Prognostic value of malondialdehyde serum levels in severe sepsis: a multicenter study
The oxidant/antioxidant state in septic patients has only been studied in small series. We wished to determine whether malondialdehyde (MDA) serum levels were associated with severity and 30-day mortality in a large series of patients with sepsis. We performed an observational, prospective, multicen...
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| creator | Lorente, Leonardo Martín, María M Abreu-González, Pedro Domínguez-Rodríguez, Alberto Labarta, Lorenzo Díaz, César Solé-Violán, Jordi Ferreres, José Borreguero-León, Juan María Jiménez, Alejandro Morera-Fumero, Armando |
| description | The oxidant/antioxidant state in septic patients has only been studied in small series. We wished to determine whether malondialdehyde (MDA) serum levels were associated with severity and 30-day mortality in a large series of patients with sepsis.
We performed an observational, prospective, multicenter study in six Spanish Intensive Care Units. Serum levels of MDA were measured in a total of 228 patients (145 survivors and 83 non-survivors) with severe sepsis and 100 healthy controls.
Serum levels of MDA were higher in severe septic patients than in healthy controls. Non-surviving septic patients had higher MDA values than survivors. MDA serum levels were associated with severity markers (lactic acid, SOFA, APACHE-II) and coagulation indices. Regression analysis showed that MDA serum levels were associated with 30-day survival (Hazard ratio = 1.05; 95% confidence interval = 1.009-1.091; p = 0.016). Receiver operating characteristic analysis showed that the area under curve of MDA serum levels to predict 30-day survival was 0.62 (95% CI = 0.56-0.69; P = 0.002). The risk of death in septic patients with MDA serum levels above 4.11 nmol/mL was higher than in patients with lower values (Hazard Ratio = 2.43; 95% CI = 1.49-3.94; p |
| doi_str_mv | 10.1371/journal.pone.0053741 |
| format | Article |
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We performed an observational, prospective, multicenter study in six Spanish Intensive Care Units. Serum levels of MDA were measured in a total of 228 patients (145 survivors and 83 non-survivors) with severe sepsis and 100 healthy controls.
Serum levels of MDA were higher in severe septic patients than in healthy controls. Non-surviving septic patients had higher MDA values than survivors. MDA serum levels were associated with severity markers (lactic acid, SOFA, APACHE-II) and coagulation indices. Regression analysis showed that MDA serum levels were associated with 30-day survival (Hazard ratio = 1.05; 95% confidence interval = 1.009-1.091; p = 0.016). Receiver operating characteristic analysis showed that the area under curve of MDA serum levels to predict 30-day survival was 0.62 (95% CI = 0.56-0.69; P = 0.002). The risk of death in septic patients with MDA serum levels above 4.11 nmol/mL was higher than in patients with lower values (Hazard Ratio = 2.43; 95% CI = 1.49-3.94; p<0.001).
The novel findings of our study on severe septic patients, to our knowledge the largest series providing data on the oxidative state, are that elevated MDA serum levels probably represent an unbalanced oxidant state and are related with poor prognosis in patients with severe sepsis.</description><identifier>ISSN: 1932-6203</identifier><identifier>EISSN: 1932-6203</identifier><identifier>DOI: 10.1371/journal.pone.0053741</identifier><identifier>PMID: 23341989</identifier><language>eng</language><publisher>United States: Public Library of Science</publisher><subject>Adult ; Aged ; Analysis ; Antioxidants ; Biomarkers - blood ; Blood ; Chronic obstructive pulmonary disease ; Clinical outcomes ; Coagulation ; Confidence intervals ; Diabetes ; Female ; Health aspects ; Heart attacks ; Hospitals ; Humans ; Infection ; Intensive care ; Intensive care units ; Lactic acid ; Male ; Malondialdehyde ; Malondialdehyde - blood ; Medical prognosis ; Medical research ; Medicine ; Melatonin ; Middle Aged ; Mortality ; Oxidizing agents ; Patients ; Physiology ; Prognosis ; Prospective Studies ; Regression Analysis ; ROC Curve ; Rodents ; Sepsis ; Sepsis - blood ; Sepsis - diagnosis ; Serum levels ; Statistical analysis ; Survival ; Tumor necrosis factor-TNF ; Variables</subject><ispartof>PloS one, 2013-01, Vol.8 (1), p.e53741-e53741</ispartof><rights>COPYRIGHT 2013 Public Library of Science</rights><rights>2013 Lorente et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License: https://creativecommons.org/licenses/by/4.0/ (the “License”), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>2013 Lorente et al 2013 Lorente et al</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c585t-123db01f81c2a03846b922bbc3249ee11ee884db116d28da10f4fc07e16096e83</citedby><cites>FETCH-LOGICAL-c585t-123db01f81c2a03846b922bbc3249ee11ee884db116d28da10f4fc07e16096e83</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544841/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3544841/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,723,776,780,860,881,2096,2915,23845,27901,27902,53766,53768,79569,79570</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/23341989$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Lorente, Leonardo</creatorcontrib><creatorcontrib>Martín, María M</creatorcontrib><creatorcontrib>Abreu-González, Pedro</creatorcontrib><creatorcontrib>Domínguez-Rodríguez, Alberto</creatorcontrib><creatorcontrib>Labarta, Lorenzo</creatorcontrib><creatorcontrib>Díaz, César</creatorcontrib><creatorcontrib>Solé-Violán, Jordi</creatorcontrib><creatorcontrib>Ferreres, José</creatorcontrib><creatorcontrib>Borreguero-León, Juan María</creatorcontrib><creatorcontrib>Jiménez, Alejandro</creatorcontrib><creatorcontrib>Morera-Fumero, Armando</creatorcontrib><title>Prognostic value of malondialdehyde serum levels in severe sepsis: a multicenter study</title><title>PloS one</title><addtitle>PLoS One</addtitle><description>The oxidant/antioxidant state in septic patients has only been studied in small series. We wished to determine whether malondialdehyde (MDA) serum levels were associated with severity and 30-day mortality in a large series of patients with sepsis.
We performed an observational, prospective, multicenter study in six Spanish Intensive Care Units. Serum levels of MDA were measured in a total of 228 patients (145 survivors and 83 non-survivors) with severe sepsis and 100 healthy controls.
Serum levels of MDA were higher in severe septic patients than in healthy controls. Non-surviving septic patients had higher MDA values than survivors. MDA serum levels were associated with severity markers (lactic acid, SOFA, APACHE-II) and coagulation indices. Regression analysis showed that MDA serum levels were associated with 30-day survival (Hazard ratio = 1.05; 95% confidence interval = 1.009-1.091; p = 0.016). Receiver operating characteristic analysis showed that the area under curve of MDA serum levels to predict 30-day survival was 0.62 (95% CI = 0.56-0.69; P = 0.002). The risk of death in septic patients with MDA serum levels above 4.11 nmol/mL was higher than in patients with lower values (Hazard Ratio = 2.43; 95% CI = 1.49-3.94; p<0.001).
The novel findings of our study on severe septic patients, to our knowledge the largest series providing data on the oxidative state, are that elevated MDA serum levels probably represent an unbalanced oxidant state and are related with poor prognosis in patients with severe sepsis.</description><subject>Adult</subject><subject>Aged</subject><subject>Analysis</subject><subject>Antioxidants</subject><subject>Biomarkers - blood</subject><subject>Blood</subject><subject>Chronic obstructive pulmonary disease</subject><subject>Clinical outcomes</subject><subject>Coagulation</subject><subject>Confidence intervals</subject><subject>Diabetes</subject><subject>Female</subject><subject>Health aspects</subject><subject>Heart attacks</subject><subject>Hospitals</subject><subject>Humans</subject><subject>Infection</subject><subject>Intensive care</subject><subject>Intensive care units</subject><subject>Lactic acid</subject><subject>Male</subject><subject>Malondialdehyde</subject><subject>Malondialdehyde - blood</subject><subject>Medical prognosis</subject><subject>Medical research</subject><subject>Medicine</subject><subject>Melatonin</subject><subject>Middle Aged</subject><subject>Mortality</subject><subject>Oxidizing agents</subject><subject>Patients</subject><subject>Physiology</subject><subject>Prognosis</subject><subject>Prospective Studies</subject><subject>Regression Analysis</subject><subject>ROC Curve</subject><subject>Rodents</subject><subject>Sepsis</subject><subject>Sepsis - blood</subject><subject>Sepsis - diagnosis</subject><subject>Serum levels</subject><subject>Statistical analysis</subject><subject>Survival</subject><subject>Tumor necrosis factor-TNF</subject><subject>Variables</subject><issn>1932-6203</issn><issn>1932-6203</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2013</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><sourceid>BENPR</sourceid><sourceid>DOA</sourceid><recordid>eNptkk2P0zAQhi0EYpfCP0AQCQlxafFXEpsD0mq1CyutBAfgajn2pHXlxMVOKvXf49DsqkWcbI8fv_POeBB6TfCKsJp83IYx9tqvdqGHFcYlqzl5gi6JZHRZUcyenuwv0IuUthMkquo5uqCMcSKFvES_vsew7kManCn22o9QhLbotA-9ddpb2BwsFAni2BUe9uBT4fp83kOcwrvk0qdCF93oswD0A8QiDaM9vETPWu0TvJrXBfp5e_Pj-uvy_tuXu-ur-6UpRTksCWW2waQVxFCNmeBVIyltGsMolwCEAAjBbUNIZamwmuCWtwbXQCosKxBsgd4edXc-JDW3JClChRR1yUqeibsjYYPeql10nY4HFbRTfwMhrpWO2bwHpRveEkkak8U55rUGgaVlDa5MbTGfsn2es41NB3YqOGp_Jnp-07uNWoe9yka44CQLfJgFYvg9QhpU55IB73UPYZx810xgLvNHLdC7f9D_VzdTa50LcH0bcl4ziaorXgsqqiyXqfcn1Aa0HzYp-HFwoU_nID-CJoaUIrSPtRGspql7MKGmqVPz1OVnb0778vjoYczYH6tX1CI</recordid><startdate>20130114</startdate><enddate>20130114</enddate><creator>Lorente, Leonardo</creator><creator>Martín, María M</creator><creator>Abreu-González, Pedro</creator><creator>Domínguez-Rodríguez, Alberto</creator><creator>Labarta, Lorenzo</creator><creator>Díaz, César</creator><creator>Solé-Violán, Jordi</creator><creator>Ferreres, José</creator><creator>Borreguero-León, Juan María</creator><creator>Jiménez, Alejandro</creator><creator>Morera-Fumero, Armando</creator><general>Public Library of Science</general><general>Public Library of Science (PLoS)</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7QG</scope><scope>7QL</scope><scope>7QO</scope><scope>7RV</scope><scope>7SN</scope><scope>7SS</scope><scope>7T5</scope><scope>7TG</scope><scope>7TM</scope><scope>7U9</scope><scope>7X2</scope><scope>7X7</scope><scope>7XB</scope><scope>88E</scope><scope>8AO</scope><scope>8C1</scope><scope>8FD</scope><scope>8FE</scope><scope>8FG</scope><scope>8FH</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABJCF</scope><scope>ABUWG</scope><scope>AEUYN</scope><scope>AFKRA</scope><scope>ARAPS</scope><scope>ATCPS</scope><scope>AZQEC</scope><scope>BBNVY</scope><scope>BENPR</scope><scope>BGLVJ</scope><scope>BHPHI</scope><scope>C1K</scope><scope>CCPQU</scope><scope>D1I</scope><scope>DWQXO</scope><scope>FR3</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>H94</scope><scope>HCIFZ</scope><scope>K9.</scope><scope>KB.</scope><scope>KB0</scope><scope>KL.</scope><scope>L6V</scope><scope>LK8</scope><scope>M0K</scope><scope>M0S</scope><scope>M1P</scope><scope>M7N</scope><scope>M7P</scope><scope>M7S</scope><scope>NAPCQ</scope><scope>P5Z</scope><scope>P62</scope><scope>P64</scope><scope>PATMY</scope><scope>PDBOC</scope><scope>PHGZM</scope><scope>PHGZT</scope><scope>PIMPY</scope><scope>PJZUB</scope><scope>PKEHL</scope><scope>PPXIY</scope><scope>PQEST</scope><scope>PQGLB</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>PTHSS</scope><scope>PYCSY</scope><scope>RC3</scope><scope>7X8</scope><scope>5PM</scope><scope>DOA</scope></search><sort><creationdate>20130114</creationdate><title>Prognostic value of malondialdehyde serum levels in severe sepsis: a multicenter study</title><author>Lorente, Leonardo ; Martín, María M ; Abreu-González, Pedro ; Domínguez-Rodríguez, Alberto ; Labarta, Lorenzo ; Díaz, César ; Solé-Violán, Jordi ; Ferreres, José ; Borreguero-León, Juan María ; Jiménez, Alejandro ; Morera-Fumero, Armando</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c585t-123db01f81c2a03846b922bbc3249ee11ee884db116d28da10f4fc07e16096e83</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2013</creationdate><topic>Adult</topic><topic>Aged</topic><topic>Analysis</topic><topic>Antioxidants</topic><topic>Biomarkers - blood</topic><topic>Blood</topic><topic>Chronic obstructive pulmonary disease</topic><topic>Clinical outcomes</topic><topic>Coagulation</topic><topic>Confidence intervals</topic><topic>Diabetes</topic><topic>Female</topic><topic>Health aspects</topic><topic>Heart attacks</topic><topic>Hospitals</topic><topic>Humans</topic><topic>Infection</topic><topic>Intensive care</topic><topic>Intensive care units</topic><topic>Lactic acid</topic><topic>Male</topic><topic>Malondialdehyde</topic><topic>Malondialdehyde - blood</topic><topic>Medical prognosis</topic><topic>Medical research</topic><topic>Medicine</topic><topic>Melatonin</topic><topic>Middle Aged</topic><topic>Mortality</topic><topic>Oxidizing agents</topic><topic>Patients</topic><topic>Physiology</topic><topic>Prognosis</topic><topic>Prospective Studies</topic><topic>Regression Analysis</topic><topic>ROC Curve</topic><topic>Rodents</topic><topic>Sepsis</topic><topic>Sepsis - blood</topic><topic>Sepsis - diagnosis</topic><topic>Serum levels</topic><topic>Statistical analysis</topic><topic>Survival</topic><topic>Tumor necrosis factor-TNF</topic><topic>Variables</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Lorente, Leonardo</creatorcontrib><creatorcontrib>Martín, María M</creatorcontrib><creatorcontrib>Abreu-González, Pedro</creatorcontrib><creatorcontrib>Domínguez-Rodríguez, Alberto</creatorcontrib><creatorcontrib>Labarta, Lorenzo</creatorcontrib><creatorcontrib>Díaz, César</creatorcontrib><creatorcontrib>Solé-Violán, Jordi</creatorcontrib><creatorcontrib>Ferreres, José</creatorcontrib><creatorcontrib>Borreguero-León, Juan María</creatorcontrib><creatorcontrib>Jiménez, Alejandro</creatorcontrib><creatorcontrib>Morera-Fumero, Armando</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Animal Behavior Abstracts</collection><collection>Bacteriology Abstracts (Microbiology B)</collection><collection>Biotechnology Research Abstracts</collection><collection>Nursing & Allied Health Database</collection><collection>Ecology Abstracts</collection><collection>Entomology Abstracts (Full archive)</collection><collection>Immunology Abstracts</collection><collection>Meteorological & Geoastrophysical Abstracts</collection><collection>Nucleic Acids Abstracts</collection><collection>Virology and AIDS Abstracts</collection><collection>Agricultural Science Collection</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Medical Database (Alumni Edition)</collection><collection>ProQuest Pharma Collection</collection><collection>Public Health Database</collection><collection>Technology Research Database</collection><collection>ProQuest SciTech Collection</collection><collection>ProQuest Technology Collection</collection><collection>ProQuest Natural Science Collection</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Materials Science & Engineering Collection</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest One Sustainability</collection><collection>ProQuest Central UK/Ireland</collection><collection>Advanced Technologies & Aerospace Collection</collection><collection>Agricultural & Environmental Science Collection</collection><collection>ProQuest Central Essentials</collection><collection>Biological Science Collection</collection><collection>ProQuest Central</collection><collection>Technology Collection</collection><collection>Natural Science Collection</collection><collection>Environmental Sciences and Pollution Management</collection><collection>ProQuest One Community College</collection><collection>ProQuest Materials Science Collection</collection><collection>ProQuest Central Korea</collection><collection>Engineering Research Database</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>SciTech Premium Collection</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Materials Science Database</collection><collection>Nursing & Allied Health Database (Alumni Edition)</collection><collection>Meteorological & Geoastrophysical Abstracts - 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Academic</collection><collection>PubMed Central (Full Participant titles)</collection><collection>DOAJ Directory of Open Access Journals</collection><jtitle>PloS one</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Lorente, Leonardo</au><au>Martín, María M</au><au>Abreu-González, Pedro</au><au>Domínguez-Rodríguez, Alberto</au><au>Labarta, Lorenzo</au><au>Díaz, César</au><au>Solé-Violán, Jordi</au><au>Ferreres, José</au><au>Borreguero-León, Juan María</au><au>Jiménez, Alejandro</au><au>Morera-Fumero, Armando</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Prognostic value of malondialdehyde serum levels in severe sepsis: a multicenter study</atitle><jtitle>PloS one</jtitle><addtitle>PLoS One</addtitle><date>2013-01-14</date><risdate>2013</risdate><volume>8</volume><issue>1</issue><spage>e53741</spage><epage>e53741</epage><pages>e53741-e53741</pages><issn>1932-6203</issn><eissn>1932-6203</eissn><abstract>The oxidant/antioxidant state in septic patients has only been studied in small series. We wished to determine whether malondialdehyde (MDA) serum levels were associated with severity and 30-day mortality in a large series of patients with sepsis.
We performed an observational, prospective, multicenter study in six Spanish Intensive Care Units. Serum levels of MDA were measured in a total of 228 patients (145 survivors and 83 non-survivors) with severe sepsis and 100 healthy controls.
Serum levels of MDA were higher in severe septic patients than in healthy controls. Non-surviving septic patients had higher MDA values than survivors. MDA serum levels were associated with severity markers (lactic acid, SOFA, APACHE-II) and coagulation indices. Regression analysis showed that MDA serum levels were associated with 30-day survival (Hazard ratio = 1.05; 95% confidence interval = 1.009-1.091; p = 0.016). Receiver operating characteristic analysis showed that the area under curve of MDA serum levels to predict 30-day survival was 0.62 (95% CI = 0.56-0.69; P = 0.002). The risk of death in septic patients with MDA serum levels above 4.11 nmol/mL was higher than in patients with lower values (Hazard Ratio = 2.43; 95% CI = 1.49-3.94; p<0.001).
The novel findings of our study on severe septic patients, to our knowledge the largest series providing data on the oxidative state, are that elevated MDA serum levels probably represent an unbalanced oxidant state and are related with poor prognosis in patients with severe sepsis.</abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>23341989</pmid><doi>10.1371/journal.pone.0053741</doi><oa>free_for_read</oa></addata></record> |
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| identifier | ISSN: 1932-6203 |
| ispartof | PloS one, 2013-01, Vol.8 (1), p.e53741-e53741 |
| issn | 1932-6203 1932-6203 |
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| recordid | cdi_plos_journals_1289875354 |
| source | Public Library of Science (PLoS) Journals Open Access; MEDLINE; DOAJ Directory of Open Access Journals; Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals; PubMed Central; Free Full-Text Journals in Chemistry |
| subjects | Adult Aged Analysis Antioxidants Biomarkers - blood Blood Chronic obstructive pulmonary disease Clinical outcomes Coagulation Confidence intervals Diabetes Female Health aspects Heart attacks Hospitals Humans Infection Intensive care Intensive care units Lactic acid Male Malondialdehyde Malondialdehyde - blood Medical prognosis Medical research Medicine Melatonin Middle Aged Mortality Oxidizing agents Patients Physiology Prognosis Prospective Studies Regression Analysis ROC Curve Rodents Sepsis Sepsis - blood Sepsis - diagnosis Serum levels Statistical analysis Survival Tumor necrosis factor-TNF Variables |
| title | Prognostic value of malondialdehyde serum levels in severe sepsis: a multicenter study |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-02-21T20%3A02%3A40IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-gale_plos_&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Prognostic%20value%20of%20malondialdehyde%20serum%20levels%20in%20severe%20sepsis:%20a%20multicenter%20study&rft.jtitle=PloS%20one&rft.au=Lorente,%20Leonardo&rft.date=2013-01-14&rft.volume=8&rft.issue=1&rft.spage=e53741&rft.epage=e53741&rft.pages=e53741-e53741&rft.issn=1932-6203&rft.eissn=1932-6203&rft_id=info:doi/10.1371/journal.pone.0053741&rft_dat=%3Cgale_plos_%3EA478286804%3C/gale_plos_%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=1289875354&rft_id=info:pmid/23341989&rft_galeid=A478286804&rft_doaj_id=oai_doaj_org_article_ab4f191bc6094047ae809d3b06c7d048&rfr_iscdi=true |