-
Frontiers in Endocrinology 2023Sodium-glucose co-transporter 2 (SGLT2) inhibitors provide cardiovascular protection for patients with heart failure (HF) and type 2 diabetes mellitus (T2DM). However,... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Sodium-glucose co-transporter 2 (SGLT2) inhibitors provide cardiovascular protection for patients with heart failure (HF) and type 2 diabetes mellitus (T2DM). However, there is little evidence of their application in patients with chronic kidney disease (CKD). Furthermore, there are inconsistent results from studies on their uses. Therefore, to explore the cardiovascular protective effect of SGLT2 inhibitors in the CKD patient population, we conducted a systematic review and meta-analysis to evaluate the cardiovascular effectiveness and safety of SGLT2 inhibitors in this patient population.
METHOD
We searched the PubMed® (National Library of Medicine, Bethesda, MD, USA) and Web of Science™ (Clarivate™, Philadelphia, PA, USA) databases for randomized controlled trials (RCTs) of SGLT2 inhibitors in CKD patients and built the database starting in January 2023. In accordance with our inclusion and exclusion criteria, the literature was screened, the quality of the literature was evaluated, and the data were extracted. RevMan 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark) and Stata® 17.0 (StataCorp LP, College Station, TX, USA) were used for the statistical analyses. Hazard ratios (HRs), odds ratios (ORs), and corresponding 95% confidence intervals (CIs) were used for the analysis of the outcome indicators.
RESULTS
Thirteen RCTs were included. In CKD patients, SGLT2 inhibitors reduced the risk of cardiovascular death (CVD) or hospitalization for heart failure (HHF) by 28%, CVD by 16%. and HHF by 35%. They also reduced the risk of all-cause death by 14% without increasing the risk of serious adverse effects (SAEs) and urinary tract infections (UTIs). However, they increased the risk of reproductive tract infections (RTIs).
CONCLUSION
SGLT2 inhibitors have a cardiovascular protective effect on patients with CKD, which in turn can significantly reduce the risk of CVD, HHF, and all-cause death without increasing the risk of SAEs and UTIs but increasing the risk of RTIs.
Topics: United States; Humans; Sodium-Glucose Transporter 2 Inhibitors; Diabetes Mellitus, Type 2; Renal Insufficiency, Chronic; Cardiovascular Diseases; Heart Failure
PubMed: 38047108
DOI: 10.3389/fendo.2023.1236404 -
Nephrology (Carlton, Vic.) May 2017Total parathyroidectomy with autotransplantation (TPTX + AT) and subtotal parathyroidectomy (SPTX) have been recommended to patients with renal hyperparathyroidism... (Meta-Analysis)
Meta-Analysis Review
AIM
Total parathyroidectomy with autotransplantation (TPTX + AT) and subtotal parathyroidectomy (SPTX) have been recommended to patients with renal hyperparathyroidism (RHPT).But which one is the best surgical method remains controversial. The aim of the present study was to compare the two surgical procedures with respect to long-term outcomes.
METHODS
A literature search was undertaken using Medline, EMBASE, CNKI and CBM from inception to May 2015. Study quality was assessed using the Newcastle-Ottawa Scale. Data were analyzed using Review Manager version 5.1.0.
RESULTS
A total of 13 studies comprising 1589 patients with renal failure were identified. There was no statistically significant difference in the rate of symptomatic improvement (OR 0.77; 95%CI 0.22 to 2.69; P = 0.68), radiological success (OR 0.17; 95%CI 0.02 to 1.56; P = 0.90), hyperparathyroidism recurrence or persistence (OR 1.31; 95%CI 0.65 to 2.65; P = 0.45) and reoperation (OR 1.55; 95%CI 0.62 to 3.86; P = 0.35) between TPTX + AT and SPTX. The effects on serum calcium and parathyroid hormone (PTH) were similar between two surgical protocols.
CONCLUSION
Both the TPTX + AT and SPTX were effective in treating RHPT and preventing recurrence. The difference between the two surgeries in recurrence or persistence and reoperation rate was insignificant. Further prospective, randomized controlled trials with high statistic power are necessary to comparative the two surgeries on the long term safety.
Topics: Adult; Biomarkers; Calcium; Chi-Square Distribution; Female; Humans; Hyperparathyroidism, Secondary; Male; Middle Aged; Odds Ratio; Parathyroid Hormone; Parathyroidectomy; Postoperative Complications; Recurrence; Renal Insufficiency; Risk Factors; Time Factors; Transplantation, Autologous; Treatment Outcome
PubMed: 27085089
DOI: 10.1111/nep.12801 -
World Journal of Urology Jul 2023To determine the role of pressure pop-off mechanisms, including vesicoureteral reflux and renal dysplasia (VURD) syndrome, in determining long-term kidney outcomes in... (Meta-Analysis)
Meta-Analysis
PURPOSE
To determine the role of pressure pop-off mechanisms, including vesicoureteral reflux and renal dysplasia (VURD) syndrome, in determining long-term kidney outcomes in boys with posterior urethral valves (PUV).
METHODS
A systematic search was performed in December 2022. Descriptive and comparative studies with a defined pressure pop-off group were included. Assessed outcomes included end-stage renal disease (ESRD), kidney insufficiency (defined as chronic kidney disease [CKD] stage 3 + or SCr > 1.5 mg/dL), and kidney function. Pooled proportions and relative risks (RR) with 95% confidence intervals (CI) were extrapolated from available data for quantitative synthesis. Random-effects meta-analyses were performed according to the study design and techniques. The risk of bias was assessed with the QUIPS tool and GRADE quality of evidence. The systematic review was prospectively registered on PROSPERO (CRD42022372352).
RESULTS
A total of 15 studies describing 185 patients with a median follow-up of 6.8 years were included. By the last follow-up, overall effect estimates demonstrate the prevalence of CKD and ESRD to be 15.2% and 4.1%, respectively. There was no significant difference in the risk of ESRD in patients with pop-off compared to no pop-off patients [RR 0.34, 95%CI 0.12, 1.10; p = 0.07]. There was a significantly reduced risk for kidney insufficiency in boys with pop-off [RR 0.57, 95%CI 0.34, 0.97; p = 0.04], but this protective effect was not re-demonstrated after excluding studies with inadequate reporting of CKD outcomes [RR 0.63, 95%CI 0.36, 1.10; p = 0.10]. Included study quality was low, with 6 studies having moderate risk and 9 having a high risk of bias.
CONCLUSIONS
Pop-off mechanisms may be associated with reducing the risk of kidney insufficiency, but current certainty in the evidence is low. Further research is warranted to investigate sources of heterogeneity and long-term sequelae in pressure pop-offs.
Topics: Male; Humans; Kidney Failure, Chronic; Kidney; Renal Insufficiency, Chronic; Urethral Obstruction; Disease Progression
PubMed: 37330439
DOI: 10.1007/s00345-023-04451-7 -
Health Technology Assessment... Apr 2010Chronic kidney disease (CKD) is a long-term condition and has been described as the gradual loss of kidney function over time. Early in the disease process, people with... (Review)
Review
Early referral strategies for management of people with markers of renal disease: a systematic review of the evidence of clinical effectiveness, cost-effectiveness and economic analysis.
BACKGROUND
Chronic kidney disease (CKD) is a long-term condition and has been described as the gradual loss of kidney function over time. Early in the disease process, people with CKD often experience no symptoms. For a long time, CKD has been an underdiagnosed condition. Even in the absence of symptoms, CKD appears to add significantly to the burden of cardiovascular disease and death and, for an important minority, can progress to kidney failure.
OBJECTIVE
To systematically review the evidence of the clinical effectiveness and cost-effectiveness of early referral strategies for management of people with markers of renal disease.
DATA SOURCES
Electronic searches of 12 major databases (such as MEDLINE, EMBASE, CINAHL, etc.) were conducted for the time period of 1990 to April 2008 to identify studies comparing early referral to other care options for people with CKD. Additional searching was performed in the NHS Economic Evaluation Database to support the cost-effectiveness literature review.
REVIEW METHODS
Two authors reviewed all titles, abstracts and full papers to select relevant literature. A Markov model was constructed to represent the natural history of CKD. The model allowed cohorts to be tracked according to estimated glomerular filtration rate (eGFR) status and the presence of other complications known to influence CKD progression and the incidence of cardiovascular events.
RESULTS
From 36 relevant natural history studies, CKD was found to be, despite marked heterogeneity between studies, a marker of increased risk of mortality, renal progression and end-stage renal disease. Mortality was generally high and increased with stage of CKD. After adjustment for comorbidities, the relative risk of mortality among those with CKD identified from the general population increased with stage. For clinical populations, the relative risk was higher. All three outcomes increased as eGFR fell. Only seven studies, and no randomised controlled trials, were identified as relevant to assessing the clinical effectiveness of early referral strategies for CKD. In the five retrospective studies constructed from cohorts starting on renal replacement therapy (RRT), mortality was reduced in the early referral group (more than 12 months prior to RRT) even as late as 5 years after initiation of RRT. Only two studies included predialysis participants. One study, in people screened for diabetic nephropathy, reported a reduction in the decline in renal function associated with early referral to nephrology specialists (eGFR decline 3.4 ml/min/1.73 m(2)) when compared with a similar group that had no access to nephrology services until dialysis was required (eGFR decline 12.0 ml/min/1.73 m(2)). The second study, among a group of veterans with two creatinine levels of at least 140 mg/dl, reported that a composite end point of death or progression was lower in the group receiving nephrology follow-up than in those receiving only primary care follow-up. The greatest effect was observed in those with stage 3 or worse disease after adjustment for comorbidities, age, race, smoking and proteinuria {stage 3: hazard ratio (HR) 0.8 [95% confidence interval (CI) 0.61 to 0.9)]; stage 4: HR 0.75 (95% CI 0.45 to 0.89)}. In the base-case analysis, all early referral strategies produced more quality-adjusted life-years (QALYs) than referral upon transit to stage 5 CKD (eGFR 15 ml/min/1.73 m(2)). Referral for everyone with an eGFR below 60 ml/min/1.73 m(2) (stage 3a CKD) generated the most QALYs and, compared with referral for stage 4 CKD (eGFR < 30 ml/min/1.73 m(2)), had an incremental cost-effectiveness ratio of approximately 3806 pounds per QALY.
LIMITATIONS
Because of a lack of data on the natural history of CKD in individuals without diabetes, and a lack of evidence on the costs and effects of early referral, the Markov model relied on many assumptions. The findings were particularly sensitive to changes in eGFR decline rates and the relative effect of early referral on CKD progression and cardiovascular events; the latter parameter being derived from a single non-randomised study.
CONCLUSIONS
Despite substantial focus on the early identification and proactive management of CKD in the last few years, we have identified significant evidence gaps about how best to manage people with CKD. There was some evidence to suggest that the care of people with CKD could be improved and, because these people are at risk from both renal and cardiovascular outcomes, strategies to improve the management of people with CKD have the potential to offer an efficient use of health service resources. Given the number of people now being recognised as having markers of kidney impairment, there is an urgent need for further research to support service change.
Topics: Biomarkers; Cardiovascular Diseases; Cost-Benefit Analysis; Creatinine; Disease Progression; Early Diagnosis; Evidence-Based Practice; Humans; Kidney Function Tests; Markov Chains; Models, Econometric; Models, Organizational; Nephrology; Outcome Assessment, Health Care; Referral and Consultation; Renal Insufficiency, Chronic; Research Design; United Kingdom
PubMed: 20441712
DOI: 10.3310/hta14210 -
Blood Purification 2023Hyperphosphatemia is associated with cardiovascular morbidity and mortality in adults with chronic kidney disease (CKD). Drug therapy has an irreplaceable role in the... (Meta-Analysis)
Meta-Analysis
Comparative Efficacy and Acceptability of 12 Phosphorus-Lowering Drugs in Adults with Hyperphosphatemia and Chronic Kidney Disease: A Systematic Review and Network Meta-Analysis.
BACKGROUND
Hyperphosphatemia is associated with cardiovascular morbidity and mortality in adults with chronic kidney disease (CKD). Drug therapy has an irreplaceable role in the management of hyperphosphatemia.
OBJECTIVES
We aimed to compare and rank phosphorus-lowering drugs, including phosphate binder and nonphosphate binder, in hyperphosphatemia adults with CKD.
METHODS
We did a systematic review and frequentist random-effect network meta-analysis. We searched in PubMed, Cochrane Library, Web of Science, and Embase from inception to February 1, 2023, for randomized controlled trials of 12 phosphorus-lowering drugs in adults with hyperphosphatemia and CKD. Primary outcomes were efficacy (changes in serum phosphorus) and acceptability (treatment withdrawals due to any cause). We ranked each drug according to the value of surface under the cumulative ranking curve. We applied the Confidence in Network Meta-Analysis frameworks to rate the certainty of evidence. This study was registered with PROSPERO, number CRD42022322270.
RESULTS
We identified 2,174 citations, and of these, we included 94 trials comprising 14,459 participants and comparing 13 drugs or placebo. In terms of efficacy, except for niacinamide, all drugs lowered the level of serum phosphorus compared with placebo, with mean difference ranging between -1.61 (95% credible interval [CrI], -2.60 to -0.62) mg/dL for magnesium carbonate and -0.85 (-1.66 to -0.05) mg/dL for bixalomer. Only ferric citrate with odds ratios 0.56 (95% CrI: 0.36-0.89) was significantly associated with fewer dropouts for acceptability. Of the 94 trials, 43 (46%), 7 (7%), and 44 (47%) trials were rated as high, moderate, and low risk of bias, respectively, the certainty of the evidence was moderate to very low.
CONCLUSIONS
Magnesium carbonate has the best phosphorus-lowering effect in hyperphosphatemia adults with CKD; considering efficacy and acceptability, ferric citrate shows evidence to be the most appropriate drug with or without dialysis.
Topics: Humans; Adult; Hyperphosphatemia; Network Meta-Analysis; Renal Dialysis; Renal Insufficiency, Chronic
PubMed: 37591223
DOI: 10.1159/000531577 -
Journal of Nephrology May 2023Mineralocorticoid receptor antagonists (MRAs) were shown to delay chronic kidney disease (CKD) progression in patients with hypertension and/or heart failure (HF) and... (Review)
Review
BACKGROUND
Mineralocorticoid receptor antagonists (MRAs) were shown to delay chronic kidney disease (CKD) progression in patients with hypertension and/or heart failure (HF) and proteinuria.
OBJECTIVE
We conducted a systematic literature review on real-world evidence to identify the literature gaps related to the efficacy and safety outcomes of MRAs administered to CKD patients.
RESULTS
A total of 751 records were identified of which, 23 studies (26 publications) were analyzed. Studies included heterogeneous populations, including the overall CKD, CKD and diabetes, CKD and HF, and CKD and a history of cardiovascular disease. Most of the studies were small and non-rigorous, resulting in a notable lack of evidence in these populations. In the overall CKD population, steroidal MRAs resulted in a significant or sustained eGFR reduction but no efficacy in delaying progression to end-stage kidney disease. No cardiovascular protection was found. Results for all-cause mortality and hospitalization for HF were inconsistent; however, the longest follow-up studies indicate similar or lower incidence for spironolactone non-users. Most results consistently reported a higher incidence of hyperkalemia among patients on steroidal MRAs in all CKD stages, and side effects led to high discontinuation rates in the real-world setting.
CONCLUSIONS
Despite the limited availability of evidence on the effectiveness and safety of steroidal MRAs in CKD patients and subgroups with diabetes, HF or history of cardiovascular disease, MRAs were shown to have a limited effect on renal and cardiovascular outcomes. Gaps in the evidence regarding the efficacy and safety of MRAs are particularly relevant in diabetic CKD patients; therefore, further research is warranted.
Topics: Humans; Mineralocorticoid Receptor Antagonists; Cardiovascular Diseases; Mineralocorticoids; Renal Insufficiency, Chronic; Heart Failure; Diabetic Nephropathies
PubMed: 36422853
DOI: 10.1007/s40620-022-01492-w -
British Journal of Clinical Pharmacology Jul 2024Randomized controlled trials (RCTs) show a reduction in acute kidney injury, renal impairment and acute renal failure after initiation of a sodium glucose... (Review)
Review
Randomized controlled trials (RCTs) show a reduction in acute kidney injury, renal impairment and acute renal failure after initiation of a sodium glucose cotransporter-2 inhibitor. Observational literature on the association is conflicting, but important to understand for populations with a higher risk of medication-related adverse renal events. We aimed to systematically review the literature to summarize the association between sodium glucose cotransporter-2 inhibitor use and acute kidney injury, renal impairment and acute renal failure in three at-risk groups: older people aged >65 years, people with heart failure and people with reduced renal function. A systematic search of Embase (1974 until 23 February 2024) and PubMed (1946 until 23 February 2024) was performed. RCTs were included if they reported numbers of acute kidney injury or acute renal failure in people using sodium glucose cotransporter-2 inhibitors compared to other diabetic therapies. Studies needed to report results by level of renal function, heart failure status or age. Of 922 results, eight studies were included. The absolute risk of acute kidney injury or acute renal failure was higher in people >65 years compared to those <65 years, higher in people with heart failure (vs without) and higher in people with reduced kidney function (vs preserved kidney function), but insufficient evidence to determine if the relative effect of sodium glucose cotransporter-2 inhibitors on this risk was similar for each group. At-risk cohorts are associated with a higher incidence of acute kidney problems in users of sodium glucose cotransporter-2 inhibitors.
Topics: Aged; Humans; Acute Kidney Injury; Age Factors; Diabetes Mellitus, Type 2; Heart Failure; Randomized Controlled Trials as Topic; Renal Insufficiency; Risk Factors; Sodium-Glucose Transporter 2 Inhibitors
PubMed: 38784979
DOI: 10.1111/bcp.16088 -
BMJ Open Mar 2022To summarise available chronic kidney disease (CKD) diagnostic and prognostic models in low-income and middle-income countries (LMICs).
OBJECTIVE
To summarise available chronic kidney disease (CKD) diagnostic and prognostic models in low-income and middle-income countries (LMICs).
METHOD
Systematic review (Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines). We searched Medline, EMBASE, Global Health (these three through OVID), Scopus and Web of Science from inception to 9 April 2021, 17 April 2021 and 18 April 2021, respectively. We first screened titles and abstracts, and then studied in detail the selected reports; both phases were conducted by two reviewers independently. We followed the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies recommendations and used the Prediction model Risk Of Bias ASsessment Tool for risk of bias assessment.
RESULTS
The search retrieved 14 845 results, 11 reports were studied in detail and 9 (n=61 134) were included in the qualitative analysis. The proportion of women in the study population varied between 24.5% and 76.6%, and the mean age ranged between 41.8 and 57.7 years. Prevalence of undiagnosed CKD ranged between 1.1% and 29.7%. Age, diabetes mellitus and sex were the most common predictors in the diagnostic and prognostic models. Outcome definition varied greatly, mostly consisting of urinary albumin-to-creatinine ratio and estimated glomerular filtration rate. The highest performance metric was the negative predictive value. All studies exhibited high risk of bias, and some had methodological limitations.
CONCLUSION
There is no strong evidence to support the use of a CKD diagnostic or prognostic model throughout LMIC. The development, validation and implementation of risk scores must be a research and public health priority in LMIC to enhance CKD screening to improve timely diagnosis.
Topics: Adult; Developing Countries; Female; Glomerular Filtration Rate; Humans; Middle Aged; Poverty; Prognosis; Renal Insufficiency, Chronic
PubMed: 35292503
DOI: 10.1136/bmjopen-2021-058921 -
International Urology and Nephrology Mar 2024The risk of developing and worsening chronic kidney disease (CKD) is associated with unhealthy dietary patterns. Food insecurity is defined by a limited or uncertain... (Review)
Review
BACKGROUND
The risk of developing and worsening chronic kidney disease (CKD) is associated with unhealthy dietary patterns. Food insecurity is defined by a limited or uncertain availability of nutritionally adequate and safe food; it is also associated with several chronic medical conditions. The aim of this systematic review is to investigate the current knowledge about the relationship between food insecurity and renal disease.
METHODS
We selected the pertinent publications by searching on the PubMed, Scopus, and the Web of Science databases, without any temporal limitations being imposed. The searching and selecting processes were carried out through pinpointed inclusion and exclusion criteria and in accordance with the Prisma statement.
RESULTS
Out of the 26,548 items that were first identified, only 9 studies were included in the systemic review. Eight out of the nine investigations were conducted in the US, and one was conducted in Iran. The studies evaluated the relationship between food insecurity and (i) kidney disease in children, (ii) kidney stones, (iii) CKD, (iv) cardiorenal syndrome, and (v) end stage renal disease (ESRD). In total, the different research groups enrolled 49,533 subjects, and food insecurity was reported to be a risk factor for hospitalization, kidney stones, CKD, ESRD, and mortality.
CONCLUSIONS
The relationship between food insecurity and renal disease has been underestimated. Food insecurity is a serious risk factor for health problems in both wealthy and poor populations; however, the true prevalence of the condition is unknown. Healthcare professionals need to take action to prevent the dramatic effect of food insecurity on CKD and on other chronic clinical conditions.
Topics: Child; Humans; Food Supply; Kidney Failure, Chronic; Renal Insufficiency, Chronic; Kidney Calculi; Food Insecurity
PubMed: 37679580
DOI: 10.1007/s11255-023-03777-w -
Deutsche Medizinische Wochenschrift... Aug 2015The assessment of the renal function of patients with a deep vein thrombosis/pulmonary embolism (VTE patients) is of utmost importance for the selection/dosage of an... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND STUDY OBJECTIVES
The assessment of the renal function of patients with a deep vein thrombosis/pulmonary embolism (VTE patients) is of utmost importance for the selection/dosage of an agent in the initial anticoagulation management of these patients because the majority of available anticoagulants are cleared renally. Specifically, there is a high risk of drug accumulation and subsequent bleedings in patients with severe renal insufficiency. Consequently, specific recommendations have been made for the initial anticoagulation management of these patients in both product labels and AWMF treatment recommendations: some drugs should not be used in these patients, for other drugs a careful use, intensified screening (anti-Xa), or, in the case of enoxaparin, a dose-adjustment are recommended.This literature review aimed to answer the following questions: · What is the prevalence of renal insufficiency in VTE patients?. · Which data are available with regard to the real-world initial anticoagulation management and corresponding clinical outcomes (recurrent VTE events, bleedings, mortality) of these patients?
METHODOLOGY
We did a systematic review of existing publications in german or english published in 2004-2014. Only quantitative analyses have been included in the review.
RESULTS
We identified 1,135 publications, 37 of them were included in our review. The prevalence of renal insufficiency in VTE patients, defined as CrCl < 60 ml / min, was reported to be 12.3 %-71.9 % related to all VTE patients. The prevalence of severe renal insufficiency, defined as CrCl < 30 ml / min, was reported to be 3,3 %-13,6 %. The substantial ranges in reported prevalences are mainly due to differences in the characteristics of patients addressed in the different publications.A CrCl < 30 ml / min is an independent predictor for both mortality and lethal recurrent pulmonary embolism, possibly also for severe bleedings in VTE patients. In addition to that, a severe renal insufficiency may also be a predictor for the probability that a first VTE event occurs.Several anticoagulants approved for the initial anticoagulation management of VTE patients face the risk of drug accumulation in renally insufficent patients. So, for example, a standard enoxaparin dosage was shown to be associated with elevated bleeding risk compared to adjusted enoxaparin dosage in renally insufficient patients. However, similar data do not exist for other low molecular weight heparins (LMWHs) or unfractioned heparins (UFHs). Only for two LMWHs, Certoparin and Tinzaparin, safety data with regard to renally insufficient patients have been published so far.None of the included studies showed advantages of UFH therapy in comparison to LMWH therapy in initial anticoagulation management of VTE patients. In contrast to that, available evidence shows disadvantageous efficacy/safety of UFH in comparison to LMWH treatment. However, this evidence is not based on head-to-head comparisons but is derived from registry and observational study data only.
CONCLUSION
A detailed knowledge of product labels is of utmost importance in the inital anticoagulation treatment of VTE patients because several agents may not be used in the addressed patients with severe renal insufficiency at all while others may be used based on specific dosage/surveillance schemes only. We also recommend to critically appraise the current AWMF treatment guideline because it still recommends initial anticoagulation management with UFHs in VTE patients with severe renal insufficiency. Available data do not support that recommendation.
Topics: Anticoagulants; Causality; Comorbidity; Hemorrhage; Humans; Renal Insufficiency; Risk Assessment; Risk Factors; Survival Rate; Thromboembolism; Treatment Outcome
PubMed: 26306024
DOI: 10.1055/s-0041-103168