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McBride SA, Small R, Hurd K, Claassens S. Prééclampsie et syndrome HELLP compliqués d’un hématome sous-capsulaire du foie rompu. CMAJ 2024; 196:E104-E107. [PMID: 38286490 PMCID: PMC10833099 DOI: 10.1503/cmaj.230851-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024] Open
Affiliation(s)
- S Ainslie McBride
- École de médecine Cumming (McBride, Small, Hurd, Claassens), et Département de médecine et d'obstétrique et gynécologie (Hurd), Université de Calgary, Calgary, Alb.
| | - Rebecca Small
- École de médecine Cumming (McBride, Small, Hurd, Claassens), et Département de médecine et d'obstétrique et gynécologie (Hurd), Université de Calgary, Calgary, Alb
| | - Kelle Hurd
- École de médecine Cumming (McBride, Small, Hurd, Claassens), et Département de médecine et d'obstétrique et gynécologie (Hurd), Université de Calgary, Calgary, Alb
| | - Sunette Claassens
- École de médecine Cumming (McBride, Small, Hurd, Claassens), et Département de médecine et d'obstétrique et gynécologie (Hurd), Université de Calgary, Calgary, Alb
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Azad H, Wen T, Bello NA, Booker WA, Purisch S, D'Alton ME, Friedman AM. Peripartum cardiomyopathy delivery hospitalization and postpartum readmission trends, risk factors, and outcomes. Pregnancy Hypertens 2023; 34:116-123. [PMID: 37948872 DOI: 10.1016/j.preghy.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To evaluate risk for peripartum cardiomyopathy during delivery and postpartum hospitalizations, and analyze associated trends, risk factors, and clinical outcomes. METHODS The 2010-2020 Nationwide Readmissions Database was used for this retrospective cohort study. Delivery hospitalizations along with postpartum readmissions occurring within five months of delivery discharge were analyzed. Risk factors associated with peripartum cardiomyopathy were analyzed with unadjusted and adjusted logistic regression models with odds ratios as measures of effect. Risk for severe adverse outcomes associated with peripartum cardiomyopathy was analyzed. Trends were analyzed with joinpoint regression. RESULTS Of 39,790,772 delivery hospitalizations identified, 9,210 were complicated by a diagnosis of peripartum cardiomyopathy (2.3 per 10,000). Risk for a 5-month readmission with a peripartum cardiomyopathy diagnosis was 4.8 per 10,000. Factors associated with peripartum cardiomyopathy during deliveries included preeclampsia with severe features (OR 18.9, 95 % CI 17.2, 20.7), preeclampsia without severe features (OR 6.9, 95 % CI 6.1, 7.8), multiple gestation (OR 4.7, 95 % CI 4.1, 5.3), chronic hypertension (OR 10.1, 95 % CI 8.9, 11.3), and older maternal age. Associations were attenuated but retained significance in adjusted models. Similar estimates were found when evaluating associations with postpartum readmissions. Peripartum cardiomyopathy readmissions were associated with 10 % of overall postpartum deaths, 21 % of cardiac arrest/ventricular fibrillation diagnoses, 18 % of extracorporeal membrane oxygenation cases, and 40 % of cardiogenic shock. In joinpoint analysis, peripartum cardiomyopathy increased significantly during delivery hospitalizations (average annual percent change [AAPC] 2.2 %, 95 % CI 1.0 %, 3.4 %) but not postpartum readmissions (AAPC 0.0 %, 95 % CI -1.6 %, 1.6 %). CONCLUSION Risk for peripartum cardiomyopathy increased during delivery hospitalizations over the study period. Obstetric conditions such as preeclampsia and chronic medical conditions that are increasing in prevalence in the obstetric population were associated with the highest odds of peripartum cardiomyopathy.
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Affiliation(s)
- Hooman Azad
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Timothy Wen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California-San Francisco, San Francisco, CA, USA
| | - Natalie A Bello
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Stephanie Purisch
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY 10032, USA.
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McBride SA, Small R, Hurd K, Claassens S. Preeclampsia and HELLP syndrome complicated by subcapsular liver hematoma and rupture. CMAJ 2023; 195:E1543-E1545. [PMID: 37984930 PMCID: PMC10662496 DOI: 10.1503/cmaj.230851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023] Open
Affiliation(s)
- S Ainslie McBride
- Cumming School of Medicine (McBride, Small, Hurd, Claassens), and Department of Medicine and Obstetrics and Gynaecology (Hurd), University of Calgary, Calgary, Alta.
| | - Rebecca Small
- Cumming School of Medicine (McBride, Small, Hurd, Claassens), and Department of Medicine and Obstetrics and Gynaecology (Hurd), University of Calgary, Calgary, Alta
| | - Kelle Hurd
- Cumming School of Medicine (McBride, Small, Hurd, Claassens), and Department of Medicine and Obstetrics and Gynaecology (Hurd), University of Calgary, Calgary, Alta
| | - Sunette Claassens
- Cumming School of Medicine (McBride, Small, Hurd, Claassens), and Department of Medicine and Obstetrics and Gynaecology (Hurd), University of Calgary, Calgary, Alta
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Shoemaker R, Poglitsch M, Davis D, Huang H, Schadler A, Patel N, Vignes K, Srinivasan A, Cockerham C, Bauer JA, O’Brien JM. Association of Elevated Serum Aldosterone Concentrations in Pregnancy with Hypertension. Biomedicines 2023; 11:2954. [PMID: 38001956 PMCID: PMC10669350 DOI: 10.3390/biomedicines11112954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/26/2023] Open
Abstract
Emerging evidence indicates a previously unrecognized, clinically relevant spectrum of abnormal aldosterone secretion associated with hypertension severity. It is not known whether excess aldosterone secretion contributes to hypertension during pregnancy. We quantified aldosterone concentrations and angiotensin peptides in serum (using liquid chromatography with tandem mass spectrometry) in a cohort of 128 pregnant women recruited from a high-risk obstetrics clinic and followed prospectively for the development of gestational hypertension, pre-eclampsia, superimposed pre-eclampsia, chronic hypertension, or remaining normotensive. The cohort was grouped by quartile of aldosterone concentration in serum measured in the first trimester, and blood pressure, angiotensin peptides, and hypertension outcomes compared across the four quartiles. Blood pressures and body mass index were greatest in the top and bottom quartiles, with the top quartile having the highest blood pressure throughout pregnancy. Further stratification of the top quartile based on increasing (13 patients) or decreasing (19 patients) renin activity over gestation revealed that the latter group was characterized by the highest prevalence of chronic hypertension, use of anti-hypertensive agents, pre-term birth, and intrauterine growth restriction. Serum aldosterone concentrations greater than 704 pmol/L, the 75th percentile defined within the cohort, were evident across all categories of hypertension in pregnancy, including normotensive. These findings suggest that aldosterone excess may underlie the development of hypertension in pregnancy in a significant subpopulation of individuals.
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Affiliation(s)
- Robin Shoemaker
- Department of Dietetics and Human Nutrition, University of Kentucky, Lexington, KY 40506, USA
| | | | - Dolph Davis
- Department of Dietetics and Human Nutrition, University of Kentucky, Lexington, KY 40506, USA
| | - Hong Huang
- Department of Pediatrics, University of Kentucky, Lexington, KY 40536, USA
| | - Aric Schadler
- Department of Pediatrics, University of Kentucky, Lexington, KY 40536, USA
| | - Neil Patel
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY 40536, USA
| | - Katherine Vignes
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY 40536, USA
| | - Aarthi Srinivasan
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY 40536, USA
| | - Cynthia Cockerham
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY 40536, USA
| | - John A. Bauer
- Department of Pediatrics, University of Kentucky, Lexington, KY 40536, USA
| | - John M. O’Brien
- Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY 40536, USA
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Hu X, Liao Z, Li J, Zhou Y, Guo Y, Qian K. Young women were associated with higher risk of hypertensive disorders of pregnancy and cesarean section from hormone replaced cycles in frozen-thawed embryo transfer: a retrospective study of 5316 singleton deliveries. Front Endocrinol (Lausanne) 2023; 14:1238887. [PMID: 37772083 PMCID: PMC10523772 DOI: 10.3389/fendo.2023.1238887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/21/2023] [Indexed: 09/30/2023] Open
Abstract
Background The utilization of frozen-thawed embryo transfer (FET) cycles has been linked to heightened risks of adverse perinatal outcomes. However, the potential association between adverse perinatal outcomes and distinct endometrial preparation regimens remains unclear. Therefore, we aim to investigate the maternal and neonatal outcomes after hormone replacement treatment (HRT) cycles, natural cycles (NC) and HRT cycles with pretreatment using GnRHa (HRT + GnRHa) for ovulatory women undergoing FET cycles. Methods A large sample retrospective cohort study was carried out from 2016 to 2020. The data included a total of 5316 women who had singleton deliveries undergoing FET cycles and which were divided into three groups based on different endometrial preparation protocols: 4399 patients in HRT groups, 621 in GnRHa+HRT groups, 296 in NC groups. The outcomes consisted of maternal outcomes (cesarean section, hypertensive disorders of pregnancy (HDP), placenta previa, gestational diabetes mellitus (GDM));and neonatal outcomes (preterm birth, newborn birthweight, low birthweight, small for gestational age (SGA), macrosomia, large for gestational age (LGA), fetal malformation). Results After adjusting for a series of confounding variables, we found an increased risk of HDP (aOR=3.362; 95%CI, 1.059-10.675) and cesarean section (aOR=1.838; 95%CI, 1.333-2.535) in HRT cycles compared with NC, especially for ovulatory women under 35 years old. However, in all three groups, newborn birth weight was not significantly different. Meanwhile, perinatal outcomes did not differ significantly in terms of perinatal outcomes in HRT +GnRHa cycles compared with HRT cycles solely. Conclusion During FET cycles, singletons from HRT were related to higher risks of HDP and cesarean section, particularly for young women. GnRHa pretreatment didn't bring any benefit to perinatal outcomes compared with HRT cycles alone. Therefore, the natural cycle may be a more appropriate and safer option for young ovulatory women.
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Affiliation(s)
| | | | | | | | - Yaxin Guo
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kun Qian
- Reproductive Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Shoemaker R, Poglitsch M, Huang H, Vignes K, Srinivasan A, Cockerham C, Schadler A, Bauer JA, O’Brien JM. Activation of the Renin-Angiotensin-Aldosterone System Is Attenuated in Hypertensive Compared with Normotensive Pregnancy. Int J Mol Sci 2023; 24:12728. [PMID: 37628909 PMCID: PMC10454898 DOI: 10.3390/ijms241612728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/04/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Hypertension during pregnancy increases the risk of adverse maternal and fetal outcomes, but the mechanisms of pregnancy hypertension are not precisely understood. Elevated plasma renin activity and aldosterone concentrations play an important role in the normal physiologic adaptation to pregnancy. These effectors are reduced in patients with pregnancy hypertension, creating an opportunity to define the features of the renin-angiotensin-aldosterone system (RAAS) that are characteristic of this disorder. In the current study, we used a novel LC-MS/MS-based methodology to develop comprehensive profiles of RAAS peptides and effectors over gestation in a cohort of 74 pregnant women followed prospectively for the development of gestational hypertension and pre-eclampsia (HYP, 27 patients) versus those remaining normotensive (NT, 47 patients). In NT pregnancy, the plasma renin activity surrogate, (PRA-S, calculated from the sum of Angiotensin I + Angiotensin II) and aldosterone concentrations significantly increased from the first to the third trimester, accompanied by a modest increase in the concentrations of angiotensin peptide metabolites. In contrast, in HYP pregnancies, PRA-S and angiotensin peptides were largely unchanged over gestation, and third-trimester aldosterone concentrations were significantly lower compared with those in NT pregnancies. The results indicated that the predominant features of pregnancies that develop HYP are stalled or waning activation of the RAAS in the second half of pregnancy (accompanied by unchanging levels of angiotensin peptides) and the attenuated secretion of aldosterone.
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Affiliation(s)
- Robin Shoemaker
- Department of Dietetics and Human Nutrition, University of Kentucky, Lexington, KY 40506, USA
| | | | - Hong Huang
- Department of Pediatrics, University of Kentucky, Lexington, KY 40536, USA
| | - Katherine Vignes
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY 40506, USA
| | - Aarthi Srinivasan
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY 40506, USA
| | - Cynthia Cockerham
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY 40506, USA
| | - Aric Schadler
- Department of Pediatrics, University of Kentucky, Lexington, KY 40536, USA
| | - John A. Bauer
- Department of Pediatrics, University of Kentucky, Lexington, KY 40536, USA
| | - John M. O’Brien
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Kentucky, Lexington, KY 40506, USA
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Vatish M, Powys VR, Cerdeira AS. Novel therapeutic and diagnostic approaches for preeclampsia. Curr Opin Nephrol Hypertens 2023; 32:124-133. [PMID: 36683536 DOI: 10.1097/mnh.0000000000000870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW This review will summarize recent findings relating to the diagnostic approach to preeclampsia and current avenues of research aimed at modifying the underlying disease process. RECENT FINDINGS Growing international consensus supports a broad preeclampsia definition that incorporates maternal end-organ and uteroplacental dysfunction. Recent evidence demonstrates that this definition better identifies women and babies at risk of adverse outcomes compared to the traditional definition of hypertension and proteinuria. Multiple studies have demonstrated the usefulness and cost-effectiveness of angiogenic biomarkers such as soluble fms-like tyrosine kinase-1 and placental growth factor as a clinical adjunct to diagnose and predict severity of preeclampsia associated outcomes. Current novel therapeutic approaches to preeclampsia target pathogenic pathways (e.g. antiangiogenesis) or downstream effects such as oxidative stress and nitric oxide. Recent findings relating to these promising candidates are discussed. Multicenter clinical trials are needed to evaluate their effectiveness and ability to improve fetal and maternal outcomes. SUMMARY We provide an updated framework of the current approaches to define and diagnose preeclampsia. Disease modifying therapies (in particular, targeting the angiogenic pathway) are being developed for the first time and promise to revolutionize the way we manage preeclampsia.
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Affiliation(s)
- Manu Vatish
- Nuffield Department of Women's Health and Reproductive Research, University of Oxford, Oxford
| | | | - Ana Sofia Cerdeira
- Nuffield Department of Women's Health and Reproductive Research, University of Oxford, Oxford
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Pipes GM, Logue TC, Wen T, Booker WA, D'Alton ME, Friedman AM. Postpartum stroke trends, risk factors, and associated adverse outcomes. Am J Obstet Gynecol MFM 2023; 5:100864. [PMID: 36791844 DOI: 10.1016/j.ajogmf.2023.100864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/05/2023] [Accepted: 01/10/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Management of postpartum stroke has been the focus of several quality improvement efforts in the past decade. However, there is little recent national trends data for postpartum stroke readmissions. OBJECTIVE This study aimed to determine trends, risk factors, and complications associated with postpartum stroke readmission. STUDY DESIGN The 2013 to 2019 Nationwide Readmissions Database was used to perform a retrospective cohort study that evaluated the risk for readmission for stroke within 60 days of delivery hospitalization discharge. Temporal trends in readmissions were analyzed using the National Cancer Institute's Joinpoint Regression Program to estimate the average annual percent change with 95% confidence intervals. Stratified trends were analyzed for hemorrhage stroke, ischemic stroke, and stroke readmissions at 1 to 10, 11 to 30, and 31 to 60 days after delivery discharge. Risk factors for stroke were analyzed using unadjusted and adjusted logistic regression models with odds ratios and 95% confidence intervals as measures of association. The risk for stroke complications, including mechanical ventilation, seizures, death, and a prolonged stay ≥14 days, was analyzed. RESULTS Of an estimated 21,754,603 delivery hospitalizations, 5006 were complicated by a 60-day postpartum readmission with a diagnosis of stroke. The average annual percent change for all stroke readmissions over the study period was not significant (average annual percent change, 0.1%; 95% confidence interval, -2.2% to 2.4%). When the trends in readmission for ischemic and hemorrhagic stroke were analyzed, the results were similar, as were the stratified analyses by readmission timing. Risk factors associated with increased odds included superimposed preeclampsia (odds ratio, 4.8; 95% confidence interval, 3.9-5.9), preeclampsia with severe features (odds ratio, 3.7; 95% confidence interval, 3.0-4.4), maternal cardiac disease (odds ratio, 3.0; 95% confidence interval, 2.5-3.7), chronic kidney disease (odds ratio, 5.0; 95% confidence interval, 3.4-7.5), and lupus (odds ratio, 7.0; 95% confidence interval, 4.9-10.2). Risk was retained in adjusted analyses. Common stroke-related complications included a prolonged hospital stay ≥14 days (12.1 per 1000 stroke-related readmissions), seizures (9.9 per 1000 stroke-related readmissions), and mechanical ventilation (6.6 per 1000 stroke-related readmissions). CONCLUSION This analysis of nationally representative data demonstrated no change in the rate of 60-day postpartum hospitalizations for stroke from 2013 to 2019. Further clinical research is indicated to optimize risk reduction for stroke after delivery hospitalization discharge.
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Affiliation(s)
- Grace M Pipes
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (Ms Pipes and Drs Logue, Booker, D'Alton, and Friedman)
| | - Teresa C Logue
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (Ms Pipes and Drs Logue, Booker, D'Alton, and Friedman)
| | - Timothy Wen
- and Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California-San Francisco, San Francisco, CA (Dr Wen)
| | - Whitney A Booker
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (Ms Pipes and Drs Logue, Booker, D'Alton, and Friedman)
| | - Mary E D'Alton
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (Ms Pipes and Drs Logue, Booker, D'Alton, and Friedman)
| | - Alexander M Friedman
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY (Ms Pipes and Drs Logue, Booker, D'Alton, and Friedman).
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Bortoletto P, Prabhu M, Baker VL. Association between programmed frozen embryo transfer and hypertensive disorders of pregnancy. Fertil Steril 2022; 118:839-848. [PMID: 36171152 DOI: 10.1016/j.fertnstert.2022.07.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 01/13/2023]
Abstract
Dissociation of embryo transfer from the ovarian stimulation cycle has afforded patients increased flexibility for genetic testing and fertility preservation. Although frozen embryo transfer (FET) has largely been demonstrated to be safe and effective compared with fresh transfer, programmed FET cycles, where a corpus luteum is absent, have come under increasing scrutiny. In observational trials, programmed FET protocols appear to be associated with an increased risk of ineffective decidualization and impaired placental function. Together with the appropriate preexisting risk factors, this additive risk may potentiate hypertensive disorders of pregnancy later in gestation. Efforts to understand the reasons for this apparent risk may afford us opportunities to better individualize the FET cycle type offered to patients with cryopreserved embryos. Randomized controlled trials will help us to understand whether the apparent risk is due to patient factors, which influence protocol choice, or a characteristic of the protocol itself, such as the absence of the corpus luteum or suboptimal replacement of estradiol and progesterone.
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Affiliation(s)
- Pietro Bortoletto
- Boston IVF, Waltham, Massachusetts; Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Malavika Prabhu
- Harvard Medical School, Boston, Massachusetts; Department of Obstetrics, Gynecology and Reproductive Biology, Massachusetts General Hospital, Boston, Massachusetts
| | - Valerie L Baker
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Präeklampsie: Konsequente antihypertensive Therapie senkt Schlaganfallrisiko. Geburtshilfe Frauenheilkd 2022. [DOI: 10.1055/a-1870-2180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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