Clinical Commander

Back to dossier
id.geriatric-infection-syndromes.v1PRODUCTION
id.geriatric-infection-syndromes.v1

Geriatric infection syndromes overlay — atypical presentation, blunted fever, UTI stewardship in older adults

overlayacutesubacutegeriatric
Hard-required inputs
0 / 15
Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Geriatric overlay framing: age ≥ 65, frailty tier (Fried / Rockwood CFS), cognitive baseline, residential setting (community / SNF), goals-of-care; layered on top of underlying primary infection engine. Sets geriatric-host flag for downstream sepsis routing.

Inputs
3
Actions
0
Advance rule
Set
Advance when

Geriatric-host flag set + frailty + cognitive baseline documented

Patient inputs (23)

Rockwood CFS 1-9 stratifies treatment intensity; CFS ≥ 7 in sepsis triggers palliative + goals-of-care discussion (Rockwood CMAJ 2005 PMID 16129869)

Cognitive baseline (intact / MCI / mild-mod dementia / severe dementia) anchors delirium detection (change-from-baseline) and informs goals-of-care (Inouye NEJM 2006 PMID 16540616)

Baseline ADL / IADL function — acute decline is sepsis-screen trigger; informs disposition (community / hospital-at-home / SNF / LTAC) (Bellelli Age Ageing 2014)

Community / assisted-living / SNF / LTAC — SNF residents have ASB prevalence 25-50 % + HAP-spectrum pneumonia coverage (IDSA Nicolle 2019; ATS/IDSA Metlay 2019)

Full-code-aggressive vs DNR-modified vs comfort-focused — drives ICU vs ward vs hospital-at-home disposition + treatment intensity (Rockwood 2005 CFS ≥ 7 trigger)

Comprehensive medication list for Beers + STOPP/START + anticholinergic-burden review during infection (AGS Beers 2023 O'Mahony Age Ageing 2023)

Fever ≥ 38 °C OR 1.3 °C above baseline; hypothermia < 36 °C equally concerning in older adult (Norman 2000)

Age ≥ 65 is overlay-engine anchor; informs Beers PIM list applicability + frailty-stratification (AGS Beers 2023)

Leukocytosis or leukopenia in older adult sepsis; blunted leukocytosis common in frail elderly (use with clinical context)

Renal function via CKD-EPI 2021 for age-related GFR decline; drives renal dose-adjustment for cefepime / vancomycin / aminoglycosides; nitrofurantoin AVOID if CrCl < 30 (AGS Beers 2023)

Lactate > 2 → resuscitation; > 4 → septic shock physiology even without overt hypotension in older adult (SSC 2026)

Hypotension on adequate fluids → septic shock → routes to id.sepsis.core.v1 with geriatric-host flag (SSC 2026)

Tachycardia is sepsis criterion; blunted in beta-blocker + frailty — paradoxically lower threshold for concern (SSC 2026)

Tachypnea > 22 is qSOFA component; sensitive sepsis sign in older adults (Singer JAMA 2016 PMID 26903336)

Hypoxemia in pneumonia / sepsis; older adults may have baseline lower SpO2 from chronic disease

CT abdomen / pelvis for atypical abdominal presentation (cholecystitis / appendicitis / diverticulitis with blunted peritonitis in older adult)

Older adults have blunted fever response; baseline-delta (1.3 °C above baseline) is clinically significant even when absolute < 38 °C (Norman J Am Geriatr Soc 2000 PMID 10968297)

Recent fall + acute change → occult infection workup; falls + sepsis bidirectional

CAM (Inouye 2006) OR 4AT (Bellelli 2014) bedside delirium screen — sensitivity 88-94 %, specificity 88-89 %

UA + culture for UTI workup; ALONE insufficient in SNF resident without Loeb criteria → DO NOT treat ASB (IDSA Nicolle 2019 PMID 30895288; Loeb 2001 PMID 11380742)

Two sets from separate sites BEFORE antibiotics if no delay > 45 min (SSC 2026); sensitive in older adults with bacteraemia (often UTI / pneumonia source)

Adjunct for sepsis-screen in older adult with blunted fever / atypical presentation; trend more informative than single value (ProGUARD-ICU 2021)

CXR for CAP / aspiration / HAP in older adult; atypical presentation may have minimal infiltrate (ATS/IDSA Metlay 2019 PMID 31573350)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (10)

10 need judgement
  • informationallife_threateninggeriatric_sepsis_with_blunted_fever_response
    Older adult with sepsis features (qSOFA ≥ 2 / hypotension on adequate fluids / lactate ≥ 4 / SOFA delta ≥ 2) WITHOUT classical fever ≥ 38 °C — life-threatening; treat as sepsis based on clinical features + lactate + procalcitonin even without fever ≥ 38; routes to id.sepsis.core.v1 with geriatric-host flag (Norman 2000 PMID 10968297; Singer JAMA 2016 PMID 26903336; SSC 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredelirium_with_fever_or_functional_decline_in_older_adult
    New delirium (positive CAM / 4AT) + fever ≥ 38 °C OR 1.3 °C above baseline OR new functional decline in older adult — severe; sepsis-screen with full workup; CAM-positive triggers immediate evaluation; do NOT attribute to "old age" (Inouye NEJM 2006 PMID 16540616; Bellelli 4AT 2014 Norman 2000 PMID 10968297)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverefunctional_decline_acute_in_older_adult
    New ADL loss / acute fall / inability to perform prior activities / new dependence in older adult — severe; infection-as-cause until ruled out (Bellelli Age Ageing 2014; geriatric acute illness presentation framework)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereloeb_minimum_criteria_uti_in_snf
    SNF resident WITHOUT catheter: acute dysuria OR fever ≥ 37.9 °C OR 1.5 °C above baseline + ≥ 1 of (new / worsened urgency, frequency, suprapubic pain, gross haematuria, CVA tenderness, urinary incontinence). SNF resident WITH catheter: fever / rigors / new hypotension / acute mental status change / acute haematuria / pelvic discomfort / CVA tenderness. Severe; treat as UTI; otherwise re-evaluate alternative source (Loeb 2001 PMID 11380742)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereantibiotic_renal_adjustment_in_older_adult
    Older adult with empiric cefepime / vancomycin / aminoglycosides / piperacillin-tazobactam — severe; age-appropriate CrCl via CKD-EPI 2021 + dose-adjustment to prevent neurotoxicity (cefepime), nephrotoxicity (vancomycin / aminoglycosides), and accumulation (Inker NEJM 2021; Rybak IDSA 2020 PMID 32191793)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaspiration_pneumonia_risk_in_dementia
    Dementia + recurrent pneumonia + dysphagia signs (coughing on swallow, food residue, weight loss, repeated chest infections) — severe; swallowing-eval + nutrition + speech-pathology consult + repeat-event-prevention; goals-of-care discussion if advanced dementia (ATS/IDSA Metlay 2019 PMID 31573350)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategoals_of_care_discussion_triggered_in_frail_older_sepsis
    Clinical Frailty Scale ≥ 7 + sepsis features in older adult — moderate; palliative + geriatric consult + family discussion of goals-of-care (aggressive vs comfort-focused management); inform decisions about ICU / ventilation / vasopressors (Rockwood CMAJ 2005 PMID 16129869)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepolypharmacy_drug_drug_interactions_during_empirics
    Older adult with ≥ 5 chronic medications + new empiric antibiotics — moderate; STOPP/START review during acute illness; deprescribe per Beers (AGS Beers 2023 O'Mahony Age Ageing 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateanticholinergic_burden_worsening_delirium
    Older adult with new delirium + cumulative anticholinergic burden (diphenhydramine, oxybutynin, scopolamine, TCAs, antihistamines, antiemetics, antimuscarinic bronchodilators) — moderate; review meds + minimise anticholinergic burden during infection (Inouye NEJM 2006 PMID 16540616; AGS Beers 2023)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildasymptomatic_bacteriuria_in_older_adult
    Positive UA / urine culture in older adult WITHOUT urinary symptoms + non-pregnant + no planned urologic instrumentation — mild; DO NOT treat (IDSA Nicolle 2019 PMID 30895288)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RED_FLAGSrequiredDrives screening
Loading…

Recommended regimen

Geriatric infection empiric antibiotics — by source × Beers/STOPP review × renal dose-adjustment
axis: geriatric_infection_empirics_by_source_and_frailtystep uti_pyelonephritis_in_older_adult - UTI / pyelonephritis in older adult — ceftriaxone or cefepime; AVOID nitrofurantoin if CrCl < 30; AVOID fluoroquinolones unless no alternative
Selected step "UTI / pyelonephritis in older adult — ceftriaxone or cefepime; AVOID nitrofurantoin if CrCl < 30; AVOID fluoroquinolones unless no alternative" — Loeb minimum criteria positive (SNF resident) OR symptomatic UTI (community-dwelling older adult) + positive UA / culture
  • ceftriaxone
    first line
    cephalosporin_3rd
    1-2 g IV q24h (no renal adjustment unless CrCl < 10) • IV • daily
    triggers: pyelonephritis_in_older_adult, sepsis_features_in_older_adult
    IDSA Hooton 2010 + standard for pyelonephritis in older adult; preserved renal function not required
    rxcui 2193
  • cefepime
    first line
    cephalosporin_4th
    2 g IV q8-12h with renal adjustment per CrCl (1 g q24h if CrCl 11-29; 500 mg q24h if CrCl ≤ 10) • IV • q8-12h
    triggers: suspected_pseudomonas, health_care_associated_uti, esbl_risk
    IDSA Hooton 2010 + IDSA/ATS 2016 Kalil for HCA-spectrum; cefepime neurotoxicity in older adult with renal impairment — dose-adjust strictly per CrCl
    rxcui 20481
  • nitrofurantoin
    comorbidity specific
    urinary_antiinfective
    100 mg PO BID × 5-7 d (uncomplicated cystitis only) • PO • BID
    triggers: uncomplicated_cystitis_in_older_adult_with_crcl_30_or_higher
    AGS Beers 2023 — AVOID if CrCl < 30 (inadequate urinary concentrations + pulmonary / hepatic toxicity in long-term suppression). Acceptable if CrCl ≥ 30 for short-course uncomplicated cystitis
    rxcui 7454
  • trimethoprim-sulfamethoxazole
    second line
    sulfonamide_diaminopyrimidine
    160-800 mg PO BID × 3 d (uncomplicated cystitis) • PO • BID
    triggers: uncomplicated_cystitis_in_older_adult, culture_susceptible
    IDSA Gupta 2011 + AGS Beers 2023 — caution with renal impairment + hyperkalemia + warfarin DDI; use only if susceptible
    rxcui 10831
  • ciprofloxacin
    rescue
    fluoroquinolone
    500 mg PO BID OR 400 mg IV q12h × 7 d • PO/IV • BID
    triggers: no_alternative_available, culture_directed_fluoroquinolone_only_susceptible
    AGS Beers 2023 — AVOID for uncomplicated UTI when alternatives available (delirium / tendinopathy / QTc / aortic dissection risks). DailyMed fluoroquinolone black box. Reserve for culture-directed when no alternative
    rxcui 2551

outpatient playbook — drug actions (3)

  1. 1. PO antibiotic continuation if course ongoing
    Per agent + indication • PO • per agent
    trigger: Outpatient with PO course remaining
    Complete course
  2. 2. STOPP/START re-review at 4-6 wk
    Per O'Mahony 2023 • review • 4_to_6_wk
    trigger: Post-discharge interval
    O'Mahony 2023 — re-evaluate empiric and home meds after acute episode
  3. 3. vaccination administration
    Per ACIP age + indication • IM • per ACIP
    trigger: Vaccination status review identifies gaps
    Reduce future infection risk; especially important in frail older adult

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Age ≥ 65 with suspected infection (fever / delirium / functional decline / falls / non-specific decline) — geriatric overlay anchor (Norman J Am Geriatr Soc 2000 PMID 10968297); Acute change in cognition / inattention / disorganised thinking / altered level of consciousness in older adult — CAM / 4AT positive → infection workup (Inouye NEJM 2006 PMID 16540616; Bellelli 4AT 2014); Acute loss of ADLs / inability to perform prior activities / new dependence in older adult — infection workup (Bellelli Age Ageing 2014; geriatric acute illness presentation framework).

Objective

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

Assessment

**Geriatric infection syndromes overlay — atypical presentation, blunted fever, UTI stewardship in older adults** (id.geriatric-infection-syndromes.v1).
Phenotype framing: Distinguish infection from non-infectious mimics (drug fever, dehydration, transfusion reaction, DVT, malignancy fever, congestive heart failure exacerbation, medication-induced delirium); rule out asymptomatic bacteriuria masquerading as UTI; identify chronic venous stasis vs recurrent cellulitis.
Scope: Geriatric overlay framing: age ≥ 65, frailty tier (Fried / Rockwood CFS), cognitive baseline, residential setting (community / SNF), goals-of-care; layered on top of underlying primary infection engine. Sets geriatric-host flag for downstream sepsis routing.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Geriatric infection empiric antibiotics — by source × Beers/STOPP review × renal dose-adjustment** — step "UTI / pyelonephritis in older adult — ceftriaxone or cefepime; AVOID nitrofurantoin if CrCl < 30; AVOID fluoroquinolones unless no alternative".
1. ceftriaxone 1-2 g IV q24h (no renal adjustment unless CrCl < 10) IV daily (cephalosporin_3rd, first line) — IDSA Hooton 2010 + standard for pyelonephritis in older adult; preserved renal function not required
2. cefepime 2 g IV q8-12h with renal adjustment per CrCl (1 g q24h if CrCl 11-29; 500 mg q24h if CrCl ≤ 10) IV q8-12h (cephalosporin_4th, first line) — IDSA Hooton 2010 + IDSA/ATS 2016 Kalil for HCA-spectrum; cefepime neurotoxicity in older adult with renal impairment — dose-adjust strictly per CrCl
3. nitrofurantoin 100 mg PO BID × 5-7 d (uncomplicated cystitis only) PO BID (urinary_antiinfective, comorbidity specific) — AGS Beers 2023 — AVOID if CrCl < 30 (inadequate urinary concentrations + pulmonary / hepatic toxicity in long-term suppression). Acceptable if CrCl ≥ 30 for short-course uncomplicated cystitis
4. trimethoprim-sulfamethoxazole 160-800 mg PO BID × 3 d (uncomplicated cystitis) PO BID (sulfonamide_diaminopyrimidine, second line) — IDSA Gupta 2011 + AGS Beers 2023 — caution with renal impairment + hyperkalemia + warfarin DDI; use only if susceptible
5. ciprofloxacin 500 mg PO BID OR 400 mg IV q12h × 7 d PO/IV BID (fluoroquinolone, rescue) — AGS Beers 2023 — AVOID for uncomplicated UTI when alternatives available (delirium / tendinopathy / QTc / aortic dissection risks). DailyMed fluoroquinolone black box. Reserve for culture-directed when no alternative

Setting playbook (outpatient) — Post-discharge geriatrics + ID follow-up; surveillance for recurrence + post-hospital syndrome; vaccination; STOPP/START re-review at 4-6 wk; advance care planning; caregiver support
6. PO antibiotic continuation if course ongoing Per agent + indication PO per agent — Outpatient with PO course remaining (Complete course)
7. STOPP/START re-review at 4-6 wk Per O'Mahony 2023 review 4_to_6_wk — Post-discharge interval (O'Mahony 2023 — re-evaluate empiric and home meds after acute episode)
8. vaccination administration Per ACIP age + indication IM per ACIP — Vaccination status review identifies gaps (Reduce future infection risk; especially important in frail older adult)

Non-pharmacologic actions:
- Outpatient geriatrics + ID follow-up at 1-2 wk + monthly during OPAT
- Quarterly follow-up for chronic complications (recurrent UTI, recurrent pneumonia, chronic line)
- Cognitive trajectory monitoring (CAM-S / MoCA at 4-6 wk + 6 mo)
- Functional trajectory monitoring (ADL / IADL / gait speed)
- Falls prevention follow-up (home safety, assistive devices)
- Caregiver burnout assessment + respite care planning
- Advance care planning + POLST review

AVOID / contraindication checks:
- Do not treat asymptomatic bacteriuria in non pregnant older adult (IDSA Nicolle 2019 PMID 30895288)
- Nitrofurantoin avoid if crcl under 30 (AGS Beers 2023 + DailyMed nitrofurantoin label)
- Fluoroquinolone caution in older adult delirium tendinopathy qtc aortic dissection (AGS Beers 2023 + DailyMed black box)
- Tmp smx hyperkalemia and warfarin DDI (AGS Beers 2023 + DailyMed label)
- Anticholinergic burden minimisation during infection (Inouye NEJM 2006 + AGS Beers 2023)
- Loeb minimum criteria for snf uti required before treatment (Loeb 2001 PMID 11380742)
- Delirium equals sepsis screen in frail older adult (Inouye NEJM 2006 PMID 16540616)
- Fever blunted in older adult use baseline delta 1.3C (Norman 2000 PMID 10968297)
- Cfs 7 or higher trigger goals of care discussion (Rockwood CMAJ 2005 PMID 16129869)
- Snf resident pneumonia treat as hap (ATS/IDSA Metlay 2019 PMID 31573350)
- Chronic venous stasis misdiagnosed as recurrent cellulitis (IDSA Stevens 2014 PMID 24973422)
- Renal dose adjust cefepime vancomycin aminoglycoside in older adult (CKD EPI 2021 + Rybak IDSA 2020 PMID 32191793)
- Stopp start v3 review during acute illness (O'Mahony Age Ageing 2023)
- Cefepime neurotoxicity in renal impairment dose adjust strictly (cefepime label)
- Vancomycin AUC target not trough in older adult (Rybak IDSA 2020 PMID 32191793)

Monitoring

Regimen monitoring:
- Delirium reassessment (CAM / 4AT) q4-6 h during admission
- Functional trajectory (PT/OT) daily
- Daily Beers + STOPP/START review during admission
- Vancomycin AUC q48-72 h (target 400-600) (Rybak IDSA 2020)
- Cefepime trough + neurotoxicity surveillance in renal impairment
- CrCl recalculation q48 h with electrolyte trend
- QTc surveillance during fluoroquinolone / macrolide (ECG q48-72 h)
- Anticholinergic burden recheck if new meds added
- Aspiration risk reassessment if dementia + pneumonia
- Falls precautions during admission + post-discharge

Setting (outpatient) monitoring:
- Monthly ID follow-up while on OPAT
- Quarterly follow-up for chronic complications
- Annual immunisation status audit
- Annual frailty + cognitive trajectory reassessment

Follow-up plan: Post-hospital syndrome surveillance (delirium recovery, functional restoration, sarcopenia screening); caregiver education on signs of recurrence; advance care planning + POLST update; vaccination (PCV20, influenza, COVID-19, herpes zoster per ACIP 2024); STOPP/START re-review at 4-6 wk; outpatient geriatrics follow-up; SNF / hospital-at-home coordination if applicable.
- Close-out criterion: Post-discharge geriatric care plan documented + caregiver + family aligned

Monitoring phase: Delirium reassessment (CAM / 4AT) q4-6h during admission; functional trajectory (PT/OT q daily); DDI monitoring + Beers/STOPP daily; renal trajectory + dose-adjustment; vancomycin AUC q48-72 h (Rybak IDSA 2020); ASB recurrence surveillance; aspiration risk in dementia; falls prevention.

Disposition

Current setting: outpatient — Post-discharge geriatrics + ID follow-up; surveillance for recurrence + post-hospital syndrome; vaccination; STOPP/START re-review at 4-6 wk; advance care planning; caregiver support

Disposition criteria:
- Sustained recovery at 6 mo — return to baseline cognitive + functional state → discharge from acute geriatric infection surveillance
- Long-term geriatrics + primary care continuity for chronic management

Escalation triggers (move to higher acuity):
- Recurrence of infection features → ED + cultures + ID urgent consult
- New cognitive / functional decline → geriatric psychiatry + neurology + caregiver support
- Caregiver crisis → palliative + social work + alternative placement

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Older adult with sepsis features (qSOFA ≥ 2 / hypotension on adequate fluids / lactate ≥ 4 / SOFA delta ≥ 2) WITHOUT classical fever ≥ 38 °C — life-threatening; treat as sepsis based on clinical features + lactate + procalcitonin even without fever ≥ 38; routes to id.sepsis.core.v1 with geriatric-host flag (Norman 2000 PMID 10968297; Singer JAMA 2016 PMID 26903336; SSC 2026)
- [SEVERE] New delirium (positive CAM / 4AT) + fever ≥ 38 °C OR 1.3 °C above baseline OR new functional decline in older adult — severe; sepsis-screen with full workup; CAM-positive triggers immediate evaluation; do NOT attribute to "old age" (Inouye NEJM 2006 PMID 16540616; Bellelli 4AT 2014 Norman 2000 PMID 10968297)
- [SEVERE] New ADL loss / acute fall / inability to perform prior activities / new dependence in older adult — severe; infection-as-cause until ruled out (Bellelli Age Ageing 2014; geriatric acute illness presentation framework)

Citations

- IDSA Nicolle 2019 Asymptomatic Bacteriuria guideline (PMID 30895288) + AGS Beers Criteria 2023 + STOPP/START v3 2023 (O'Mahony Age Ageing 2023) + Loeb 2001 SNF UTI minimum criteria (PMID 11380742) + Norman 2000 fever in elderly (PMID 10968297) + Inouye 2006 delirium NEJM (PMID 16540616) + Bellelli 4AT 2014 + Rockwood 2005 Clinical Frailty Scale (PMID 16129869) + Fried 2001 frailty phenotype (PMID 11253156) + ATS/IDSA Metlay 2019 CAP (PMID 31573350) + IDSA Stevens 2014 SSTI (PMID 24973422) + Mid-Atlantic Stewardship Network 2022 antibiotic-stewardship-for-the-elderly + NICE NG144 catheter UTI + SSC 2026 sepsis bundle [PMID:30895288](https://pubmed.ncbi.nlm.nih.gov/30895288/)
- Cited evidence (PMID 16540616) [PMID:16540616](https://pubmed.ncbi.nlm.nih.gov/16540616/)
- Cited evidence (PMID 16129869) [PMID:16129869](https://pubmed.ncbi.nlm.nih.gov/16129869/)
- Cited evidence (PMID 11253156) [PMID:11253156](https://pubmed.ncbi.nlm.nih.gov/11253156/)
- Cited evidence (PMID 31573350) [PMID:31573350](https://pubmed.ncbi.nlm.nih.gov/31573350/)

Last reconciled with current guidelines: 2026-05-22.
References
  • IDSA Nicolle 2019 Asymptomatic Bacteriuria guideline (PMID 30895288) + AGS Beers Criteria 2023 + STOPP/START v3 2023 (O'Mahony Age Ageing 2023) + Loeb 2001 SNF UTI minimum criteria (PMID 11380742) + Norman 2000 fever in elderly (PMID 10968297) + Inouye 2006 delirium NEJM (PMID 16540616) + Bellelli 4AT 2014 + Rockwood 2005 Clinical Frailty Scale (PMID 16129869) + Fried 2001 frailty phenotype (PMID 11253156) + ATS/IDSA Metlay 2019 CAP (PMID 31573350) + IDSA Stevens 2014 SSTI (PMID 24973422) + Mid-Atlantic Stewardship Network 2022 antibiotic-stewardship-for-the-elderly + NICE NG144 catheter UTI + SSC 2026 sepsis bundle — PMID:30895288
  • Cited evidence (PMID 16540616) — PMID:16540616
  • Cited evidence (PMID 16129869) — PMID:16129869
  • Cited evidence (PMID 11253156) — PMID:11253156
  • Cited evidence (PMID 31573350) — PMID:31573350