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SEASONAL MOLD EXPOSURE: SYMPTOMS, RISKS AND 9 TIPS FOR COPING

SEASONAL MOLD EXPOSURE: SYMPTOMS, RISKS AND 9 TIPS FOR COPING

Medically Reviewed by Dr. Sony Sherpa, (MBBS) - September 20, 2024

Regular sufferers from hay fever, IBS, or flu-like symptoms may, in fact, be suffering from the little-acknowledged global phenomenon of environmental mold. Mold is an ancient healthcare concern that continues to affect a lot of people worldwide. 

The below article takes a look at symptoms of mold exposure, factors that increase its prevalence and damage, as well as tips for how one can cope with seasonal mold exposure like a pro.

Mold is Everywhere

Mold is as prolific in the environment as bacteria, with the two being critical to life on the planet. The two are required in order to balance environmental growth and decay, with bacteria often being conducive to growth promotion and mold being instrumental to decay. Without mold, there would be an abundance of organic waste matter and no true way for it to break down properly enough to contribute towards cycles of growth on the planet at large.[1] For this reason, mold is one of the most resilient organisms on the planet, and exposure to it is unavoidable.

The Usefulness of Molds. Despite being known to promote terrible symptoms (as discussed later on), molds are vital for decomposition. Over and above the decay of natural materials, molds have been shown to be important for degrading xenobiotics and for helping to restore the environment from chemical damage[2]. Mold toxins have been used for over a century as antibiotics and edible molds are crucial components of many ferments, including aged cheeses and some oriental fermented products.

Common Symptoms of Mold Exposure

Symptoms of mold exposure are usually mild and typically affect immune-compromised individuals and infants[3] more on average than other population groups.

Types of Mold and Associated Symptoms. Alternaria Alternata, Cladosporium, Penicillium, and Aspergillus strains of mold have been classically associated with symptoms. They can be found in habitats all over the world, commonly growing on building materials.[4] [5] These molds are some of the most frequently associated with mold-related symptoms, which often fluctuate according to environmental conditions.

The most common symptoms of mold exposure include[6]:

  • Allergic Reactions and Irritation. Mold spores in the environment can promote allergic symptoms similar to hay fever in susceptible individuals. These include red eyes, headaches, fever, a runny nose, sneezing, wheezing, coughing, skin irritation, or a rash (similar to contact dermatitis). Those exposed can also experience burning or mild irritation in the nose, throat, eyes and airways.[7] Mold spores constitute allergens capable of eliciting an IgE immune response. Very sensitive individuals can experience an immediate response within seconds up to one hour after exposure, while less sensitive individuals may experience a delayed immune response which could occur from an hour to several days post-exposure. Repeat exposure to mold can increase sensitivity towards it, which rises in tandem with IgE and IgM antibodies.
  • Asthma is a common side effect in those chronically exposed to mold spores of common outdoor and indoor mold varieties[8]. Mold exposure may also exacerbate asthma in non-allergic individuals suffering from respiratory ailments for other reasons or due to other exposures[9]. Mold-induced asthma is a result of an allergic reaction that induces immediate symptoms upon inhalation or ingestion of mold spores or toxins.
  • Hypersensitivity Reactions and Pneumonitis. Mold can induce hypersensitive allergic reactions, which are delayed by comparison to acute allergic reactions.[10] Long or short-term mold exposure is known to increase the risk of hypersensitivity pneumonitis, which is a respiratory condition similar to bacterial pneumonia.
  • Infections. Molds are known to cause both primary and secondary infections in immune-compromised individuals. These are collectively referred to as mycoses. Skin mycoses are common, such as athlete’s foot. Respiratory fungal infections constitute other common types of mycoses. As the lungs hold a lot of moisture in order to accommodate for gaseous diffusion, hence it is a prime site for chronic mold infections that can contribute to respiratory disease and cancer.
  • Other Symptoms. Mold can contribute to mood swings, depression, anxiety, movement abnormality, loss of smell, and increased pain sensitivity in highly exposed individuals. In studies on mice, exposure to molds caused impaired memory and was shown to increase inflammation in the hippocampus.[11] Preliminary epidemiological studies suggest that mold spores may contribute to cognitive impairment and neurodegenerative diseases by promoting dyslipidemia, white brain matter lesions, and neuroinflammation.

Particulate Size. Mold spores range in size. Some of them are small enough to penetrate into the deeper compartments of the lungs, able to reach the alveoli and enter the bloodstream. Air particles of this size are known to promote an increase in hospitalization events, even after only short-term exposures. Exposures within the course of a day have been linked to exacerbating symptoms of respiratory and cardiovascular conditions, including respiratory tract infections and ischemic heart disease.[12] Other studies have reported longer-term associations with these small particulates and hospitalization for congestive heart failure and attacks, arrhythmias, increased blood carbon dioxide levels, and various other heart conditions.[13] Deeper investigation reveals that these particles increase heart rate, promote vascular damage, and increase the risk for thrombosis (blood-clotting issues), as well as metabolic disorders such as diabetes and obesity.

Mycotoxin-Related Micro-Damage. Molds give off many spores and many poisonous metabolites known as mycotoxins.[14] Most mycotoxins are known to break down organic matter and promote mold-related decay. In this respect, they are toxic at both low and high concentrations to all types of organisms on the planet, including plants, animals, and humans. It is estimated that a quarter of the world’s crops are contaminated with mycotoxins. Mycotoxins contribute to mycotoxin-related diseases or states of poisoning known as mycotoxicoses. They can induce similar states of toxicity to chemical and heavy metal poisoning, affecting the nerves, many organs, and body tissues. Most of the well-known mycotoxins are produced by Aspergillus and Penicillium strains of mold, which have been shown to be a prevalent health concern all year round in Germany and present all over the world in homes, schools, and other residential buildings. The World Health Organisation is working on a shared initiative to reduce mycotoxin exposure worldwide[15]. A few of the most studied mycotoxins are briefly discussed below:

  • Aflatoxins are mycotoxins produced by aspergillus strains of mold and are some of the most prevalent and toxic mold-derived compounds. They can contaminate cereal grains, figs, seeds, nuts (especially groundnuts like peanuts), tobacco, and much more. Out of all the studied mycotoxins, aflatoxins are known to have the most carcinogenic potential.
  • Patulin is commonly seen on rotten apples, other fruits, and grains, as well as contaminated apple juice. It appears to be degraded during fermentation, as it is not found in cider or cider vinegar. It was shown in vitro to inhibit the uptake of potassium into the cells, capable of inducing cell death in high quantities.[16]  Animal studies suggest acute patulin poisoning can cause gastrointestinal upset and nausea as well as promote liver, kidney, and spleen damage.
  • Ochratoxin A can be found in pulses, cereal grains, coffee, some wine, and dried fruits. These mycotoxins are commonly associated with promoting nephropathy and the risk off kidney disease. Other studies point toward fetal, birth, and growth defects.
  • Trichothecene Family Mold Toxins. Deoxynivalenol (DON), nivalenol, zearalenone, fumonisins, T2, and HT2 are mainly produced by Fusarium strains of mold. These are commonly found in soil and in contaminated cereal grains, including wheat, barley, oat, rye, corn, and rice. Zearalenone has estrogenic growth-promoting effects and is regarded as a potent phytoestrogen, capable of inducing miscarriage. Fumonisins are known to promote varying symptoms in humans, with the most common being esophageal cancer. The rest mentioned above are capable of increasing the permeability of the gut and blood-brain barrier, contributing towards maldigestion and gastrointestinal problems[17], promoting neurological symptoms, and facilitating DNA and cellular damage.[18]

Systemic Toxicity and Disease Risk. Mold spores are known to induce mycosis, increase inflammation, and promote damage to multiple organs. As the first points of contact, the respiratory and gastrointestinal tracts are known to give rise to initial symptoms. Spores can affect the functioning of these organs, “clog” them up, and lower cellular antioxidant reserves[19], resulting in reduced clearance of mold alongside other pathogens and other potentially harmful foreign antigens. In the gut, mold spores can lower the diversity of bacteria, increase pathogenic bacteria, reduce intestinal barrier function and increase its permeability, negatively impact the metabolism of gut cells, and more. The liver and nervous system are also commonly affected by molds and their toxins, with some strains able to destroy neurons and promote permanent liver damage. Mycotoxins increase oxidative stress levels in the cell and contribute to the chronic production of low-grade inflammation.[20] As a result, mycotoxins have been associated with increasing the risk for all-cause morbidity[21] and worsening the symptoms of several diseases, including IBS, arthritis, Alzheimer’s disease, autoimmune, HIV[22], heart and liver diseases, respiratory conditions, cancers, diabetes, and obesity.

Factors Associated with Mold Exposure

Mold continues to thrive in every environment on the planet. The following factors can increase its environmental presence, exposure-related symptoms, and the risk of contracting various health conditions:

  • Contaminated Food. Mold is found in soil and in plants. Thus contaminated food is a common route of exposure, as is skin contact with plant material. All foods can contain mold spores, including plant-based, animal, and dairy products. Some studies found mycotoxins even in foods that are strictly regulated for spores, such as baby food.
  • Moisture is known to be the primary factor responsible for the growth of molds. Molds can technically “digest” nearly all substrates, requiring relatively little nutrients in order to thrive. When mold spores come into contact with water, they begin to grow and typically break down any surface they grow upon. This is why mold can often be found at higher concentrations in areas where moisture collects and condenses, such as window frames, bathroom surfaces, sinks, gutters, rooftops, and basements. Moist weather conditions can increase the levels of mold in the air[23]. Rising damp is a common type of indoor mold problem that often occurs due to plumbing faults or water that does not drain properly from beneath a building, causing mold to rise from the foundations upwards. If not contained, mold can take over and damage moisture-prone areas, serving as a major health problem that eventually damages infrastructure.
  • Wind, Dust, and Pollen. When the wind picks up, it can cause dust, pollen, and mold spores to redistribute in the environment, which can either increase or decrease exposure to molds. Pollen and other air-bourn allergic components can increase one’s sensitivity to mold when found together in the air during the transitional seasons.[24] Despite being loaded with potentially healthful compounds, bee pollen is associated with promoting allergies, which may be exacerbated by the presence of yeasts and molds.[25] Several contagious mold species were identified in 40 pollen samples collected from Italian bees, of which aspergillus and penicillium were the most prominent.[26]
  • Thunderstorms and Atmospheric Pressure. Thunderstorms, especially when coupled with heavy rains, are known to trigger mold release into the air in larger quantities than other extreme weather conditions.[27] Mold and pollen are believed to be responsible for thunderstorm-induced asthma, coupled with moisture, a pressure drop, and charged particles in the air. Case reports in various locations around the world suggest that conditions before, during, and after the thunderstorm contribute towards the heightened number of asthma-related events and hospitalizations. Prior to the storm, the air stagnates, allowing for the deposition of mold and pollen on plants and surfaces as a result of the charge build-up.
  • Weather Changes and Environmental Acidity can increase atmospheric concentrations of mold as well as promote its distribution in an area, resulting in a general increase in its growth on compatible surfaces. Aside from moisture, temperature drops, lightning, and acid rain can contribute.[28] Acid rain and lightning discharge both lower the pH of the rain and promote a more acidic environment[29] that tends to kill off some of the bacteria in the environment. Mold strains such as aspergillus and penicillium are resistant to both acid rain and heavy metals such as aluminium.[30] Some studies show that acid rain increases the concentration of mold in the environment.[31] For these reasons and more, sensitive individuals ought to pay special attention to thunderstorms and heavy rains.
  • Seasonal Environmental Conditions. It has long been known that seasonal variations in mold can give rise to allergies and hay fever symptoms, respiratory conditions including asthma, and hospitalization as a result. Seasonal mold may increase in summer, winter or be constant year-round.[32] In 2005, a study was conducted across three mold-free German regions. Low levels of Alternaria, Cladosporium, fusarium, and yeast were detected to rise in summer, while penicillium and aspergillus were found year-round at equal concentrations.[33]
  • Poor Living Conditions. Mold is known to grow on building materials. Older houses that have leaks and poor ventilation tend to have much higher concentrations of rising damp and mold than newer houses that are properly maintained. Leaks and cracks can promote sub-optimal insulation and temperature control, while a lack of proper ventilation can facilitate the build-up of moisture and spores. Plumbing problems may also contribute to rising damp, especially if present in the building’s foundations. In newer dwellings, mold is less prominent as a result of wear and tear. Air conditioning units and carpets older than 5 years also lead to indoor mold development.

9 Tips for Coping with Seasonal Mold

The below tips may help to reduce the severity of mold-related symptoms:

1. HEPA (High-Efficiency Particulate Air) Purifiers were shown to be some of the best air cleansing technology available[34]. These filters have been shown to release charged ions into the air which help to destroy mold, bacteria, and other organisms[35], as well as enrich the air quality[36].

2. Thorough Cleaning and Optimal Ventilation have been shown to help lower the presence of mold in homes. Dust and air pollution are also known to promote mold growth or increase susceptibility to mold[37], particularly in moist areas. Cleaning homes with harsh chemicals may contribute to respiratory issues independently of mold and is associated with the development of asthma in children. Air conditioning units need to be cleaned well and properly dried before use to prevent chronic spore and mycotoxin exposure when in use.[38]

3. Keeping Food Clean and Well-Cooked. Soaking one’s whole foods where possible in water with sodium bicarbonate helps to remove dirt as well as potential spores and mycotoxins. Optimal cooking methods also help lower the availability of mold toxins and are especially important in foods that are higher in mold (see below).

4. Timing the consumption of Mold-Heavy Foods. Grains, aged cheeses, and grain-fed animal products are known to be some of the highest mold-containing foods. As mold is known to increase with environmental conditions and seasonal variation, consumption of these foods can be tailored in order to reduce the intake of mold or mycotoxins and resultant symptoms. Out of these types of foods, some varieties are more mold-resistant than others and may be better alternatives for those who live in areas where concentrations of mold are high. Examples of anti-fungal grains include pearl millet[39], quinoa,[40] and buckwheat[41], which stand a lesser chance off mold contamination than wheat, rice, and corn. Fermented dairy products with live cultures are better alternatives to aged cheeses that are made mature by strains of mold. Kefir[42], whey, and dairy-derived probiotic strains[43] were shown to reduce the risk of mold contamination in dairy products.

5. Healthy Nutrient-Dense Diet. A diet high in nutrients and fiber helps to promote a strong gut microbiome that can protect against molds and toxins. Nutrients also bio-accumulate in the system and contribute towards antioxidant reserves across cells of all tissues. Specific antioxidants with anti-fungal properties are mentioned below.

6. Antioxidant Supplements. Mold is known to lower bodily antioxidant reserves, and this is believed to be an underlying factor involved in perpetuating mold-related illnesses. Below are a few antioxidant supplements that may be helpful during mold season:

  • NAC or N-Acetyl-Cysteine is a supplemental form of cysteine, which is one of the three building blocks required to make the cellular antioxidant glutathione, alongside glutamate and glycine (which are ubiquitous in foods). Glutathione is known to be one of the main antioxidants that mold is capable of depleting in the cell. When combined with methionine and glutathione, NAC proved to fully protect against the blood-brain barrier permeability and neuroinflammation that occurs as a result of systemic inflammation.
  • Vitamin C, E, and A are known to conserve all other cellular antioxidants. In vitro studies revealed that the combination of these vitamins can help to keep antioxidant levels stable in immune cells exposed to mold toxins. It is likely that other vitamins, especially B vitamins, can also serve to keep the immune system strong against mold.[44]
  • Minerals. Selenium, zinc, and copper have all surfaced in research from time to time for their antifungal properties[45]. These minerals are able to effectively bind to various opportunistic mold pathogens and inhibit their growth. They are also known to enhance immune function and provide antioxidant benefits for the cell.

7. Binding Agents. Mold spores and toxins may be bound to sequester compounds that can be found throughout the diet. These will help to neutralize mold toxicity and enhance bodily removal. Binding agents should be taken away from food and medications to avoid nutritional depletion. A few examples of binding agents include:

  • Activated Charcoal has been shown to have a high affinity for binding to mycotoxins and promoting their clearance from the body, due to charge-based mechanisms. When added to a mycotoxin-contaminated solution, activated charcoal removed up to 90% of the toxins present.46]
  • Chlorella and Spirulina are types of green-blue algae that are high in many healthy antioxidant nutrients. Both of them are known to bind and chelate to heavy metals, which helps to reduce inflammation and may improve immune function with regard to mold as molds typically thrive in environments high in heavy metal contamination.[47] Recent research has highlighted the antifungal potential of both chlorella and spirulina[48] [49], which are related to their binding actions to mold toxins and spores. In addition, these food extracts can serve as sources of antifungal antioxidants that further improve immune defenses against molds.
  • Albumin and amino acids. mold toxicity may resemble symptoms similar to the flu. Some studies show that molds and mycotoxins can form complexes with serum albumin[50] [51], suggesting that like many common infections, mycotoxicity can lower reserves of albumin and other proteins. Albumin and other amino acids may therefore bind to mold spores and toxins, able to promote their clearance from the body. Eggs are a great dietary source of albumin and other helpful amino acids, like cysteine.

8. Focusing on Anti-Fungal Foods During Mold Season and Symptom Onset. Many plant-based foods contain anti-fungal phytochemical compounds. Plants with the highest levels are typically resistant to decay for longer periods of time and are often associated with healthy qualities, such as herbs and spices. Foods that may specifically aid the body during seasonal and acute exposure include:

  • Herbs and Exotic Spices such as mint[52],basil, rosemary, sage, thyme, garlic, turmeric, clove, and ginger, to name a few, all possess antifungal properties that can help to improve the health of the gut while reducing mold toxin content. Cooking with these can also reduce the mold content of potentially contaminated foods, including grains and meat products.
  • Phytochemical Extracts. Lycopene from tomatoes and other red-orange foods may be able to lower the concentrations of mold spores and toxins in the gut after ingestion. Resveratrol from grape seeds and other dietary sources may be able to protect cells against mold-induced DNA damage and possible malignant mutations. Several other plant-derived antioxidant compounds may also pose mold-protective potentials, such as quercetin, kaempferol, and rutin, as well as herb and spice phytochemicals.[53] Teas and nutritious fruits and vegetables (often termed superfoods for their high nutrient content) can offer higher amounts of these antioxidant nutrients and more[54].
  • Essential Oils. Many essential oils possess strong antimicrobial and antifungal properties, often magnitudes more than their whole-plant counterparts. Floral, tree-derived, citrus[55], herbal and spice-derived essential oils have all shown promise for inhibiting molds and mycotoxins. You can consume essential oils by adding in water or as meal additives. Be sure to check how diluted the essential oil should be before ingesting it as some of them can burn the skin if taken without dilution.

9. Probiotics. Most mycotoxins are degraded in the stomach and colon by common gut bacteria, which release compounds that bind to mold spores, inhibit their growth and prevent mycotoxin production[56]. However, long-term exposures may be able to reduce gut microbiome diversity and promote mycosis. In vitro experiments reveal that lactobacilli strains have been shown to have a success rate of between just under 15% to 57%, respectively, for binding to mold spores and mycotoxins.[57] When added to contaminated chicken feed and left to ferment for 6 hours, probiotics reduced mycotoxin levels of ochratoxin A by 55-73%.[58] Good quality dairy products with live cultures (e.g., kefir) are often good sources of probiotic bacteria capable of degrading mold. Probiotic supplements also exist. Either source needs to be consumed alongside a nutrient-dense, fiber-laden diet.

Conclusion

Mold is a prolific environmental health problem that has plagued mankind since time immemorial. It is able to grow on anything provided there is sufficient moisture, including building materials, fauna, and flora. Seasonal fluctuations in temperature, moisture, and air electrodynamics can all contribute towards increasing environmental molds, amongst other factors. Mold spores can be damaging to the respiratory and vascular systems as micro-particulates, while molds themselves are known to directly infect the host or generate a number of toxic compounds that can be life-threatening. Cleaning, ventilation, optimal nutrition, and maintaining the health of the microbiome are all known to reduce the risk of acute mold toxicity. Various antioxidant compounds are also known to help in improving one’s immune defenses against molds and their toxins, as well as, being able to neutralize them in situ. As mold and bacteria share a relationship between growth and decay on the planet as a whole, it is hardly surprising that probiotics offer some of the best protective benefits against mold exposure alongside leading a healthy lifestyle.

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Sources:
  • [1] https://www.sciencedirect.com/science/article/pii/B9780124158405000026
  • [2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2681198/
  • [3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1241132/
  • [4] https://pubmed.ncbi.nlm.nih.gov/17624415/
  • [5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3782748/
  • [6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8835129/
  • [7] https://www.sciencedirect.com/topics/engineering/mould-growth
  • [8] https://pubmed.ncbi.nlm.nih.gov/28370571/
  • [9] https://pubmed.ncbi.nlm.nih.gov/12117641/
  • [10] https://pubmed.ncbi.nlm.nih.gov/9451141/
  • [11] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231651/
  • [12] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3543154/
  • [13] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924678/
  • [14] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC164220/
  • [15] https://www.who.int/news-room/fact-sheets/detail/mycotoxins
  • [16] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6354945/
  • [17] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7404981/
  • [18] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7662353/
  • [19] https://pubmed.ncbi.nlm.nih.gov/17161924/
  • [20] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7761905/
  • [21] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8877819/
  • [22] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8619365/
  • [23] https://pubmed.ncbi.nlm.nih.gov/7751516/
  • [24] https://pubmed.ncbi.nlm.nih.gov/7751516/
  • [25] https://www.researchgate.net/publication/344666634_Bee_Pollen_Its_Yeast_and_Mold_Communities
  • [26] https://www.aaem.pl/Occurrence-of-moulds-from-bee-pollen-in-Central-Italy-A-preliminary-study,72383,0,2.html
  • [27] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8672486/
  • [28] https://pubmed.ncbi.nlm.nih.gov/8595333/
  • [29] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7122886/
  • [30] https://pubmed.ncbi.nlm.nih.gov/10930728/
  • [31] https://pubmed.ncbi.nlm.nih.gov/32608867/
  • [32] https://pubmed.ncbi.nlm.nih.gov/6342846/
  • [33] https://pubmed.ncbi.nlm.nih.gov/15650904/
  • [34] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8449022/
  • [35] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9017056/
  • [36] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6213340/
  • [37] https://pubmed.ncbi.nlm.nih.gov/36168229/
  • [38] https://pubmed.ncbi.nlm.nih.gov/35353713/
  • [39] https://pubmed.ncbi.nlm.nih.gov/35922686/
  • [40] https://pubmed.ncbi.nlm.nih.gov/34641455/
  • [41] https://pubmed.ncbi.nlm.nih.gov/32180947/
  • [42] https://pubmed.ncbi.nlm.nih.gov/27210497/
  • [43] https://pubmed.ncbi.nlm.nih.gov/32151821/
  • [44] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3654247/
  • [45] https://pubmed.ncbi.nlm.nih.gov/22426818/
  • [46] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3654247/
  • [47] https://pubmed.ncbi.nlm.nih.gov/32749124/
  • [48] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8848030/
  • [49] https://pubmed.ncbi.nlm.nih.gov/24485311/
  • [50] https://pubmed.ncbi.nlm.nih.gov/31083629/
  • [51] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1552036/
  • [52] https://pubmed.ncbi.nlm.nih.gov/28017987/
  • [53] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8659076/
  • [54] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586119/
  • [55] https://pubmed.ncbi.nlm.nih.gov/30131466/
  • [56] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6354945/
  • [57] https://pubmed.ncbi.nlm.nih.gov/33801544/
  • [58] https://pubmed.ncbi.nlm.nih.gov/25528900/

 

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