Publications by authors named "Amit Rastogi"

209 Publications

Letter to the Editor in Response to "Endoscopic Recognition and Management Strategies for Malignant Colorectal Polyps: Recommenda-tions of the US Multi-Society Task Force on Colorectal Cancer".

Am J Gastroenterol 2021 Apr 6. Epub 2021 Apr 6.

Academy of Endoscopy, Woodside, California, USA; Division of Gastroenterology, San Francisco Veterans Affairs Medical Center, San Francisco, California, USA; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Health Management Center, National Taiwan University Hospital, Taipei, Taiwan; Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore; Department of Endoscopy and Medicine, Hiroshima University, Hiroshima, Japan; Department of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansas, USA; Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan; Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California, USA.

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http://dx.doi.org/10.14309/ajg.0000000000001223DOI Listing
April 2021

Impact of feedback on adenoma detection rate: a systematic review and meta-analysis.

Ann Gastroenterol 2021 27;34(2):214-223. Epub 2021 Jan 27.

Division of Gastroenterology, Hepatology, and Motility, Department of Medicine, University of Kansas Medical Center, Kansas City, KS (Venkat Nutalapati, Mojtaba Olyaee).

Background: Adenoma detection rate (ADR) is one of the most important quality indicators of colonoscopy. Monitoring endoscopists and providing feedback has shown to improve ADR. We performed a systematic review of the literature and meta-analysis to determine the effect of any form of feedback on ADR.

Methods: A literature search for comparative studies that employed any form of feedback to assess the impact on ADR before and after the feedback was done on MEDLINE, EMBASE, and Cochrane Database. The primary outcome of interest was ADR. Secondary outcomes included polyp detection rate, advanced adenoma detection rate, sessile serrated adenoma detection rate, withdrawal time, and cecal intubation rate. Cochrane Revman 5.3 software was used for statistical analysis.

Results: A total of 12 studies met the inclusion criteria for the analysis of primary outcomes. There were 78,355 subjects (45.42% male) with a mean age of 59.52 years. There was a significant improvement in ADR after any form of feedback compared to no feedback: 36.18% vs. 26.75%; pooled odds ratio 1.51, 95% confidence interval 1.37-1.66; P<0.001. There was a substantial heterogeneity (I=82%). ADR improved in both active or passive feedback, irrespective of whether endoscopists knew about being monitored for their performance or not.

Conclusions: Monitoring and providing feedback to endoscopists in any form leads to improvement in ADR. Feedback is an easy and effective way of improving the ADR of endoscopists, especially in those not achieving the recommended benchmarks.
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http://dx.doi.org/10.20524/aog.2021.0591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903562PMC
January 2021

IMAGES IN PEDIATRIC ENDOCRINOLOGY. Pseudopuberty and Juvenile Hypothyroidism.

J Pediatr Endocrinol Metab 2020 Oct 22;21(6):521-522. Epub 2020 Oct 22.

Department of Endocrinology and Metabolism, Institute of Medical Sciences, Banaras Hindu University,Varanasi, India.

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http://dx.doi.org/10.1515/jpem-2008-210605DOI Listing
October 2020

Delayed Graft Dysfunction due to Invasive Hepatic Mucormycosis After Living Donor Liver Transplantation.

J Clin Exp Hepatol 2020 Nov-Dec;10(6):629-632. Epub 2020 Apr 16.

Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Haryana, India.

Mucormycosis is a rare but emerging fungal infection complicating solid organ transplantation. It is associated with a high mortality rate. We describe an unusual case of hepatic mucormycosis in a living donor liver transplant recipient presenting as delayed graft dysfunction, which was successfully treated with combination of liposomal amphotericin B and oral posaconazole therapy, without surgical resection. The patient had clinical improvement with normalization of liver function tests.
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http://dx.doi.org/10.1016/j.jceh.2020.04.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719969PMC
April 2020

FACTORS ASSOCIATED WITH COMPLETE CLIP CLOSURE AFTER ENDOSCOPIC MUCOSAL RESECTION OF LARGE COLORECTAL POLYPS.

Endoscopy 2020 Dec 8. Epub 2020 Dec 8.

Hospital Clínic Barcelona, Gastroenterology, Barcelona, Spain.

Background: Delayed bleeding is a common adverse event following endoscopic mucosal resection (EMR) of large colorectal polyps. Prophylactic clip closure of the mucosal defect after EMR of ≥20 mm non-pedunculated polyps reduces the incidence of severe delayed bleeding, especially in proximal polyps.

Aim: Evaluate factors associated with complete prophylactic clip closure of the mucosal defect after EMR of large polyps.

Methods: This is a post-hoc analysis of the CLIP STUDY (NCT01936948). All patients randomized to the clip group were included. Main outcome was complete clip closure of the mucosal resection defect. The defect was considered completely closed when there was no remaining visible mucosal defect and clips were <1cm apart. Factors associated with complete closure were evaluated in multivariable analysis.

Results: 458 patients (age 65, 58% men) with 494 large polyps were included. Complete clip closure of the resection defect was achieved for 338 polyps (68.4%) and was not complete for 156 (31.6%). Factors associated with complete closure in adjusted analysis were smaller polyp size (OR 1.06 for every mm decrease [1.02-1.08]), good access (OR 3.58 [1.94-9.59]), complete submucosal lifting (OR 2.28 [1.36-3.90]), en bloc resection (OR 5.75 [1.48-22.39]), and serrated histology (OR 2.74 [1.35-5.56]).

Conclusions: Complete clip closure was not achieved for almost 1 out of 3 resected large non-pedunculated polyps. While stable access and en bloc resection facilitate clip closure, most factors associated with clip closure are not modifiable and highlight the need for alternative closure options and preventative bleeding measures.
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http://dx.doi.org/10.1055/a-1332-6727DOI Listing
December 2020

Effect of dynamic position changes on adenoma detection rate during colonoscope withdrawal: systematic review and meta-analysis.

Endosc Int Open 2020 Dec 17;8(12):E1842-E1849. Epub 2020 Nov 17.

Department of Gastroenterology, University of Kansas Medical Center, Kansas City, Kansa, United States.

 The adenoma detection rate (ADR) is an important quality metric of colonoscopy. Higher ADR correlates with lower incidence of interval colorectal cancer. ADR is variable between endoscopists and depends upon the withdrawal technique amongst other factors. Dynamic position change (lateral rotation of patients with a view to keep the portion of the colon being inspected at a higher level) helps with luminal distension during the withdrawal phase. However, impact of this on ADR is not known in a pooled sample. We performed a systematic review and meta-analysis to study the impact of dynamic position changes during withdrawal phase of colonoscopy on ADR  A comprehensive search of MEDLINE, EMBASE, Google Scholar, and the Cochrane Database was conducted from each database's inception to search for studies comparing dynamic position changes during colonoscope withdrawal with static left lateral position (control). The primary outcome of interest was ADR. Other studied outcomes were polyp detection rate (PDR) and withdrawal time. Outcomes were reported as pooled odds ratio (OR) with 95 % confidence intervals (CI) with statistical significance (  < 0.05). RevMan 5.3 software was used for statistical analysis.  Six studies were included in our analysis with 2860 patients. Of these, dynamic position change was implemented in 1177 patients while 1183 patients served as the controls. ADR was significantly higher in the dynamic position change group with pooled OR 1.36 (95 % CI, 1.15-1.61;  < 0.01). There was low heterogeneity in inclusion studies (I  = 0 %). PDR was numerically higher in position change group (53.4 % vs 49.6 %) but not statistically significant (  = 0.16). Mean withdrawal time did not significantly change with dynamic position change (12.43 min vs 11.46 min,  = 0.27).  Position change during the withdrawal phase of colonoscopy can increase the ADR compared to static left lateral position. This is an easy and practical technique that can be implemented to improve ADR.
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http://dx.doi.org/10.1055/a-1265-6634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671762PMC
December 2020

Incorporating Tumor Biology to Predict Hepatocellular Carcinoma Recurrence in Patients Undergoing Living Donor Liver Transplantation Using Expanded Selection Criteria.

Liver Transpl 2021 02 29;27(2):209-221. Epub 2021 Jan 29.

Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Delhi NCR, India.

Conventional selection criteria for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) are based on tumour size/number only, and do not consider vital surrogates of tumor biology such as alpha-fetoprotein (AFP) and tumor [ F]fluorodeoxyglucose positron emission tomography ([ F]FDG PET) avidity. We analyzed survival outcomes, and predictors of HCC recurrence in 405 patients with cirrhosis and HCC (HCC-cirr) who underwent living donor LT (LDLT) using our expanded selection criteria: no extrahepatic disease or major vascular invasion, irrespective of tumor size/number. Fifty-one percent patients had tumours beyond Milan, and 43% beyond the University of California San Francisco [UCSF] criteria. The 5-year overall survival (OS) and recurrence-free survival (RFS) were 64% and 70%, respectively. Three preoperatively available factors predicted recurrence: pre-LT AFP ≥100 ng/mL (P = 0.005; hazard ratio [HR], 2.190), tumor burden beyond the UCSF criteria (P = 0.001; HR, 2.640), and [ F]FDG PET avidity (P = 0.004; HR, 2.442). A prognostic model based on the number and combination of the aforementioned preoperative risk factors was developed using a competing-risk RFS model. Three risk groups were identified: low (none or a single risk factor present, 9.3% recurrence), moderate (AFP ≥100 ng/mL and [ F]FDG PET avidity, or beyond UCSF tumor and [ F]FDG PET avidity, 25% recurrence), and high (AFP ≥100 ng/mL and beyond UCSF, or presence of all 3 risk factors, 46% recurrence). Acceptable long-term outcomes were achieved using our expanded selection criteria. Our prognostic model to predict recurrence based on preoperative biological and morphological factors could guide pretransplant management (downstaging versus upfront LDLT) with the aim of reducing post-LDLT recurrence.
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http://dx.doi.org/10.1002/lt.25956DOI Listing
February 2021

Gla-100 Initiation: The When, Why, and How.

J Assoc Physicians India 2020 Dec;68(12[Special]):31-37

Chairman and Chief Diabetologist, Dr. Mohan's Diabetes Specialities Centre, Chennai, Tamil Nadu.

Early insulin initiation benefits people with diabetes by inducing a rapid and sustained glycemic control along with preventing the onset of adverse legacy effects early in the disease course. This has an over-arching effect as it could possibly modify the disease course and prevent the development of vascular complications, as has been attested to in landmark studies like the UKPDS and GRACE. Insulin glargine 100 U/mL (Gla-100) has been extensively studied under various scenarios as the initial insulin administered early in T2DM disease course, registering significant glycemic and vascular benefits over the standard of care. By virtue of its ease of use and better safety profile, basal insulin like Gla-100 has been recommended by various international and Indian guidelines as the go-to initial insulin in people with diabetes. Further, the ability to personalize the initiating dose basis one's HbA1c and weight is an additional feature that contributes to the scientific merit of initiating with basal insulin like Gla-100. However, early insulin initiation is mostly delayed owing to 'clinical inertia,' thereby causing an evitable glycemic burden. Therefore, physicians managing diabetes must aim to increase acceptance, persistence, and adherence to insulin therapy by focusing on the safety, simplicity, and convenience of therapies.
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December 2020

Outcome of hepatitis C-related liver transplantation in direct-acting antiviral era.

Indian J Gastroenterol 2020 Dec 24;39(6):539-543. Epub 2020 Nov 24.

Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity Hospital, Sector 38, Gurugram, Delhi (NCR), 122 413, India.

Background: Hepatitis C virus (HCV) has become an easily treatable disease after the introduction of sofosbuvir-based direct-acting antiviral (DAA) regimens. This is a large single center experience of changing severity and outcome profile of HCV-related liver disease after availability of DAAs.

Methods: A retrospective analysis of prospectively collected liver transplantation (LT) database of adults (age > 18 years at the time of LT) was performed from June 2010 to July 2018. A total of 410 patients (including 26 co-infection with hepatitis B) underwent LT for hepatitis C-related decompensated cirrhosis and/or hepatocellular carcinoma (HCC) out of 1754 adult transplantation in the defined period.

Results: The study group comprised of 296 males and 114 females aged 52.1 ± 7.9 years. HCV-related decompensated cirrhosis and/or HCC as indication of LT was present in 289/1016 (28.4%) during 2010-2014, which was reduced to 121/738 (16.3%) during 2015-2018 (p = 0.000). The LT recipients for HCV-related cirrhosis had significantly lower Child's and model for end-stage liver disease (MELD) score during 2015-2018 as compared to that during 2010-2014; Child's score was 7.9 ± 2.2 vs. 8.6 ± 2.1, p = 0.003; MELD score was 13.9 ± 5.3 vs. 17.1 ± 5.8, p = 0.000, respectively. There was a trend towards better survival in HCV patients during 2015-2018 as compared to that during 2010-2014. Significantly more patients had HCV RNA negative status before LT during 2015-2018 (38.8% vs. 13%, p = 0.000); moreover, the proportion of LT for decompensated cirrhosis (without HCC) decreased significantly in the latter period, 64.0% vs. 42.1% (p = 0.000).

Conclusion: In the DAA era, HCV as an indication for LT has decreased and patients have less severe disease at transplantation. There is a trend towards better patient survival.
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http://dx.doi.org/10.1007/s12664-020-01105-zDOI Listing
December 2020

Radial Head Arthroplasty, Excision and Osteosynthesis in Complex Elbow Fracture-Dislocations in Young Adults: What is Preferred?

Indian J Orthop 2020 Dec 18;54(Suppl 2):260-269. Epub 2020 May 18.

Department of Biostatistics, IMS BHU, Varanasi, India.

Objective: Complex elbow fractures are common injuries in young adults. Results in recent studies with various operative treatment protocols are equivocal. We compared the results of radial head arthroplasty, excision with osteosynthesis in such injuries at two follow-ups 1 year apart.

Methods: Thirty-five patients of complex elbow fracture-dislocations including, posterior/anterior olecranon dislocation of elbow, terrible triad injury, anteromedial facet of coronoid fracture, Type IV Monteggia fracture-dislocation and unclassified elbow dislocation were enrolled. They were managed operatively by standardized protocol similar to McKee et al. radial head reconstruction with miniplates, lag screws or non-operative treatment for undisplaced fractures. Arthroplasty of radial head with cemented prosthesis + LCL repair with suture anchor/transosseous tunnel was done. Coronoid and olecranon fixation was always performed. Patients were evaluated as follows: Q-DASH score, MEPI, pain according to VAS, range of motion, complications and radiographic findings and fracture union, and elbow instability.

Results: The mean length of follow-up among the patients was 18 months. There were statistically significant differences between the DASH score/MEPS between radial head excision and replacement/reconstruction. Instability was significantly reduced in those with LCL reconstruction. Excising the comminuted radial head without replacement had the worst outcome. Best PROM was reported in patients with osteosynthesis.

Conclusion: Provided a standard protocol is applied, radial head osteosynthesis has preferable outcomes in terms of patient-related outcomes as compared to arthroplasty, although not statistically significant. Radial head excision though has acceptable outcomes but there is a restriction of movements especially flexion-extension. Acceptable rate of complications major or minor warrants need of secondary surgical procedures or a staged treatment.
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http://dx.doi.org/10.1007/s43465-020-00136-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7609614PMC
December 2020

Plant celluloses, hemicelluloses, lignins, and volatile oils for the synthesis of nanoparticles and nanostructured materials.

Nanoscale 2020 Nov;12(45):22845-22890

Chemistry Department, Faculty of Science, Helwan University, 11795 Cairo, Egypt.

A huge variety of plants are harvested worldwide and their different constituents can be converted into a broad range of bionanomaterials. In parallel, much research effort in materials science and engineering is focused on the formation of nanoparticles and nanostructured materials originating from agricultural residues. Cellulose (40-50%), hemicellulose (20-40%), and lignin (20-30%) represent major plant ingredients and many techniques have been described that separate the main plant components for the synthesis of nanocelluloses, nano-hemicelluloses, and nanolignins with divergent and controllable properties. The minor components, such as essential oils, could also be used to produce non-toxic metal and metal oxide nanoparticles with high bioavailability, biocompatibility, and/or bioactivity. This review describes the chemical structure, the physical and chemical properties of plant cell constituents, different techniques for the synthesis of nanocelluloses, nanohemicelluloses, and nanolignins from various lignocellulose sources and agricultural residues, and the extraction of volatile oils from plants as well as their use in metal and metal oxide nanoparticle production and emulsion preparation. Furthermore, details about the formation of activated carbon nanomaterials by thermal treatment of lignocellulose materials, a few examples of mineral extraction from agriculture waste for nanoparticle fabrication, and the emerging applications of plant-based nanomaterials in different fields, such as biotechnology and medicine, environment protection, environmental remediation, or energy production and storage, are also included. This review also briefly discusses the recent developments and challenges of obtaining nanomaterials from plant residues, and the issues surrounding toxicity and regulation.
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http://dx.doi.org/10.1039/d0nr04795cDOI Listing
November 2020

Covid 19 and its cardiovascular effects.

Ann Card Anaesth 2020 Oct-Dec;23(4):401-408

Department of Anaesthesiology, SGPGI, Lucknow, Uttar Pradesh, India.

COVID-19 pandemic is mainly related with the pulmonary problems initially but now as the pandemic is growing it is observed that almost all organ systems of the body are affected. Up to 20-30% patients who are admitted in Covid hospitals are showing cardiovascular involvement. Severity of cardiovascular disease in a COVID-19 patient depends whether a patient is having pre-existing cardiac disease or not. Patients with pre-existing cardiac disease have more severe infection and associated mortality. Severe COVID-19 infection shows close association with myocardial damage and various arrythmias. The cardiovascular involvement occurs by either engagement directly with the angiotensin converting enzyme 2 or indirectly by the effect of inflammatory mediators which are generated as a result of viral-host response to infection. The COVID-19 disease is said to produce a wide spectrum of affliction ranging between even asymptomatic patient to Cardiovascular syndrome. Even after recovering from COVID-19 patients can reappear in the hospital with cardiomyopathies and arrythmias.
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http://dx.doi.org/10.4103/aca.aca_237_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7879919PMC
November 2020

Restructuring Living Donor Liver Transplantation at a High Volume Center During the COVID-19 Pandemic.

J Clin Exp Hepatol 2020 Oct 8. Epub 2020 Oct 8.

Liver Transplant Anesthesia, Medanta the Medicity, Gurgaon, Delhi (NCR), India.

Background: Coronavirus disease 2019 (COVID-19) pandemic has led to deferral of elective transplants and pro-active pre-transplant testing of donor/recipient. The impact of these on living donor liver transplantation (LDLT) activity and outcome is not known. We performed LDLT only for sick or advanced hepatocellular carcinoma (HCC) patients in this period, with special COVID protocols.

Methods: Patients undergoing LDLT counseling, evaluation and transplant in the period March to June 2020 (group A) under COVID-19 restrictions and special protocols were included. LDLT activity and outcomes among these patients was compared to those in the same period in 2019 (group B).

Results: In the period March 15-June 10, we performed 39 and 23 (59%) LDLTs in 2019 and 2020 respectively. The adult patients with cirrhosis in-group A (n=20) had significantly higher MELD score, 19.8±7.0 versus 16.1±5.6 in-group B (n=36), p=0.034. Early recipient mortality was similar in 2019 (2/39) and 2020 (2/23). One out of 23 post-transplant recipients, 3/71 recipients and donors during evaluation, and 8/125 health care workers (HCWs) developed COVID-19, all of whom recovered uneventfully.

Conclusion: LDLT activity substantially reduced during the COVID era. The incidence and outcome of COVID-19 among the waiting or transplanted patients and HCWs was similar to the general population. The outcome after LDLT in the COVID era was similar to non-COVID times. These data suggest that LDLT may be extended to more stable patients with strict protocols.
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http://dx.doi.org/10.1016/j.jceh.2020.09.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543734PMC
October 2020

Indian National Association for the Study of Liver Consensus Statement on Acute Liver Failure (Part-2): Management of Acute Liver Failure.

J Clin Exp Hepatol 2020 Sep-Oct;10(5):477-517. Epub 2020 Apr 22.

Institute of Liver & Digestive Diseases and Head of Hepatology & Liver Transplant (Medicine), BLK Super Speciality Hospital, Delhi, India.

Acute liver failure (ALF) is not an uncommon complication of a common disease such as acute hepatitis. Viral hepatitis followed by antituberculosis drug-induced hepatotoxicity are the commonest causes of ALF in India. Clinically, such patients present with appearance of jaundice, encephalopathy, and coagulopathy. Hepatic encephalopathy (HE) and cerebral edema are central and most important clinical event in the course of ALF, followed by superadded infections, and determine the outcome in these patients. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a crucial role in the pathogenesis, and several therapies aim to correct this abnormality. The role of newer ammonia-lowering agents is still evolving. These patients are best managed at a tertiary care hospital with facility for liver transplantation (LT). Aggressive intensive medical management has been documented to salvage a substantial proportion of patients. In those with poor prognostic factors, LT is the only effective therapy that has been shown to improve survival. However, recognizing suitable patients with poor prognosis has remained a challenge. Close monitoring, early identification and treatment of complications, and couseling for transplant form the first-line approach to manage such patients. Recent research shows that use of dynamic prognostic models is better for selecting patients undergoing liver transplantation and timely transplant can save life of patients with ALF with poor prognostic factors.
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http://dx.doi.org/10.1016/j.jceh.2020.04.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527855PMC
April 2020

Organ Procurement in the Brain Dead Donors Without In Vivo Cold Perfusion: A Novel Technique.

J Clin Exp Hepatol 2020 Sep-Oct;10(5):462-466. Epub 2020 Jan 7.

Medanta Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, India.

Introduction: We describe our technique of ex vivo organ perfusion and procurement in donation after deceased brain death (DBD) donors.

Material And Methods: This technique comprises warm dissection of liver, kidneys, and heart, in hemodynamically stable DBD donors and perfusing them ex vivo. The cardiac and abdominal dissection can take place simultaneously. As a precaution, the iliac arteries and the abdominal aorta are dissected and kept ready for rapid cannulation and perfusion, should the donor become unstable at any stage.The liver dissection is in principle similar to living donor hepatectomy, where portal dissection is combined with supra and infrahepatic caval dissection to completely mobilize liver to allow it to be removed and perfused ex vivo. The renal dissection is done after hepatic dissection is complete. The sequence of recovery of organ was modified where kidneys were procured first followed by hepatic and cardiac procurement simultaneously.

Results: Twelve multivisceral (liver and kidneys in all and heart in four) procurements have been performed. The average perfusion fluid volume for liver was 3.4 L. All recipients had uneventful postoperative course.

Conclusion: Our technique has not affected recipient outcomes and with benefits of less use of preservation solution, shortening bench surgery time, and decreasing the propensity of procurement injuries by avoiding cold-phase dissection.
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http://dx.doi.org/10.1016/j.jceh.2019.12.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527850PMC
January 2020

De Novo Malignancy After Living Donor Liver Transplantation: A Large Volume Experience.

J Clin Exp Hepatol 2020 Sep-Oct;10(5):448-452. Epub 2020 Feb 13.

Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurugram, India.

Background And Aims: Liver transplantation (LT) recipients such as all organ transplant recipients, have a risk of developing de novo malignancies owing to prolonged immunosuppression. However, there is limited data on this after living donor liver transplantation (LDLT), wherein immunosuppression levels are less than in deceased donor transplantation. We aim to describe experience of de novo malignancies from a predominantly LDLT center.

Materials And Methods: A total of 2100 adults (age >18 years) who underwent LT between January 2006 and December 2017 were retrospectively analyzed from a prospectively collected database. The data were analyzed up to June 2019. Data are shown as number, percentage, mean ± standard deviation, and median (interquartile range).

Results: Of 2100 patients who underwent LDLT, 21 (1%) patients developed de novo malignancy after transplantation. The de novo malignancy cohort comprised 20 males and 1 female, aged 50 ± 8.8 years. The distribution of de novo malignancies was as follows: 7 oropharyngeal (carcinoma of buccal and oral mucosa), 4 lung, 2 squamous cell carcinoma of skin, 2 lymphoma, 1 each of brain, colonic, gastric; ovary, pancreatic, and prostate. These malignancies were diagnosed at a median follow-up of 42 months (32-73) after LT. Over a median follow-up of 38 months (10-56) after the diagnosis of de novo malignancy, 6 patients (28.5%) died. Patients with de novo malignancy had a higher follow-up after LDLT, 94.3 ± 32.9 versus 62.5 ± 41.8 months,  = 0.000. Patients with alcohol as etiology for LT had higher trend of de novo malignancies (33.3% versus 26.4%),  = 0.46.

Conclusion: The incidence of de novo malignancy was 1% at a median follow-up of 42 (32-73) months. De novo malignancies following LDLT, although uncommon, are associated with significant mortality. A careful screening protocol should be followed after transplantation for early detection of de novo malignancies.
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http://dx.doi.org/10.1016/j.jceh.2020.02.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527845PMC
February 2020

Good Long-Term Outcomes in Patients With Primary Sclerosing Cholangitis Undergoing Living Donor Liver Transplantation.

J Clin Exp Hepatol 2020 Sep-Oct;10(5):442-447. Epub 2020 Feb 14.

Institute of Liver Transplantation and Regenerative Medicine, Medanta the Medicity, Gurugram, Delhi (NCR), India.

Background: Primary sclerosing cholangitis (PSC) is a progressive cholestatic disorder with liver transplantation (LT) being the only definitive treatment in end-stage disease. Recurrence of PSC after LT is a significant concern which can lead to graft loss. The aim of this study is to find out the disease recurrence and long-term outcome after living donor liver transplantation (LDLT) in PSC.

Methods: We conducted a retrospective review of all patients undergoing LDLT for PSC at our centre. Of 2268 adult LTs from August 2004 to July 2018, 32 (1.4%) patients underwent LDLT for PSC including 6 with PSC and autoimmune hepatitis overlap. The data were reviewed to look for PSC recurrence, complications, and overall survival. All patients received tacrolimus-based immunosuppression. Data are shown as number, percentage, median, and interquartile range (IQR).

Result: The mean age of 32 LDLT recipients was 44 ± 12 years (males 22, females 10). At the time of transplantation, the mean child's score was 9 ± 1.6 and model for end-stage liver disease score was 18.9 ± 6.4. Ulcerative colitis was seen in 7 patients and none had cholangiocarcinoma. Majority of patients (n = 29) received right lobe graft and all but 3 underwent hepaticojejunostomy for biliary reconstruction. PSC recurrence was seen in 6 (20%) patients during a median follow-up of 59 (29-101) months, after exclusion of 2 patients with early mortality. A total of five patients died during follow-up, and one of these deaths was due to PSC recurrence. There were 2 perioperative deaths due to sepsis and 3 deaths on follow-up (sepsis in 2 and PSC recurrence in 1).

Conclusion: LDLT can be performed in PSC with good overall long-term outcomes.
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http://dx.doi.org/10.1016/j.jceh.2020.02.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527842PMC
February 2020

Outcomes of Coronavirus Disease 2019 in Living Donor Liver Transplant Recipients.

Liver Transpl 2020 12 5;26(12):1665-1666. Epub 2020 Nov 5.

Institute of Liver Transplantation and Regenerative Medicine, Medanta-The Medicity, Gurugram, India.

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http://dx.doi.org/10.1002/lt.25909DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675322PMC
December 2020

A simple modification of sphenopalatine block for post-dural puncture headache.

Indian J Anaesth 2020 Jun 1;64(6):531-532. Epub 2020 Jun 1.

Department of Anesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.

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http://dx.doi.org/10.4103/ija.IJA_922_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7398019PMC
June 2020

A comparative study on polyp classification using convolutional neural networks.

PLoS One 2020 30;15(7):e0236452. Epub 2020 Jul 30.

School of Engineering, University of Kansas, Lawrence, KS, United States of America.

Colorectal cancer is the third most common cancer diagnosed in both men and women in the United States. Most colorectal cancers start as a growth on the inner lining of the colon or rectum, called 'polyp'. Not all polyps are cancerous, but some can develop into cancer. Early detection and recognition of the type of polyps is critical to prevent cancer and change outcomes. However, visual classification of polyps is challenging due to varying illumination conditions of endoscopy, variant texture, appearance, and overlapping morphology between polyps. More importantly, evaluation of polyp patterns by gastroenterologists is subjective leading to a poor agreement among observers. Deep convolutional neural networks have proven very successful in object classification across various object categories. In this work, we compare the performance of the state-of-the-art general object classification models for polyp classification. We trained a total of six CNN models end-to-end using a dataset of 157 video sequences composed of two types of polyps: hyperplastic and adenomatous. Our results demonstrate that the state-of-the-art CNN models can successfully classify polyps with an accuracy comparable or better than reported among gastroenterologists. The results of this study can guide future research in polyp classification.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236452PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392235PMC
September 2020

Indian National Association for the Study of the Liver Consensus Statement on Acute Liver Failure (Part 1): Epidemiology, Pathogenesis, Presentation and Prognosis.

J Clin Exp Hepatol 2020 Jul-Aug;10(4):339-376. Epub 2020 Apr 28.

Institute of Liver & Digestive Diseases and Head of Hepatology & Liver Transplant (Medicine), BLK Super Speciality Hospital, Delhi, India.

Acute liver failure (ALF) is an infrequent, unpredictable, potentially fatal complication of acute liver injury (ALI) consequent to varied etiologies. Etiologies of ALF as reported in the literature have regional differences, which affects the clinical presentation and natural course. In this part of the consensus article designed to reflect the clinical practices in India, disease burden, epidemiology, clinical presentation, monitoring, and prognostication have been discussed. In India, viral hepatitis is the most frequent cause of ALF, with drug-induced hepatitis due to antituberculosis drugs being the second most frequent cause. The clinical presentation of ALF is characterized by jaundice, coagulopathy, and encephalopathy. It is important to differentiate ALF from other causes of liver failure, including acute on chronic liver failure, subacute liver failure, as well as certain tropical infections which can mimic this presentation. The disease often has a fulminant clinical course with high short-term mortality. Death is usually attributable to cerebral complications, infections, and resultant multiorgan failure. Timely liver transplantation (LT) can change the outcome, and hence, it is vital to provide intensive care to patients until LT can be arranged. It is equally important to assess prognosis to select patients who are suitable for LT. Several prognostic scores have been proposed, and their comparisons show that indigenously developed dynamic scores have an edge over scores described from the Western world. Management of ALF will be described in part 2 of this document.
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http://dx.doi.org/10.1016/j.jceh.2020.04.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7335721PMC
April 2020

Do Recipients of Genetically Related Donors Have Better Outcomes After Living Donor Liver Transplantation?

J Clin Exp Hepatol 2020 Jul-Aug;10(4):334-338. Epub 2019 Dec 27.

Institute of Liver Transplantation and Regenerative Medicine, Medanta, the Medicity, India.

Background: There are few data on genetic relation of the donor and outcomes in living donor liver transplantation (LDLT) recipients. We compared outcomes of LDLT between recipients of genetically related and unrelated donors in a large single-center series.

Methods: The study included 1372 adult, ABO-compatible, primary LDLT recipients, who received a graft from either a first-degree relative (parent, sibling, son, or daughter; n = 756) or unrelated donor (spouse or relative of the spouse; n = 616).

Results: The mean age of the recipients with a related donor was 50.2 ± 10.8 years compared with 47.3 ± 9.3 years for recipients with unrelated donors ( = 0.000). Chronic rejection was significantly more common in the genetically unrelated donor group than in the genetically related donor group (28 [4.5%] versus 9 [1.1%];  = 0.000) at a mean follow-up of 37 months (15-95 months). There were no significant differences in other outcomes between the 2 groups. The 12-month and 36-month survival between the unrelated and related groups was 87.6% versus 90%, and 86.3% versus 89.7% respectively ( = 0.115). The multivariate analysis revealed genetically unrelated donors (odds ratio [OR]: 3.88, 95% confidence interval [CI]: 1.80-8.34,  = 0.001) and history of acute cellular rejection (OR: 3.39, 95% CI: 1.68-6.81,  = 0.001) as predictors of chronic rejection.

Conclusion: Although chronic rejection was found to be more common in genetically unrelated donors, the patient survival after LDLT was similar.
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http://dx.doi.org/10.1016/j.jceh.2019.12.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7335709PMC
December 2019

The utility of immunohistochemical testing for mismatch repair proteins in fine needle aspiration specimens of pancreatic adenocarcinoma.

Ann Diagn Pathol 2020 Aug 17;47:151552. Epub 2020 Jun 17.

Department of Pathology and Laboratory Medicine, University of Kansas Medical Center, Kansas City, KS, United States of America. Electronic address:

Introduction: Microsatellite instability (MSI) testing is recommended for all colonic and endometrial carcinomas to screen for Lynch syndrome. The role of MSI testing in pancreatic adenocarcinoma has not been well-established. Screening can be done via immunohistochemical (IHC) staining for mismatch repair (MMR) proteins (MLH1, MSH2, MSH6, PMS2). We report our experience and the clinical utility of MMR IHC on pancreatic adenocarcinomas in fine-needle aspiration (FNA) specimens.

Materials And Methods: We performed a retrospective review to identify all patients diagnosed with pancreatic adenocarcinoma by FNA at our institution between December 2017 and September 2019. For cases with sufficient tumor cells for testing, the MMR results and morphology were summarized, as well as corresponding clinical information, including age, clinical stage, treatment, and concurrent other cancers.

Results: From December 2017 to September 2019, there were a total of 184 pancreatic FNAs with a diagnosis of adenocarcinoma. Of these 184 FNAs, 65 (35%) contained sufficient material in the cell block to perform IHC for MMR. The cell block material was collected in either RPMI or CytoLyt. Poor technical quality precluded interpretation of PMS2 in 4 cases and MSH6 in 2 cases. All other cases showed intact expression of all four proteins.

Conclusions: IHC for MMR proteins can be done on specimens collected in RPMI or CytoLyt, but RPMI appears to be more reliable. None of the pancreatic adenocarcinomas in this study showed loss of MMR protein expression. Routine testing of MMR loss may not be indicated in pancreatic adenocarcinomas in the general patient population.
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http://dx.doi.org/10.1016/j.anndiagpath.2020.151552DOI Listing
August 2020

Evaluation of Serratus Anterior Plane Block for Pain Relief in Patients Undergoing MIDCAB Surgery.

Innovations (Phila) 2020 Mar/Apr;15(2):148-154

30093 Department of Anesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.

Objective: The minimally invasive direct coronary artery bypass (MIDCAB) surgery is associated with severe chest pain in the first 2 to 3 postoperative days; this may delay the patient recovery. In this randomized controlled trial we evaluated the role of serratus anterior plane (SAP) block for postoperative pain relief in patients undergoing MIDCAB surgery.

Methods: Patients undergoing MIDCAB surgery were randomized into 2 groups of 25 each; SAP group received 20 mL of 0.2% ropivacaine with 1 μg/mL fentanyl as bolus followed by infusion at 8 mL/h; control group received saline for both bolus and infusion. Primary outcome measure was postoperative pain when supine, and during deep inspiration, coughing, and patient movement; secondary outcome measures were requirement of postoperative intravenous fentanyl and opioid-related side effects. All patients were followed at 6-hourly intervals for 48 hours in the postoperative period. Results were analyzed by the Student's -test, test, Mann-Whitney -test and Kruskall-Wallis test. A -value <0.05 was considered significant.

Results: The 2 groups were similar with respect to patient characteristics. Static and dynamic pain visual analog scale scores were significantly reduced in the SAP group as compared to the control group at most of the time points of assessment ( < 0.05). Patient-controlled fentanyl requirements were reduced in the SAP group as compared to control group on the second postoperative day ( < 0.05).

Conclusions: SAP block reduced the postoperative pain scores and opioid requirements in patients undergoing MIDCAB surgery.
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http://dx.doi.org/10.1177/1556984520908962DOI Listing
January 2021

Liver transplantation and COVID-19 (Coronavirus) infection: guidelines of the liver transplant Society of India (LTSI).

Hepatol Int 2020 Jul 8;14(4):429-431. Epub 2020 Apr 8.

Medanta The Medicity, Gurugram, India.

The Liver Transplant Society of India (LTSI) has come up with guidelines for transplant centres across the country to deal with liver transplantation during this evolving pandemic of COVID-19 infection. The guidelines are applicable to both deceased donor as well as living donor liver transplants. In view of the rapidly changing situation of COVID-19 infection in India and worldwide, these guidelines will need to be updated according to the emerging data.
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http://dx.doi.org/10.1007/s12072-020-10041-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140588PMC
July 2020

Cost savings in colonoscopy with artificial intelligence-aided polyp diagnosis: an add-on analysis of a clinical trial (with video).

Gastrointest Endosc 2020 10 30;92(4):905-911.e1. Epub 2020 Mar 30.

Graduate School of Informatics, Nagoya University, Nagoya, Japan.

Background And Aims: Artificial intelligence (AI) is being implemented in colonoscopy practice, but no study has investigated whether AI is cost saving. We aimed to quantify the cost reduction using AI as an aid in the optical diagnosis of colorectal polyps.

Methods: This study is an add-on analysis of a clinical trial that investigated the performance of AI for differentiating colorectal polyps (ie, neoplastic versus non-neoplastic). We included all patients with diminutive (≤5 mm) rectosigmoid polyps in the analyses. The average colonoscopy cost was compared for 2 scenarios: (1) a diagnose-and-leave strategy supported by the AI prediction (ie, diminutive rectosigmoid polyps were not removed when predicted as non-neoplastic), and (2) a resect-all-polyps strategy. Gross annual costs for colonoscopies were also calculated based on the number and reimbursement of colonoscopies conducted under public health insurances in 4 countries.

Results: Overall, 207 patients with 250 diminutive rectosigmoid polyps (104 neoplastic, 144 non-neoplastic, and 2 indeterminate) were included. AI correctly differentiated neoplastic polyps with 93.3% sensitivity, 95.2% specificity, and 95.2% negative predictive value. Thus, 105 polyps were removed and 145 were left under the diagnose-and-leave strategy, which was estimated to reduce the average colonoscopy cost and the gross annual reimbursement for colonoscopies by 18.9% and US$149.2 million in Japan, 6.9% and US$12.3 million in England, 7.6% and US$1.1 million in Norway, and 10.9% and US$85.2 million in the United States, respectively, compared with the resect-all-polyps strategy.

Conclusions: The use of AI to enable the diagnose-and-leave strategy results in substantial cost reductions for colonoscopy.
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http://dx.doi.org/10.1016/j.gie.2020.03.3759DOI Listing
October 2020

Effects of Blended (Yellow) vs Forced Coagulation (Blue) Currents on Adverse Events, Complete Resection, or Polyp Recurrence After Polypectomy in a Large Randomized Trial.

Gastroenterology 2020 07 12;159(1):119-128.e2. Epub 2020 Mar 12.

Indiana University School of Medicine, Indianapolis, Indiana.

Background & Aims: There is debate over the type of electrosurgical setting that should be used for polyp resection. Some endoscopists use a type of blended current (yellow), whereas others prefer coagulation (blue). We performed a single-blinded, randomized trial to determine whether type of electrosurgical setting affects risk of adverse events or recurrence.

Methods: Patients undergoing endoscopic mucosal resection of nonpedunculated colorectal polyps 20 mm or larger (n = 928) were randomly assigned, in a 2 × 2 design, to groups that received clip closure or no clip closure of the resection defect (primary intervention) and then to either a blended current (Endocut Q) or coagulation current (forced coagulation) (Erbe Inc) (secondary intervention and focus of the study). The study was performed at multiple centers, from April 2013 through October 2017. Patients were evaluated 30 days after the procedure (n = 919), and 675 patients underwent a surveillance colonoscopy at a median of 6 months after the procedure. The primary outcome was any severe adverse event in a per patient analysis. Secondary outcomes were complete resection and recurrence at first surveillance colonoscopy in a per polyp analysis.

Results: Serious adverse events occurred in 7.2% of patients in the Endocut group and 7.9% of patients in the forced coagulation group, with no significant differences in the occurrence of types of events. There were no significant differences between groups in proportions of polyps that were completely removed (96% in the Endocut group vs 95% in the forced coagulation group) or the proportion of polyps found to have recurred at surveillance colonoscopy (17% and 17%, respectively). Procedural characteristics were comparable, except that 17% of patients in the Endocut group had immediate bleeding that required an intervention, compared with 11% in the forced coagulation group (P = .006).

Conclusions: In a randomized trial to compare 2 commonly used electrosurgical settings for the resection of large colorectal polyps (Endocut vs forced coagulation), we found no difference in risk of serious adverse events, complete resection rate, or polyp recurrence. Electrosurgical settings can therefore be selected based on endoscopist expertise and preference. Clinicaltrials.gov ID NCT01936948.
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http://dx.doi.org/10.1053/j.gastro.2020.03.014DOI Listing
July 2020

Efficacy of Hemospray in non-variceal upper gastrointestinal bleeding: a systematic review with meta-analysis.

Ann Gastroenterol 2020 Mar-Apr;33(2):145-154. Epub 2020 Jan 20.

Department of Gastroenterology and Hepatology, University of Kansas Medical Center, Kansas City, Kansas (Amit Rastogi), USA.

Background: Recently, amongst other hemostatic modalities, Hemospray (TC-325) has emerged as an effective method for managing patients with non-variceal upper gastrointestinal bleeding (GIB). We conducted this systematic review and meta-analysis to assess the efficacy of Hemospray in patients with non-variceal upper GIB.

Methods: Our primary outcomes were clinical and technical success; secondary outcomes were aggregate rebleeding, early rebleeding, delayed rebleeding, refractory bleeding, mortality, and treatment failure. A meta-analysis of proportions was conducted for all reported primary and secondary outcomes. A relative risk meta-analysis was conducted for studies reporting direct comparisons between Hemospray and other hemostatic measures.

Results: A total of 20 studies with 1280 patients were included in the final analysis. Technical success of Hemospray was seen in 97% of cases (95% confidence interval [CI] 94-98%, =52.89%) and a significant trend towards increasing technical success was seen during publication years 2011-2019. Clinical success of Hemospray was seen in 91% of cases (95%CI 88-94%, =47.72%), compared to 87% (95%CI 75-94%, =0.00%) for other hemostatic measures. The secondary outcomes of aggregate rebleeding, early rebleeding, delayed rebleeding, refractory rebleeding, mortality and treatment failure following the use of Hemospray were seen in 27%, 20%, 9%, 8%, 8%, and 31% of cases, respectively.

Conclusion: Hemospray is safe, effective and non-inferior to traditional hemostatic measures for the management of non-variceal upper GIB, and can thus be used as an alternative option.
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http://dx.doi.org/10.20524/aog.2020.0448DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7049242PMC
January 2020

Generation of scaffold incorporated with nanobioglass encapsulated in chitosan/chondroitin sulfate complex for bone tissue engineering.

Int J Biol Macromol 2020 Jun 18;153:1-16. Epub 2020 Feb 18.

School of Biochemical Engineering, Indian Institute of Technology (Banaras Hindu University), Varanasi 221005, India. Electronic address:

Over the past decade, various composite materials fabricated using natural or synthetic biopolymers incorporated with bioceramic have been widely investigated for the regeneration of segmental bone defect. In the present study, nano-bioglass incorporated osteoconductive composite scaffolds were fabricated through polyelectrolyte complexation/phase separation and resuspension of separated complex in gelatin matrix. Developed scaffold exhibits controlled bioreactivity, minimize abrupt pH rise (~7.8), optimal swelling behavior (2.6+-3.1) and enhances mechanical strength (0.62 ± 0.18 MPa) under wet condition. Moreover, in-vitro cell study shows that the fabricated scaffold provide suitable template for cellular attachment, spreading, biomineralization and collagen based matrix deposition. Also, the developed scaffold was evaluated for biocompatibility and bone tissue regeneration potential through implantation in non-union segmental bone defect created in rabbit animal model. The obtained histological analysis indicates strong potential of the composite scaffold for bone tissue regeneration, vascularization and reconstruction of defects. Thus, the developed composite scaffold might be a suitable biomaterial for bone tissue engineering applications.
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http://dx.doi.org/10.1016/j.ijbiomac.2020.02.173DOI Listing
June 2020