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gyn.bartholin-abscess.v1PRODUCTION
gyn.bartholin-abscess.v1

Bartholin gland cyst / abscess (I&D + Word catheter, marsupialization for recurrent)

obstetricsacuteadultpregnancygeriatric
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Bartholin gland duct obstruction → cyst → abscess (when infected). Spectrum: asymptomatic cyst (observation / sitz baths) → symptomatic enlarging cyst (sitz baths +/- conservative) → fluctuant uncomplicated abscess (office I&D + Word catheter × 4-6 wk) → abscess with systemic features (antibiotics + drainage + observation) → recurrent disease (marsupialization or gland excision) → postmenopausal atypical (biopsy abscess wall for malignancy ddx). Partition by clinical state (cyst vs abscess vs recurrent vs atypical) + population (reproductive-age vs pregnancy vs postmenopausal vs immunocompromised) + severity (mild / moderate / severe / atypical) (Wechter 2009 PMID 19099613).

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clinical state + population + severity tier tagged

Patient inputs (18)

Reproductive-age (20-30 peak) is the typical phenotype; postmenopausal > 40 yr mandates malignancy ddx + biopsy abscess wall (Visco 1996 PMID 8559513)

Pregnancy modifies antibiotic selection (avoid TMP-SMX 1st trimester / late pregnancy; avoid doxycycline; prefer amox-clav OR cefuroxime + metronidazole); drainage itself is safe in pregnancy

Fluctuance is the clinical determinant for abscess vs cyst — abscess with fluctuance → drainage; non-fluctuant cyst → observation / sitz baths

STI risk factors (younger, multiple partners, prior STI, mucopurulent cervicitis) drive NAAT for GC/CT + HIV + syphilis screen per CDC 2021 PMID 34292926

Recurrent disease (≥ 2 ipsilateral abscesses) → marsupialization or gland excision; document number of prior episodes + prior interventions (Wechter 2009 PMID 19099613)

Immunocompromised host (HIV / DM / steroid / chemotherapy / transplant) → broader antibiotic coverage + lower admission threshold; CA-MRSA risk increased

Acute (hours-days) suggests abscess; subacute / chronic (weeks-months) suggests cyst or atypical entity; recurrent timeline informs escalation to marsupialization

Severity drives intervention urgency; mild / asymptomatic cyst → conservative; severe pain + functional impact → I&D + Word

Fever suggests systemic infection / cellulitis extension / sepsis; uncomplicated Bartholin abscess is typically afebrile

Hypotension flags sepsis pathway; rare in uncomplicated abscess but possible with NF / Fournier extension

Tachycardia + fever raises sepsis suspicion + SIRS / qSOFA component

Pain out of proportion / crepitus / bullae / rapid spread / systemic toxicity → necrotizing fasciitis / Fournier gangrene (mortality 25-35 %); route to id.cellulitis.core.v1 / surgical emergency

Drives empiric antibiotic selection — penicillin anaphylaxis avoids amox-clav + cefuroxime; consider clindamycin + ciprofloxacin OR TMP-SMX + metronidazole alternative

Bedside ultrasound is rarely needed for clinical Bartholin diagnosis; useful if mass is atypical / deep / extension suspected / PID overlap (TOA ddx routing to gyn.pid)

Leukocytosis with systemic features informs severity tier; not required for uncomplicated office I&D

NAAT for Neisseria gonorrhoeae + Chlamydia trachomatis when STI risk factors present; CDC 2021 routine recommendation (PMID 34292926)

Wound culture at I&D when systemic features OR recurrent disease OR immunocompromised host OR MRSA suspected — guides targeted antibiotic narrowing

Routine STI screen for risk-factor patients per CDC 2021 (PMID 34292926)

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Severity triggers (8)

8 need judgement
  • informationalseverebartholin_abscess_at_diagnosis_drainage
    Symptomatic fluctuant Bartholin abscess at office / clinic / ED presentation — I&D + Word catheter × 4-6 wk is definitive primary therapy; recurrence < 5 % vs 5-15 % with I&D alone (Wechter 2009 PMID 19099613)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresystemic_symptoms_or_immunocompromised
    Bartholin abscess with fever / cellulitis / immunocompromised host (HIV / DM / steroid / chemotherapy / transplant) — antibiotics adjunctive + I&D + observation (CDC 2021 PMID 34292926; Wechter 2009 PMID 19099613)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepostmenopausal_atypical_bartholin
    Postmenopausal patient or > 40 yr with Bartholin mass OR atypical features (firm, fixed, induration of abscess wall, persistent or recurrent disease, poor response to standard therapy) — biopsy abscess wall for malignancy ddx (Visco 1996 PMID 8559513; Heller 2014 PMID 24803013)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereabscess_extension_or_cellulitis
    Bartholin abscess with extension into surrounding labial / perineal / perirectal tissue OR cellulitis OR necrotizing fasciitis red flags (pain out of proportion / crepitus / bullae / rapid spread / systemic toxicity) — broader antibiotics + surgical consultation; rule out Fournier gangrene (mortality 25-35 %) (IDSA 2014 SSTI Stevens framework)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_bartholin_abscess
    Pregnant patient with symptomatic Bartholin abscess — drainage acceptable (no fetal risk from local procedure); antibiotic considerations modified (avoid TMP-SMX 1st trimester / late pregnancy; avoid doxycycline; prefer amox-clav OR cefuroxime + metronidazole); OB co-management (CDC 2021 PMID 34292926)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_bartholin_abscess
    Recurrent ipsilateral Bartholin abscess (≥ 2 episodes) — escalate to marsupialization OR gland excision; underlying duct anatomy predisposes to recurrence (Wechter 2009 PMID 19099613)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesuspected_pid_or_sti_overlap
    Bartholin abscess with PID overlap features (mucopurulent cervicitis, lower abdominal pain, CMT, fever) OR STI risk factors (younger, multiple partners, prior STI) — NAAT for GC/CT + HIV + syphilis + treat empirically per CDC 2021 if PID criteria met; ddx routes to gyn.pelvic-inflammatory-disease.core.v1 (CDC 2021 PMID 34292926)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildword_catheter_displacement_premature
    Word catheter falls out before adequate epithelialization (< 4 wk) — replace catheter if accessible; consider marsupialization for repeated displacement (Wechter 2009 PMID 19099613)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Bartholin abscess — drainage primary (I&D + Word catheter); antibiotics adjunctive for systemic features / immunocompromise / pregnancy / sepsis / STI overlap (Wechter 2009 PMID 19099613; CDC 2021 PMID 34292926)
axis: bartholin_abscess_managementstep incision_and_drainage_word_catheter - Office I&D + Word catheter × 4-6 wk (definitive for uncomplicated abscess; Wechter 2009 PMID 19099613)
Selected step "Office I&D + Word catheter × 4-6 wk (definitive for uncomplicated abscess; Wechter 2009 PMID 19099613)" — Symptomatic fluctuant Bartholin abscess; non-pregnant or pregnant; immunocompetent or moderately immunocompromised. Office or ED procedure.
  • incision_and_drainage_word_catheter
    first line
    office_procedure
    triggers: symptomatic_fluctuant_bartholin_abscess
    Wechter 2009 PMID 19099613 — I&D with Word catheter (small Foley-like catheter inflated with 3-5 mL water; dwell × 4-6 wk for epithelialization) is the office-based standard; recurrence < 5 % vs 5-15 % with I&D alone
  • lidocaine_local_infiltration
    first line
    local_anesthetic
    1 % lidocaine 5-10 mL infiltrated subcutaneously over abscess • subcutaneous_infiltration • single_procedure
    triggers: office_or_ed_ind_for_bartholin_abscess
    Local anesthesia for office I&D; 1 % lidocaine without epinephrine for vulvar tissue
    rxcui 6387
  • acetaminophen
    add on
    analgesic
    650-1000 mg PO • PO • q6h PRN, max 3 g/day
    triggers: post_procedure_analgesia
    Post-procedure analgesia; multimodal opioid-sparing; safe in pregnancy
    rxcui 161
  • ibuprofen
    add on
    NSAID
    400-600 mg PO • PO • q6h PRN, max 2.4 g/day
    triggers: post_procedure_analgesia, not_pregnant_no_renal_or_bleeding_concerns
    Effective post-procedure NSAID; avoid in pregnancy and renal impairment
    rxcui 5640

outpatient playbook — drug actions (5)

  1. 1. I&D + Word catheter (procedural)
    Local anesthesia with 1 % lidocaine 5-10 mL; small incision; Word catheter inserted; bulb inflated with 3-5 mL water; dwell × 4-6 wk • procedural • single_procedure
    trigger: Symptomatic fluctuant Bartholin abscess in office / clinic
    Wechter 2009 PMID 19099613 — office-based standard; recurrence < 5 %
  2. 2. sitz baths
    Warm water 15-20 min QID × 1-2 wk post-I&D • topical • QID × 1-2 wk
    trigger: Symptomatic relief after I&D
    Comfort + may facilitate epithelialization
  3. 3. acetaminophen / ibuprofen
    Acetaminophen 650-1000 mg PO q6h PRN + ibuprofen 400-600 mg PO q6h PRN (if not pregnant) • PO • q6h PRN
    trigger: Post-procedure pain
    Multimodal analgesia; opioid-sparing
  4. 4. antibiotics if systemic / immunocompromise / pregnancy
    TMP-SMX 1-2 DS PO BID + metronidazole 500 mg PO TID × 7 d OR amox-clav 875/125 mg PO BID × 7 d (pregnancy-safe) • PO • per agent × 7 d
    trigger: Fever / cellulitis / immunocompromise / pregnancy with complications
    Polymicrobial coverage; not routine for uncomplicated drained abscess (CDC 2021 PMID 34292926; Wechter 2009 PMID 19099613)
  5. 5. STI treatment if NAAT positive
    Ceftriaxone 500 mg IM single + doxycycline 100 mg PO BID × 7 d (or azithromycin 1 g PO single in pregnancy) • IM + PO • per agent
    trigger: GC/CT NAAT positive
    CDC 2021 PMID 34292926

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Unilateral labial swelling at 4 or 8 oclock position with fluctuance — classic Bartholin abscess (Wechter 2009 PMID 19099613); Painful vulvar mass with difficulty sitting / walking / intercourse — symptomatic Bartholin abscess (Wechter 2009 PMID 19099613); Asymptomatic unilateral labial swelling — Bartholin cyst (often incidental; observation / sitz baths if mild).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Bartholin gland cyst / abscess (I&D + Word catheter, marsupialization for recurrent)** (gyn.bartholin-abscess.v1).
Phenotype framing: Bartholin abscess vs labial inflammatory cyst vs vulvar epidermal inclusion cyst vs hidradenitis suppurativa (recurrent labial / inguinal nodules) vs vulvar lipoma vs vulvar leiomyoma (rare) vs vulvar malignancy (rare; postmenopausal-driven priority) vs Skene gland abscess (periurethral location) vs vulvar abscess (more diffuse / not localized to 4-8 oclock). PID with TOA overlap if mucopurulent cervicitis + lower abdominal pain + CMT — route to gyn.pid.
Scope: Bartholin gland duct obstruction → cyst → abscess (when infected). Spectrum: asymptomatic cyst (observation / sitz baths) → symptomatic enlarging cyst (sitz baths +/- conservative) → fluctuant uncomplicated abscess (office I&D + Word catheter × 4-6 wk) → abscess with systemic features (antibiotics + drainage + observation) → recurrent disease (marsupialization or gland excision) → postmenopausal atypical (biopsy abscess wall for malignancy ddx). Partition by clinical state (cyst vs abscess vs recurrent vs atypical) + population (reproductive-age vs pregnancy vs postmenopausal vs immunocompromised) + severity (mild / moderate / severe / atypical) (Wechter 2009 PMID 19099613).

No severity triggers fired against current inputs.

Plan

Regimen axis: **Bartholin abscess — drainage primary (I&D + Word catheter); antibiotics adjunctive for systemic features / immunocompromise / pregnancy / sepsis / STI overlap (Wechter 2009 PMID 19099613; CDC 2021 PMID 34292926)** — step "Office I&D + Word catheter × 4-6 wk (definitive for uncomplicated abscess; Wechter 2009 PMID 19099613)".
1. incision_and_drainage_word_catheter (office_procedure, first line) — Wechter 2009 PMID 19099613 — I&D with Word catheter (small Foley-like catheter inflated with 3-5 mL water; dwell × 4-6 wk for epithelialization) is the office-based standard; recurrence < 5 % vs 5-15 % with I&D alone
2. lidocaine_local_infiltration 1 % lidocaine 5-10 mL infiltrated subcutaneously over abscess subcutaneous_infiltration single_procedure (local_anesthetic, first line) — Local anesthesia for office I&D; 1 % lidocaine without epinephrine for vulvar tissue
3. acetaminophen 650-1000 mg PO PO q6h PRN, max 3 g/day (analgesic, add on) — Post-procedure analgesia; multimodal opioid-sparing; safe in pregnancy
4. ibuprofen 400-600 mg PO PO q6h PRN, max 2.4 g/day (NSAID, add on) — Effective post-procedure NSAID; avoid in pregnancy and renal impairment

Setting playbook (outpatient) — Diagnose Bartholin cyst vs abscess in office / clinic; conservative (sitz baths) for cyst; I&D + Word catheter × 4-6 wk for uncomplicated abscess; STI testing for risk factors; postmenopausal biopsy of abscess wall for malignancy ddx; outpatient follow-up at 4-6 wk for Word removal + recurrence assessment (Wechter 2009 PMID 19099613; CDC 2021 PMID 34292926)
5. I&D + Word catheter (procedural) Local anesthesia with 1 % lidocaine 5-10 mL; small incision; Word catheter inserted; bulb inflated with 3-5 mL water; dwell × 4-6 wk procedural single_procedure — Symptomatic fluctuant Bartholin abscess in office / clinic (Wechter 2009 PMID 19099613 — office-based standard; recurrence < 5 %)
6. sitz baths Warm water 15-20 min QID × 1-2 wk post-I&D topical QID × 1-2 wk — Symptomatic relief after I&D (Comfort + may facilitate epithelialization)
7. acetaminophen / ibuprofen Acetaminophen 650-1000 mg PO q6h PRN + ibuprofen 400-600 mg PO q6h PRN (if not pregnant) PO q6h PRN — Post-procedure pain (Multimodal analgesia; opioid-sparing)
8. antibiotics if systemic / immunocompromise / pregnancy TMP-SMX 1-2 DS PO BID + metronidazole 500 mg PO TID × 7 d OR amox-clav 875/125 mg PO BID × 7 d (pregnancy-safe) PO per agent × 7 d — Fever / cellulitis / immunocompromise / pregnancy with complications (Polymicrobial coverage; not routine for uncomplicated drained abscess (CDC 2021 PMID 34292926; Wechter 2009 PMID 19099613))
9. STI treatment if NAAT positive Ceftriaxone 500 mg IM single + doxycycline 100 mg PO BID × 7 d (or azithromycin 1 g PO single in pregnancy) IM + PO per agent — GC/CT NAAT positive (CDC 2021 PMID 34292926)

Non-pharmacologic actions:
- Sitz baths 15-20 min QID × 1-2 wk post-I&D (Wechter 2009 PMID 19099613)
- Pelvic rest (no intercourse / tampons / douching) for 1-2 wk post-I&D
- Counsel on Word catheter care — keep in place, do not pull, return for displacement
- Counsel on recurrence risk + early presentation for recurrent symptoms (route to marsupialization)
- Safer-sex practices counseling if STI testing positive
- Partner notification + treatment if STI positive (CDC 2021 PMID 34292926)
- Patient education on red-flag symptoms — fever / increasing pain / extension / NF features → ED immediately

AVOID / contraindication checks:
- TMP SMX avoid first trimester pregnancy (folate antagonism; ACOG)
- TMP SMX avoid late pregnancy kernicterus (sulfa kernicterus risk near term; ACOG)
- Doxycycline pregnancy contraindication (ACOG / FDA category D; fetal tooth staining + bone development)
- Metronidazole acceptable throughout pregnancy (ACOG; weighted vs maternal benefit)
- NSAIDs avoid third trimester pregnancy (PDA constriction)
- NSAIDs avoid in renal impairment
- Clindamycin c diff counsel (IDSA 2014 SSTI)
- MRSA coverage when purulent or risk factor (IDSA 2014 SSTI)
- Penicillin anaphylaxis block amox clav and cefuroxime (cross reactivity risk)
- Postmenopausal mass biopsy mandatory (Visco 1996 PMID 8559513 — Bartholin gland malignancy ddx > 40 yr)

Monitoring

Regimen monitoring:
- Word catheter dwell × 4-6 wk; check position at 1-2 wk; replace if premature displacement
- Sitz baths 15-20 min QID × 1-2 wk post-I&D
- Outpatient gyn follow-up at 4-6 wk for Word removal + recurrence + STI test review
- Wound culture susceptibility review if obtained at I&D — narrow empiric coverage
- Pathology review for biopsied abscess wall (postmenopausal / atypical) at 1-2 wk
- STI test results review at 1-2 wk (NAAT for GC/CT + HIV + syphilis)
- Partner notification + treatment if STI positive (CDC 2021 PMID 34292926)
- If hospitalised systemic infection: vitals q4h + repeat CBC + wound check + antibiotic streamline based on culture susceptibility
- Return precautions: increasing pain / fever / extension / NF features → ED immediately

Setting (outpatient) monitoring:
- Word catheter check at 1-2 wk for position + displacement
- STI test results review at 1-2 wk
- Outpatient gyn follow-up at 4-6 wk for Word removal + recurrence assessment
- Pathology review at 1-2 wk if biopsied (postmenopausal / atypical)

Follow-up plan: Outpatient gyn follow-up at 4-6 wk for Word catheter removal + recurrence assessment + STI test result review + treatment of asymptomatic partner if STI positive (CDC 2021 PMID 34292926). Counsel on recurrence risk + early presentation for recurrent symptoms (route to marsupialization). Pathology review for postmenopausal / atypical biopsy — gyn-onc referral if malignant (Heller 2014 PMID 24803013). Counsel on safer-sex practices if STI testing positive; HIV / syphilis screen review. Reproductive planning + contraception counseling unchanged. Postpartum coordination if peripartum.
- Close-out criterion: Word removed; STI follow-up complete; pathology reviewed; recurrence + safer-sex counseling documented

Monitoring phase: Word catheter dwell × 4-6 wk for epithelialization; catheter check at 1-2 wk to confirm position + monitor for displacement (replace if displaced premature). Sitz baths 15-20 min QID × 1-2 wk post-I&D for symptomatic relief. Outpatient assessment at 4-6 wk for Word removal + recurrence evaluation. Pathology review at 1-2 wk for biopsied abscess wall (postmenopausal / atypical). For hospitalised systemic infection: vitals q4h + repeat CBC + wound check + antibiotic streamline based on culture susceptibility.

Disposition

Current setting: outpatient — Diagnose Bartholin cyst vs abscess in office / clinic; conservative (sitz baths) for cyst; I&D + Word catheter × 4-6 wk for uncomplicated abscess; STI testing for risk factors; postmenopausal biopsy of abscess wall for malignancy ddx; outpatient follow-up at 4-6 wk for Word removal + recurrence assessment (Wechter 2009 PMID 19099613; CDC 2021 PMID 34292926)

Disposition criteria:
- Continue outpatient management for uncomplicated abscess with office I&D + Word; follow-up at 4-6 wk
- ED for systemic features / NF / sepsis / immunocompromise / pregnancy complications
- OR for marsupialization (recurrent) or gland excision (refractory / suspected malignancy)

Escalation triggers (move to higher acuity):
- Systemic features (fever / hypotension / tachycardia / sepsis) → ED for IV antibiotics + admission
- NF red flags (pain out of proportion / crepitus / bullae / rapid spread / systemic toxicity) → emergent ED + surgical consultation; Fournier mortality 25-35 %
- Recurrent ipsilateral disease (≥ 2 episodes) → gyn for marsupialization (office or OR)
- Postmenopausal or atypical features → gyn-onc referral if histology malignant
- Pregnancy with complications → OB co-management
- Word catheter premature displacement → replace OR marsupialization for repeat displacement

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [SEVERE] Symptomatic fluctuant Bartholin abscess at office / clinic / ED presentation — I&D + Word catheter × 4-6 wk is definitive primary therapy; recurrence < 5 % vs 5-15 % with I&D alone (Wechter 2009 PMID 19099613)
- [SEVERE] Bartholin abscess with fever / cellulitis / immunocompromised host (HIV / DM / steroid / chemotherapy / transplant) — antibiotics adjunctive + I&D + observation (CDC 2021 PMID 34292926; Wechter 2009 PMID 19099613)
- [SEVERE] Postmenopausal patient or > 40 yr with Bartholin mass OR atypical features (firm, fixed, induration of abscess wall, persistent or recurrent disease, poor response to standard therapy) — biopsy abscess wall for malignancy ddx (Visco 1996 PMID 8559513; Heller 2014 PMID 24803013)

Citations

- ACOG Patient Information on Bartholin gland disease (no dedicated Practice Bulletin; consolidated in patient education + Williams Gynecology Ch. 4 + Berek & Novak Gynecology Ch. 14) + CDC STI Treatment Guidelines 2021, updated 2024 (Workowski MMWR 2021 PMID 34292926) + Wechter 2009 Obstet Gynecol Surv PMID 19099613 + Word 1968 (PMID NEEDS_SOURCE_REVIEW) + Visco & Del Priore 1996 Obstet Gynecol PMID 8559513 + Heller & Bean 2014 J Low Genit Tract Dis PMID 24803013 + Kessous 2013 Obstet Gynecol PMID 23232761 + Tanaka 2005 J Clin Microbiol PMID 15634986 + Berger 2012 Obstet Gynecol PMID 22914407 + Pundir 2008 J Obstet Gynaecol PMID 18608239 + Marzano & Haefner 2004 J Low Genit Tract Dis PMID 15454803 [PMID:34292926](https://pubmed.ncbi.nlm.nih.gov/34292926/)
- Cited evidence (PMID 19099613) [PMID:19099613](https://pubmed.ncbi.nlm.nih.gov/19099613/)
- Cited evidence (PMID 8559513) [PMID:8559513](https://pubmed.ncbi.nlm.nih.gov/8559513/)
- Cited evidence (PMID 24803013) [PMID:24803013](https://pubmed.ncbi.nlm.nih.gov/24803013/)
- Cited evidence (PMID 23232761) [PMID:23232761](https://pubmed.ncbi.nlm.nih.gov/23232761/)

Last reconciled with current guidelines: 2026-05-15.
References
  • ACOG Patient Information on Bartholin gland disease (no dedicated Practice Bulletin; consolidated in patient education + Williams Gynecology Ch. 4 + Berek & Novak Gynecology Ch. 14) + CDC STI Treatment Guidelines 2021, updated 2024 (Workowski MMWR 2021 PMID 34292926) + Wechter 2009 Obstet Gynecol Surv PMID 19099613 + Word 1968 (PMID NEEDS_SOURCE_REVIEW) + Visco & Del Priore 1996 Obstet Gynecol PMID 8559513 + Heller & Bean 2014 J Low Genit Tract Dis PMID 24803013 + Kessous 2013 Obstet Gynecol PMID 23232761 + Tanaka 2005 J Clin Microbiol PMID 15634986 + Berger 2012 Obstet Gynecol PMID 22914407 + Pundir 2008 J Obstet Gynaecol PMID 18608239 + Marzano & Haefner 2004 J Low Genit Tract Dis PMID 15454803 — PMID:34292926
  • Cited evidence (PMID 19099613) — PMID:19099613
  • Cited evidence (PMID 8559513) — PMID:8559513
  • Cited evidence (PMID 24803013) — PMID:24803013
  • Cited evidence (PMID 23232761) — PMID:23232761