Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation

Muscle depletion or sarcopenia is associated with increased mortality in patients with cirrhosis; how it affects mortality after liver transplantation requires further study. In this study, we aimed to establish whether sarcopenia predicts increased morbidity or mortality after liver transplantation...

Ausführliche Beschreibung

Gespeichert in:
Bibliographische Detailangaben
Veröffentlicht in:Liver transplantation 2014-06, Vol.20 (6), p.640-648
Hauptverfasser: Montano‐Loza, Aldo J., Meza‐Junco, Judith, Baracos, Vickie E., Prado, Carla M. M., Ma, Mang, Meeberg, Glenda, Beaumont, Crystal, Tandon, Puneeta, Esfandiari, Nina, Sawyer, Michael B., Kneteman, Norman
Format: Artikel
Sprache:eng
Schlagworte:
Online-Zugang:Volltext
Tags: Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
container_end_page 648
container_issue 6
container_start_page 640
container_title Liver transplantation
container_volume 20
creator Montano‐Loza, Aldo J.
Meza‐Junco, Judith
Baracos, Vickie E.
Prado, Carla M. M.
Ma, Mang
Meeberg, Glenda
Beaumont, Crystal
Tandon, Puneeta
Esfandiari, Nina
Sawyer, Michael B.
Kneteman, Norman
description Muscle depletion or sarcopenia is associated with increased mortality in patients with cirrhosis; how it affects mortality after liver transplantation requires further study. In this study, we aimed to establish whether sarcopenia predicts increased morbidity or mortality after liver transplantation. We analyzed 248 patients with cirrhosis who had a computed tomography (CT) scan including the third lumbar vertebra before liver transplantation. Data were recovered from medical charts, the skeletal muscle cross‐sectional area was measured with CT, and sarcopenia was defined with previously published sex‐ and body mass index–specific cutoffs. One hundred sixty‐nine patients (68%) were male, and the mean age at transplantation was 55 ± 1 years. The etiologies of cirrhosis were hepatitis C virus (51%), alcohol (19%), autoimmune liver diseases (15%), hepatitis B virus (8%), and other etiologies (7%). Sarcopenia was present in 112 patients (45%), and it was more frequent in males (P = 0.002), patients with ascites (P = 0.02), and patients with higher bilirubin levels (P = 0.05), creatinine levels (P = 0.02), international normalized ratios (P = 0.04), Child‐Pugh scores (P = 0.002), and Model for End‐Stage Liver Disease scores (P = 0.002). The median survival period after liver transplantation was 117 ± 17 months for sarcopenic patients and 146 ± 20 months for nonsarcopenic patients (P = 0.4). Sarcopenic patients had longer hospital stays (40 ± 4 versus 25 ± 3 days; P = 0.005) and a higher frequency of bacterial infections within the first 90 days after liver transplantation (26% versus 15%, P = 0.04) in comparison with nonsarcopenic patients. In conclusion, sarcopenia is one of the most common complications in patients with cirrhosis and is predictive of longer hospital stays and a higher risk of perioperative bacterial infections after liver transplantation, but it is not associated with increased mortality. Liver Transpl 20:640–648, 2014. © 2014 AASLD.
doi_str_mv 10.1002/lt.23863
format Article
fullrecord <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_1529839607</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>1529839607</sourcerecordid><originalsourceid>FETCH-LOGICAL-c3493-80e9c9981d58b5b03f911eb61b7eefc9cf32f4e6351d33bf052eb91fe00b1b843</originalsourceid><addsrcrecordid>eNp1kU1r3DAQhkVJaD5a6C8oglx6cSJZ_pCOJaRJYKGHbs9GkkeNgtZyNfIue8h_rze7CSWQ08zhmWeGeQn5wtklZ6y8CvmyFLIRH8gpr8u2aKpWHL32TX1CzhAfGeO8VuwjOSmrppWM1afk6ResIQFdTWgD0B7GANnHgY4Jem8z0jFijiMknf0aaIDhT36g0VHMekvNlKlHOsRMNWK0Xmfo6cbPCE5p7dc6UO0yJBrm6URz0gOOQQ9Z77Z8IsdOB4TPh3pOfv-4WV7fFYuft_fX3xeFFZUShWSgrFKS97U0tWHCKc7BNNy0AM4q60TpKmhEzXshjGN1CUZxB4wZbmQlzsm3vXdM8e8EmLuVRwthPgTihN38KCWFalg7oxdv0Mc4pWG-bkdJIXn1v9CmiJjAdWPyK522HWfdLpIu5O45khn9ehBOZgX9K_iSwQwUe2DjA2zfFXWL5V74DxLNlwM</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>1528381484</pqid></control><display><type>article</type><title>Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation</title><source>MEDLINE</source><source>Wiley Online Library Journals Frontfile Complete</source><source>Alma/SFX Local Collection</source><creator>Montano‐Loza, Aldo J. ; Meza‐Junco, Judith ; Baracos, Vickie E. ; Prado, Carla M. M. ; Ma, Mang ; Meeberg, Glenda ; Beaumont, Crystal ; Tandon, Puneeta ; Esfandiari, Nina ; Sawyer, Michael B. ; Kneteman, Norman</creator><creatorcontrib>Montano‐Loza, Aldo J. ; Meza‐Junco, Judith ; Baracos, Vickie E. ; Prado, Carla M. M. ; Ma, Mang ; Meeberg, Glenda ; Beaumont, Crystal ; Tandon, Puneeta ; Esfandiari, Nina ; Sawyer, Michael B. ; Kneteman, Norman</creatorcontrib><description>Muscle depletion or sarcopenia is associated with increased mortality in patients with cirrhosis; how it affects mortality after liver transplantation requires further study. In this study, we aimed to establish whether sarcopenia predicts increased morbidity or mortality after liver transplantation. We analyzed 248 patients with cirrhosis who had a computed tomography (CT) scan including the third lumbar vertebra before liver transplantation. Data were recovered from medical charts, the skeletal muscle cross‐sectional area was measured with CT, and sarcopenia was defined with previously published sex‐ and body mass index–specific cutoffs. One hundred sixty‐nine patients (68%) were male, and the mean age at transplantation was 55 ± 1 years. The etiologies of cirrhosis were hepatitis C virus (51%), alcohol (19%), autoimmune liver diseases (15%), hepatitis B virus (8%), and other etiologies (7%). Sarcopenia was present in 112 patients (45%), and it was more frequent in males (P = 0.002), patients with ascites (P = 0.02), and patients with higher bilirubin levels (P = 0.05), creatinine levels (P = 0.02), international normalized ratios (P = 0.04), Child‐Pugh scores (P = 0.002), and Model for End‐Stage Liver Disease scores (P = 0.002). The median survival period after liver transplantation was 117 ± 17 months for sarcopenic patients and 146 ± 20 months for nonsarcopenic patients (P = 0.4). Sarcopenic patients had longer hospital stays (40 ± 4 versus 25 ± 3 days; P = 0.005) and a higher frequency of bacterial infections within the first 90 days after liver transplantation (26% versus 15%, P = 0.04) in comparison with nonsarcopenic patients. In conclusion, sarcopenia is one of the most common complications in patients with cirrhosis and is predictive of longer hospital stays and a higher risk of perioperative bacterial infections after liver transplantation, but it is not associated with increased mortality. Liver Transpl 20:640–648, 2014. © 2014 AASLD.</description><identifier>ISSN: 1527-6465</identifier><identifier>EISSN: 1527-6473</identifier><identifier>DOI: 10.1002/lt.23863</identifier><identifier>PMID: 24678005</identifier><identifier>CODEN: LITRFO</identifier><language>eng</language><publisher>United States: Wolters Kluwer Health, Inc</publisher><subject>Adult ; Aged ; Bacterial Infections - etiology ; Female ; Humans ; Kaplan-Meier Estimate ; Length of Stay ; Liver Cirrhosis - complications ; Liver Cirrhosis - diagnosis ; Liver Cirrhosis - mortality ; Liver Cirrhosis - surgery ; Liver Transplantation - adverse effects ; Liver Transplantation - mortality ; Male ; Middle Aged ; Multivariate Analysis ; Muscle, Skeletal - diagnostic imaging ; Proportional Hazards Models ; Retrospective Studies ; Risk Factors ; Sarcopenia - diagnosis ; Sarcopenia - etiology ; Sarcopenia - mortality ; Severity of Illness Index ; Time Factors ; Tomography, X-Ray Computed ; Treatment Outcome ; Young Adult</subject><ispartof>Liver transplantation, 2014-06, Vol.20 (6), p.640-648</ispartof><rights>2014 American Association for the Study of Liver Diseases</rights><rights>2014 American Association for the Study of Liver Diseases.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c3493-80e9c9981d58b5b03f911eb61b7eefc9cf32f4e6351d33bf052eb91fe00b1b843</citedby><cites>FETCH-LOGICAL-c3493-80e9c9981d58b5b03f911eb61b7eefc9cf32f4e6351d33bf052eb91fe00b1b843</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://onlinelibrary.wiley.com/doi/pdf/10.1002%2Flt.23863$$EPDF$$P50$$Gwiley$$H</linktopdf><linktohtml>$$Uhttps://onlinelibrary.wiley.com/doi/full/10.1002%2Flt.23863$$EHTML$$P50$$Gwiley$$H</linktohtml><link.rule.ids>314,776,780,1411,27901,27902,45550,45551</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/24678005$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Montano‐Loza, Aldo J.</creatorcontrib><creatorcontrib>Meza‐Junco, Judith</creatorcontrib><creatorcontrib>Baracos, Vickie E.</creatorcontrib><creatorcontrib>Prado, Carla M. M.</creatorcontrib><creatorcontrib>Ma, Mang</creatorcontrib><creatorcontrib>Meeberg, Glenda</creatorcontrib><creatorcontrib>Beaumont, Crystal</creatorcontrib><creatorcontrib>Tandon, Puneeta</creatorcontrib><creatorcontrib>Esfandiari, Nina</creatorcontrib><creatorcontrib>Sawyer, Michael B.</creatorcontrib><creatorcontrib>Kneteman, Norman</creatorcontrib><title>Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation</title><title>Liver transplantation</title><addtitle>Liver Transpl</addtitle><description>Muscle depletion or sarcopenia is associated with increased mortality in patients with cirrhosis; how it affects mortality after liver transplantation requires further study. In this study, we aimed to establish whether sarcopenia predicts increased morbidity or mortality after liver transplantation. We analyzed 248 patients with cirrhosis who had a computed tomography (CT) scan including the third lumbar vertebra before liver transplantation. Data were recovered from medical charts, the skeletal muscle cross‐sectional area was measured with CT, and sarcopenia was defined with previously published sex‐ and body mass index–specific cutoffs. One hundred sixty‐nine patients (68%) were male, and the mean age at transplantation was 55 ± 1 years. The etiologies of cirrhosis were hepatitis C virus (51%), alcohol (19%), autoimmune liver diseases (15%), hepatitis B virus (8%), and other etiologies (7%). Sarcopenia was present in 112 patients (45%), and it was more frequent in males (P = 0.002), patients with ascites (P = 0.02), and patients with higher bilirubin levels (P = 0.05), creatinine levels (P = 0.02), international normalized ratios (P = 0.04), Child‐Pugh scores (P = 0.002), and Model for End‐Stage Liver Disease scores (P = 0.002). The median survival period after liver transplantation was 117 ± 17 months for sarcopenic patients and 146 ± 20 months for nonsarcopenic patients (P = 0.4). Sarcopenic patients had longer hospital stays (40 ± 4 versus 25 ± 3 days; P = 0.005) and a higher frequency of bacterial infections within the first 90 days after liver transplantation (26% versus 15%, P = 0.04) in comparison with nonsarcopenic patients. In conclusion, sarcopenia is one of the most common complications in patients with cirrhosis and is predictive of longer hospital stays and a higher risk of perioperative bacterial infections after liver transplantation, but it is not associated with increased mortality. Liver Transpl 20:640–648, 2014. © 2014 AASLD.</description><subject>Adult</subject><subject>Aged</subject><subject>Bacterial Infections - etiology</subject><subject>Female</subject><subject>Humans</subject><subject>Kaplan-Meier Estimate</subject><subject>Length of Stay</subject><subject>Liver Cirrhosis - complications</subject><subject>Liver Cirrhosis - diagnosis</subject><subject>Liver Cirrhosis - mortality</subject><subject>Liver Cirrhosis - surgery</subject><subject>Liver Transplantation - adverse effects</subject><subject>Liver Transplantation - mortality</subject><subject>Male</subject><subject>Middle Aged</subject><subject>Multivariate Analysis</subject><subject>Muscle, Skeletal - diagnostic imaging</subject><subject>Proportional Hazards Models</subject><subject>Retrospective Studies</subject><subject>Risk Factors</subject><subject>Sarcopenia - diagnosis</subject><subject>Sarcopenia - etiology</subject><subject>Sarcopenia - mortality</subject><subject>Severity of Illness Index</subject><subject>Time Factors</subject><subject>Tomography, X-Ray Computed</subject><subject>Treatment Outcome</subject><subject>Young Adult</subject><issn>1527-6465</issn><issn>1527-6473</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2014</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp1kU1r3DAQhkVJaD5a6C8oglx6cSJZ_pCOJaRJYKGHbs9GkkeNgtZyNfIue8h_rze7CSWQ08zhmWeGeQn5wtklZ6y8CvmyFLIRH8gpr8u2aKpWHL32TX1CzhAfGeO8VuwjOSmrppWM1afk6ResIQFdTWgD0B7GANnHgY4Jem8z0jFijiMknf0aaIDhT36g0VHMekvNlKlHOsRMNWK0Xmfo6cbPCE5p7dc6UO0yJBrm6URz0gOOQQ9Z77Z8IsdOB4TPh3pOfv-4WV7fFYuft_fX3xeFFZUShWSgrFKS97U0tWHCKc7BNNy0AM4q60TpKmhEzXshjGN1CUZxB4wZbmQlzsm3vXdM8e8EmLuVRwthPgTihN38KCWFalg7oxdv0Mc4pWG-bkdJIXn1v9CmiJjAdWPyK522HWfdLpIu5O45khn9ehBOZgX9K_iSwQwUe2DjA2zfFXWL5V74DxLNlwM</recordid><startdate>201406</startdate><enddate>201406</enddate><creator>Montano‐Loza, Aldo J.</creator><creator>Meza‐Junco, Judith</creator><creator>Baracos, Vickie E.</creator><creator>Prado, Carla M. M.</creator><creator>Ma, Mang</creator><creator>Meeberg, Glenda</creator><creator>Beaumont, Crystal</creator><creator>Tandon, Puneeta</creator><creator>Esfandiari, Nina</creator><creator>Sawyer, Michael B.</creator><creator>Kneteman, Norman</creator><general>Wolters Kluwer Health, Inc</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>K9.</scope><scope>7X8</scope></search><sort><creationdate>201406</creationdate><title>Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation</title><author>Montano‐Loza, Aldo J. ; Meza‐Junco, Judith ; Baracos, Vickie E. ; Prado, Carla M. M. ; Ma, Mang ; Meeberg, Glenda ; Beaumont, Crystal ; Tandon, Puneeta ; Esfandiari, Nina ; Sawyer, Michael B. ; Kneteman, Norman</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c3493-80e9c9981d58b5b03f911eb61b7eefc9cf32f4e6351d33bf052eb91fe00b1b843</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2014</creationdate><topic>Adult</topic><topic>Aged</topic><topic>Bacterial Infections - etiology</topic><topic>Female</topic><topic>Humans</topic><topic>Kaplan-Meier Estimate</topic><topic>Length of Stay</topic><topic>Liver Cirrhosis - complications</topic><topic>Liver Cirrhosis - diagnosis</topic><topic>Liver Cirrhosis - mortality</topic><topic>Liver Cirrhosis - surgery</topic><topic>Liver Transplantation - adverse effects</topic><topic>Liver Transplantation - mortality</topic><topic>Male</topic><topic>Middle Aged</topic><topic>Multivariate Analysis</topic><topic>Muscle, Skeletal - diagnostic imaging</topic><topic>Proportional Hazards Models</topic><topic>Retrospective Studies</topic><topic>Risk Factors</topic><topic>Sarcopenia - diagnosis</topic><topic>Sarcopenia - etiology</topic><topic>Sarcopenia - mortality</topic><topic>Severity of Illness Index</topic><topic>Time Factors</topic><topic>Tomography, X-Ray Computed</topic><topic>Treatment Outcome</topic><topic>Young Adult</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Montano‐Loza, Aldo J.</creatorcontrib><creatorcontrib>Meza‐Junco, Judith</creatorcontrib><creatorcontrib>Baracos, Vickie E.</creatorcontrib><creatorcontrib>Prado, Carla M. M.</creatorcontrib><creatorcontrib>Ma, Mang</creatorcontrib><creatorcontrib>Meeberg, Glenda</creatorcontrib><creatorcontrib>Beaumont, Crystal</creatorcontrib><creatorcontrib>Tandon, Puneeta</creatorcontrib><creatorcontrib>Esfandiari, Nina</creatorcontrib><creatorcontrib>Sawyer, Michael B.</creatorcontrib><creatorcontrib>Kneteman, Norman</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 Health &amp; Medical Complete (Alumni)</collection><collection>MEDLINE - Academic</collection><jtitle>Liver transplantation</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Montano‐Loza, Aldo J.</au><au>Meza‐Junco, Judith</au><au>Baracos, Vickie E.</au><au>Prado, Carla M. M.</au><au>Ma, Mang</au><au>Meeberg, Glenda</au><au>Beaumont, Crystal</au><au>Tandon, Puneeta</au><au>Esfandiari, Nina</au><au>Sawyer, Michael B.</au><au>Kneteman, Norman</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation</atitle><jtitle>Liver transplantation</jtitle><addtitle>Liver Transpl</addtitle><date>2014-06</date><risdate>2014</risdate><volume>20</volume><issue>6</issue><spage>640</spage><epage>648</epage><pages>640-648</pages><issn>1527-6465</issn><eissn>1527-6473</eissn><coden>LITRFO</coden><abstract>Muscle depletion or sarcopenia is associated with increased mortality in patients with cirrhosis; how it affects mortality after liver transplantation requires further study. In this study, we aimed to establish whether sarcopenia predicts increased morbidity or mortality after liver transplantation. We analyzed 248 patients with cirrhosis who had a computed tomography (CT) scan including the third lumbar vertebra before liver transplantation. Data were recovered from medical charts, the skeletal muscle cross‐sectional area was measured with CT, and sarcopenia was defined with previously published sex‐ and body mass index–specific cutoffs. One hundred sixty‐nine patients (68%) were male, and the mean age at transplantation was 55 ± 1 years. The etiologies of cirrhosis were hepatitis C virus (51%), alcohol (19%), autoimmune liver diseases (15%), hepatitis B virus (8%), and other etiologies (7%). Sarcopenia was present in 112 patients (45%), and it was more frequent in males (P = 0.002), patients with ascites (P = 0.02), and patients with higher bilirubin levels (P = 0.05), creatinine levels (P = 0.02), international normalized ratios (P = 0.04), Child‐Pugh scores (P = 0.002), and Model for End‐Stage Liver Disease scores (P = 0.002). The median survival period after liver transplantation was 117 ± 17 months for sarcopenic patients and 146 ± 20 months for nonsarcopenic patients (P = 0.4). Sarcopenic patients had longer hospital stays (40 ± 4 versus 25 ± 3 days; P = 0.005) and a higher frequency of bacterial infections within the first 90 days after liver transplantation (26% versus 15%, P = 0.04) in comparison with nonsarcopenic patients. In conclusion, sarcopenia is one of the most common complications in patients with cirrhosis and is predictive of longer hospital stays and a higher risk of perioperative bacterial infections after liver transplantation, but it is not associated with increased mortality. Liver Transpl 20:640–648, 2014. © 2014 AASLD.</abstract><cop>United States</cop><pub>Wolters Kluwer Health, Inc</pub><pmid>24678005</pmid><doi>10.1002/lt.23863</doi><tpages>9</tpages></addata></record>
fulltext fulltext
identifier ISSN: 1527-6465
ispartof Liver transplantation, 2014-06, Vol.20 (6), p.640-648
issn 1527-6465
1527-6473
language eng
recordid cdi_proquest_miscellaneous_1529839607
source MEDLINE; Wiley Online Library Journals Frontfile Complete; Alma/SFX Local Collection
subjects Adult
Aged
Bacterial Infections - etiology
Female
Humans
Kaplan-Meier Estimate
Length of Stay
Liver Cirrhosis - complications
Liver Cirrhosis - diagnosis
Liver Cirrhosis - mortality
Liver Cirrhosis - surgery
Liver Transplantation - adverse effects
Liver Transplantation - mortality
Male
Middle Aged
Multivariate Analysis
Muscle, Skeletal - diagnostic imaging
Proportional Hazards Models
Retrospective Studies
Risk Factors
Sarcopenia - diagnosis
Sarcopenia - etiology
Sarcopenia - mortality
Severity of Illness Index
Time Factors
Tomography, X-Ray Computed
Treatment Outcome
Young Adult
title Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation
url https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-02-18T15%3A34%3A48IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_cross&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Severe%20muscle%20depletion%20predicts%20postoperative%20length%20of%20stay%20but%20is%20not%20associated%20with%20survival%20after%20liver%20transplantation&rft.jtitle=Liver%20transplantation&rft.au=Montano%E2%80%90Loza,%20Aldo%20J.&rft.date=2014-06&rft.volume=20&rft.issue=6&rft.spage=640&rft.epage=648&rft.pages=640-648&rft.issn=1527-6465&rft.eissn=1527-6473&rft.coden=LITRFO&rft_id=info:doi/10.1002/lt.23863&rft_dat=%3Cproquest_cross%3E1529839607%3C/proquest_cross%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=1528381484&rft_id=info:pmid/24678005&rfr_iscdi=true