Why should we not eat spoiled food?
By
Dr Miguel Fernandez-Nino PhD
| Reviewed by
Dr Anny Manrich (PhD)
The contents of this article are fact-based except otherwise stated within the article.
Author bio
Dr Miguel Fernández-Niño is a food scientist with expertise in food biochemistry, Food microbiology, synthetic biology, food waste valorisation, and industrial biotechnology. He writes and reviews content on these topics.
Dr. Fernández-Niño’s Highlights:
- Colombian scientist, with a Ph.D. in Biochemical Engineering from the Jacobs University Bremen (Germany).
- Alexander von Humboldt Postdoctoral Fellow at the Leibniz Institute of Plant Biochemistry in Halle (Germany).
- Expertise in using multi-omics approaches (e.g., metabolomics, metagenomics, and metatranscriptomics) to re-engineer products and processes of relevance for the food industry.
- Expertise in designing microorganisms (microbial biofactories and starter cultures) to produce value-added products and food waste valorisation.
“My professional goal is to contribute to the education and research in Food Engineering and Food Biotechnology. The major incentive of my career is to contribute to the diffusion of scientific knowledge in society, thus promoting rational thinking and evidence-based decision-making”- Dr. Fernández-Niño’s, PhD.
Professional Experience:
Dr Fernández-Niño works as an Alexander von Humboldt Postdoctoral Fellow, at the Leibniz Institute of Plant Biochemistry, in Halle (Germany). He leads a project that aims to improve fine-flavour cocoa bean fermentation for local farmers in Colombia through controlled fermentation systems.
Previously, Dr Fernández-Niño worked as a Postdoctoral Fellow on the bio-catalytic synthesis of isoferulic acid (BMBF project) in the same institution.
Dr Fernández-Niño also worked as a Postdoctoral researcher at the Department of Chemical and Food Engineering at Los Andes University in Colombia, working on the development of a platform to produce novel aroma precursor compounds and high value-added products from analysis of cocoa fermentation.
In addition, Dr. Fernández-Niño worked on the assembly of a platform for heterologous polyphenols production in E. coli from analysis of cacao fermentation pathways, in the same institution.
Dr. Fernández-Niño has been an occasional scientific adviser of Casa Luker S.A. (leader in the Colombian chocolate market), working on projects related to the post-harvesting of fine-flavour cocoa. He also worked as instructor and coordinator of the lab course General Biochemistry and Molecular Biology II Lab (Course No. CH02-520121) at Jacobs University Bremen (Germany) and as a Resident Associate in the same institution.
Finally, Dr Miguel Fernández-Niño has experience as Part-Time Assistant Professor, Occasional Professor, and Master Teaching Assistant.
Education:
- 2009 B.Sc. Biologist at Universidad Nacional de Colombia
- 2012 Master in Science – Biochemistry (Thesis “magna cum laude”) at Universidad Nacional de Colombia
- 2017 PhD in Biochemical Engineering at Jacobs University Bremen-Germany
The main publications of Dr Miguel Fernández-Niño are:
Fabio Herrera-Rocha, Miguel Fernández-Niño*, Mónica P. Cala, Jorge Duitama, Andrés Fernando González Barrios (2023) Omics approaches to understand cocoa processing and chocolate flavor development: A review. Food Research International. https://doi.org/10.1016/j.foodres.2023.112555
Fernández-Niño Miguel* and Burgos-Toro Daniela (2022) Engineering microbial biofactories for a sustainable future. Chapter edited by Catalina Correa & Adriana Suarez-Gonzalez in the book: Genomics and the Global Bioeconomy -1st Edition-. ISBN 9780323916011. Publisher: ELSEVIER: https://www.elsevier.com/books/genomics-and-the-global-bioeconomy/patrinos/978-0-323-91601-1
Fabio Herrera-Rocha, Mónica P. Cala, Ana Maria León-Inga, Jenny Lorena Aguirre Mejía, Claudia M. Rodríguez-López, Sergio Leonardo Florez, María José Chica, Héctor Hugo Olarte, Jorge Duitama, Andrés Fernando González Barrios, Miguel Fernández-Niño* (2022) Lipidomic profiling of bioactive lipids during spontaneous fermentations of fine-flavor cocoa. Food Chemistry. Volume 397. 133845, ISSN 0308-8146. https://doi.org/10.1016/j.foodchem.2022.133845.
Díaz-Bustamante ML, Fernández-Niño M, Reyes LH and Alvarez Solano OA (2022) Multiscale Approach to Dairy Products Design. Front. Chem. Eng. 4:830314. doi: https://doi.org/10.3389/fceng.2022.830314.
Ramón E. Jaimez*, Luigy Barragan, Miguel Fernández-Niño*, Ludger A. Wessjohann, George Cedeño-Garcia, Ignacio Sotomayor, Francisco Arteaga, (2022): Theobroma cacao L. cultivar CCN 51: A comprehensive review on origin, genetics, sensory properties, production dynamics, and physiological aspects. PeerJ 10:e12676 https://doi.org/10.7717/peerj.12676.
Fabio Herrera‑Rocha, Mónica P. Cala, Jenny Lorena Aguirre Mejía, Claudia M. Rodríguez‑López, María José Chica, Héctor Hugo Olarte, Miguel Fernández‑Niño* & Andrés Fernando Gonzalez Barrios*. (2021): Dissecting fine‑flavor cocoa bean fermentation through metabolomics analysis to break down the current metabolic paradigm. Scientific Reports 11(21904) DOI: https://doi.org/10.1038/s41598-021-01427-8.
Fernández-Niño, M., Rodríguez-Cubillos, MJ., Herrera-Rocha, F., Anzola, JM., Cepeda-Hernández, ML., Aguirre, L., Chica, MJ., Olarte, HH., Rodríguez, CM., Calderón, D., Ramírez-Rojas, A., Del Portillo, P., Restrepo, S., González Barrios, A.* (2021): Dissecting on-farm industrial fermentations of fine-flavour cocoa through metagenomic analysis. Scientific Reports 11(8638) DOI: https://doi.org/10.1038/s41598-021-88048-3.
Buitrago Mora, HM., Arango Piñeros, M., Espinosa Moreno, D., Restrepo, S., Cardona Jaramillo, JEC., Álvarez Solano, OA., Fernandez-Niño, M., González Barrios, A.* (2019): Multiscale design of a dairy beverage model composed of Candida utilis single cell protein supplemented with oleic acid. Journal of Dairy Science. 102(11) 9749-9762 DOI: https://doi.org/10.3168/jds.2019-16729.
Fernández-Niño, M., Giraldo, D., Gomez-Porras, JL., Dreyer, I., González Barrios, A., Arevalo-Ferro, C.* (2017): A synthetic multi-cellular network of coupled self-sustained oscillators. PLOS ONE 12(6): e0180155 DOI: https://doi.org/10.1371/journal.pone.0180155.
Fernández-Niño, M., Marquina, M. Swinnen, S.,Rodríguez-Porrata, B., Nevoigt, E.*, Ariño, J. (2015):The Cytosolic pH of Individual Saccharomyces cerevisiae Cells Is a Key Factor in Acetic Acid Tolerance. Appl Environ Microbiol 81(22): 7813-7821 DOI: https://doi.org/10.1128/AEM.02313-15.
Swinnen, S., Fernández-Niño, M., González-Ramos, D., van Maris, AJ., Nevoigt, E.* (2014): The fraction of cells that resume growth after acetic acid addition is a strain-dependent parameter of acetic acid tolerance in Saccharomyces cerevisiae. FEMS Yeast Res 14(4): 642-653 DOI: https://doi.org/10.1111/1567-1364.12151.
Conference appearances and other speaking engagements
Selected courses delivered:
Course: Current technologies in the production of chocolates. (20 hours course). Invited as professor by the Department of Chemical and Food Engineering / Faculty of Engineering at Los Andes University-Colombia. July (2021).
Course: Design and assembly of microorganisms for the biomedical industry (20 horas course). Invited as professor by the School of Engineering and Science- Instituto Tecnologico de Monterrey (México). January 15-17 (2019)
Selected oral presentations and conferences:
Conference: Dissecting fine-flavour cocoa bean fermentation through multi-omics approaches. Speaker invited by the Organic Chemistry Department at The University of Buenos Aires -Argentina. Sep. 07 (2022).
Conference: Theobroma cacao L. cultivar CCN 51. Association of Producers of Fine Cocoa and Aroma (APROCAFA), Ecuador. March 15 (2022).
Conference: Biology of probiotics and prebiotics. Speaker invited by the Chemical and Food Engineer Department at Los Andes University-Colombia. June 27 (2020).
Conference: Pandemic food revolution. Speaker invited by the Chemical and Food Engineer Department at Los Andes University-Colombia. May 5 (2020).
Conference: Biochemistry and microbiology of cocoa fermentation. Speaker invited to the elective course: cocoa and Chocolate, organized by Casa Luker and the Department of Chemical Engineering at Los Andes University-Colombia. February 5 and 7 (2019)
Oral presentation: Lipidomic profiling of bioactive lipids during spontaneous fermentation of fine-flavour cocoa. Metabolomics 2022. Valencia, Spain. June 19-23 (2022).
Oral presentation: Exploration of Saccharomyces cerevisiae intra-species diversity for the identification of novel genetic determinants for acetic acid tolerance with the help of pooled-segregant RNA sequencing. ISSY33 International Specialized Symposium on Yeasts at University College Cork, Cork, Ireland, June 24-29. (2017)
You can view some of Dr Miguel’s work below and links to his professional profile.
https://www.researchgate.net/profile/Miguel-Fernandez-Nino
https://www.linkedin.com/in/miguel-fern%C3%A1ndez-ni%C3%B1o-4a064b168/?locale=en_US
https://scholar.google.com/citations?user=JBb1zuoAAAAJ&hl=en
https://orcid.org/0000-0002-8231-7989
https://www.scopus.com/authid/detail.uri?authorId=56123747300
https://loop.frontiersin.org/people/1296449/overview
https://www.intechopen.com/profiles/158295
Reviewer bio
Dr Anny Manrich PhD is a food Engineer with expertise in Food Technology, Natural Polymers, Edible Films, Enzymes, and Nanotechnology. She writes and reviews content on these topics.
Dr Anny Manrich’s Highlights:
- Research and Technology at the Brazilian Agricultural Research Corporation
- PhD in Chemical Engineering with a focus on Biochemistry at the Federal University of Sao Carlos/ Brazil and a one-year scholarship at the Technical University of Munich/ Germany
- Bachelor of Food Engineering at the University of Campinas/ Brazil and a one-year scholarship at the Technical University of Munich/ Germany
“To solve a problem, global vision and multifactorial understanding are necessary. Therefore, in addition to expertise, one should seek multidisciplinary thinking connected with science and reality” – Dr Anny Manrich, PhD.
Professional Experience:
Dr Anny Manrich’s Experience Joining the Brazilian Agricultural Research Corporation, as soon as she completed her doctorate,
Dr Anny Manrich has worked on several projects, including the more than three-year partnership project with BRF, a major food producer in Brazil. As a postdoctoral fellow.
Dr Anny Manrich has also contributed to several business consultancies and research projects of the National Nanotechnology Laboratory System in areas such as food technology, fibres, films and coatings and Nanotechnology; in a very determined way, having a great team relationship, being creative and committed.
Growing concerns about the safe introduction of nanomaterials into today’s life emphasises the need to create regulatory documentation in front of characterising, using and testing them. Dr Anny Manrich worked for two years on a characterization project for nanoscale materials, with the aim of exploring their possible health effects.
Despite not having specific academic training in packaging or polymeric films, Dr Anny Manrich works at the Brazilian Agricultural Research Corporation in areas of edible and biodegradable films produced from agricultural waste and in the development of films with greater resistance to water, having articles published in renowned scientific journals, which demonstrates her multidisciplinary understanding and creativity.
In addition, she worked for four years as a consultant to a food company to develop a line of snacks that are healthy and that add functional ingredients, physiologically active compounds that bring health benefits, made from fruits and vegetables, enabling diet improvement, disease prevention and reduction of nutritional deficiencies.
Dr Anny Manrich participated as a member of the examination board for two Master’s exams and one PhD exam at the Department of Chemical Engineering of the Federal University of São Carlos.
Education:
- 2001 Bachelor in Food Engineering at the State University of Campinas, Brazil
- 1999 One year scholarship at the Technical University of Munich
- 2004 Master in Chemical Engineering at the Federal University of São Carlos, Brazil
- 2012 PhD in Chemical Engineering at the Federal University of São Carlos, Brazil
- 2010 One year scholarship at the Technical University of Munich
The main publications of Dr. Anny Manrich are:
Articles
Manrich, A., Moreira, F. K., Otoni, C. G., Lorevice, M. V., Martins, M. A., & Mattoso, L. H. (2017). Hydrophobic edible films made up of tomato cutin and pectin. Carbohydrate Polymers, 164, 83-91.
Mendes, J. F., Norcino, L. B., Martins, H. H. A., Manrich, A., Otoni, C. G., Carvalho, E. E. N., … & Mattoso, L. H. C. (2020). Correlating emulsion characteristics with the properties of active starch films loaded with lemongrass essential oil. Food Hydrocolloids, 100, 105428.
Norcino, L. B., Mendes, J. F., Natarelli, C. V. L., Manrich, A., Oliveira, J. E., & Mattoso, L. H. C. (2020). Pectin films loaded with copaiba oil nanoemulsions for potential use as bio-based active packaging. Food Hydrocolloids, 106, 105862.
Manrich, Anny, et al. Immobilization of trypsin on chitosan gels: Use of different activation protocols and comparison with other supports. International Journal of Biological Macromolecules 43.1 (2008): 54-61.
Manrich, Anny; Komesu, Andrea ; Adriano, Wellington Sabino; Tardioli, Paulo Waldir ; Giordano, Raquel Lima Camargo . Immobilization and Stabilization of Xylanase by Multipoint Covalent Attachment on Agarose and on Chitosan Supports. Applied Biochemistry and Biotechnology, v. 161, p. 455-467, 2010.
Mendes, J. F., Martins, J. T., Manrich, A., Neto, A. S., Pinheiro, A. C. M., Mattoso, L. H. C., & Martins, M. A. (2019). Development and physical-chemical properties of pectin film reinforced with spent coffee grounds by continuous casting. Carbohydrate polymers, 210, 92-99..
Milessi, T. S., Kopp, W., Rojas, M. J., Manrich, A., Baptista-Neto, A., Tardioli, P. W., … & Giordano, R. L. (2016). Immobilization and stabilization of an endoxylanase from Bacillus subtilis (XynA) for xylooligosaccharides (XOs) production. Catalysis Today, 259, 130-139.
Mendes, J. F., Norcino, L. B., Manrich, A., Pinheiro, A. C. M., Oliveira, J. E., & Mattoso, L. H. C. (2020). Development, physical‐chemical properties, and photodegradation of pectin film reinforced with malt bagasse fibers by continuous casting. Journal of Applied Polymer Science, 137(39), 49178.
Mendes, J. F., Martins, J. T., Manrich, A., Luchesi, B. R., Dantas, A. P. S., Vanderlei, R. M., … & Martins, M. A. (2021). Thermo-physical and mechanical characteristics of composites based on high-density polyethylene (HDPE) e spent coffee grounds (SCG). Journal of Polymers and the Environment, 29, 2888-2900..
Mendes, J. F., Norcino, L. B., Martins, H. H., Manrich, A., Otoni, C. G., Carvalho, E. E. N., … & Mattoso, L. H. C. (2021). Development of quaternary nanocomposites made up of cassava starch, cocoa butter, lemongrass essential oil nanoemulsion, and brewery spent grain fibers. Journal of Food Science, 86(5), 1979-1996.
Manrich, A., Martins, M. A., & Mattoso, L. H. C. (2021). Manufacture and performance of peanut skin cellulose nanocrystals. Scientia Agricola, 79.
Nascimento, V. M., Manrich, A., Tardioli, P. W., de Campos Giordano, R., de Moraes Rocha, G. J., & Giordano, R. D. L. C. (2016). Alkaline pretreatment for practicable production of ethanol and xylooligosaccharides. Bioethanol, 2(1)..
Manrich, Anny, de Oliveira, J. E., Martins, M. A., & Mattoso, L. H. C. Physicochemical and Thermal Characterization of the Spirulina platensis. J. Agric. Sci. Technol. B, v. 10, p. 298-307, 2020.
Book Chapter
Terra, I. A. A., Aoki, P. H., Delezuk, J. A. D. M., Martins, M. A., Manrich, A., Silva, M. J., … & Miranda, P. B. (2022). Técnicas de Caracterização de Polímeros. Nanotecnologia Aplicada a Polímeros, 614.
Conference Papers
Ferreira, L. F., Luvizaro, L. B., Manrich, A., Martins, M. A., Júnior, M. G., & Dias, M. V. (2017). Comparação da estabilidade de suspensões poliméricas de amido/tocoferol e quitosana/tocoferol. In: CONGRESSO BRASILEIRO DE POLÍMEROS, 14., 2017, Águas de Lindóia, SP.
Manrich, A., Hubinger, S. Z., & Paris, E. C. (2017). Citotoxicidade causada por nanomateriais: avaliação do micronúcleo. In: WORKSHOP DA REDE DE NANOTECNOLOGIA APLICADA AO AGRONEGÓCIO, 9., 2017, São Carlos. Anais… São Carlos: Embrapa Instrumentação, 2017. p. 655-658.
Manrich, Anny, et al. Immobilization and Stabilization of Xylanase by multipoint covalent attachment on Glyoxyl Agarose Support. The 31st Symposium on Biotechnology for Fuels and Chemicals. 2009.
Manrich, Anny, et al. Application of immobilized xylanase on hydrolysis of soluble wood hemicelluloses after using microwave and organosolv pre-treatments. The 32nd Symposium on Biotechnology for Fuels and Chemicals. 2010.
You can view some of Dr Anny’s work below and links to her professional profile.
Research Gate: https://www.researchgate.net/profile/Anny-Manrich-2
Scopus: https://www.scopus.com/authid/detail.uri?authorId=23103497100
Google Scholar: https://scholar.google.com/citations?hl=en&user=Ea9qpr0AAAAJ
Linkedin: https://br.linkedin.com/in/anny-manrich-20693129
In this article, we answer the following question: Why should we not eat spoiled food? We tell you the signs of spoiled food and the main risks of eating spoiled food.
Why should we not eat spoiled food?
Eating spoiled food is dangerous and can even cause you different severe health problems (1-3). People at high risk are pregnant women, young children, the elderly, and those with immune problems (4). In these cases, it can even lead to death (1-3).
Thus, It is very important that you are careful when eating food that has passed its expiration date or looks, smells, or tastes different than it should.
If you have any doubt, please throw the food away! Thus you could avoid the potential health risks associated with consuming spoiled food.
What are the main risks of eating spoiled food?
Some of the main risks related with to the consume of spoiled food are:
- Food Poisoning: You can be poisoned when consuming spoiled food that is contaminated with pathogenic bacteria, viruses, or parasites (5-7).
- Gastrointestinal Distress: Your digestive system could be irritated by eating spoiled food, thus leading to gastrointestinal distress (1-2).
- Allergic Reactions: Eating spoiled food (especially moldy bread or rotten fruits) can trigger allergic reactions (8). The allergic reactions could be severe, so please be careful!
- Foodborne Illness: If you eat spoiled food you are also increasing the risk of experiencing a serious foodborne illness, such as Botulism, Salmonella or E. coli intoxication (4,6,9). This microorganism can cause severe symptoms and even death.
What are the most common symptoms of food poisoning?
The symptoms of food poisoning vary depending on the severity of the infection and the type of contaminant in your food (1-2). The most common symptoms of food poisoning include nausea, vomiting, diarrhea, abdominal pain and cramping, fever, headache, fatigue and dehydration (1).
You will experience some of these symptoms within a few hours to a few days after consuming contaminated food (2-3). In most cases of food poisoning, you will recover after a few days to a week without any medical treatment (1).
However, in some cases, the duration and severity can lead to complications, especially in vulnerable individuals like children, elderly, and people with weakened immune systems (4). In that case, they will require urgent medical attention. This is the case of infections produced by pathogenic bacteria like E. coli or Salmonella that are among the most dangerous (4,6,9).
If you experience severe or prolonged symptoms after eating food, do not wait too long! it is always better to seek medical attention.
How can we identify spoiled food and prevent food poisoning?
The following tips will help you to you identify and prevent the consumption of spoiled food and thus avoid food poisoning:
- Always check the expiration date: As a rule: food that has passed its expiration date should be thrown away.
- Always check for signs of spoilage: Be aware of any sign of spoilage such as discoloration, unusual texture, changes in smells and tastes. If you see any of these signals it is best to throw it away.
- Always practice good hygiene: wash your hands before handling food! Also, keep all cooking surfaces and utensils clean to prevent cross-contamination.
- Store food properly: This can prevent the growth of harmful bacteria. Keep raw meat, poultry and seafood separate from other food items.
- Cook food thoroughly: an appropriate temperature can kill harmful bacteria (10). You can always use a food thermometer to ensure that your food is cooked to the appropriate temperature inside.
Finally, the most important tip is to trust your instincts!
If the food looks, smells, or tastes off, trust your instincts and don’t eat it!
What should we do if we suspect we have eaten spoiled food?
In the case that you suspect that you have eaten spoiled food, you should:
- Check and monitor your symptoms. Pay special attention to any symptoms including nausea, vomiting, diarrhea, and abdominal pain.
- Drink a lot of fluids important to stay hydrated and replace electrolytes.
- If you experience severe and persistent symptoms, you should seek medical attention. This is even more relevant if you belong to one of the high-risk groups (elderly, young children, or pregnant women)
- Do not wait and seek medical attention immediately!
- Discard any food that you suspect is spoiled to prevent further consumption from you or others.
Finally, remember that it is always best to be on the safe side and discard your food if you have any doubts.
Prevention is better than cure!
Conclusions
In this article, we answered the following question: Why should we not eat spoiled food? We taught you the signs of spoiled food and the main risks of eating spoiled food.
References
1. Hurst WC, Reynolds AE, Schuler GA, Tybor PT. Preventing food poisoning and food infection [Internet]. University of Georgia; 2010 [cited 2023 May 3]. Available from: https://esploro.libs.uga.edu/esploro/outputs/9949316166102959?institution=01GALI_UGA&skipUsageReporting=true&recordUsage=false
2. Lawrence DT, Dobmeier SG, Bechtel LK, Holstege CP. Food Poisoning. Emerg Med Clin North Am. 2007 May 1;25(2):357–73. https://pubmed.ncbi.nlm.nih.gov/17482025/
3. Maddock EC. Food Poisoning. http://dx.doi.org/1012968/pnur199910335 [Internet]. 2014 Jun 11 [cited 2023 Apr 24];104(4344):87. Available from: https://www.magonlinelibrary.com/doi/10.12968/pnur.1999.10.3.35
4. Olsvik Ø, Wasteson Y, Lund A, Hornes E. Pathogenic Escherichia coli found in food. Int J Food Microbiol. 1991 Jan 1;12(1):103–13. https://pubmed.ncbi.nlm.nih.gov/2018703/
5. Newell DG, Koopmans M, Verhoef L, Duizer E, Aidara-Kane A, Sprong H, et al. Food-borne diseases — The challenges of 20 years ago still persist while new ones continue to emerge. Int J Food Microbiol. 2010 May 30;139(SUPPL. 1):S3–15. https://pubmed.ncbi.nlm.nih.gov/20153070/
6. Turnbull PCB. Food Poisoning with Special Reference to Salmonella — Its Epidemiology, Pathogenesis and Control. Clin Gastroenterol. 1979 Sep 1;8(3):663–714. https://pubmed.ncbi.nlm.nih.gov/387301/
7. Aaliya B, Valiyapeediyekkal Sunooj K, Navaf M, Parambil Akhila P, Sudheesh C, Ahmed Mir S, et al. Recent trends in bacterial decontamination of food products by hurdle technology: A synergistic approach using thermal and non-thermal processing techniques. Food Res Int. 2021 Sep 1;147:110514. https://pubmed.ncbi.nlm.nih.gov/34399492/
8. Sicherer SH, Sampson HA. Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management. J Allergy Clin Immunol. 2018 Jan 1;141(1):41–58. https://pubmed.ncbi.nlm.nih.gov/29157945/
9. Ting PT, Freiman A. The story of Clostridium botulinum: from food poisoning to Botox. Clin Med (Northfield Il) [Internet]. 2004 May 5 [cited 2023 May 3];4(3):258. Available from: /pmc/articles/PMC4953590/?report=abstract. https://pubmed.ncbi.nlm.nih.gov/15244362/
10. Juneja VK, Huang L, Yan X. Thermal inactivation of foodborne pathogens and the USDA pathogen modeling program. J Therm Anal Calorim [Internet]. 2011 Apr 1 [cited 2023 May 3];106(1):191–8. Available from: https://akjournals.com/view/journals/10973/106/1/article-p191.xml
