Characterisation of anal intraepithelial neoplasia and anal cancer in HIV‐positive men by immunohistochemical markers p16, Ki‐67, HPV‐E4 and DNA methylation markers
Human papillomavirus (HPV)‐induced anal intraepithelial neoplasia (AIN, graded 1‐3) is highly prevalent in HIV‐positive (HIV+) men who have sex with men (MSM), but only a minority of lesions progresses to cancer. Our study aimed to characterise comprehensively anal tissue samples from a cross‐sectio...
Gespeichert in:
| Veröffentlicht in: | International journal of cancer 2021-11, Vol.149 (10), p.1833-1844 |
|---|---|
| Hauptverfasser: | , , , , , , , , |
| Format: | Artikel |
| Sprache: | eng |
| Schlagworte: | |
| Online-Zugang: | Volltext |
| Tags: |
Tag hinzufügen
Keine Tags, Fügen Sie den ersten Tag hinzu!
|
| container_end_page | 1844 |
|---|---|
| container_issue | 10 |
| container_start_page | 1833 |
| container_title | International journal of cancer |
| container_volume | 149 |
| creator | Zee, Ramon P. Meijer, Chris J. L. M. Cuming, Tamzin Kreuter, Alexander Sandt, Miekel M. Quint, Wim G. V. Vries, Henry J. C. Prins, Jan M. Steenbergen, Renske D. M. |
| description | Human papillomavirus (HPV)‐induced anal intraepithelial neoplasia (AIN, graded 1‐3) is highly prevalent in HIV‐positive (HIV+) men who have sex with men (MSM), but only a minority of lesions progresses to cancer. Our study aimed to characterise comprehensively anal tissue samples from a cross‐sectional series (n = 104) of HIV+ MSM and longitudinal series (n = 40) of AIN2/3 progressing to cancer using different biomarkers. The cross‐sectional series consisted of 8 normal, 26 AIN1, 45 AIN2, 15 AIN3 and 10 anal squamous cell carcinoma. Tissue sections were immunohistochemically (IHC) stained for p16 (viral transformation marker), Ki‐67 (cellular proliferation marker) and HPV‐E4 (viral production marker). We evaluated the expression of IHC markers and compared it with DNA methylation, a marker for malignant transformation. E4 positivity decreased, whereas p16 and Ki‐67 scores and methylation marker positivity increased (P values |
| doi_str_mv | 10.1002/ijc.33748 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_pubme</sourceid><recordid>TN_cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_9292283</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2575749811</sourcerecordid><originalsourceid>FETCH-LOGICAL-c4208-c368bd3d175403707449f46bf7e8fe8eddbea7a5fb130ddf4dca791b60f8773f3</originalsourceid><addsrcrecordid>eNp1ktGK1DAYhYMo7rh64RsEvFHY7iZN2qQ3wjKuzuiiXqi3IU3_2IxtU5N2Ze58BJ_Dx_JJzGwHQcGrEP7vHA6Hg9BjSs4pIfmF25lzxgSXd9CKkkpkJKfFXbRKN5IJysoT9CDGHSGUFoTfRyeMM0rKSq7Qz3WrgzYTBBf15PyAvcV60B12wxQ0jG5qoXPpP4AfOx2dTudmQYweDIRE4s3206_vP0Yf3eRuAPcw4HqPXd_Pg29dnLxpoXcmaXodvkCIeKTlGX7jkqoUZ3jz_qC_4rfeL95eJoep3XdLoqPkIbpndRfh0fE9RR9fXn1Yb7Lrd6-268vrzPCcyMywUtYNa6goOGGCCM4ry8vaCpAWJDRNDVrowtaUkaaxvDFaVLQuiZVCMMtO0fPFd5zrHhoDhyI6NQaXguyV1079fRlcqz77G1XlVZ5LlgyeHg2C_zpDnFTvooGu06nDOaq8KIqSCZqXCX3yD7rzc0jdHihRCF5JShP1bKFM8DEGsH_CUKIOC1BpAep2AYm9WNhvroP9_0G1fb1eFL8B7ey2Mg</addsrcrecordid><sourcetype>Open Access Repository</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2575749811</pqid></control><display><type>article</type><title>Characterisation of anal intraepithelial neoplasia and anal cancer in HIV‐positive men by immunohistochemical markers p16, Ki‐67, HPV‐E4 and DNA methylation markers</title><source>Wiley Online Library Journals Frontfile Complete</source><source>Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals</source><creator>Zee, Ramon P. ; Meijer, Chris J. L. M. ; Cuming, Tamzin ; Kreuter, Alexander ; Sandt, Miekel M. ; Quint, Wim G. V. ; Vries, Henry J. C. ; Prins, Jan M. ; Steenbergen, Renske D. M.</creator><creatorcontrib>Zee, Ramon P. ; Meijer, Chris J. L. M. ; Cuming, Tamzin ; Kreuter, Alexander ; Sandt, Miekel M. ; Quint, Wim G. V. ; Vries, Henry J. C. ; Prins, Jan M. ; Steenbergen, Renske D. M.</creatorcontrib><description>Human papillomavirus (HPV)‐induced anal intraepithelial neoplasia (AIN, graded 1‐3) is highly prevalent in HIV‐positive (HIV+) men who have sex with men (MSM), but only a minority of lesions progresses to cancer. Our study aimed to characterise comprehensively anal tissue samples from a cross‐sectional series (n = 104) of HIV+ MSM and longitudinal series (n = 40) of AIN2/3 progressing to cancer using different biomarkers. The cross‐sectional series consisted of 8 normal, 26 AIN1, 45 AIN2, 15 AIN3 and 10 anal squamous cell carcinoma. Tissue sections were immunohistochemically (IHC) stained for p16 (viral transformation marker), Ki‐67 (cellular proliferation marker) and HPV‐E4 (viral production marker). We evaluated the expression of IHC markers and compared it with DNA methylation, a marker for malignant transformation. E4 positivity decreased, whereas p16 and Ki‐67 scores and methylation marker positivity increased (P values < .001) with increasing severity of anal lesions. Within AIN2, a heterogeneous biomarker pattern was observed concerning E4, p16 and methylation status, reflecting the biological heterogeneity of these lesions. In the longitudinal series, all AIN2/3 and carcinomas showed high p16 and Ki‐67 expression, strong methylation positivity and occasional E4 positivity. We earlier showed that high methylation levels are associated with progression to cancer. The observed E4 expression in some AIN2/3 during the course of progression to cancer and absence of E4 in a considerable number of AIN1 lesions make the potential clinical significance of E4 expression difficult to interpret. Our data show that IHC biomarkers can help to characterise AIN; however, their prognostic value for cancer risk stratification, next to objective methylation analysis, appears to be limited.
What's new?
Anal high‐grade squamous intraepithelial lesions (HSILs) constitute a heterogeneous group of precancerous lesions. Understanding which HSILs progress to cancer could facilitate early detection and treatment of anal cancer. Here, the prognostic value of expression of the immunohistochemical (IHC) markers p16, Ki‐67, and HPV‐E4 was evaluated in anal tissues with evidence of precancerous lesions. While analyses revealed positive associations between p16 and Ki‐67 expression and severity of anal dysplasia, HSILs overall exhibited complex biomarker patterns, reflecting their ambiguous clinical behaviour. Thus, while IHC markers are useful for molecular characterisation of HSIL, their prognostic value, particularly compared to methylation analysis, is limited.</description><identifier>ISSN: 0020-7136</identifier><identifier>EISSN: 1097-0215</identifier><identifier>DOI: 10.1002/ijc.33748</identifier><identifier>PMID: 34310698</identifier><language>eng</language><publisher>Hoboken, USA: John Wiley & Sons, Inc</publisher><subject>Anal cancer ; anal high‐grade squamous intraepithelial lesion ; Anus ; Biomarkers ; Cancer ; Colorectal cancer ; Deoxyribonucleic acid ; DNA ; DNA methylation ; HIV ; host cell DNA methylation markers ; Human immunodeficiency virus ; Human papillomavirus ; immunohistochemistry ; Lesions ; Medical research ; Squamous cell carcinoma ; Tumor Markers and Signatures</subject><ispartof>International journal of cancer, 2021-11, Vol.149 (10), p.1833-1844</ispartof><rights>2021 The Authors. published by John Wiley & Sons Ltd on behalf of UICC.</rights><rights>2021. This article is published under http://creativecommons.org/licenses/by-nc/4.0/ (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c4208-c368bd3d175403707449f46bf7e8fe8eddbea7a5fb130ddf4dca791b60f8773f3</citedby><cites>FETCH-LOGICAL-c4208-c368bd3d175403707449f46bf7e8fe8eddbea7a5fb130ddf4dca791b60f8773f3</cites><orcidid>0000-0002-2327-9839</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://onlinelibrary.wiley.com/doi/pdf/10.1002%2Fijc.33748$$EPDF$$P50$$Gwiley$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://onlinelibrary.wiley.com/doi/full/10.1002%2Fijc.33748$$EHTML$$P50$$Gwiley$$Hfree_for_read</linktohtml><link.rule.ids>230,314,776,780,881,1411,27901,27902,45550,45551</link.rule.ids></links><search><creatorcontrib>Zee, Ramon P.</creatorcontrib><creatorcontrib>Meijer, Chris J. L. M.</creatorcontrib><creatorcontrib>Cuming, Tamzin</creatorcontrib><creatorcontrib>Kreuter, Alexander</creatorcontrib><creatorcontrib>Sandt, Miekel M.</creatorcontrib><creatorcontrib>Quint, Wim G. V.</creatorcontrib><creatorcontrib>Vries, Henry J. C.</creatorcontrib><creatorcontrib>Prins, Jan M.</creatorcontrib><creatorcontrib>Steenbergen, Renske D. M.</creatorcontrib><title>Characterisation of anal intraepithelial neoplasia and anal cancer in HIV‐positive men by immunohistochemical markers p16, Ki‐67, HPV‐E4 and DNA methylation markers</title><title>International journal of cancer</title><description>Human papillomavirus (HPV)‐induced anal intraepithelial neoplasia (AIN, graded 1‐3) is highly prevalent in HIV‐positive (HIV+) men who have sex with men (MSM), but only a minority of lesions progresses to cancer. Our study aimed to characterise comprehensively anal tissue samples from a cross‐sectional series (n = 104) of HIV+ MSM and longitudinal series (n = 40) of AIN2/3 progressing to cancer using different biomarkers. The cross‐sectional series consisted of 8 normal, 26 AIN1, 45 AIN2, 15 AIN3 and 10 anal squamous cell carcinoma. Tissue sections were immunohistochemically (IHC) stained for p16 (viral transformation marker), Ki‐67 (cellular proliferation marker) and HPV‐E4 (viral production marker). We evaluated the expression of IHC markers and compared it with DNA methylation, a marker for malignant transformation. E4 positivity decreased, whereas p16 and Ki‐67 scores and methylation marker positivity increased (P values < .001) with increasing severity of anal lesions. Within AIN2, a heterogeneous biomarker pattern was observed concerning E4, p16 and methylation status, reflecting the biological heterogeneity of these lesions. In the longitudinal series, all AIN2/3 and carcinomas showed high p16 and Ki‐67 expression, strong methylation positivity and occasional E4 positivity. We earlier showed that high methylation levels are associated with progression to cancer. The observed E4 expression in some AIN2/3 during the course of progression to cancer and absence of E4 in a considerable number of AIN1 lesions make the potential clinical significance of E4 expression difficult to interpret. Our data show that IHC biomarkers can help to characterise AIN; however, their prognostic value for cancer risk stratification, next to objective methylation analysis, appears to be limited.
What's new?
Anal high‐grade squamous intraepithelial lesions (HSILs) constitute a heterogeneous group of precancerous lesions. Understanding which HSILs progress to cancer could facilitate early detection and treatment of anal cancer. Here, the prognostic value of expression of the immunohistochemical (IHC) markers p16, Ki‐67, and HPV‐E4 was evaluated in anal tissues with evidence of precancerous lesions. While analyses revealed positive associations between p16 and Ki‐67 expression and severity of anal dysplasia, HSILs overall exhibited complex biomarker patterns, reflecting their ambiguous clinical behaviour. Thus, while IHC markers are useful for molecular characterisation of HSIL, their prognostic value, particularly compared to methylation analysis, is limited.</description><subject>Anal cancer</subject><subject>anal high‐grade squamous intraepithelial lesion</subject><subject>Anus</subject><subject>Biomarkers</subject><subject>Cancer</subject><subject>Colorectal cancer</subject><subject>Deoxyribonucleic acid</subject><subject>DNA</subject><subject>DNA methylation</subject><subject>HIV</subject><subject>host cell DNA methylation markers</subject><subject>Human immunodeficiency virus</subject><subject>Human papillomavirus</subject><subject>immunohistochemistry</subject><subject>Lesions</subject><subject>Medical research</subject><subject>Squamous cell carcinoma</subject><subject>Tumor Markers and Signatures</subject><issn>0020-7136</issn><issn>1097-0215</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2021</creationdate><recordtype>article</recordtype><sourceid>24P</sourceid><recordid>eNp1ktGK1DAYhYMo7rh64RsEvFHY7iZN2qQ3wjKuzuiiXqi3IU3_2IxtU5N2Ze58BJ_Dx_JJzGwHQcGrEP7vHA6Hg9BjSs4pIfmF25lzxgSXd9CKkkpkJKfFXbRKN5IJysoT9CDGHSGUFoTfRyeMM0rKSq7Qz3WrgzYTBBf15PyAvcV60B12wxQ0jG5qoXPpP4AfOx2dTudmQYweDIRE4s3206_vP0Yf3eRuAPcw4HqPXd_Pg29dnLxpoXcmaXodvkCIeKTlGX7jkqoUZ3jz_qC_4rfeL95eJoep3XdLoqPkIbpndRfh0fE9RR9fXn1Yb7Lrd6-268vrzPCcyMywUtYNa6goOGGCCM4ry8vaCpAWJDRNDVrowtaUkaaxvDFaVLQuiZVCMMtO0fPFd5zrHhoDhyI6NQaXguyV1079fRlcqz77G1XlVZ5LlgyeHg2C_zpDnFTvooGu06nDOaq8KIqSCZqXCX3yD7rzc0jdHihRCF5JShP1bKFM8DEGsH_CUKIOC1BpAep2AYm9WNhvroP9_0G1fb1eFL8B7ey2Mg</recordid><startdate>20211115</startdate><enddate>20211115</enddate><creator>Zee, Ramon P.</creator><creator>Meijer, Chris J. L. M.</creator><creator>Cuming, Tamzin</creator><creator>Kreuter, Alexander</creator><creator>Sandt, Miekel M.</creator><creator>Quint, Wim G. V.</creator><creator>Vries, Henry J. C.</creator><creator>Prins, Jan M.</creator><creator>Steenbergen, Renske D. M.</creator><general>John Wiley & Sons, Inc</general><general>Wiley Subscription Services, Inc</general><scope>24P</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7T5</scope><scope>7TO</scope><scope>7U9</scope><scope>H94</scope><scope>K9.</scope><scope>7X8</scope><scope>5PM</scope><orcidid>https://orcid.org/0000-0002-2327-9839</orcidid></search><sort><creationdate>20211115</creationdate><title>Characterisation of anal intraepithelial neoplasia and anal cancer in HIV‐positive men by immunohistochemical markers p16, Ki‐67, HPV‐E4 and DNA methylation markers</title><author>Zee, Ramon P. ; Meijer, Chris J. L. M. ; Cuming, Tamzin ; Kreuter, Alexander ; Sandt, Miekel M. ; Quint, Wim G. V. ; Vries, Henry J. C. ; Prins, Jan M. ; Steenbergen, Renske D. M.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c4208-c368bd3d175403707449f46bf7e8fe8eddbea7a5fb130ddf4dca791b60f8773f3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2021</creationdate><topic>Anal cancer</topic><topic>anal high‐grade squamous intraepithelial lesion</topic><topic>Anus</topic><topic>Biomarkers</topic><topic>Cancer</topic><topic>Colorectal cancer</topic><topic>Deoxyribonucleic acid</topic><topic>DNA</topic><topic>DNA methylation</topic><topic>HIV</topic><topic>host cell DNA methylation markers</topic><topic>Human immunodeficiency virus</topic><topic>Human papillomavirus</topic><topic>immunohistochemistry</topic><topic>Lesions</topic><topic>Medical research</topic><topic>Squamous cell carcinoma</topic><topic>Tumor Markers and Signatures</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Zee, Ramon P.</creatorcontrib><creatorcontrib>Meijer, Chris J. L. M.</creatorcontrib><creatorcontrib>Cuming, Tamzin</creatorcontrib><creatorcontrib>Kreuter, Alexander</creatorcontrib><creatorcontrib>Sandt, Miekel M.</creatorcontrib><creatorcontrib>Quint, Wim G. V.</creatorcontrib><creatorcontrib>Vries, Henry J. C.</creatorcontrib><creatorcontrib>Prins, Jan M.</creatorcontrib><creatorcontrib>Steenbergen, Renske D. M.</creatorcontrib><collection>Wiley Online Library Open Access</collection><collection>CrossRef</collection><collection>Immunology Abstracts</collection><collection>Oncogenes and Growth Factors Abstracts</collection><collection>Virology and AIDS Abstracts</collection><collection>AIDS and Cancer Research Abstracts</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>International journal of cancer</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Zee, Ramon P.</au><au>Meijer, Chris J. L. M.</au><au>Cuming, Tamzin</au><au>Kreuter, Alexander</au><au>Sandt, Miekel M.</au><au>Quint, Wim G. V.</au><au>Vries, Henry J. C.</au><au>Prins, Jan M.</au><au>Steenbergen, Renske D. M.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Characterisation of anal intraepithelial neoplasia and anal cancer in HIV‐positive men by immunohistochemical markers p16, Ki‐67, HPV‐E4 and DNA methylation markers</atitle><jtitle>International journal of cancer</jtitle><date>2021-11-15</date><risdate>2021</risdate><volume>149</volume><issue>10</issue><spage>1833</spage><epage>1844</epage><pages>1833-1844</pages><issn>0020-7136</issn><eissn>1097-0215</eissn><abstract>Human papillomavirus (HPV)‐induced anal intraepithelial neoplasia (AIN, graded 1‐3) is highly prevalent in HIV‐positive (HIV+) men who have sex with men (MSM), but only a minority of lesions progresses to cancer. Our study aimed to characterise comprehensively anal tissue samples from a cross‐sectional series (n = 104) of HIV+ MSM and longitudinal series (n = 40) of AIN2/3 progressing to cancer using different biomarkers. The cross‐sectional series consisted of 8 normal, 26 AIN1, 45 AIN2, 15 AIN3 and 10 anal squamous cell carcinoma. Tissue sections were immunohistochemically (IHC) stained for p16 (viral transformation marker), Ki‐67 (cellular proliferation marker) and HPV‐E4 (viral production marker). We evaluated the expression of IHC markers and compared it with DNA methylation, a marker for malignant transformation. E4 positivity decreased, whereas p16 and Ki‐67 scores and methylation marker positivity increased (P values < .001) with increasing severity of anal lesions. Within AIN2, a heterogeneous biomarker pattern was observed concerning E4, p16 and methylation status, reflecting the biological heterogeneity of these lesions. In the longitudinal series, all AIN2/3 and carcinomas showed high p16 and Ki‐67 expression, strong methylation positivity and occasional E4 positivity. We earlier showed that high methylation levels are associated with progression to cancer. The observed E4 expression in some AIN2/3 during the course of progression to cancer and absence of E4 in a considerable number of AIN1 lesions make the potential clinical significance of E4 expression difficult to interpret. Our data show that IHC biomarkers can help to characterise AIN; however, their prognostic value for cancer risk stratification, next to objective methylation analysis, appears to be limited.
What's new?
Anal high‐grade squamous intraepithelial lesions (HSILs) constitute a heterogeneous group of precancerous lesions. Understanding which HSILs progress to cancer could facilitate early detection and treatment of anal cancer. Here, the prognostic value of expression of the immunohistochemical (IHC) markers p16, Ki‐67, and HPV‐E4 was evaluated in anal tissues with evidence of precancerous lesions. While analyses revealed positive associations between p16 and Ki‐67 expression and severity of anal dysplasia, HSILs overall exhibited complex biomarker patterns, reflecting their ambiguous clinical behaviour. Thus, while IHC markers are useful for molecular characterisation of HSIL, their prognostic value, particularly compared to methylation analysis, is limited.</abstract><cop>Hoboken, USA</cop><pub>John Wiley & Sons, Inc</pub><pmid>34310698</pmid><doi>10.1002/ijc.33748</doi><tpages>12</tpages><orcidid>https://orcid.org/0000-0002-2327-9839</orcidid><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0020-7136 |
| ispartof | International journal of cancer, 2021-11, Vol.149 (10), p.1833-1844 |
| issn | 0020-7136 1097-0215 |
| language | eng |
| recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_9292283 |
| source | Wiley Online Library Journals Frontfile Complete; Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals |
| subjects | Anal cancer anal high‐grade squamous intraepithelial lesion Anus Biomarkers Cancer Colorectal cancer Deoxyribonucleic acid DNA DNA methylation HIV host cell DNA methylation markers Human immunodeficiency virus Human papillomavirus immunohistochemistry Lesions Medical research Squamous cell carcinoma Tumor Markers and Signatures |
| title | Characterisation of anal intraepithelial neoplasia and anal cancer in HIV‐positive men by immunohistochemical markers p16, Ki‐67, HPV‐E4 and DNA methylation markers |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-02-03T13%3A28%3A33IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_pubme&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Characterisation%20of%20anal%20intraepithelial%20neoplasia%20and%20anal%20cancer%20in%20HIV%E2%80%90positive%20men%20by%20immunohistochemical%20markers%20p16,%20Ki%E2%80%9067,%20HPV%E2%80%90E4%20and%20DNA%20methylation%20markers&rft.jtitle=International%20journal%20of%20cancer&rft.au=Zee,%20Ramon%20P.&rft.date=2021-11-15&rft.volume=149&rft.issue=10&rft.spage=1833&rft.epage=1844&rft.pages=1833-1844&rft.issn=0020-7136&rft.eissn=1097-0215&rft_id=info:doi/10.1002/ijc.33748&rft_dat=%3Cproquest_pubme%3E2575749811%3C/proquest_pubme%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2575749811&rft_id=info:pmid/34310698&rfr_iscdi=true |