with GBCA administration and gadolinium retention and deposition in the human brain, the chemical properties of GBCAs such as relative thermodynamic and kinetic stabilities and their likelihood of forming gadolinium deposits in vivo will be reviewed. The chemical form of gadolinium causing the hyperintensity is an open question. On the basis of estimates of total gadolinium concentration present, it is highly unlikely that the intact chelate is causing the T1 hyperintensities observed in the human brain. Although it is possible that there is a water-soluble form of gadolinium that has high relaxitvity present, our experience indicates that the insoluble gadolinium-based agents/salts could have high relaxivities on the surface of the solid due to higher water access. This review assesses the safety of GBCAs from a chemical point of view based on their thermodynamic and kinetic properties, discusses how these properties influence in vivo behavior, and highlights some clinical implications regarding the development of future imaging agents.
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Affiliation(s)
- Quyen N. Do
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; (Q.N.D.); (R.E.L.)
| | - Robert E. Lenkinski
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; (Q.N.D.); (R.E.L.)
| | - Gyula Tircso
- Department of Physical Chemistry Debrecen, University of Debrecen, Egyetem tér 1, H-4032 Debrecen, Hungary;
| | - Zoltan Kovacs
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
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Fretellier N, Rasschaert M, Bocanegra J, Robert P, Factor C, Seron A, Idée JM, Corot C. Safety and Gadolinium Distribution of the New High-Relaxivity Gadolinium Chelate Gadopiclenol in a Rat Model of Severe Renal Failure. Invest Radiol 2021; 56:826-836. [PMID: 34091462 DOI: 10.1097/rli.0000000000000793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the toxicological profile of gadopiclenol, a new high-relaxivity macrocyclic gadolinium-based contrast agent (GBCA), in renally impaired rats, in comparison with 2 other macrocyclic GBCAs, gadoterate meglumine and gadobutrol, and 1 linear and nonionic GBCA, gadodiamide. METHODS Renal failure was induced by adding 0.75% wt/wt adenine to the diet for 3 weeks. During the second week of adenine-enriched diet, the animals (n = 8/group × 5 groups) received 5 consecutive intravenous injections of GBCA at 2.5 mmol/kg per injection, resulting in a cumulative dose of 12.5 mmol/kg or saline followed by a 3-week treatment-free period after the last injection. The total (elemental) gadolinium (Gd) concentration in different tissues (brain, cerebellum, femoral epiphysis, liver, skin, heart, kidney, spleen, plasma, urine, and feces) was measured by inductively coupled plasma mass spectrometry. Transmission electron microscopy (and electron energy loss spectroscopy analysis of metallic deposits) was used to investigate the presence and localization of Gd deposits in the skin. Relaxometry was used to evaluate the presence of dissociated Gd in the skin, liver, and bone. Skin histopathology was performed to investigate the presence of nephrogenic systemic fibrosis-like lesions. RESULTS Gadodiamide administrations were associated with high morbidity-mortality but also with macroscopic and microscopic skin lesions in renally impaired rats. No such effects were observed with gadopiclenol, gadoterate, or gadobutrol. Overall, elemental Gd concentrations were significantly higher in gadodiamide-treated rats than in rats treated with the other GBCAs for all tissues except the liver (where no significant difference was found with gadopiclenol) and the kidney and the heart (where statistically similar Gd concentrations were observed for all GBCAs). No plasma biochemical abnormalities were observed with gadopiclenol or the control GBCAs. Histopathology revealed a normal skin structure in the rats treated with gadopiclenol, gadoterate, and gadobutrol, contrary to those treated with gadodiamide. No evidence of Gd deposits on collagen fibers and inclusions in fibroblasts was found with gadopiclenol and its macrocyclic controls, unlike with gadodiamide. Animals of all test groups had Gd-positive lysosomal inclusions in the dermal macrophages. However, the textures differed for the different products (speckled texture for gadodiamide and rough-textured appearance for the 2 tested macrocyclic GBCAs). CONCLUSIONS No evidence of biochemical toxicity or pathological abnormalities of the skin was observed, and similar to other macrocyclic GBCAs, gadoterate and gadobutrol, tissue retention of Gd was found to be low (except in the liver) in renally impaired rats treated with the new high-relaxivity GBCA gadopiclenol.
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Affiliation(s)
- Nathalie Fretellier
- From the Research and Innovation Department, Guerbet, Aulnay-sous-Bois, France
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Khairinisa MA, Amano I, Miyazaki W, Koibuchi N, Tsushima Y. Gadolinium-based contrast agents toxicity in animal studies. Magn Reson Imaging 2019; 62:57-58. [DOI: 10.1016/j.mri.2019.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 05/16/2019] [Accepted: 05/19/2019] [Indexed: 10/26/2022]
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Gadolinium retention in the body: what we know and what we can do. Radiol Med 2017; 122:589-600. [PMID: 28361260 DOI: 10.1007/s11547-017-0757-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 03/21/2017] [Indexed: 01/08/2023]
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Current status of nephrogenic systemic fibrosis. Clin Radiol 2014; 69:661-8. [PMID: 24582176 DOI: 10.1016/j.crad.2014.01.003] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 12/24/2013] [Accepted: 01/06/2014] [Indexed: 12/14/2022]
Abstract
Nephrogenic systemic fibrosis (NSF) occurs in patients with advanced chronic kidney disease (CKD) or acute renal failure, most commonly following exposure to gadolinium-based contrast agents (GBCAs). NSF can be debilitating and associated with increased mortality. The putative association of NSF with GBCAs prompted the development of guidelines to limit the use of these contrast agents in at-risk patients. Indeed, the incidence of NSF has decreased dramatically following application of these guidelines, which appears to be the only effective means of decreasing NSF incidence. Thus, increasing clinician awareness of these updated guidelines is important. The present review introduces and compares updated guidelines for GBCA use and discusses the latest advances in the understanding of the pathogenic mechanisms and treatment of NSF.
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Bernstein EJ, Schmidt-Lauber C, Kay J. Nephrogenic systemic fibrosis: A systemic fibrosing disease resulting from gadolinium exposure. Best Pract Res Clin Rheumatol 2012; 26:489-503. [DOI: 10.1016/j.berh.2012.07.008] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 07/17/2012] [Indexed: 12/18/2022]
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Abu-Alfa AK. Nephrogenic systemic fibrosis and gadolinium-based contrast agents. Adv Chronic Kidney Dis 2011; 18:188-98. [PMID: 21531325 DOI: 10.1053/j.ackd.2011.03.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 02/25/2011] [Accepted: 03/01/2011] [Indexed: 12/26/2022]
Abstract
The strong association between nephrogenic systemic fibrosis (NSF) and exposure to gadolinium-based contrast agents (GBCAs) has greatly affected the care of patients with kidney disease. NSF has been reported in patients with ESRD, CKD, and acute kidney injury (AKI). The majority of cases have occurred in patients with ESRD, but about 20% have been reported in patients with AKI or CKD stages 4 and 5. There is also a risk difference among GBCAs, with the Food and Drug Administration contraindicating 3 linear agents in patients at risk. Given the significant morbidity and mortality of NSF, it is imperative to identify individuals at risk. Although there are no data to support a role for hemodialysis (HD) in reducing the risk for NSF after administration of GBCAs, immediate HD is still recommended within 2 hours. Patients maintained on peritoneal dialysis seem to be at high risk and immediate HD is also recommended. However, this is not the current recommendation for CKD stages 4 and 5, especially with suspected lower risk of noncontraindicated agents. Individualized assessment is important and especially in those patients close to dialysis initiation. Instituting policies is important to address the imaging needs of patients with CKD and AKI while ensuring a balance between benefits and risks.
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Aguilera C, Agustí A. Fibrosis sistémica nefrogénica y contrastes de gadolinio. Med Clin (Barc) 2011; 136:643-5. [DOI: 10.1016/j.medcli.2010.11.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 11/03/2010] [Accepted: 11/04/2010] [Indexed: 11/30/2022]
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Quantification of gadolinium in fresh skin and serum samples from patients with nephrogenic systemic fibrosis. J Am Acad Dermatol 2011; 64:91-6. [DOI: 10.1016/j.jaad.2009.12.044] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Revised: 12/11/2009] [Accepted: 12/21/2009] [Indexed: 11/22/2022]
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Leung N, Shaikh A, Cosio FG, Griffin MD, Textor SC, Gloor JM, Schwab TR, Larson TS, Dean PG, Prieto M, Nyberg SL, Stegall MD, Lee CU, Pittelkow MR. The outcome of patients with nephrogenic systemic fibrosis after successful kidney transplantation. Am J Transplant 2010; 10:558-62. [PMID: 20055804 DOI: 10.1111/j.1600-6143.2009.02959.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Nephrogenic systemic fibrosis (NSF) is a debilitating disease in patients with severely diminished kidney function. Currently, no standard treatment exists but improvement has been reported after restoration of kidney function. We retrospectively studied 17 NSF patients with and without successful kidney transplantation (KTx) to evaluate the effects of KTx on NSF. Nine of the 11 KTx developed NSF pretransplant whereas two developed NSF immediately after KTx with delayed graft function. Two of the six dialysis patients had previous failed kidney transplants. Age and sex were well matched. All but one patient was dialysis dependent at the time of NSF. Median follow-up was 35 months for KTx patients and 9 months for dialysis patients. Kidney transplants achieved adequate renal function with median serum creatinine of 1.4 (0.9-2.8) mg/dL and a glomerular filtration rate of 42 (19-60) mL/min/1.73 m(2). NSF improved in 54.6% of the transplanted patients and 50% of the nontransplanted patients (p = 0.86). Two KTx patients had complete resolution of their symptoms whereas four had partial improvement. Improvement in the dialysis patients was all partial. Successful KTx did not insure improvement in NSF and in fact appeared to have no significant benefit over dialysis.
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Affiliation(s)
- N Leung
- Division of Nephrology and Hypertension, Mayo Clinic Rochester, 200 First Street SW, Rochester, MN 55905, USA.
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Koreishi AF, Nazarian RM, Saenz AJ, Klepeis VE, McDonald AG, Farris AB, Colvin RB, Duncan LM, Mandal RV, Kay J. Nephrogenic systemic fibrosis: a pathologic study of autopsy cases. Arch Pathol Lab Med 2010; 133:1943-8. [PMID: 19961249 DOI: 10.5858/133.12.1943] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2009] [Indexed: 11/06/2022]
Abstract
CONTEXT -Nephrogenic systemic fibrosis (NSF) is a rare but serious disorder initially described as a purely dermatologic process. Isolated autopsy reports have described multiorgan involvement by this disease. OBJECTIVE -To further illustrate the varied and systemic involvement of NSF by describing the autopsy experience at the Massachusetts General Hospital. DESIGN -We describe the findings in a series of 4 autopsy cases of patients diagnosed with NSF. This report describes the history of renal dysfunction, exposure to gadolinium-containing contrast agents, specific laboratory parameters, and the extent of systemic involvement identified by postmortem examination. RESULTS -Causes of death included systemic thromboembolic disease (n = 3) and pneumonia (n = 1). Laboratory parameters and type, dose, or timing of gadolinium-containing contrast-agent exposure did not correlate with clinical findings and outcomes. All patients demonstrated cutaneous manifestations of the disease and nephrocalcinosis, with some exhibiting calcification and fibrosis of the dura, thyroid, and heart including the cardiac conduction system, on postmortem examination. Soft tissue calcification was associated with concurrent hyperparathyroidism or high serum parathyroid hormone levels. CONCLUSIONS -Thromboembolic disease can be a significant clinical complication of NSF. Patients with NSF may also develop characteristic histologic features of fibrosis and calcification in multiple organs, with significant morbidity and mortality. This autopsy series highlights the variability of systemic manifestations of NSF.
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Affiliation(s)
- Aashiyana F Koreishi
- Department of Pathology, James Homer Wright Pathology Laboratories, Massachusetts General Hospital and Harvard Medical School, Boston, USA
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Boyd AS, Sanyal S, Abraham JL. Tissue gadolinium deposition and fibrosis mimicking nephrogenic systemic fibrosis (NSF)-subclinical nephrogenic systemic fibrosis? J Am Acad Dermatol 2009; 62:337-42. [PMID: 19939504 DOI: 10.1016/j.jaad.2009.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 03/25/2009] [Accepted: 04/04/2009] [Indexed: 10/20/2022]
Abstract
Nephrogenic systemic fibrosis is a condition with significant and often debilitating cutaneous manifestations. Recent research on this disease has delineated an association between nephrogenic systemic fibrosis and exposure to magnetic resonance imaging studies using gadolinium-based contrast agents in patients with ongoing renal failure. This metal has been detected in cutaneous biopsy specimens taken from lesional skin suggesting that gadolinium provides an impetus for the deposition of circulating fibrocytes in the skin and subsequent fibrosis. We describe a hemodialysis-dependent liver transplant recipient who received a gadolinium-based contrast agent and demonstrated insoluble gadolinium deposition in a fibrotic dermis and subcutaneous septum using scanning electron microscopy/energy dispersive x-ray spectroscopy. He has yet to manifest symptoms and signs of nephrogenic systemic fibrosis 3 years after his magnetic resonance imaging study.
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Affiliation(s)
- Alan S Boyd
- Department of Medicine (Dermatology), Vanderbilt University, Nashville, Tennessee, USA.
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The Evolution of Osseous Metaplasia in Localized Cutaneous Nephrogenic Systemic Fibrosis: A Case Report. Am J Dermatopathol 2009; 31:674-81. [DOI: 10.1097/dad.0b013e3181a1fb55] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Nephrogenic Systemic Fibrosis: Histology and Gadolinium Detection. Radiol Clin North Am 2009; 47:841-53, vi-vii. [DOI: 10.1016/j.rcl.2009.06.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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