Journal of The Korean Medical Association最新文献_第6页

Renal diseases causing hematuria 引起血尿的肾脏疾病

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Journal of The Korean Medical Association Pub Date : 2023-06-10 DOI: 10.5124/jkma.2023.66.6.348

Hyo Jin Kim, J. Jeong

{"title":"Renal diseases causing hematuria","authors":"Hyo Jin Kim, J. Jeong","doi":"10.5124/jkma.2023.66.6.348","DOIUrl":"https://doi.org/10.5124/jkma.2023.66.6.348","url":null,"abstract":"Background: Hematuria is a common laboratory finding in clinical practice, occurring mostly in the kidneys. However, it can occur in the rest of the urinary system, including the ureters, bladder, and urethra, as well as in the prostate in men. This paper will discuss cases of hematuria observed in various diseases, especially kidney disease.Current Concepts: Hematuria is diagnosed when three or more red blood cells are found in a high-power field microscopic urinalysis. Identifying urine sediment is critical in differentiating between glomerular and nonglomerular hematuria, classified according to location. If hematuria is accompanied by proteinuria, dysmorphic red blood cells, or cellular casts in urine microscopy, as well as hypertension or renal function decline, glomerular disease may be present; thus, a nephrologist should be consulted. Hematuria is also observed in renal vascular diseases, including renal infarction, renal artery dissection, and nutcracker syndrome. In polycystic kidney disease, hematuria may present in combination with renal stones or malignancy. Diabetic nephropathy can manifest hematuria, which is a negative prognosticator of end-stage kidney disease.Discussion and Conclusion: Hematuria is a laboratory finding for various diseases, and appropriate diagnosis and treatment should be provided according to its clinical features.","PeriodicalId":17300,"journal":{"name":"Journal of The Korean Medical Association","volume":"50 1","pages":""},"PeriodicalIF":0.3,"publicationDate":"2023-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87590636","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Infectious diseases and biomarker use 传染病和生物标志物的使用

IF 0.3

Journal of The Korean Medical Association Pub Date : 2023-06-10 DOI: 10.5124/jkma.2023.66.6.374

Jooyun Kim, D. Park

{"title":"Infectious diseases and biomarker use","authors":"Jooyun Kim, D. Park","doi":"10.5124/jkma.2023.66.6.374","DOIUrl":"https://doi.org/10.5124/jkma.2023.66.6.374","url":null,"abstract":"Background: Biomarkers are used in diverse clinical fields, including oncological, cardiovascular, infectious, and rheumatoid diseases. In infectious diseases, biomarkers are widely used for identifying fever due to infection, evaluating the possibility of progression to sepsis, predicting prognosis, estimating treatment response, and determining the timing of discontinuation of antibiotic treatment. Thus, biomarkers are used as indicators that can inform clinical decisions.Current Concepts: Biomarkers for infectious diseases typically relate to inflammatory processes in, which are activated by external antigens. Historically, research has focused on acute phase reactants; however, more recently, various inflammatory response biomarkers have been investigated.Discussion and Conclusion: To date, no infallible biomarker has been identified for infectious diseases. The main reasons are the potential for these molecules to also be affected by non-infectious causes and the individual differences in the degree of change of the biomarker. Although diagnosis and clinical decisions cannot depend on biomarkers alone, these are undoubtedly essential tools in clinical contexts, if thoroughly and carefully characterized. Here, we review several substances used or showing significant potential as biomarkers for infectious diseases.","PeriodicalId":17300,"journal":{"name":"Journal of The Korean Medical Association","volume":"37 1","pages":""},"PeriodicalIF":0.3,"publicationDate":"2023-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79858501","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Survey study of telemedicine-experienced physicians on the acceptability of telemedicine: using propensity score matching method 远程医疗经验医师对远程医疗可接受性的调查研究:使用倾向评分匹配法

IF 0.3

Journal of The Korean Medical Association Pub Date : 2023-06-10 DOI: 10.5124/jkma.2023.66.6.393

Jeong-Hun Park, Jin Suk Kim

{"title":"Survey study of telemedicine-experienced physicians on the acceptability of telemedicine: using propensity score matching method","authors":"Jeong-Hun Park, Jin Suk Kim","doi":"10.5124/jkma.2023.66.6.393","DOIUrl":"https://doi.org/10.5124/jkma.2023.66.6.393","url":null,"abstract":"Background: The purpose of this study is to analyze the differences in the acceptability of telemedicine between telemedicine-experienced and -inexperienced physicians.Methods: A questionnaire survey was conducted using the Doctor Survey of the Korean Medical Association. A total of 1,385 physicians were included in the analysis. Propensity score matching was used to control selection bias. The chi-square tests were used for bivariate analysis. Multiple logistic regression analysis and multinomial logistic regression analysis were used to adjust for covariates (gender, age, working area, working type, institution type, and the specialty of physicians).Results: Physicians with experience in telemedicine were 2.53 times more likely to accept to allow telemedicine as a medical system than physicians without experience in telemedicine. Physicians with experience in telemedicine responded that telemedicine should be allowed to returning patients only and not be allowed to first-time patients. This response of telemedicine-experienced physicians was 3.73 times higher than that of telemedicineinexperienced physicians. Physicians with experience in telemedicine responded that telemedicine for first-time patients should be only allowed under specific situations. This response of telemedicine-experienced physicians was 2.59 times higher than that of telemedicine-inexperienced physicians.Conclusion: Telemedicine-inexperienced physicians were more acceptable to telemedicine as a medical system than telemedicine-inexperienced physicians. Physicians with experience in telemedicine suggested that telemedicine should be allowed to returning patients only and might be allowed to first-time patients only under specific situations.","PeriodicalId":17300,"journal":{"name":"Journal of The Korean Medical Association","volume":"26 1","pages":""},"PeriodicalIF":0.3,"publicationDate":"2023-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78373761","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Targeted therapies in ovarian cancer: where we stand and where we are heading 卵巢癌的靶向治疗:我们的现状和我们的方向

IF 0.3

Journal of The Korean Medical Association Pub Date : 2023-06-10 DOI: 10.5124/jkma.2023.66.6.384

T. Lee

{"title":"Targeted therapies in ovarian cancer: where we stand and where we are heading","authors":"T. Lee","doi":"10.5124/jkma.2023.66.6.384","DOIUrl":"https://doi.org/10.5124/jkma.2023.66.6.384","url":null,"abstract":"Background: Ovarian cancer is a highly lethal gynecological cancer globally. The standard treatment for this disease is cytoreductive surgery followed by platinum-based chemotherapy. However, most patients develop platinum resistance after multiple relapses and have an inadequate response to second-line chemotherapy. Additionally, molecular heterogeneity poses a challenge to effective treatment.Current Concepts: Advancements in understanding the molecular mechanisms of cancer progression provide insight into novel targeted therapies, which have emerged as groundbreaking and promising cancer treatment strategies. Poly(ADP-ribose) polymerase inhibitors and anti-vascular endothelial growth factor monoclonal antibodies are currently the two approved and most effective targeted drugs for ovarian cancer.Discussion and Conclusion: This review article discusses related clinical trials assessing the efficacy and safety of promising targets in ovarian cancer as well as challenges associated with targeted therapy, including drug resistance, heterogeneity, and toxicity. Additionally, possible solutions to optimize treatment effects are proposed. Targeting these molecular abnormalities will bring us closer to the goal of personalized therapy and improve the prognosis for patients with ovarian cancer.","PeriodicalId":17300,"journal":{"name":"Journal of The Korean Medical Association","volume":"121 1","pages":""},"PeriodicalIF":0.3,"publicationDate":"2023-06-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85035801","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Perioperative care for drug abusers in the opioid crisis era 阿片类药物危机时期药物滥用者的围手术期护理

IF 0.3

Journal of The Korean Medical Association Pub Date : 2023-05-10 DOI: 10.5124/jkma.2023.66.5.314

Ji-Yoon Kim

{"title":"Perioperative care for drug abusers in the opioid crisis era","authors":"Ji-Yoon Kim","doi":"10.5124/jkma.2023.66.5.314","DOIUrl":"https://doi.org/10.5124/jkma.2023.66.5.314","url":null,"abstract":"Background: Narcotic abuse and addiction have recently emerged as significant global issues. The consumption of dependence-inducing substances has become increasingly prevalent among younger generations in numerous countries, exacerbating the problem. Until 2015, South Korea had been relatively narcotic-free; however, this is no longer true. Consequently, encountering narcotic abusers in clinical settings, including operating rooms, is becoming more common. It is crucial to be prepared for these phenomena.Current Concepts: Research on managing narcotic abusers during the perioperative period remains insufficient. In 2023, the American Society of Regional Anesthesiologists and Pain Medicine published guidelines for the perioperative management of cannabinoid users. The decision to discontinue or continue medical cannabinoids before surgery remains uncertain. When managing patients with short- or long-term exposure to cannabinoids, anesthetic requirements tend to decrease in cases of acute intoxication and increase among long-term users. Therefore, the duration from the last use should be considered when adjusting the anesthetic dose.Discussion and Conclusion: Punishment is not a viable solution in a reality where narcotic abuse is increasingly common. Preventing addiction in individuals and supporting addicts’ treatment and rehabilitation is essential. There is an urgent need for interest and research focused on narcotic abuse.","PeriodicalId":17300,"journal":{"name":"Journal of The Korean Medical Association","volume":"75 1","pages":""},"PeriodicalIF":0.3,"publicationDate":"2023-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83367477","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Management of adverse effects in hyperosmolar therapy of brain edema 脑水肿高渗治疗不良反应的处理

IF 0.3

Journal of The Korean Medical Association Pub Date : 2023-05-10 DOI: 10.5124/jkma.2023.66.5.303

Soo-Hyun Park, S. Ko

{"title":"Management of adverse effects in hyperosmolar therapy of brain edema","authors":"Soo-Hyun Park, S. Ko","doi":"10.5124/jkma.2023.66.5.303","DOIUrl":"https://doi.org/10.5124/jkma.2023.66.5.303","url":null,"abstract":"Background: Mannitol and hypertonic saline are the most frequently used hyperosmolar agents to treat cerebral edema resulting from acute brain injury. However, there are several issues with using hyperosmolar therapies. Here, we focus on the potential adverse effects of hyperosmolar therapies and practical tips to overcome these issues in the neurointensive care unit.Current Concepts: Among the hyperosmolar agents used, mannitol may decrease intravascular volume and pose a potential risk of acute kidney injury for patients. Complications associated with using hypertonic saline include the risk of central pontine myelinolysis, coagulopathy, electrolyte imbalances, metabolic acidosis, and pulmonary edema. In addition, prolonged use of hypertonic saline increases the risk of hyperchloremic metabolic acidosis, which may be overcome with the concomitant use of sodium acetate.Discussion and Conclusion: Several laboratory variables were monitored in the neurointensive care unit to limit and possibly detect early complications related to hyperosmolar therapies. When using hyperosmolar agents, including mannitol and hypertonic saline, for therapeutic purposes in patients with cerebral edema, determining whether to use peripheral or central lines and determining the appropriate rate and infusion dose can minimize their adverse effects. Clinicians need to be aware of the potential adverse events of administering hyperosmolar agents.","PeriodicalId":17300,"journal":{"name":"Journal of The Korean Medical Association","volume":"9 1","pages":""},"PeriodicalIF":0.3,"publicationDate":"2023-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82003738","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Hyperosmolar therapy for regulation of cerebral edema and intracranial pressure 高渗疗法对脑水肿和颅内压的调节作用

IF 0.3

Journal of The Korean Medical Association Pub Date : 2023-05-10 DOI: 10.5124/jkma.2023.66.5.297

Dong-Seok Gwak, S. Ko

{"title":"Hyperosmolar therapy for regulation of cerebral edema and intracranial pressure","authors":"Dong-Seok Gwak, S. Ko","doi":"10.5124/jkma.2023.66.5.297","DOIUrl":"https://doi.org/10.5124/jkma.2023.66.5.297","url":null,"abstract":"Background: Hyperosmolar therapy is an essential treatment method for increased intracranial pressure and cerebral edema. Mannitol and hypertonic saline are frequently used in clinical practice; however, more helpful recommendations are needed for the optimal management of cerebral edema in terms of the choice, dosage, and timing of these medications. This study aimed to introduce the characteristics and relative strengths of two agents, i.e., mannitol and hypertonic saline, and review clinical data supporting their use in various diseases.Current Concepts: Hyperosmolar therapy reduces intracranial pressure by removing water from the brain tissue and transferring it to the vascular space by creating an osmotic gradient. Mannitol improves cerebral blood flow by reducing the hematocrit, decreasing blood viscosity, and increasing deformability of red blood cells. Hypertonic saline increases intravascular volume, transiently increases cardiac output, and improves tissue oxygen partial pressure in the brain. Hypertonic saline has several advantages over mannitol, including quicker onset and longer-lasting reduction in intracranial pressure. However, no significant differences are noted in clinical, functional outcomes, or mortality between the two treatment agents.Discussion and Conclusion: Both mannitol and hypertonic saline are effective in reducing increased intracranial pressure. Clinicians should be able to select an appropriate agent in different clinical situations based on available evidence and patients’ individual medical conditions.","PeriodicalId":17300,"journal":{"name":"Journal of The Korean Medical Association","volume":"12 1","pages":""},"PeriodicalIF":0.3,"publicationDate":"2023-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80222187","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Basic principle in the management of brain edema and elevated intracranial pressure 处理脑水肿和颅内压升高的基本原则

IF 0.3

Journal of The Korean Medical Association Pub Date : 2023-05-10 DOI: 10.5124/jkma.2023.66.5.278

S. Ko

{"title":"Basic principle in the management of brain edema and elevated intracranial pressure","authors":"S. Ko","doi":"10.5124/jkma.2023.66.5.278","DOIUrl":"https://doi.org/10.5124/jkma.2023.66.5.278","url":null,"abstract":"Background: Brain edema is a well-recognized pathophysiological secondary change after primary brain injury. The mechanism of brain edema may differ based on the types of brain edema. However, numerous ion channels are involved in its development and are therefore currently a hot target for anti-edema therapy. Here, this paper reviews the clinically important differences among the types of brain edema and a step-wise management strategy for brain edema and elevated intracranial pressure (ICP).Current Concepts: Brain edema can be classified as cytotoxic, ionic, vasogenic, and interstitial edema. Although the underlying mechanisms may differ among the various types of brain edema, multiple ion channels and the integrity of tight junctions are associated with the development of brain edema. If brain edema aggravates, the intracranial volume expands and leads to an elevation of ICP. A basic principle in the management of ICP includes proper positioning, screening for a need for extraventricular drainage, proper sedation, transient hyperventilation, assessing the intracranial water status with the serum sodium level, optimization of cerebral perfusion pressure, hyperosmolar therapy, targeted temperature management, and induction of a pharmacological coma with sedatives.Discussion and Conclusion: Stepwise treatment strategies are recommended in the management of patients with ICP crisis. Based on the principle, detailed management plans need to be adjusted based on the status of an individual patient.","PeriodicalId":17300,"journal":{"name":"Journal of The Korean Medical Association","volume":"41 1","pages":""},"PeriodicalIF":0.3,"publicationDate":"2023-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78576303","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

How to cope with suspected mpox patients in the outpatient clinic 门诊如何应对疑似m痘患者

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Journal of The Korean Medical Association Pub Date : 2023-05-10 DOI: 10.5124/jkma.2023.66.5.325

Nam Joong Kim, S. Huh

{"title":"How to cope with suspected mpox patients in the outpatient clinic","authors":"Nam Joong Kim, S. Huh","doi":"10.5124/jkma.2023.66.5.325","DOIUrl":"https://doi.org/10.5124/jkma.2023.66.5.325","url":null,"abstract":"Background: This article outlines procedures for monitoring and handling mpox outbreaks in Korea based on the 5th edition of the guidelines for response to mpox and recent briefing material from the Korea Disease Prevention and Control Agency (KDCA). Covering epidemiology, pathogenesis, clinical characteristics, diagnosis, treatment, prognosis, and prevention, and focusing on domestic resources, it offers guidance for healthcare professionals on coping with suspected mpox cases.Current Concepts: Human mpox infections mainly occur through person-to-person transmission. Historically, sporadic outbreaks of mpox have taken place, primarily in Africa, but mpox has subsequently spread globally. In Korea, after the first case report in June 2022, 52 cases had been reported as of May 1, 2023. Fifty cases had sexual contact with high-risk persons with mpox infection. Furthermore, 46 cases had not travelled abroad within 3 weeks prior to symptoms/signs onset. Mpox lesions involve the skin, lymph node, and respiratory tract. Confirmation of diagnosis requires laboratory testing, including polymerase chain reaction (PCR). Treatment is mainly supportive, but antivirals, e.g., tecovirimat, show favorable efficacy. The prognosis is generally favorable, with a 0.13% case fatality rate (116/86,930) from January 1, 2021, to April 10, 2023, worldwide. Prevention involves avoiding contact with suspected cases, practicing good hygiene, and timely reporting.Discussion and Conclusion: Suspected mpox cases should receive accurate information and undergo PCR testing while maintaining privacy. Physicians should report suspected cases to the KDCA. Seeking medical attention and vaccination is crucial for preventing infection in higher-risk groups, including men who have sex with men.","PeriodicalId":17300,"journal":{"name":"Journal of The Korean Medical Association","volume":"28 1","pages":""},"PeriodicalIF":0.3,"publicationDate":"2023-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85224360","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Targeted temperature management in brain edema 脑水肿的目标温度管理

IF 0.3

Journal of The Korean Medical Association Pub Date : 2023-05-10 DOI: 10.5124/jkma.2023.66.5.308

Sung-Ho Ahn, S. Ko

{"title":"Targeted temperature management in brain edema","authors":"Sung-Ho Ahn, S. Ko","doi":"10.5124/jkma.2023.66.5.308","DOIUrl":"https://doi.org/10.5124/jkma.2023.66.5.308","url":null,"abstract":"Background: Targeted temperature management is a treatment strategy to lower core body temperature to achieve neuroprotection or reduce elevated intracranial pressure. Therefore, it has been increasingly used in the neurointensive care unit to manage various types of acute neurologic injuries.Current Concepts: Targeted temperature management can be divided into three distinct phases, including induction, maintenance, and rewarming, and each phase has risks and predictable complications. In patients with acute neurocritical illnesses, including traumatic brain injury, subarachnoid hemorrhage, intracranial hemorrhage, and ischemic stroke, brain edema is a potentially life-threatening complication as it raises the intracranial pressure, leading to brain herniation and permanent neurological damage. In this sense, targeted temperature management can be considered the final strategy for medical treatment for controlling an intracranial pressure crisis in patients with severe brain injury.Discussion and Conclusion: In the neurointensive care unit, applying targeted temperature management to patients with severe brain injuries may be challenging. Targeted temperature management in critically ill neurological patients is associated with an increased risk of systemic complications, as hypothermia is prolonged, requiring a comprehensive patient-by-patient assessment of the advantages and disadvantages of treatment. Except for cerebral pressure management, analyses of targeted temperature management in patients with traumatic brain injury and subarachnoid hemorrhage remain controversial regarding its effect on prognosis. Targeted temperature management should be reserved for selective patients, and further studies are needed to improve the efficacy of hypothermia for individual conditions, including intracerebral hemorrhage and ischemic stroke.","PeriodicalId":17300,"journal":{"name":"Journal of The Korean Medical Association","volume":"72 1","pages":""},"PeriodicalIF":0.3,"publicationDate":"2023-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77228227","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0