Pub Date : 2023-10-01Epub Date: 2023-10-21DOI: 10.14740/gr1662
Yazan Addasi, Anny H Nguyen, Ahmed Sabri, Faran Ahmad, Rajani Rangray, Manasa Velagapudi
Mucormycosis is a devastating fungal infection that is usually seen in immunocompromised hosts. It is caused by fungi of the subphylum Mucoromycotina, order Mucorales, with most cases caused by Mucor, Rhizopus, or Rhizomucor species. It can involve any organ system and can disseminate in severe cases. Lately, there has been an increased number of reports for mucormycosis infection in immunocompetent patients. Gastrointestinal system involvement is rare compared to other organ systems but has been increasingly reported in the literature. Mucormycosis can affect any part of the gastrointestinal tract and lead to different presentations depending on the area of involvement. Due to the paucity of the condition, there has been no specific guidelines on how to treat gastrointestinal mucormycosis. In this review, we discuss the risk factors of gastrointestinal mucormycosis, clinical presentation, approach to diagnosis, and most recent treatment modalities for gastrointestinal mucormycosis.
{"title":"Gastrointestinal Mucormycosis: A Clinical Review.","authors":"Yazan Addasi, Anny H Nguyen, Ahmed Sabri, Faran Ahmad, Rajani Rangray, Manasa Velagapudi","doi":"10.14740/gr1662","DOIUrl":"10.14740/gr1662","url":null,"abstract":"<p><p>Mucormycosis is a devastating fungal infection that is usually seen in immunocompromised hosts. It is caused by fungi of the subphylum <i>Mucoromycotina</i>, order <i>Mucorales</i>, with most cases caused by <i>Mucor</i>, <i>Rhizopus</i>, or <i>Rhizomucor</i> species. It can involve any organ system and can disseminate in severe cases. Lately, there has been an increased number of reports for mucormycosis infection in immunocompetent patients. Gastrointestinal system involvement is rare compared to other organ systems but has been increasingly reported in the literature. Mucormycosis can affect any part of the gastrointestinal tract and lead to different presentations depending on the area of involvement. Due to the paucity of the condition, there has been no specific guidelines on how to treat gastrointestinal mucormycosis. In this review, we discuss the risk factors of gastrointestinal mucormycosis, clinical presentation, approach to diagnosis, and most recent treatment modalities for gastrointestinal mucormycosis.</p>","PeriodicalId":12461,"journal":{"name":"Gastroenterology Research","volume":"16 5","pages":"249-253"},"PeriodicalIF":1.5,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10627358/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71480105","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-01Epub Date: 2023-10-21DOI: 10.14740/gr1638
Zohaib Ahmed, Daryl Ramai, Nooraldin Merza, Joyce Badal, Umair Iqbal, Syeda F Arif, Alsadiq Al-Hillan, Tony Varughese, Wade Lee-Smith, Ali Nawras, Yaseen Alastal, Harshit S Khara, Bradley D Confer, David L Diehl, Douglas G Adler
Background: Endoscopic mucosal resection is a frequently employed method for removing colonic polyps. Nonetheless, the recurrence of these polyps over a healed submucosal base can complicate the extraction of leftover lesions through standard procedures. EndoRotor®, a non-thermal device specifically designed for endoscopic mucosal resection, has recently been assessed for its utility in removing colonic polyps, non-dysplastic Barrett's esophagus, and pancreatic necrosis. We conducted a systematic review and meta-analysis to ascertain the safety and efficacy of EndoRotor® in resecting scared or recurrence colonic polyps.
Methods: We conducted an exhaustive review of existing literature using databases such as Medline, Embase, Web of Science, and the Cochrane Library until January 2023. Our aim was to find all studies that assessed the safety of non-thermal endoscopic resection devices in removing colonic polyps. The primary outcome we focused on was the rate of technical success. Secondary outcomes that we considered included the frequency of remaining lesions and instances of adverse events. To analyze these data, we used comprehensive meta-analysis software.
Results: Our analysis incorporated three studies comprising 54 patients who underwent resection of 60 lesions. The combined technical success rate was 93.9% (95% confidence interval (CI): 77.7-98.6%, I2 = 25.5%). In patients who had another endoscopic examination, 20 were found to have a residual lesion. After the initial session, the combined rate of remaining lesions was 39.8% (95% CI: 15.3-70.8%, I2 = 74.5%). There were eight occurrences of intraoperative bleeding and four instances of bleeding post-procedure. The combined rate of intraoperative bleeding was 13.2% (95% CI: 6.7-24.3%, I2 = 0%), and post-procedure bleeding stood at 8.5% (95% CI: 3.4-19.8%, I2 = 0%). Only one major bleeding event was recorded, and no cases of perforation were reported.
Conclusion: Our research indicates that the EndoRotor® effectively removes scarred colonic polyps, though the rate of remaining lesions is significant, potentially necessitating several sessions for a thorough removal. There is a need for broader prospective studies, mainly randomized controlled trials, to further assess EndoRotor®'s efficiency and safety in eliminating colonic polyps.
背景:内镜下黏膜切除术是切除结肠息肉的常用方法。尽管如此,这些息肉在愈合的黏膜下基底复发可能会使通过标准程序提取残留病变变得复杂。EndoRotor®是一种专门为内镜黏膜切除术设计的非热设备,最近被评估其在去除结肠息肉、非发育异常巴雷特食管和胰腺坏死方面的效用。我们进行了一项系统综述和荟萃分析,以确定EndoRotor®切除惊恐或复发结肠息肉的安全性和有效性。方法:我们使用Medline、Embase、Web of Science和Cochrane Library等数据库对现有文献进行了详尽的综述,直到2023年1月。我们的目的是寻找所有评估非热内镜切除装置在切除结肠息肉中的安全性的研究。我们关注的主要结果是技术成功率。我们考虑的次要结果包括残留病变的频率和不良事件的发生率。为了分析这些数据,我们使用了全面的荟萃分析软件。结果:我们的分析纳入了三项研究,包括54名患者,他们接受了60个病灶的切除。综合技术成功率为93.9%(95%置信区间(CI):77.7-98.6%,I2=25.5%)。在再次进行内镜检查的患者中,发现20例有残余病变。初次治疗后,残余病变的综合发生率为39.8%(95%CI:15.3-70.8%,I2=74.5%)。术中出血8例,术后出血4例。术中出血的综合发生率为13.2%(95%CI:6.7-24.3%,I2=0%),术后出血为8.5%(95%CI:3.4-19.8%,I2=0%)。只记录了一次大出血事件,没有穿孔病例报告。结论:我们的研究表明,EndoRotor®可以有效地去除结疤的结肠息肉,尽管残留病变的发生率很高,可能需要几次手术才能彻底去除。需要进行更广泛的前瞻性研究,主要是随机对照试验,以进一步评估EndoRotor®在消除结肠息肉方面的有效性和安全性。
{"title":"Safety and Efficacy of Powered Non-Thermal Endoscopic Resection Device for Removal of Colonic Polyps: A Systematic Review and Meta-Analysis.","authors":"Zohaib Ahmed, Daryl Ramai, Nooraldin Merza, Joyce Badal, Umair Iqbal, Syeda F Arif, Alsadiq Al-Hillan, Tony Varughese, Wade Lee-Smith, Ali Nawras, Yaseen Alastal, Harshit S Khara, Bradley D Confer, David L Diehl, Douglas G Adler","doi":"10.14740/gr1638","DOIUrl":"10.14740/gr1638","url":null,"abstract":"<p><strong>Background: </strong>Endoscopic mucosal resection is a frequently employed method for removing colonic polyps. Nonetheless, the recurrence of these polyps over a healed submucosal base can complicate the extraction of leftover lesions through standard procedures. EndoRotor<sup>®</sup>, a non-thermal device specifically designed for endoscopic mucosal resection, has recently been assessed for its utility in removing colonic polyps, non-dysplastic Barrett's esophagus, and pancreatic necrosis. We conducted a systematic review and meta-analysis to ascertain the safety and efficacy of EndoRotor<sup>®</sup> in resecting scared or recurrence colonic polyps.</p><p><strong>Methods: </strong>We conducted an exhaustive review of existing literature using databases such as Medline, Embase, Web of Science, and the Cochrane Library until January 2023. Our aim was to find all studies that assessed the safety of non-thermal endoscopic resection devices in removing colonic polyps. The primary outcome we focused on was the rate of technical success. Secondary outcomes that we considered included the frequency of remaining lesions and instances of adverse events. To analyze these data, we used comprehensive meta-analysis software.</p><p><strong>Results: </strong>Our analysis incorporated three studies comprising 54 patients who underwent resection of 60 lesions. The combined technical success rate was 93.9% (95% confidence interval (CI): 77.7-98.6%, I<sup>2</sup> = 25.5%). In patients who had another endoscopic examination, 20 were found to have a residual lesion. After the initial session, the combined rate of remaining lesions was 39.8% (95% CI: 15.3-70.8%, I<sup>2</sup> = 74.5%). There were eight occurrences of intraoperative bleeding and four instances of bleeding post-procedure. The combined rate of intraoperative bleeding was 13.2% (95% CI: 6.7-24.3%, I<sup>2</sup> = 0%), and post-procedure bleeding stood at 8.5% (95% CI: 3.4-19.8%, I<sup>2</sup> = 0%). Only one major bleeding event was recorded, and no cases of perforation were reported.</p><p><strong>Conclusion: </strong>Our research indicates that the EndoRotor<sup>®</sup> effectively removes scarred colonic polyps, though the rate of remaining lesions is significant, potentially necessitating several sessions for a thorough removal. There is a need for broader prospective studies, mainly randomized controlled trials, to further assess EndoRotor<sup>®</sup>'s efficiency and safety in eliminating colonic polyps.</p>","PeriodicalId":12461,"journal":{"name":"Gastroenterology Research","volume":"16 5","pages":"254-261"},"PeriodicalIF":1.5,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10627355/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71480107","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-10-01Epub Date: 2023-10-21DOI: 10.14740/gr1637
Mohamad Khaled Almujarkesh, Anirudh R Damughatla, Jasdeep Bathla, Kyle Sugg, Dana LaBuda, Samer Alkassis, Mohammed Najeeb Al Hallak
Primary squamous cell carcinoma (SCC) of the liver is quite rare, and to our knowledge, very few cases have been reported in the literature. The exact pathogenesis of the disease is unestablished; however, it is mostly reported to be associated with hepatic cyst, Caroli's disease, hepatolithiasis, hepatic cirrhosis, and hepatic teratoma. We report a case of a 50-year-old woman with no prior medical history initially, who presented with postprandial epigastric and right upper quadrant pain that continued to worsen and was associated with early satiety, nausea, and weight loss of 25 pounds over 2 months, which prompted further evaluation by her primary care physician. Magnetic resonance imaging (MRI) examination a month later revealed a large heterogeneous area measuring 8.5 × 2.4 × 7.4 cm in the inferior right hepatic lobe with heterogeneous enhancement and involvement of the gallbladder, concerning for cholangiocarcinoma. Given radiographic findings, she underwent a computed tomography (CT)-guided core biopsy of the liver, which showed a necrotic malignant tumor favoring adenocarcinoma and was also found to have germline BRCA mutation. A positron emission tomography (PET) scan revealed a large partially necrotic fluorodeoxyglucose (FDG) avid mass, possibly arising from the gallbladder fossa with an invasion of both lobes of the liver and probable involvement of a portion of the ascending colon. There was no gross evidence of distant metastatic disease. The patient underwent staging laparoscopy prior to initiating chemotherapy, and another biopsy was done, which returned in favor of SCC, with immunohistochemical stains being positive for cytokeratin (CK)19, Ber-EP4 (epithelial antigen recognized by Ber-EP4 antibody), and P40 (DeltaNp63); while negative for CK7, CK20, caudal-type homeobox 2 (CDX-2), paired box 8 (PAX-8), and mucicarmine. The patient started platinum-based chemotherapy due to germline BRCA mutation. However, due to complications associated with therapy and the progression of the disease, the patient eventually chose hospice. Primary SSC remains an unexplored aggressive malignancy that carries an overall poor prognosis. Diagnosis can be challenging and requires high clinical suspicion due to the scarcity in specific laboratory workup. Pathological diagnosis remains the gold standard; however, it also carries its own challenges. Treatment is usually case-oriented, and definitive protocols have yet to be established.
{"title":"Primary Squamous Cell Biliary Carcinoma With Liver Metastasis Is Rare but Malicious.","authors":"Mohamad Khaled Almujarkesh, Anirudh R Damughatla, Jasdeep Bathla, Kyle Sugg, Dana LaBuda, Samer Alkassis, Mohammed Najeeb Al Hallak","doi":"10.14740/gr1637","DOIUrl":"10.14740/gr1637","url":null,"abstract":"<p><p>Primary squamous cell carcinoma (SCC) of the liver is quite rare, and to our knowledge, very few cases have been reported in the literature. The exact pathogenesis of the disease is unestablished; however, it is mostly reported to be associated with hepatic cyst, Caroli's disease, hepatolithiasis, hepatic cirrhosis, and hepatic teratoma. We report a case of a 50-year-old woman with no prior medical history initially, who presented with postprandial epigastric and right upper quadrant pain that continued to worsen and was associated with early satiety, nausea, and weight loss of 25 pounds over 2 months, which prompted further evaluation by her primary care physician. Magnetic resonance imaging (MRI) examination a month later revealed a large heterogeneous area measuring 8.5 × 2.4 × 7.4 cm in the inferior right hepatic lobe with heterogeneous enhancement and involvement of the gallbladder, concerning for cholangiocarcinoma. Given radiographic findings, she underwent a computed tomography (CT)-guided core biopsy of the liver, which showed a necrotic malignant tumor favoring adenocarcinoma and was also found to have germline <i>BRCA</i> mutation. A positron emission tomography (PET) scan revealed a large partially necrotic fluorodeoxyglucose (FDG) avid mass, possibly arising from the gallbladder fossa with an invasion of both lobes of the liver and probable involvement of a portion of the ascending colon. There was no gross evidence of distant metastatic disease. The patient underwent staging laparoscopy prior to initiating chemotherapy, and another biopsy was done, which returned in favor of SCC, with immunohistochemical stains being positive for cytokeratin (CK)19, Ber-EP4 (epithelial antigen recognized by Ber-EP4 antibody), and P40 (DeltaNp63); while negative for CK7, CK20, caudal-type homeobox 2 (CDX-2), paired box 8 (PAX-8), and mucicarmine. The patient started platinum-based chemotherapy due to germline <i>BRCA</i> mutation. However, due to complications associated with therapy and the progression of the disease, the patient eventually chose hospice. Primary SSC remains an unexplored aggressive malignancy that carries an overall poor prognosis. Diagnosis can be challenging and requires high clinical suspicion due to the scarcity in specific laboratory workup. Pathological diagnosis remains the gold standard; however, it also carries its own challenges. Treatment is usually case-oriented, and definitive protocols have yet to be established.</p>","PeriodicalId":12461,"journal":{"name":"Gastroenterology Research","volume":"16 5","pages":"276-279"},"PeriodicalIF":1.5,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10627356/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"71480106","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: We previously reported that the selective peroxisome proliferator-activated receptor alpha modulator, pemafibrate, significantly reduced serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT) and significantly increased serum albumin levels at 3, 6 and 12 months after the start of pemafibrate, with an improvement of atherogenic dyslipidemia, in patients with hypertriglyceridemia.
Methods: We performed a post hoc analysis of our previous data obtained from patients with hypertriglyceridemia who had been prescribed pemafibrate continuously for 1 year or longer. We compared the indexes for hepatic steatosis (hepatic steatosis index (HSI)) and fibrosis (nonalcoholic fatty liver disease (NAFLD) fibrosis score (NFS), AST to platelet ratio index (APRI) and FIB-4 index) at baseline with the data at 1 year after the start of pemafibrate.
Results: Pemafibrate significantly reduced HSI at 1 year after the start of pemafibrate. NFS did not show a significant change after 1 year. However, APRI was significantly reduced by pemafibrate after 1 year. FIB-4 index significantly decreased in patients with baseline FIB-4 index ≥ 1.45 at 1 year after the start of pemafibrate. HSI at baseline tended to be negatively correlated with change in HSI after 1 year. There was no significant correlation between NFS at baseline and change in this score after 1 year. APRI and FIB-4 index at baseline were significantly and negatively correlated with changes in APRI and FIB-4 index at 1 year after the start of pemafibrate.
Conclusions: The 1-year pemafibrate treatment improved hepatic steatosis and fibrosis indexes in patients with hypertriglyceridemia.
{"title":"A Significant Effect of Pemafibrate on Hepatic Steatosis and Fibrosis Indexes in Patients With Hypertriglyceridemia.","authors":"Hisayuki Katsuyama, Hidekatsu Yanai, Hiroki Adachi, Mariko Hakoshima","doi":"10.14740/gr1656","DOIUrl":"10.14740/gr1656","url":null,"abstract":"<p><strong>Background: </strong>We previously reported that the selective peroxisome proliferator-activated receptor alpha modulator, pemafibrate, significantly reduced serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT) and significantly increased serum albumin levels at 3, 6 and 12 months after the start of pemafibrate, with an improvement of atherogenic dyslipidemia, in patients with hypertriglyceridemia.</p><p><strong>Methods: </strong>We performed a <i>post hoc</i> analysis of our previous data obtained from patients with hypertriglyceridemia who had been prescribed pemafibrate continuously for 1 year or longer. We compared the indexes for hepatic steatosis (hepatic steatosis index (HSI)) and fibrosis (nonalcoholic fatty liver disease (NAFLD) fibrosis score (NFS), AST to platelet ratio index (APRI) and FIB-4 index) at baseline with the data at 1 year after the start of pemafibrate.</p><p><strong>Results: </strong>Pemafibrate significantly reduced HSI at 1 year after the start of pemafibrate. NFS did not show a significant change after 1 year. However, APRI was significantly reduced by pemafibrate after 1 year. FIB-4 index significantly decreased in patients with baseline FIB-4 index ≥ 1.45 at 1 year after the start of pemafibrate. HSI at baseline tended to be negatively correlated with change in HSI after 1 year. There was no significant correlation between NFS at baseline and change in this score after 1 year. APRI and FIB-4 index at baseline were significantly and negatively correlated with changes in APRI and FIB-4 index at 1 year after the start of pemafibrate.</p><p><strong>Conclusions: </strong>The 1-year pemafibrate treatment improved hepatic steatosis and fibrosis indexes in patients with hypertriglyceridemia.</p>","PeriodicalId":12461,"journal":{"name":"Gastroenterology Research","volume":"16 4","pages":"240-243"},"PeriodicalIF":1.4,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/41/1b/gr-16-240.PMC10482606.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10218184","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Alexander Kusnik, Sarath Lal Mannumbeth Renjithlal, Ari Chodos, Sanjana Chetana Shanmukhappa, Mohamed Magdi Eid, Keerthi Mannumbeth Renjith, Richard Alweis
Background: The United States faces a significant public health issue with colorectal cancer (CRC), which remains the third leading cause of cancer-related fatalities despite early diagnosis and treatment progress.
Methods: This investigation utilized death certificate data from the Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research (CDC WONDER) database to investigate trends in CRC mortality and location of death from 1999 to 2020. Additionally, the study utilized the annual percent change (APC) to estimate the average annual rate of change over the specific time period for the given health outcome. Incorporating the location of death in this study served the purpose of identifying patterns related to CRC and offering valuable insights into the specific locations where deaths occurred.
Results: Between 1999 and 2020, there were 1,166,158 CRC-related deaths. The age-adjusted mortality rates (AAMRs) for CRC consistently declined from 20.7 in 1999 to 12.5 in 2020. Men had higher AAMR (18.8) than women (13.4) throughout the study. Black or African American patients had the highest AAMR (21.1), followed by White (15.4), Hispanic/Latino (11.8), American Indian or Alaska native (11.4), and Asian or Pacific Islanders (10.2). The location of death varied, with 41.99% at home, 28.16% in medical facilities, 16.6% in nursing homes/long-term care facilities, 7.43% in hospices, and 5.80% at other/unknown places.
Conclusion: There has been an overall improvement in AAMR among most ethnic groups, but an increase in AAMR has been observed among white individuals below the age of 55. Notably, over one-quarter of CRC-related deaths occur in medical facilities.
{"title":"Trends in Colorectal Cancer Mortality in the United States, 1999 - 2020.","authors":"Alexander Kusnik, Sarath Lal Mannumbeth Renjithlal, Ari Chodos, Sanjana Chetana Shanmukhappa, Mohamed Magdi Eid, Keerthi Mannumbeth Renjith, Richard Alweis","doi":"10.14740/gr1631","DOIUrl":"https://doi.org/10.14740/gr1631","url":null,"abstract":"<p><strong>Background: </strong>The United States faces a significant public health issue with colorectal cancer (CRC), which remains the third leading cause of cancer-related fatalities despite early diagnosis and treatment progress.</p><p><strong>Methods: </strong>This investigation utilized death certificate data from the Centers for Disease Control and Prevention Wide-Ranging OnLine Data for Epidemiologic Research (CDC WONDER) database to investigate trends in CRC mortality and location of death from 1999 to 2020. Additionally, the study utilized the annual percent change (APC) to estimate the average annual rate of change over the specific time period for the given health outcome. Incorporating the location of death in this study served the purpose of identifying patterns related to CRC and offering valuable insights into the specific locations where deaths occurred.</p><p><strong>Results: </strong>Between 1999 and 2020, there were 1,166,158 CRC-related deaths. The age-adjusted mortality rates (AAMRs) for CRC consistently declined from 20.7 in 1999 to 12.5 in 2020. Men had higher AAMR (18.8) than women (13.4) throughout the study. Black or African American patients had the highest AAMR (21.1), followed by White (15.4), Hispanic/Latino (11.8), American Indian or Alaska native (11.4), and Asian or Pacific Islanders (10.2). The location of death varied, with 41.99% at home, 28.16% in medical facilities, 16.6% in nursing homes/long-term care facilities, 7.43% in hospices, and 5.80% at other/unknown places.</p><p><strong>Conclusion: </strong>There has been an overall improvement in AAMR among most ethnic groups, but an increase in AAMR has been observed among white individuals below the age of 55. Notably, over one-quarter of CRC-related deaths occur in medical facilities.</p>","PeriodicalId":12461,"journal":{"name":"Gastroenterology Research","volume":"16 4","pages":"217-225"},"PeriodicalIF":1.5,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/9e/77/gr-16-217.PMC10482602.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10211664","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Xheni Deda, Khaled Elfert, Mustafa Gandhi, Alexander Malik, Esraa Elromisy, Nehemias Guevara, Suresh Nayudu, Matthew Bechtold
Background: Clostridioides difficile infection (CDI) is a significant healthcare-associated infection with implications for patient morbidity, mortality, and healthcare costs. However, the connection between CDI and coronavirus disease 2019 (COVID-19) infection and its influence on patient outcomes remain uncertain. This study aimed to examine the association between CDI and COVID-19, specifically investigating whether CDI worsens outcomes in patients with COVID-19. By utilizing the extensive National Inpatient Sample (NIS) database and analyzing pertinent factors, this research endeavored to enhance our understanding of CDI within the context of COVID-19.
Methods: The NIS database was searched for adult patients hospitalized with a primary diagnosis of COVID-19 infection in 2020. Patients with a secondary diagnosis of CDI were identified and separated into two groups based on CDI status. Baseline characteristics, Charlson Comorbidity Index (CCI), and outcomes were compared between the two groups using Chi-square and t-tests. Multivariate logistic and linear regressions were performed for the identification of independent predictors of CDI and mortality.
Results: A total of 1,045,125 COVID-19 hospitalizations were included, of which 4,920 had a secondary diagnosis of CDI. Patients with CDI and COVID-19 were older (mean age 69.9 vs. 64.2 years; P < 0.001), more likely to be female (54.1% vs. 47.1%; P < 0.001) and white (60% vs. 52.4%; P < 0.001). The CDI and COVID-19 group had a longer length of stay (14.1 vs. 7.42 days; P < 0.001), higher total hospital costs ($42,336 vs. $18,974; P < 0.001), and higher inpatient mortality (21.6% vs. 11%; P < 0.001) compared to the COVID-19 group without CDI. Patients in the CDI and COVID-19 group had a higher CCI score (51.7% with a score of 3 or more vs. 27.7%; P < 0.001), indicating a higher comorbidity burden. Multivariate logistic regression analysis revealed CDI was independently associated with increased mortality (odds ratio (OR) 1.37; P = 0.001) and showed that the female gender and several pre-existing comorbidities were associated with a higher likelihood of CDI.
Conclusion: CDI is independently associated with increased mortality in patients admitted with COVID-19 infection. Female gender and several pre-existing comorbidities are independent predictors of CDI in COVID-19 patients.
{"title":"<i>Clostridioides difficile</i> Infection in COVID-19 Hospitalized Patients: A Nationwide Analysis.","authors":"Xheni Deda, Khaled Elfert, Mustafa Gandhi, Alexander Malik, Esraa Elromisy, Nehemias Guevara, Suresh Nayudu, Matthew Bechtold","doi":"10.14740/gr1639","DOIUrl":"https://doi.org/10.14740/gr1639","url":null,"abstract":"<p><strong>Background: </strong><i>Clostridioides difficile</i> infection (CDI) is a significant healthcare-associated infection with implications for patient morbidity, mortality, and healthcare costs. However, the connection between CDI and coronavirus disease 2019 (COVID-19) infection and its influence on patient outcomes remain uncertain. This study aimed to examine the association between CDI and COVID-19, specifically investigating whether CDI worsens outcomes in patients with COVID-19. By utilizing the extensive National Inpatient Sample (NIS) database and analyzing pertinent factors, this research endeavored to enhance our understanding of CDI within the context of COVID-19.</p><p><strong>Methods: </strong>The NIS database was searched for adult patients hospitalized with a primary diagnosis of COVID-19 infection in 2020. Patients with a secondary diagnosis of CDI were identified and separated into two groups based on CDI status. Baseline characteristics, Charlson Comorbidity Index (CCI), and outcomes were compared between the two groups using Chi-square and <i>t</i>-tests. Multivariate logistic and linear regressions were performed for the identification of independent predictors of CDI and mortality.</p><p><strong>Results: </strong>A total of 1,045,125 COVID-19 hospitalizations were included, of which 4,920 had a secondary diagnosis of CDI. Patients with CDI and COVID-19 were older (mean age 69.9 vs. 64.2 years; P < 0.001), more likely to be female (54.1% vs. 47.1%; P < 0.001) and white (60% vs. 52.4%; P < 0.001). The CDI and COVID-19 group had a longer length of stay (14.1 vs. 7.42 days; P < 0.001), higher total hospital costs ($42,336 vs. $18,974; P < 0.001), and higher inpatient mortality (21.6% vs. 11%; P < 0.001) compared to the COVID-19 group without CDI. Patients in the CDI and COVID-19 group had a higher CCI score (51.7% with a score of 3 or more vs. 27.7%; P < 0.001), indicating a higher comorbidity burden. Multivariate logistic regression analysis revealed CDI was independently associated with increased mortality (odds ratio (OR) 1.37; P = 0.001) and showed that the female gender and several pre-existing comorbidities were associated with a higher likelihood of CDI.</p><p><strong>Conclusion: </strong>CDI is independently associated with increased mortality in patients admitted with COVID-19 infection. Female gender and several pre-existing comorbidities are independent predictors of CDI in COVID-19 patients.</p>","PeriodicalId":12461,"journal":{"name":"Gastroenterology Research","volume":"16 4","pages":"234-239"},"PeriodicalIF":1.5,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/d5/2e/gr-16-234.PMC10482604.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10211665","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Thibault Vieille, Francois Feillet, Arnaud Wiedemann, Hadrien Winiszewski, Gael Piton
We describe a case of coma-related hyperammonemia in a woman presenting with severe edematous malnutrition (Kwashiorkor-like), without underlying hepatic disease. Our main hypothesis is that the patient developed a functional urea cycle disorder, due to the inability to synthesize N-acetylglutamate which is the activator of the first enzymes (carbamoyl phosphate synthetase) of urea cycle, in a context of severe deficiency of essential amino acids and of acetyl-CoA. Severe hyperammonemia is a medical emergency exposing to the risk of cerebral edema. Urgent treatment should interrupt protein intake, stimulate protein anabolism, and remove ammonia from the blood using renal replacement therapy and ammonia scavengers. Hyperammonemia should be searched in case of unexplained coma, even among patients without hepatic disorder, in particular among young patients. Hyperammonemia should also be searched among patients with severe protein-calorie malnutrition.
{"title":"Coma With Hyperammonemia in a Patient With Kwashiorkor.","authors":"Thibault Vieille, Francois Feillet, Arnaud Wiedemann, Hadrien Winiszewski, Gael Piton","doi":"10.14740/gr1634","DOIUrl":"https://doi.org/10.14740/gr1634","url":null,"abstract":"<p><p>We describe a case of coma-related hyperammonemia in a woman presenting with severe edematous malnutrition (Kwashiorkor-like), without underlying hepatic disease. Our main hypothesis is that the patient developed a functional urea cycle disorder, due to the inability to synthesize N-acetylglutamate which is the activator of the first enzymes (carbamoyl phosphate synthetase) of urea cycle, in a context of severe deficiency of essential amino acids and of acetyl-CoA. Severe hyperammonemia is a medical emergency exposing to the risk of cerebral edema. Urgent treatment should interrupt protein intake, stimulate protein anabolism, and remove ammonia from the blood using renal replacement therapy and ammonia scavengers. Hyperammonemia should be searched in case of unexplained coma, even among patients without hepatic disorder, in particular among young patients. Hyperammonemia should also be searched among patients with severe protein-calorie malnutrition.</p>","PeriodicalId":12461,"journal":{"name":"Gastroenterology Research","volume":"16 4","pages":"244-248"},"PeriodicalIF":1.5,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/71/5e/gr-16-244.PMC10482601.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10218183","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
William S Reiche, Stephen Cooper, Christopher J Destache, Suhail Sidhu, Bryce Schutte, Darby Keirns, Elezabeth Mac, Ian Ng, Haitam Buaisha, Manasa Velagapudi
Background: The management of patients with chronic hepatitis B (CHB) is complex and spans multiple medical specialties. As a result of this complexity, patients with CHB often do not receive adequate monitoring including hepatocellular carcinoma (HCC) surveillance with abdominal ultrasonography. Previous studies have identified multiple factors associated with decreased HCC surveillance. We aimed to identify the impact of race and sex on HCC surveillance in patients with CHB.
Methods: We performed a single health system chart review between January 2018 and January 2022. Differences between sex and race were evaluated using the Chi-square test and Fisher's exact test, and continuous variables were analyzed using analysis of variance (ANOVA).
Results: A total of 248 patient records between January 2018 and January 2022 were evaluated. In total 37% of females were adequately screened for HCC in any of the 6-month time frames compared to 26% of males. During the coronavirus disease 2019 (COVID-19) surge, surveillance rates were reduced in both men and women. During the first 6 months of the COVID-19 surge, there was a significant difference in screening between men and women (19% vs. 35%, P = 0.026). There was a decrease in HCC screening across all races during the COVID-19 surge; however, no significant difference when comparing races was found.
Conclusion: Men received less HCC surveillance compared to women. These differences were more pronounced during the COVID-19 pandemic surge. Obtaining appropriate surveillance is important and retrospective evaluations can help us determine the presence of health-related social needs so that progress can be made toward achieving health equity.
{"title":"Sex and Race Disparities in Hepatocellular Carcinoma Surveillance in Patients With Chronic Hepatitis B During COVID-19: A Single-Center Retrospective Review.","authors":"William S Reiche, Stephen Cooper, Christopher J Destache, Suhail Sidhu, Bryce Schutte, Darby Keirns, Elezabeth Mac, Ian Ng, Haitam Buaisha, Manasa Velagapudi","doi":"10.14740/gr1614","DOIUrl":"https://doi.org/10.14740/gr1614","url":null,"abstract":"<p><strong>Background: </strong>The management of patients with chronic hepatitis B (CHB) is complex and spans multiple medical specialties. As a result of this complexity, patients with CHB often do not receive adequate monitoring including hepatocellular carcinoma (HCC) surveillance with abdominal ultrasonography. Previous studies have identified multiple factors associated with decreased HCC surveillance. We aimed to identify the impact of race and sex on HCC surveillance in patients with CHB.</p><p><strong>Methods: </strong>We performed a single health system chart review between January 2018 and January 2022. Differences between sex and race were evaluated using the Chi-square test and Fisher's exact test, and continuous variables were analyzed using analysis of variance (ANOVA).</p><p><strong>Results: </strong>A total of 248 patient records between January 2018 and January 2022 were evaluated. In total 37% of females were adequately screened for HCC in any of the 6-month time frames compared to 26% of males. During the coronavirus disease 2019 (COVID-19) surge, surveillance rates were reduced in both men and women. During the first 6 months of the COVID-19 surge, there was a significant difference in screening between men and women (19% vs. 35%, P = 0.026). There was a decrease in HCC screening across all races during the COVID-19 surge; however, no significant difference when comparing races was found.</p><p><strong>Conclusion: </strong>Men received less HCC surveillance compared to women. These differences were more pronounced during the COVID-19 pandemic surge. Obtaining appropriate surveillance is important and retrospective evaluations can help us determine the presence of health-related social needs so that progress can be made toward achieving health equity.</p>","PeriodicalId":12461,"journal":{"name":"Gastroenterology Research","volume":"16 4","pages":"203-208"},"PeriodicalIF":1.5,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/16/3a/gr-16-203.PMC10482603.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10211662","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Recently, the effects of Helicobacter pylori (H. pylori) infection on the prognosis of chronic atrophic gastritis (CAG) are still unclear. The aim of our study was to discuss the role of H. pylori infection on the prognosis of CAG by inducing the M1/M2 macrophage polarization.
Methods: A total of 180 subjects as control (group 1), CAG patients without H. pylori infection (group 2) and H. pylori-associated CAG patients (group 3) were respectively recruited for this cross-sectional investigation in Daqing Oilfield General Hospital from May 2019 to July 2020. Their serum samples were collected to determine the concentrations of pro-inflammatory and anti-inflammatory cytokines. Meanwhile, the gastric mucosa was excised to determine the related gene expressions on the M1/M2 macrophage polarization. Then the prognosis of CAG was evaluated according to the status of clinical manifestations and endoscopic examination after the follow-up.
Results: Notably, it was proved that compared with the control group, the expressions and concentrations of pro-inflammatory cytokines (M1 macrophage: inducible nitric oxide synthase (iNOS), tumor necrosis factor-alpha (TNF-α), interferon-gamma (IFN-γ), and interleukin-6 (IL-6)) were significantly higher, while the anti-inflammatory cytokines (M2 macrophage: arginase-1 (Arg-1), IL-4 and IL-10) were apparently reduced in the group 2 and group 3 (P < 0.05). Moreover, more days were needed for the prognosis of CAG in group 3 than those in group 2, which was accompanied by higher expressions of pro-inflammatory and lower anti-inflammatory cytokines at the baseline (P < 0.05). Furthermore, negative correlations were shown between the concentrations of iNOS, TNF-α, IFN-γ and IL-6, and the prognosis of CAG (P < 0.05), while positive correlations were observed between the contents of IL-4 and IL-10, and prognosis of CAG (P < 0.05).
Conclusion: These above results indicated that H. pylori infection-induced disorders of M1/M2 macrophage polarization could affect the prognosis of CAG.
{"title":"Effects of <i>Helicobacter pylori</i> Infection on the Prognosis of Chronic Atrophic Gastritis by Inducing the Macrophage Polarization.","authors":"Chun Na Zhao, Li Li Xiao, Ying Zhang","doi":"10.14740/gr1636","DOIUrl":"https://doi.org/10.14740/gr1636","url":null,"abstract":"<p><strong>Background: </strong>Recently, the effects of <i>Helicobacter pylori</i> (<i>H. pylori</i>) infection on the prognosis of chronic atrophic gastritis (CAG) are still unclear. The aim of our study was to discuss the role of <i>H. pylori</i> infection on the prognosis of CAG by inducing the M1/M2 macrophage polarization.</p><p><strong>Methods: </strong>A total of 180 subjects as control (group 1), CAG patients without <i>H. pylori</i> infection (group 2) and <i>H. pylori</i>-associated CAG patients (group 3) were respectively recruited for this cross-sectional investigation in Daqing Oilfield General Hospital from May 2019 to July 2020. Their serum samples were collected to determine the concentrations of pro-inflammatory and anti-inflammatory cytokines. Meanwhile, the gastric mucosa was excised to determine the related gene expressions on the M1/M2 macrophage polarization. Then the prognosis of CAG was evaluated according to the status of clinical manifestations and endoscopic examination after the follow-up.</p><p><strong>Results: </strong>Notably, it was proved that compared with the control group, the expressions and concentrations of pro-inflammatory cytokines (M1 macrophage: inducible nitric oxide synthase (iNOS), tumor necrosis factor-alpha (TNF-α), interferon-gamma (IFN-γ), and interleukin-6 (IL-6)) were significantly higher, while the anti-inflammatory cytokines (M2 macrophage: arginase-1 (Arg-1), IL-4 and IL-10) were apparently reduced in the group 2 and group 3 (P < 0.05). Moreover, more days were needed for the prognosis of CAG in group 3 than those in group 2, which was accompanied by higher expressions of pro-inflammatory and lower anti-inflammatory cytokines at the baseline (P < 0.05). Furthermore, negative correlations were shown between the concentrations of iNOS, TNF-α, IFN-γ and IL-6, and the prognosis of CAG (P < 0.05), while positive correlations were observed between the contents of IL-4 and IL-10, and prognosis of CAG (P < 0.05).</p><p><strong>Conclusion: </strong>These above results indicated that <i>H. pylori</i> infection-induced disorders of M1/M2 macrophage polarization could affect the prognosis of CAG.</p>","PeriodicalId":12461,"journal":{"name":"Gastroenterology Research","volume":"16 4","pages":"226-233"},"PeriodicalIF":1.5,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/12/f3/gr-16-226.PMC10482605.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10211663","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-08-01Epub Date: 2023-08-26DOI: 10.14740/gr1624
Adnan Malik, Muhammad Imran Malik
Background: Patients with human immunodeficiency virus (HIV) infection suffer from alterations in gut microbiota due to recurrent gastrointestinal infections and systemic inflammation. Fecal microbiota transplantation (FMT) appears to be a potential therapy; however, there are concerns about its safety. Likewise, no previous meta-analysis evaluated FMT efficacy in HIV-infected patients.
Methods: We conducted a thorough electronic search on PubMed, Scopus, OVID, Web of Science, and Cochrane CENTRAL for clinical studies assessing the safety and efficacy of FMT in patients with HIV and gastrointestinal dysbiosis, where FMT was indicated to restore the disrupted microbiota.
Results: FMT significantly restored the typical microbiome in patients with Clostridium difficile (C. difficile) and non-C. difficile and reduced the risk of gastrointestinal infections in HIV patients receiving antiretroviral therapy (odds ratio (OR) = 0.774, 95% confidence interval (CI): (0.62, 0.966)). Furthermore, adverse events, such as distention and bloating, associated with FMT were comparable between HIV and health controls (OR = 0.60, 95% CI: (0.07, 4.6)), with no statistical difference.
Conclusions: Current evidence demonstrated that FMT is safe and effective in HIV patients suffering from alterations in gut microbiota. We recommend further multi-centric clinical studies to address the optimal transplant amount and source for FMT. To the best of our knowledge, this is the first meta-analysis to assess the safety and efficacy of FMT in patients with HIV.
背景:人类免疫缺陷病毒(HIV)感染患者因反复胃肠道感染和全身炎症而导致肠道微生物群改变。粪便微生物群移植(FMT)似乎是一种潜在的疗法,但其安全性令人担忧。同样,以前也没有荟萃分析评估过粪便微生物群移植在艾滋病病毒感染者中的疗效:我们在 PubMed、Scopus、OVID、Web of Science 和 Cochrane CENTRAL 上进行了一次全面的电子检索,以评估 FMT 在 HIV 感染者和胃肠道菌群失调患者中的安全性和有效性:结果:FMT 能明显恢复艰难梭菌(C. difficile)和非艰难梭菌患者的典型微生物群,降低接受抗逆转录病毒治疗的艾滋病患者的胃肠道感染风险(几率比(OR)= 0.774,95% 置信区间(CI):(0.62, 0.966))。此外,与 FMT 相关的不良事件,如腹胀和腹胀,在 HIV 感染者和健康对照组之间具有可比性(OR = 0.60,95% 置信区间:(0.07,4.6)),无统计学差异:目前的证据表明,FMT 对肠道微生物群发生变化的 HIV 患者是安全有效的。我们建议进一步开展多中心临床研究,以确定 FMT 的最佳移植量和来源。据我们所知,这是第一项评估 FMT 在艾滋病患者中的安全性和有效性的荟萃分析。
{"title":"Fecal Microbiota Transplantation in Human Immunodeficiency Virus-Infected Patient Population: A Systematic Review and Meta-Analysis.","authors":"Adnan Malik, Muhammad Imran Malik","doi":"10.14740/gr1624","DOIUrl":"10.14740/gr1624","url":null,"abstract":"<p><strong>Background: </strong>Patients with human immunodeficiency virus (HIV) infection suffer from alterations in gut microbiota due to recurrent gastrointestinal infections and systemic inflammation. Fecal microbiota transplantation (FMT) appears to be a potential therapy; however, there are concerns about its safety. Likewise, no previous meta-analysis evaluated FMT efficacy in HIV-infected patients.</p><p><strong>Methods: </strong>We conducted a thorough electronic search on PubMed, Scopus, OVID, Web of Science, and Cochrane CENTRAL for clinical studies assessing the safety and efficacy of FMT in patients with HIV and gastrointestinal dysbiosis, where FMT was indicated to restore the disrupted microbiota.</p><p><strong>Results: </strong>FMT significantly restored the typical microbiome in patients with <i>Clostridium difficile</i> (<i>C. difficile</i>) and non-<i>C. difficile</i> and reduced the risk of gastrointestinal infections in HIV patients receiving antiretroviral therapy (odds ratio (OR) = 0.774, 95% confidence interval (CI): (0.62, 0.966)). Furthermore, adverse events, such as distention and bloating, associated with FMT were comparable between HIV and health controls (OR = 0.60, 95% CI: (0.07, 4.6)), with no statistical difference.</p><p><strong>Conclusions: </strong>Current evidence demonstrated that FMT is safe and effective in HIV patients suffering from alterations in gut microbiota. We recommend further multi-centric clinical studies to address the optimal transplant amount and source for FMT. To the best of our knowledge, this is the first meta-analysis to assess the safety and efficacy of FMT in patients with HIV.</p>","PeriodicalId":12461,"journal":{"name":"Gastroenterology Research","volume":"16 4","pages":"209-216"},"PeriodicalIF":1.4,"publicationDate":"2023-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://ftp.ncbi.nlm.nih.gov/pub/pmc/oa_pdf/7a/f4/gr-16-209.PMC10482600.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"10211667","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}