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Belgacem A, Miane H, Fillali W, Hangard P, Ponthier L, Ballouhey Q. Hemolytic uremic syndrome following complicated appendicitis in a child: what is the missing link? J Int Med Res 2021; 49:3000605211006952. [PMID: 33840247 PMCID: PMC8044563 DOI: 10.1177/03000605211006952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We herein describe an 18-month-old boy who underwent initially successful surgical and antibiotic treatment of complicated appendicitis with postoperative occurrence of hemolytic uremic syndrome (HUS). This complication was due to Shiga toxin-producing Escherichia coli (STEC) found secondarily in rectal swabs but not in the peritoneal cavity. The literature indicates that a causal link may exist between these two entities, and HUS could be considered an iatrogenic complication of appendicitis management due to a multimodal stress effect in non-symptomatic STEC carriers.
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Affiliation(s)
- Alexis Belgacem
- Pediatric Surgery Department, Hôpital Mère-Enfant, University Hospital Centre of Limoges, 8 Avenue Dominique Larrey, Limoges, France
| | - Hortense Miane
- Pediatric Intensive Care Department, Hôpital Mère-Enfant, University Hospital Centre of Limoges, 8 Avenue Dominique Larrey, Limoges, France
| | - Wasfi Fillali
- Microbiology Department, Limoges University Hospital, Limoges, France
| | - Pauline Hangard
- Pediatric Intensive Care Department, Hôpital Mère-Enfant, University Hospital Centre of Limoges, 8 Avenue Dominique Larrey, Limoges, France
| | - Laure Ponthier
- Pediatric Intensive Care Department, Hôpital Mère-Enfant, University Hospital Centre of Limoges, 8 Avenue Dominique Larrey, Limoges, France
| | - Quentin Ballouhey
- Pediatric Surgery Department, Hôpital Mère-Enfant, University Hospital Centre of Limoges, 8 Avenue Dominique Larrey, Limoges, France
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Crabbe DC, Broklebank JT, Spicer RD. Gastrointestinal Complications of the Haemolytic Uraemic Syndrome. J R Soc Med 2018; 83:773-5. [PMID: 2269961 PMCID: PMC1292951 DOI: 10.1177/014107689008301208] [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] [Indexed: 11/15/2022] Open
Abstract
The haemolytic uraemic syndrome (HUS) is a well recognized cause of acute renal failure in children. Gastrointestinal involvement is common, and may result in rectal bleeding which can be an important presenting symptom. Previous publications have stressed the importance of correct diagnosis to avoid unnecessary surgery. Occasionally serious gastrointestinal complications do occur. We present five children with life-threatening gastrointestinal complications of the HUS and discuss the indications for laparotomy.
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Affiliation(s)
- D C Crabbe
- Department of Paediatric Surgery, St James' University Hospital, Leeds
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Harwood R, Wilkinson D, Ramkumar S, Humphrey G. Gram-negative organisms in peritoneal dialysis peritonitis: an early indication for surgery in patients with haemolytic uraemic syndrome? Pediatr Surg Int 2016; 32:235-8. [PMID: 26578260 DOI: 10.1007/s00383-015-3833-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Haemolytic uraemic syndrome (HUS) is the commonest childhood cause of acute renal failure. Peritoneal dialysis peritonitis (PDP) is a well-recognised complication, with some children requiring surgical intervention (SI). The aim of this study is to determine whether the presence of enteric organisms in cases of PDP might predict the need for SI. METHODS Retrospective, 5-year (2009-2014) case note review of all HUS cases requiring PD presenting to a single centre. Mann-Whitney U test was used for continuous non-parametric data and χ (2) for categorical data. RESULTS 48 children required PD for HUS, 18/48 (38 %) developed PDP and of these 5/18 (28 %) required SI (subtotal colectomy n = 4, small bowel resection n = 1). Peritoneal fluid was cultured as part of the work-up for PDP. The presence of enteric organisms was associated with a 10.4 fold relative risk of requiring surgery (p = 0.02, 95 % CI 1.5-71.9), with 4/5 of these patients requiring surgery (median 17 days post-culture result). Only 1/13 patients not requiring surgery grew gram-negative bacteria. CONCLUSION The presence of enteric bacteria in patients with PDP significantly decreases the chances of successful conservative management. In these patients early involvement of the surgical team is essential with a low threshold for SI.
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Fenton SJ, Kastenmeier A, Pysher TJ, Nichol PF. Acute appendicitis in a patient with hemolytic uremic syndrome: an unusual clinical scenario. Pediatr Surg Int 2008; 24:439-41. [PMID: 17410368 DOI: 10.1007/s00383-007-1917-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2007] [Indexed: 11/28/2022]
Abstract
Gastroenteritis due to Escherichia coli O157:H7 occurs in young children and is associated with consumption of under cooked beef. Approximately 5-10% of patients will develop hemolytic uremic syndrome (HUS): renal failure, microangiopathic hemolytic anemia, and thrombocytopenia. A 6-year-old boy was admitted with abdominal pain, guaiac positive stool, decreased urine output and elevated creatinine levels. Hemodialysis was initiated upon rapid progression to anuria. On hospital day # 5 he developed acute abdominal pain, which was different from his initial assessment. Exam revealed focal tenderness in the right lower quadrant with localized guarding and rebound. Ultrasound demonstrated a dilated, fluid filled tubular structure in the RLQ concerning for appendicitis. Based on these findings the patient was taken to the operating room for a laparoscopic appendectomy. The patient had undergone dialysis the previous day and was preoperatively treated with DDAVP to minimize the risk of bleeding. The procedure occurred without complication and final pathology confirmed acute appendicitis. This case highlights the unique clinical scenario in which patients with HUS require operative intervention. Surgical procedures can be performed on these patients, however, all precautions should be taken to minimize the risk of bleeding, including the use of preoperative DDAVP.
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Affiliation(s)
- Stephen J Fenton
- Department of Surgery, University of Utah, Salt Lake City, UT 84132, USA
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Rebouissoux L, Llanas B, Jouvencel P, Dobremez E, Brun M, Fayon M, Lamireau T. Pancreatic pseudocyst complicating hemolytic-uremic syndrome. J Pediatr Gastroenterol Nutr 2004; 38:102-4. [PMID: 14676604 DOI: 10.1097/00005176-200401000-00022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Murray KF, Patterson K. Escherichia coli O157:H7-induced hemolytic-uremic syndrome: histopathologic changes in the colon over time. Pediatr Dev Pathol 2000; 3:232-9. [PMID: 10742410 DOI: 10.1007/s100249910030] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The 1993 E. coli O157:H7 epidemic in the Western United States has provided a unique opportunity to evaluate the histopathologic temporal progression of disease in the colon in children who developed hemolytic uremic syndrome (HUS). In this report we briefly summarize the clinical courses of eight patients and then discuss the colonic pathology observed in specimens obtained at surgery or at the time of autopsy. The patients were divided into two groups: group 1 consisted of six subjects whose colonic samples were obtained during the acute phase of disease, and group 2 consisted of two subjects whose samples were obtained late in their disease. Both the gross and microscopic findings showed that the most severely affected as well as the earliest affected regions of the colon were the left and transverse portions. Only later in the disease progression was there right-sided colon involvement. These findings are in contrast to the distribution described in E. coli O157:H7 hemorrhagic colitis without HUS, thus suggesting a different mechanism of injury.
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Affiliation(s)
- K F Murray
- Department of Pediatrics, Division of Gastroenterology, Children's Hospital and Regional Medical Center, Seattle, WA 98105-0371, USA
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McCarthy DW, Mutabagani K, Mahan JD, Caniano DA, Cooney DR. Infarction of the choledochus, liver, gallbladder, and pancreas: a unique complication of the hemolytic uremic syndrome. J Pediatr Surg 2000; 35:502-4. [PMID: 10726698 DOI: 10.1016/s0022-3468(00)90223-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hemolytic uremic syndrome (HUS) is associated with multiple nonrenal manifestations. A unique case is described of a 3-year-old boy who presented with a classic diarrheal prodrome followed by massive necrosis of the biliary tree and common bile duct, pancreas, and the left lobe of his liver. This complication of HUS has not been reported in the English-language literature.
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Affiliation(s)
- D W McCarthy
- Department of Surgery, The Ohio State University College of Medicine and Public Health and Children's Hospital, Columbus 43205, USA
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Surgical complications of the haemolytic uraemic syndrome. Pediatr Surg Int 1996; 11:363-5. [PMID: 24057716 DOI: 10.1007/bf00497813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/1995] [Indexed: 10/26/2022]
Abstract
During the first outbreak of haemolytic uraemic syndrome (HUS) to be reported in Australia, 22 children were admitted to the Women's and Children's Hospital, Adelaide. The outbreak was caused by an entero-haemorrhagic Escherichia coli strain (EHEC) of serotype 011:H-, a strain rarely implicated as a cause for HUS. In all 22 patients, the onset of HUS was preceded by a gastrointestinal (GI) prodrome. All patients had diarrhoea. In 17 (73%), the diarrhoea became bloody; in 20 (86%) there was vomiting; in 15 (65%) there was abdominal pain; and in 12 (50%) all three symptoms were present. Abdominal symptoms continued to complicate the course of 4 patients. Two of these underwent exploratory laparotomy, both had gangrenous colon excised, and both survived. The 2 remaining patients were successfully treated non-operatively. One further patient underwent appendicectomy before the diagnosis of HUS was made. There was 1 death during this epidemic. In patients with HUS and GI involvement, optimal surgical management requires careful consideration of the indications for, and the timing of, surgical intervention.
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Bernard A, Tounian P, Leroy B, Bensman A, Girardet JP, Fontaine JL. [Digestive manifestations in hemolytic uremic syndrome in children]. Arch Pediatr 1996; 3:533-40. [PMID: 8881297 DOI: 10.1016/0929-693x(96)83223-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Gastro-intestinal manifestations are relatively frequent during the course of hemolytic uremic syndrome (HUS), some of them requiring special supportive care. This work was aimed at retrospectively studing gastrointestinal manifestations of HUS and determining their place in the prognosis. PATIENTS Thirty-seven children aged 4 months to 11 years (22 girls and 15 boys) were included in the study. RESULTS All children but one had gastrointestinal prodromes. During the course of HUS, various manifestations were seen: bloody diarrhea in 32% of patients, ileo-ileal intussusception in 3%, rectal prolapse in 8% and hepatic cytolysis in 38%. Seven patients with bloody diarrhea had a complicated course, lethal in one. Comparison between these seven children and the 30 others revealed some indicators of severe gut involvement: female sex, short duration of gastrointestinal prodromes, hemorrhagic colitis with rectal prolapse, high WBC count, high neutrophils count and less important degree of anemia at admission. Severity of the gastrointestinal lesions was correlated with that of the outcome of the renal disease. CONCLUSION Gastrointestinal tract is frequently affected in HUS and severe complications can appear, potentially leading to death. Total parenteral nutrition could prevent occurrence of gastrointestinal complications. Severe gastrointestinal lesions are associated with a poor renal outcome.
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Affiliation(s)
- A Bernard
- Service de gastroentérologie et nutrition pédiatriques, hôpital Armand-Trousseau, Paris, France
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Tapper D, Tarr P, Avner E, Brandt J, Waldhausen J. Lessons learned in the management of hemolytic uremic syndrome in children. J Pediatr Surg 1995; 30:158-63. [PMID: 7738732 DOI: 10.1016/0022-3468(95)90554-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Escherichia coli O.157:H7 is a serious and common human pathogen that can cause diarrhea, hemorrhagic colitis, and the hemolytic uremic syndrome (HUS). During a massive outbreak of infection with E coli O157:H7 in January 1993 in Washington State, more than 600 people, mostly children, acquired symptomatic infection, and 37 were hospitalized with HUS at Children's Hospital and Medical Center in Seattle, and six at other hospitals in Washington. Twenty-one (57%) required dialysis. Nineteen (51%) had significant extrarenal pathology: gastrointestinal in 14 patients (38%), cardiovascular in 13 (35%), pulmonary in 9 (24%), and neurological in 6 (16%). Most patients were managed nonoperatively, but three required total abdominal colectomy and one a left colectomy. No child had perforation. Three patients died, all of whom had multisystem disease. The authors recommend (1) that all patients with bloody diarrhea undergo microbiological evaluation for E coli O157:H7 before any surgical intervention; (2) avoidance of antibiotics and antimotility agents in patients with proven or suspected infection with E coli O157:H7 until the safety and efficacy of such interventions have been established in controlled trials; (3) that patients with E coli O157:H7 infections be evaluated for microangiopathic changes consistent with HUS in the week after onset of diarrhea; (4) nasogastric suction for severe symptoms, and frequent abdominal evaluations, tests (electrolytes/amylase), and roentgenograms to exclude treatable abdominal disorders; and (5) institution of hemodialysis for oliguria/anuria, acidosis, or rising creatinine. The authors recommend surgical exploration for toxic megacolon, colonic perforation, acidosis unresponsive to dialysis, or recurrent signs of obstruction or colonic stricture.
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Affiliation(s)
- D Tapper
- Department of Surgery, Children's Hospital and Medical Center, Seattle, WA, USA
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Affiliation(s)
- R L Siegler
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
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de la Hunt MN, Morris KP, Coulthard MG, Rangecroft L. Oesophageal and severe gut involvement in the haemolytic uraemic syndrome. Br J Surg 1991; 78:1469-72. [PMID: 1773328 DOI: 10.1002/bjs.1800781220] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Between 1982 and 1989, 78 children with diarrhoea-associated haemolytic uraemic syndrome (HUS) were referred to this hospital. Most presented with abdominal pain, bloody diarrhoea and vomiting. Seven had severe gastrointestinal involvement, four of whom required resection for bowel perforation or necrosis. One also developed an oesophageal stricture, a previously unreported complication of HUS. These seven children had a high incidence of other complications including hypertension, and cerebral and pancreatic involvement. One died from severe cerebral involvement, one has a residual neurological deficit and one has residual renal impairment. Severe gastrointestinal involvement did not significantly affect the long-term outcome. Simple haematological indices helped predict severe gut involvement. Four of the 78 children had undergone appendicectomy before the diagnosis of HUS was made. The operative findings were in no case typical of primary acute appendicitis, although histological examination did confirm inflammation of the appendix in two patients. Diagnosis is difficult in early disease, but increased awareness may help prevent unnecessary appendicectomy.
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Affiliation(s)
- M N de la Hunt
- Department of Paediatric Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Abstract
Hemolytic-uremic syndrome (HUS) of childhood is a triad of acute hemolytic anemia, thrombocytopenia, and acute renal failure associated with a gastrointestinal prodrome. From 1977 to 1988, 134 patients with HUS were admitted to this institution. All patients presented with abdominal pain and diarrhea, which was virtually always bloody. Seventy-eight patients (60%) required dialysis. Five patients died (4%). One patient died as a result of colon perforation, the other four patients died of other nonsurgical complications of HUS. Three patients underwent exploratory laparotomy. One patient had a hemoperitoneum from mesenteric and transmural bleeding of the entire intraabdominal colon. Another patient had undergone surgery elsewhere for presumed intussusception with pancolitis found at exploration. Fourteen days postoperatively, he had a spontaneous perforation of the transverse colon. The third patient presented with pancolitis and perforation of the transverse colon. Despite surgical intervention he died on the sixth postoperative day. One other patient was treated conservatively for pancreatitis, which developed 3 weeks after her presentation with HUS. Complications requiring surgical intervention in HUS are rare, potentially lethal, and usually involve the colon.
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Affiliation(s)
- M L Brandt
- Department of Surgery, Hôpital Ste-Justine, Montreal, Quebec, Canada
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Abstract
Two cases of haemolytic uraemic syndrome (HUS) associated with pseudomembranous colitis (PMC) are described. The toxin of Clostridium difficile was detected post mortem in the stool of one patient and the other patient showed a good therapeutic response to oral vancomycin, an antibiotic with established efficacy in the management of PMC. When associated with HUS, PMC is probably an independent specific disease that, in common with many other infections, may activate HUS.
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Affiliation(s)
- N Rooney
- Department of Pathology, Bristol Royal Infirmary, UK
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Richardson SE, Karmali MA, Becker LE, Smith CR. The histopathology of the hemolytic uremic syndrome associated with verocytotoxin-producing Escherichia coli infections. Hum Pathol 1988; 19:1102-8. [PMID: 3047052 DOI: 10.1016/s0046-8177(88)80093-5] [Citation(s) in RCA: 238] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Verocytotoxin-producing Escherichia coli (VTEC) infection was present in three cases of hemolytic uremic syndrome (HUS), two fatal and one non-fatal, in which detailed histopathologic investigations were conducted. Two patients had a prodrome of bloody diarrhea, one of whom required a hemicolectomy for severe bleeding. The renal histopathology was characterized primarily by glomerular thrombotic microangiopathy (TMA) with greater than 95% of glomeruli showing changes of capillary wall thickening, endothelial cell swelling, and narrowing or thrombosis of the capillary lumen. Preglomerular arterioles were frequently thrombosed, and abnormalities of the medium-sized vessels, including endothelial cell damage and thrombosis, were also commonly observed. Gastrointestinal involvement was prominent in all three cases. The colon was most severely involved, with marked mucosal and submucosal edema and hemorrhage, in the absence of significant inflammation or widespread ulceration. Microvascular angiopathy was present in all cases, with changes ranging from endothelial cell damage to overt thrombosis. Similar pathology was seen throughout the small bowel, including the presence of TMA. In one patient, typical morphologic changes of pseudomembranous enterocolitis were found in the absence of infection with Clostridium difficile. The nature of vascular involvement in the kidneys and intestinal tract supports the hypothesis that HUS is mediated by systemic toxemia, and that endothelial cells are the primary target cells for the action of verocytotoxin.
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Affiliation(s)
- S E Richardson
- Department of Pathology, Hospital for Sick Children, Toronto, Ontario, Canada
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Abstract
This article reviews the more common causes of abdominal pain in children. It is divided into three sections to emphasize differential diagnosis. For some problems responsible for abdominal pain surgery is essential, for some surgery may not be initially required but may be unavoidable, and for others the condition is purely medical and surgery should be avoided. Armed with a complete differential diagnosis, the general surgical resident may avoid many pitfalls.
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Abstract
The cases of two children with the haemolytic-uraemic syndrome (HUS) in whom clinical signs of intussusception necessitated emergency surgical intervention are reported. Both patients had bilateral renal cortical necrosis and haemorrhagic gangrenous colitis; both subsequently died. The early recognition and appropriate management of HUS is advocated.
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Bax RP, Reeves DS, White LO, Holt A, Bywater M. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 12-1981. N Engl J Med 1981; 304:715-22. [PMID: 7464864 DOI: 10.1056/nejm198103193041207] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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