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Abstract
Gut bacteria are predominant microorganisms in the gut microbiota and have been recognized to mediate a variety of biotransformations of xenobiotic compounds in the gut. This review is focused on one of the gut bacterial xenobiotic metabolisms, reduction. Xenobiotics undergo different types of reductive metabolisms depending on chemically distinct groups: azo (-NN-), nitro (-NO2), alkene (-CC-), ketone (-CO), N-oxide (-NO), and sulfoxide (-SO). In this review, we have provided select examples of drugs in six chemically distinct groups that are known or suspected to be subjected to the reduction by gut bacteria. For some drugs, responsible enzymes in specific gut bacteria have been identified and characterized, but for many drugs, only circumstantial evidence is available that indicates gut bacteria-mediated reductive metabolism. The physiological roles of even known gut bacterial enzymes have not been well defined.
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Affiliation(s)
- Yukuang Guo
- Department of Pharmaceutical Sciences, Center for Biomolecular Sciences, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, United States
| | - Hyunwoo Lee
- Department of Pharmaceutical Sciences, Center for Biomolecular Sciences, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, United States.
| | - Hyunyoung Jeong
- Department of Pharmaceutical Sciences, Center for Biomolecular Sciences, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, United States.
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Aonuma K, Shiga T, Atarashi H, Doki K, Echizen H, Hagiwara N, Hasegawa J, Hayashi H, Hirao K, Ichida F, Ikeda T, Maeda Y, Matsumoto N, Sakaeda T, Shimizu W, Sugawara M, Totsuka K, Tsuchishita Y, Ueno K, Watanabe E, Hashiguchi M, Hirata S, Kasai H, Matsumoto Y, Nogami A, Sekiguchi Y, Shinohara T, Sugiyama A, Sumitomo N, Suzuki A, Takahashi N, Yukawa E, Homma M, Horie M, Inoue H, Ito H, Miura T, Ohe T, Shinozaki K, Tanaka K. Guidelines for Therapeutic Drug Monitoring of Cardiovascular Drugs Clinical Use of Blood Drug Concentration Monitoring (JCS 2015) ― Digest Version ―. Circ J 2017; 81:581-612. [DOI: 10.1253/circj.cj-66-0138] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kondo Y, Ishitsuka Y, Shigemori E, Irikura M, Kadowaki D, Hirata S, Maemura T, Irie T. Awareness and current implementation of drug dosage adjustment by pharmacists in patients with chronic kidney disease in Japan: a web-based survey. BMC Health Serv Res 2014; 14:615. [PMID: 25464858 PMCID: PMC4258280 DOI: 10.1186/s12913-014-0615-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 11/18/2014] [Indexed: 12/05/2022] Open
Abstract
Background The aims of this study were to evaluate the current awareness of and implementation by pharmacists in Japan of adjustment of drug dosage according to renal function (ADDR) in patients with chronic kidney disease (CKD) and to clarify the factors influencing implementation of ADDR by community pharmacists. Methods We conducted a web-based questionnaire of Japanese community and hospital pharmacists. Responders were compared by characteristics, rate of implementation of ADDR, experience with adverse drug events, pharmacist awareness of implementation of ADDR, and obstacles to ADDR implementation experienced by pharmacists. Additionally, the factors influencing the implementation of ADDR by community pharmacists were investigated by logistic regression analysis. Results Fewer community pharmacists had implemented ADDR than hospital pharmacists. The community pharmacists had less experience with adverse drug events caused by an inappropriate dosage than the hospital pharmacists, while the hospital pharmacists had encountered more severe adverse drug events than the community pharmacists. The community pharmacists had less awareness of ADDR implementation, and believed that problems in implementing ADDR were caused by a lack of information on the renal function of patients. In the logistic regression analysis, the factors influencing implementation of ADDR were “Routinely receiving prescriptions from nephrologists”, “Experience with adverse drug events caused by inappropriate dosage for CKD patients”, and “Awareness of the need for pharmacists to check the dosage of renally excreted drugs”; they did not include “Lack of information on patient renal function”. Conclusions This study indicates that fewer Japanese community pharmacists than hospital pharmacists implement ADDR and that implementation of ADDR by community pharmacists is hindered by their limited awareness of the importance of patient renal function. We advocate that many countermeasures be introduced to prevent CKD patients from experiencing adverse drug events caused by inappropriate dosage. Such countermeasures would include a training program to educate pharmacists about the impact of impaired renal function on dosage of drugs that are excreted by the kidneys. Electronic supplementary material The online version of this article (doi:10.1186/s12913-014-0615-0) contains supplementary material, which is available to authorized users.
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Ma TKW, Chow KM, Choy ASM, Kwan BCH, Szeto CC, Li PKT. Clinical manifestation of macrolide antibiotic toxicity in CKD and dialysis patients. Clin Kidney J 2014; 7:507-12. [PMID: 25859365 PMCID: PMC4389137 DOI: 10.1093/ckj/sfu098] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 08/21/2014] [Indexed: 11/15/2022] Open
Abstract
Macrolide antibiotics, erythromycin, clarithromycin and azithromycin are commonly prescribed for upper respiratory infection, and their use has recently been further linked to immunomodulatory effects. With the widespread and expanded use of macrolides, special attention should be paid to their potential adverse effects. We reported two cases of end-stage renal disease (ESRD) patients who developed hallucinations such as vivid images of worms after taking clarithromycin. Similar to previous case reports of clarithromycin neurotoxicity, the visual hallucination resolved upon cessation of clarithromycin. Furthermore, we discussed the pharmacokinetic properties and other toxicities of macrolide antibiotics in patients with chronic kidney disease and ESRD.
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Affiliation(s)
- Terry King-Wing Ma
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin, Hong Kong , China
| | - Kai-Ming Chow
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin, Hong Kong , China
| | - Agnes Shin Man Choy
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin, Hong Kong , China
| | - Bonnie Ching-Ha Kwan
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin, Hong Kong , China
| | - Cheuk-Chun Szeto
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin, Hong Kong , China
| | - Philip Kam-Tao Li
- Carol and Richard Yu Peritoneal Dialysis Research Centre, Department of Medicine & Therapeutics, Prince of Wales Hospital , The Chinese University of Hong Kong , Shatin, Hong Kong , China
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He J, Yu Y, Prasad B, Chen X, Unadkat JD. Mechanism of an unusual, but clinically significant, digoxin-bupropion drug interaction. Biopharm Drug Dispos 2014; 35:253-63. [PMID: 24436229 DOI: 10.1002/bdd.1890] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 12/30/2013] [Accepted: 01/09/2014] [Indexed: 11/11/2022]
Abstract
An unusual, but clinically significant, digoxin (DIG)-bupropion (BUP) drug interaction (DDI), in which BUP increased DIG renal clearance by 80% is reported. To investigate the mechanism(s) of this unusual DDI, first the effect of BUP, its circulating metabolites or their combination on [(3) H]-DIG transport by cells expressing human P-gp or human OATP4C1 was determined. Second, the study asked whether this DDI could be replicated in the rat so that it could be used to conduct mechanistic studies. Then, the effect of BUP and its rat metabolites on [(3) H]-DIG transport were tested by cells expressing rat Oatp4c1. Bupropion and its metabolites had no effect on human P-gp mediated transepithelial transport of [(3) H]-DIG. Bupropion and hydroxybupropion (HBUP) significantly stimulated H-OATP4C1 mediated transport of [(3) H]-DIG. In addition, BUP cocktail (BUP plus its metabolites) significantly increased the H-OATP4C1 mediated transport of [(3) H]-DIG, and partially reversed the inhibition by 100 µm DIG. However, erythro-hydrobupropion (EBUP) and threo-hydrobupropion (TBUP) did not affect the [(3) H]-DIG uptake by H-OATP4C1 cells. Bupropion administration significantly increased digoxin renal clearance in rats. Surprisingly, bupropion significantly inhibited r-Oatp4c1 mediated transport of [(3) H]-DIG at clinically relevant unbound plasma concentrations of BUP or those observed in the rat study, while HBUP or TBUP did not. These data support our hypothesis that at clinically relevant plasma concentrations, bupropion and its metabolites activate H-OATP4C1 mediated DIG tubular secretion, and could possibly explain the increase in digoxin renal clearance produced by bupropion. While bupropion increased digoxin renal clearance in the rat, it appeared to do so by inhibiting r-Oatp4c1-mediated digoxin renal reabsorption.
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Affiliation(s)
- Jiake He
- Department of Pharmaceutics, University of Washington, Seattle, Washington, 98195, USA; Center of Drug Metabolism and Pharmacokinetics, China Pharmaceutical University, Nanjing, Jiangsu, 210009, P.R. China
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Moffett BS, Valdes SO, Kim JJ. Possible digoxin toxicity associated with concomitant ciprofloxacin therapy. Int J Clin Pharm 2013; 35:673-6. [PMID: 23868369 DOI: 10.1007/s11096-013-9818-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 06/24/2013] [Indexed: 11/25/2022]
Abstract
CASE (DESCRIPTION) A 27 year old female with a complex history of congenital heart disease, cardiac surgery, heart failure, and arrhythmias was admitted for a Pseudomonas aeruginosa sternal wound infection and treated with intravenous antibiotics. After discharge and completion of an outpatient course of intravenous antibiotics, suppressive antibiotic therapy with ciprofloxacin was initiated. She presented to clinic with nausea and anorexia within a few days of addition of ciprofloxacin to her current regimen of medications, which included digoxin. The digoxin was discontinued, with all other medications remaining the same, and the symptoms resolved in 48 h. The dose of digoxin was restarted at 50 % of the previous dose with no further complications. The proposed cause of the nausea and anorexia was digoxin toxicity secondary to a drug-drug interaction with ciprofloxacin. CONCLUSION Patients receiving ciprofloxacin and digoxin should be monitored closely for the risk of digoxin toxicity.
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Affiliation(s)
- Brady S Moffett
- Department of Pharmacy, Texas Children's Hospital, 6621 Fannin Street, Suite WB 1120, Houston, TX, 77030, USA,
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Hughes J, Crowe A. Inhibition of P-glycoprotein–Mediated Efflux of Digoxin and Its Metabolites by Macrolide Antibiotics. J Pharmacol Sci 2010; 113:315-24. [DOI: 10.1254/jphs.10109fp] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Abstract
Modulation of P-glycoprotein (Pgp)-mediated transport has significant pharmacokinetic implications for Pgp substrates. Pharmacokinetic alterations may be at the systemic (blood concentrations), regional (organ or tissue concentrations), or local (intracellular concentrations) level. Regardless of the particular location of Pgp modulation, changes in substrate pharmacokinetics will have the potential to alter the magnitude and duration of pharmacologic effect (pharmacodynamics). It is important to understand each of the aspects of Pgp modulation for a given Pgp substrate in order to predict the degree to which Pgp modulation may affect that substrate, to minimize untoward effects associated with that modulation, or to exploit that modulation for specific therapeutic advantage.
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Affiliation(s)
- Jeannie M Padowski
- Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Fagerholm U. The role of permeability in drug ADME/PK, interactions and toxicity--presentation of a permeability-based classification system (PCS) for prediction of ADME/PK in humans. Pharm Res 2007; 25:625-38. [PMID: 17710514 DOI: 10.1007/s11095-007-9397-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Accepted: 06/26/2007] [Indexed: 02/05/2023]
Abstract
PURPOSE The objective was to establish in vitro passive permeability (Pe) vs in vivo fraction absorbed (fa)-relationships for each passage through the human intestine, liver, renal tubuli and brain, and develop a Pe-based ADME/PK classification system (PCS). MATERIALS AND METHODS Pe- and intestinal fa-data were taken from an available data set. Hepatic fa was calculated based on extraction ratios of the unbound fraction of drugs (with support from animal in vivo uptake data). Renal fa (reabsorption) was estimated using renal pharmacokinetic data, and brain fa was predicted using animal in vitro and in vivo brain Pe-data. Hepatic and intestinal fa-data were used to predict bile excretion potential. RESULTS Relationships were established, including predicted curves for bile excretion potential and minimum oral bioavailability, and a 4-Class PCS was developed: I (very high Pe; elimination mainly by metabolism); II (high Pe) and III (intermediate Pe and incomplete fa); IV (low Pe and fa). The system enables assessment of potential drug-drug transport interactions, and drug and metabolite organ trapping. CONCLUSIONS The PCS and high quality Pe-data (with and without active transport) are believed to be useful for predictions and understanding of ADME/PK, elimination routes, and potential interactions and organ trapping/toxicity in humans.
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Affiliation(s)
- Urban Fagerholm
- Clinical Pharmacology, AstraZeneca R&D Södertälje, S-151 85, Södertälje, Sweden.
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Abstract
The objective of this study was to examine the effect of macrolide antibiotics, clarithromycin, erythromycin, roxithromycin, josamycin and azithromycin, on the hepatic uptake of digoxin. The uptake of [(3)H]digoxin was studied in rats in vivo, using the tissue-sampling single-injection technique, and in isolated rat hepatocytes in vitro. The uptake of [(3)H]digoxin into rat hepatocytes was concentration-dependent with a Michaelis constant (K(m)) of 445 nM. All the macrolide antibiotics inhibited the uptake of [(3)H]digoxin into rat hepatocytes in a concentration-dependent manner. However, clarithromycin did not affect the in vivo hepatic uptake of digoxin in rats. The in vivo permeability-surface area product of digoxin for hepatic uptake (PS(inf)) was estimated to be 12.5 ml/min/g liver from the present in vitro data, which is far larger than the hepatic blood flow rate (1.4 ml/min/g liver). Macrolide antibiotics at clinically relevant concentrations inhibit digoxin uptake by rat hepatocytes in vitro, but not in vivo, probably because hepatic uptake of digoxin in rats is blood flow-limited. Clinically observed digoxin-macrolide interaction in humans could be due to macrolide inhibition of hepatic digoxin uptake, if the uptake is permeation-limited.
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Affiliation(s)
- Suwako Ito
- Department of Medico-Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka 812-8582, Japan
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Abstract
A 58-year-old woman who had been taking digoxin 0.25 mg/day for more than 35 years for heart palpitations after mitral valve repair was prescribed a 5-day course of telithromycin for acute bronchitis. On the sixth day of therapy, she came to the emergency department complaining of general malaise and having experienced three episodes of syncope over the previous 2 days. Laboratory analysis revealed elevated digoxin plasma levels, and electrocardiography showed several nonspecific repolarization anomalies. Telithromycin is known to increase digoxin plasma levels; however, the clinical significance of this interaction is not known. To our knowledge, this is the first report of elevated plasma digoxin levels associated with signs and symptoms of toxicity. This drug interaction-determined as probable according to the Naranjo adverse drug reaction probability scale-may be mediated by P-glycoprotein. By inhibiting the transport of digoxin by P-glycoprotein, telithromycin may have decreased digoxin elimination in the intestinal lumen and its renal tubular excretion, resulting in elevated plasma levels and drug toxicity. Clinicians should be aware of possible digoxin toxicity after concomitant administration with telithromycin, especially in patients who are at risk, such as those with electrolyte abnormalities and decreased renal function.
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Affiliation(s)
- Laura M Nenciu
- Pharmacy Department, Hôpital du Sacré-Coeur de Montréal, and the Faculté de Pharmacie, Université de Montréal, Quebec, Canada
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Abstract
The kidneys play a critical role in the elimination of xenobiotics. Factors affecting the ability of the kidney to eliminate drugs may result in marked changes in the pharmacokinetics of a given compound. Drug-drug interactions due to competitive inhibition of renal organic anion or cation secretion systems have been noticed clinically for a long time. However, our understanding of the physical sites of interactions, that is, the specific transport proteins that the interacting drugs act on, has just begun very recently. This review summarises the latest progress in molecular identification and functional characterisation of major drug transporters in the human kidney. In particular, the review focuses on relating cloned renal drug transporters to clinically observed drug-drug interactions. The authors' opinion on the current status and future directions of research in these areas is also offered.
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Affiliation(s)
- Meng Li
- University of Washington, Department of Pharmaceutics, School of Pharmacy, Seattle, 98195, USA
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Cambonie G, Sabatier E, Guillaumont S, Masson F, Charbit J, Pidoux O, Hillaire-Buys D, Picaud JC. Digoxine-Josamycine : une interaction dangereuse chez l'enfant. Arch Pediatr 2006; 13:1118-20. [PMID: 16766164 DOI: 10.1016/j.arcped.2006.04.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2005] [Accepted: 04/19/2006] [Indexed: 01/11/2023]
Abstract
Digitalis intoxication is usually accidental in children. We report the case of a young infant with congenital heart disease in whom the coadministration of digoxin and josamycin led to a 50% increase in the digoxin concentration, generating sinoatrial block and cardiac failure. Clinical and electrocardiographic symptoms very quickly resolved following immunotherapy with antidigitalis Fab fragments. Digoxin concentrations must be carefully monitored in patients concomitantly receiving macrolides to ensure that the digoxin dose can be readjusted if necessary.
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Affiliation(s)
- G Cambonie
- Service de réanimation néonatale et pédiatrique, hôpital Arnaud-de-Villeneuve, France.
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Abstract
This review focuses on drug-drug interactions with three major groups of antimicrobial agents: macrolides (including azalides and ketolides), quinolones, which are widely used for the treatment of bacterial infections, and azoles, which are used for antifungal therapy. Macrolides and the ketolide telithromycin are potent inhibitors of CYP3A4 and thus interfere with the pharmacokinetics of many other drugs that are metabolised by this enzyme. In contrast, although closely related, azithromycin is not a cytochrome inhibitor. All quinolones form complexes with di- and trivalent cations and, therefore, the absorption of quinolones can be dramatically reduced when given concomitantly with mineral antacids, zinc or iron preparations. Ciprofloxacin exhibits an inhibitory potential for the cytochrome isoenzyme 1A2, resulting in an inhibition of theophylline metabolism. Other quinolones, such as levofloxacin or moxifloxacin, do not interfere with theophylline metabolism. The systemic azoles, such as ketoconazole, itraconazole, fluconazole and voriconazole, are inhibitors of CYP isoenzymes, such as CYP3A4, CYP2C9 and CYP2C19, to varying degrees. In addition, some are substrates of the MDR-1 gene product, P-glycoprotein. These features are the basis for most of the interactions occurring during azole therapy (e.g., in severely ill patients in the hospital who are treated with multiple drugs).
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Affiliation(s)
- Kasra Shakeri-Nejad
- PAREXEL International GmbH, Institute of Clinical Pharmacology, Clinical Operations, Spandauer Damm 130, Haus 18, 14050 Berlin, Germany
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Current awareness: Pharmacoepidemiology and drug safety: Current Awareness. Pharmacoepidemiol Drug Saf 2005; 14:i-xii. [DOI: 10.1002/pds.1030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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