Prevalence of non-tuberculous mycobacterial infections among tuberculosis suspects in Nigeria
Nigeria is ranked in the top five countries for tuberculosis deaths worldwide. This study investigated the mycobacterial agents associated with presumptive clinical pulmonary tuberculosis (TB) in Nigeria and evaluated the pattern and frequency of mycobacterial infections over twelve calendar months...
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| Veröffentlicht in: | PloS one 2013-05, Vol.8 (5), p.e63170-e63170 |
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| creator | Aliyu, Gambo El-Kamary, Samer S Abimiku, Alash'le Brown, Clayton Tracy, Kathleen Hungerford, Laura Blattner, William |
| description | Nigeria is ranked in the top five countries for tuberculosis deaths worldwide. This study investigated the mycobacterial agents associated with presumptive clinical pulmonary tuberculosis (TB) in Nigeria and evaluated the pattern and frequency of mycobacterial infections over twelve calendar months period.
Sputum samples from 1,603 consecutive new cases with presumptive diagnosis of TB were collected from August 2010 to July 2011. All sputum samples were incubated for detection of mycobacterial growth and those with positive acid fast bacilli (AFB) growth were tested to detect mycobacterium tuberculosis (MTB) complex and characterized to differentiate between MTB complex species. Cultures suggestive of Non-tuberculous mycobacterial infections (NTM) were sub-cultured and characterized.
Of the 1,603 patients screened, 444 (28%) culture-positive cases of pulmonary tuberculosis were identified. Of these, 375 (85%) were due to strains of MTB complex (354 cases of M. tuberculosis, 20 M. africanum and one case of M. bovis) and 69 (15%) were due to infection with NTM. In contrast to the MTB complex cases, the NTM cases were more likely to have been diagnosed during the calendar months of the Harmattan dust season (OR = 2.34, 1.28-4.29; p = 0.01), and aged older than 35 years (OR = 2.77, 1.52-5.02, p = 0.0007), but less likely to have AFB identified on their sputum smear (OR = 0.06, 0.02-0.14, p |
| doi_str_mv | 10.1371/journal.pone.0063170 |
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Sputum samples from 1,603 consecutive new cases with presumptive diagnosis of TB were collected from August 2010 to July 2011. All sputum samples were incubated for detection of mycobacterial growth and those with positive acid fast bacilli (AFB) growth were tested to detect mycobacterium tuberculosis (MTB) complex and characterized to differentiate between MTB complex species. Cultures suggestive of Non-tuberculous mycobacterial infections (NTM) were sub-cultured and characterized.
Of the 1,603 patients screened, 444 (28%) culture-positive cases of pulmonary tuberculosis were identified. Of these, 375 (85%) were due to strains of MTB complex (354 cases of M. tuberculosis, 20 M. africanum and one case of M. bovis) and 69 (15%) were due to infection with NTM. In contrast to the MTB complex cases, the NTM cases were more likely to have been diagnosed during the calendar months of the Harmattan dust season (OR = 2.34, 1.28-4.29; p = 0.01), and aged older than 35 years (OR = 2.77, 1.52-5.02, p = 0.0007), but less likely to have AFB identified on their sputum smear (OR = 0.06, 0.02-0.14, p<0.0001). Among those with NTM infection, cases 35 years or younger were more likely to have co-infection with HIV (3.76, 1.72-8.22; p = 0.0009) compared to those older than 35 years.
The high proportion of younger patients with clinical pulmonary TB due to NTM and co-infection with HIV and the likely role of the seasonal dust exposure in the occurrence of the disease, present novel public health challenges for prevention and treatment.</description><identifier>ISSN: 1932-6203</identifier><identifier>EISSN: 1932-6203</identifier><identifier>DOI: 10.1371/journal.pone.0063170</identifier><identifier>PMID: 23671669</identifier><language>eng</language><publisher>United States: Public Library of Science</publisher><subject>Adult ; Air bases ; Bacilli ; Bacterial infections ; Coinfection - epidemiology ; Coinfection - microbiology ; Coinfection - virology ; Comorbidity ; Dust ; Epidemiology ; Female ; Genotype & phenotype ; Health aspects ; HIV ; HIV Infections - epidemiology ; HIV Infections - virology ; Human immunodeficiency virus ; Humans ; Incidence ; Infections ; Infectious diseases ; Logistic Models ; Lung diseases ; Male ; Medicine ; Middle Aged ; Multivariate Analysis ; Mycobacterium Infections, Nontuberculous - epidemiology ; Mycobacterium Infections, Nontuberculous - microbiology ; Mycobacterium tuberculosis ; Mycobacterium tuberculosis - isolation & purification ; Nigeria - epidemiology ; Nontuberculous Mycobacteria - isolation & purification ; Patients ; Prevalence ; Public health ; Sampling methods ; Seasons ; Smear ; Sputum ; Sputum - microbiology ; Sputum - virology ; Stains & staining ; Tuberculosis ; Tuberculosis, Pulmonary - epidemiology ; Tuberculosis, Pulmonary - microbiology ; Virology ; Young Adult</subject><ispartof>PloS one, 2013-05, Vol.8 (5), p.e63170-e63170</ispartof><rights>COPYRIGHT 2013 Public Library of Science</rights><rights>2013 Aliyu 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 Aliyu et al 2013 Aliyu et al</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c758t-32f37490a135f10e942cb91ceafb143a3194ea4b3bf41b486231100e162a09443</citedby><cites>FETCH-LOGICAL-c758t-32f37490a135f10e942cb91ceafb143a3194ea4b3bf41b486231100e162a09443</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/PMC3650061/pdf/$$EPDF$$P50$$Gpubmedcentral$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3650061/$$EHTML$$P50$$Gpubmedcentral$$Hfree_for_read</linktohtml><link.rule.ids>230,314,727,780,784,864,885,2102,2928,23866,27924,27925,53791,53793,79600,79601</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/23671669$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><contributor>Zhou, Dongsheng</contributor><creatorcontrib>Aliyu, Gambo</creatorcontrib><creatorcontrib>El-Kamary, Samer S</creatorcontrib><creatorcontrib>Abimiku, Alash'le</creatorcontrib><creatorcontrib>Brown, Clayton</creatorcontrib><creatorcontrib>Tracy, Kathleen</creatorcontrib><creatorcontrib>Hungerford, Laura</creatorcontrib><creatorcontrib>Blattner, William</creatorcontrib><title>Prevalence of non-tuberculous mycobacterial infections among tuberculosis suspects in Nigeria</title><title>PloS one</title><addtitle>PLoS One</addtitle><description>Nigeria is ranked in the top five countries for tuberculosis deaths worldwide. This study investigated the mycobacterial agents associated with presumptive clinical pulmonary tuberculosis (TB) in Nigeria and evaluated the pattern and frequency of mycobacterial infections over twelve calendar months period.
Sputum samples from 1,603 consecutive new cases with presumptive diagnosis of TB were collected from August 2010 to July 2011. All sputum samples were incubated for detection of mycobacterial growth and those with positive acid fast bacilli (AFB) growth were tested to detect mycobacterium tuberculosis (MTB) complex and characterized to differentiate between MTB complex species. Cultures suggestive of Non-tuberculous mycobacterial infections (NTM) were sub-cultured and characterized.
Of the 1,603 patients screened, 444 (28%) culture-positive cases of pulmonary tuberculosis were identified. Of these, 375 (85%) were due to strains of MTB complex (354 cases of M. tuberculosis, 20 M. africanum and one case of M. bovis) and 69 (15%) were due to infection with NTM. In contrast to the MTB complex cases, the NTM cases were more likely to have been diagnosed during the calendar months of the Harmattan dust season (OR = 2.34, 1.28-4.29; p = 0.01), and aged older than 35 years (OR = 2.77, 1.52-5.02, p = 0.0007), but less likely to have AFB identified on their sputum smear (OR = 0.06, 0.02-0.14, p<0.0001). Among those with NTM infection, cases 35 years or younger were more likely to have co-infection with HIV (3.76, 1.72-8.22; p = 0.0009) compared to those older than 35 years.
The high proportion of younger patients with clinical pulmonary TB due to NTM and co-infection with HIV and the likely role of the seasonal dust exposure in the occurrence of the disease, present novel public health challenges for prevention and treatment.</description><subject>Adult</subject><subject>Air bases</subject><subject>Bacilli</subject><subject>Bacterial infections</subject><subject>Coinfection - epidemiology</subject><subject>Coinfection - microbiology</subject><subject>Coinfection - virology</subject><subject>Comorbidity</subject><subject>Dust</subject><subject>Epidemiology</subject><subject>Female</subject><subject>Genotype & phenotype</subject><subject>Health aspects</subject><subject>HIV</subject><subject>HIV Infections - epidemiology</subject><subject>HIV Infections - virology</subject><subject>Human immunodeficiency virus</subject><subject>Humans</subject><subject>Incidence</subject><subject>Infections</subject><subject>Infectious diseases</subject><subject>Logistic Models</subject><subject>Lung diseases</subject><subject>Male</subject><subject>Medicine</subject><subject>Middle Aged</subject><subject>Multivariate Analysis</subject><subject>Mycobacterium Infections, Nontuberculous - epidemiology</subject><subject>Mycobacterium Infections, Nontuberculous - microbiology</subject><subject>Mycobacterium tuberculosis</subject><subject>Mycobacterium tuberculosis - isolation & purification</subject><subject>Nigeria - epidemiology</subject><subject>Nontuberculous Mycobacteria - isolation & purification</subject><subject>Patients</subject><subject>Prevalence</subject><subject>Public health</subject><subject>Sampling methods</subject><subject>Seasons</subject><subject>Smear</subject><subject>Sputum</subject><subject>Sputum - microbiology</subject><subject>Sputum - virology</subject><subject>Stains & staining</subject><subject>Tuberculosis</subject><subject>Tuberculosis, Pulmonary - epidemiology</subject><subject>Tuberculosis, Pulmonary - microbiology</subject><subject>Virology</subject><subject>Young Adult</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>ABUWG</sourceid><sourceid>AFKRA</sourceid><sourceid>AZQEC</sourceid><sourceid>BENPR</sourceid><sourceid>CCPQU</sourceid><sourceid>DWQXO</sourceid><sourceid>GNUQQ</sourceid><sourceid>DOA</sourceid><recordid>eNqNk11rFDEUhgdRbK3-A9EBQfRi12SSyUxuhFL8WChW_LqTkMmezKZkkm0yU-y_N9OdLjvSC8lFQvKcN8l5z8my5xgtManwu0s_BCftcusdLBFiBFfoQXaMOSkWrEDk4cH6KHsS4yVCJakZe5wdFYRVmDF-nP3-GuBaWnAKcq9z592iHxoIarB-iHl3o3wjVQ_BSJsbp0H1xruYy867Nt-j0cQ8DnGbjmPC8i-mHUOeZo-0tBGeTfNJ9vPjhx9nnxfnF59WZ6fnC1WVdb8ghSYV5UhiUmqMgNNCNRwrkLrBlEiCOQVJG9Joihtas4JgjBBgVkjEKSUn2cud7jY9RUyZiSLJoSRMKErEakesvbwU22A6GW6El0bcbvjQChl6oywIxCqK6zQYMFoWtJacVZpTrIpKN4olrffTbUPTwVqB64O0M9H5iTMb0fprQViZjMJJ4M0kEPzVALEXnYkKrJUOUtbHd2OGOCt5Ql_9g97_u4lqk5Ui2eTTvWoUFae0qknynY5ay3uoNNbQGZXKSJu0Pwt4OwtITA9_-lYOMYrV92__z178mrOvD9gNSNtvorfDbWnNQboDVfAxBtD7JGMkxi64y4YYu0BMXZDCXhwatA-6K3vyFyZ7AWQ</recordid><startdate>20130509</startdate><enddate>20130509</enddate><creator>Aliyu, Gambo</creator><creator>El-Kamary, Samer S</creator><creator>Abimiku, Alash'le</creator><creator>Brown, Clayton</creator><creator>Tracy, Kathleen</creator><creator>Hungerford, Laura</creator><creator>Blattner, William</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>IOV</scope><scope>ISR</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>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>PIMPY</scope><scope>PQEST</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>20130509</creationdate><title>Prevalence of non-tuberculous mycobacterial infections among tuberculosis suspects in Nigeria</title><author>Aliyu, Gambo ; El-Kamary, Samer S ; Abimiku, Alash'le ; Brown, Clayton ; Tracy, Kathleen ; Hungerford, Laura ; Blattner, William</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c758t-32f37490a135f10e942cb91ceafb143a3194ea4b3bf41b486231100e162a09443</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2013</creationdate><topic>Adult</topic><topic>Air bases</topic><topic>Bacilli</topic><topic>Bacterial infections</topic><topic>Coinfection - 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microbiology</topic><topic>Sputum - virology</topic><topic>Stains & staining</topic><topic>Tuberculosis</topic><topic>Tuberculosis, Pulmonary - epidemiology</topic><topic>Tuberculosis, Pulmonary - microbiology</topic><topic>Virology</topic><topic>Young Adult</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Aliyu, Gambo</creatorcontrib><creatorcontrib>El-Kamary, Samer S</creatorcontrib><creatorcontrib>Abimiku, Alash'le</creatorcontrib><creatorcontrib>Brown, Clayton</creatorcontrib><creatorcontrib>Tracy, Kathleen</creatorcontrib><creatorcontrib>Hungerford, Laura</creatorcontrib><creatorcontrib>Blattner, William</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Gale In Context: Opposing Viewpoints</collection><collection>Gale In Context: Science</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 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>Aliyu, Gambo</au><au>El-Kamary, Samer S</au><au>Abimiku, Alash'le</au><au>Brown, Clayton</au><au>Tracy, Kathleen</au><au>Hungerford, Laura</au><au>Blattner, William</au><au>Zhou, Dongsheng</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Prevalence of non-tuberculous mycobacterial infections among tuberculosis suspects in Nigeria</atitle><jtitle>PloS one</jtitle><addtitle>PLoS One</addtitle><date>2013-05-09</date><risdate>2013</risdate><volume>8</volume><issue>5</issue><spage>e63170</spage><epage>e63170</epage><pages>e63170-e63170</pages><issn>1932-6203</issn><eissn>1932-6203</eissn><abstract>Nigeria is ranked in the top five countries for tuberculosis deaths worldwide. This study investigated the mycobacterial agents associated with presumptive clinical pulmonary tuberculosis (TB) in Nigeria and evaluated the pattern and frequency of mycobacterial infections over twelve calendar months period.
Sputum samples from 1,603 consecutive new cases with presumptive diagnosis of TB were collected from August 2010 to July 2011. All sputum samples were incubated for detection of mycobacterial growth and those with positive acid fast bacilli (AFB) growth were tested to detect mycobacterium tuberculosis (MTB) complex and characterized to differentiate between MTB complex species. Cultures suggestive of Non-tuberculous mycobacterial infections (NTM) were sub-cultured and characterized.
Of the 1,603 patients screened, 444 (28%) culture-positive cases of pulmonary tuberculosis were identified. Of these, 375 (85%) were due to strains of MTB complex (354 cases of M. tuberculosis, 20 M. africanum and one case of M. bovis) and 69 (15%) were due to infection with NTM. In contrast to the MTB complex cases, the NTM cases were more likely to have been diagnosed during the calendar months of the Harmattan dust season (OR = 2.34, 1.28-4.29; p = 0.01), and aged older than 35 years (OR = 2.77, 1.52-5.02, p = 0.0007), but less likely to have AFB identified on their sputum smear (OR = 0.06, 0.02-0.14, p<0.0001). Among those with NTM infection, cases 35 years or younger were more likely to have co-infection with HIV (3.76, 1.72-8.22; p = 0.0009) compared to those older than 35 years.
The high proportion of younger patients with clinical pulmonary TB due to NTM and co-infection with HIV and the likely role of the seasonal dust exposure in the occurrence of the disease, present novel public health challenges for prevention and treatment.</abstract><cop>United States</cop><pub>Public Library of Science</pub><pmid>23671669</pmid><doi>10.1371/journal.pone.0063170</doi><tpages>e63170</tpages><oa>free_for_read</oa></addata></record> |
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| source | MEDLINE; DOAJ Directory of Open Access Journals; Public Library of Science (PLoS) Journals Open Access; EZB-FREE-00999 freely available EZB journals; PubMed Central; Free Full-Text Journals in Chemistry |
| subjects | Adult Air bases Bacilli Bacterial infections Coinfection - epidemiology Coinfection - microbiology Coinfection - virology Comorbidity Dust Epidemiology Female Genotype & phenotype Health aspects HIV HIV Infections - epidemiology HIV Infections - virology Human immunodeficiency virus Humans Incidence Infections Infectious diseases Logistic Models Lung diseases Male Medicine Middle Aged Multivariate Analysis Mycobacterium Infections, Nontuberculous - epidemiology Mycobacterium Infections, Nontuberculous - microbiology Mycobacterium tuberculosis Mycobacterium tuberculosis - isolation & purification Nigeria - epidemiology Nontuberculous Mycobacteria - isolation & purification Patients Prevalence Public health Sampling methods Seasons Smear Sputum Sputum - microbiology Sputum - virology Stains & staining Tuberculosis Tuberculosis, Pulmonary - epidemiology Tuberculosis, Pulmonary - microbiology Virology Young Adult |
| title | Prevalence of non-tuberculous mycobacterial infections among tuberculosis suspects in Nigeria |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-02T15%3A16%3A23IST&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=Prevalence%20of%20non-tuberculous%20mycobacterial%20infections%20among%20tuberculosis%20suspects%20in%20Nigeria&rft.jtitle=PloS%20one&rft.au=Aliyu,%20Gambo&rft.date=2013-05-09&rft.volume=8&rft.issue=5&rft.spage=e63170&rft.epage=e63170&rft.pages=e63170-e63170&rft.issn=1932-6203&rft.eissn=1932-6203&rft_id=info:doi/10.1371/journal.pone.0063170&rft_dat=%3Cgale_plos_%3EA478353849%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=1350374340&rft_id=info:pmid/23671669&rft_galeid=A478353849&rft_doaj_id=oai_doaj_org_article_0674181816e645248a967f941c27fbc6&rfr_iscdi=true |