MS, Multiple Sclerosis: Difference between revisions
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=== Clinic === | === Clinic === | ||
* MS is a demyelinating autoimmune disease of | * MS is a demyelinating autoimmune disease of nervous system. | ||
{| class="wikitable" | |||
|+ | |||
!Specific symptoms: | |||
!Related disease | |||
!MS types | |||
|- | |||
| | |||
* Double vision / Blindness in one eye | |||
* Muscle weakness | |||
* Trouble with sensation | |||
* Incoordination | |||
* Cognitive disturbance | |||
| | |||
I think MS is an umbrella covering a list of demyelinating disease. I suggest a new classification Considering sign / Symptoms which equals the localization of demyelination. | *[[GBS, Guillian Barre syndrome|GBS]] | ||
* [[ADEM, Acute disseminated encephalomyelitis entities|Acute disseminated encephalomyelitis]] | |||
* [[Subacute sclerosing panencephalitis]] | |||
|I think MS is an umbrella covering a list of demyelinating disease. I suggest a new classification Considering sign / Symptoms which equals the localization of demyelination. | |||
* Autonomic | * Autonomic | ||
* Visual | * Visual | ||
Line 23: | Line 25: | ||
* Vestibular | * Vestibular | ||
* Cerebellar | * Cerebellar | ||
|} | |||
=== Miasmatic analysis === | |||
In order to find appropriate miasm, I need to know series of miasms which could cause Encephalomyelitis. Then the localized involvement could specialized the miasm. [[ADEM, Acute disseminated encephalomyelitis entities|ADEM]] could be a good choice. | In order to find appropriate miasm, I need to know series of miasms which could cause Encephalomyelitis. Then the localized involvement could specialized the miasm. [[ADEM, Acute disseminated encephalomyelitis entities|ADEM]] could be a good choice. | ||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
! | ! | ||
=== MS types === | |||
!Pathology | !Pathology | ||
!Sign / Symptoms | !Sign / Symptoms | ||
!Entities | !Entities | ||
!Miasms | !Miasms | ||
!Suggested | |||
Remedies | |||
|- | |- | ||
|Vestibular | |'''<big>Vestibular MS</big>''' | ||
(49–59%) | |||
| | |Intra-pontine 8th nerve fascicle involvement= Acute Vestibular Syndrome (AVS) | ||
| | | | ||
* | * Vertigo, dizziness Imbalance | ||
* | * Impaired functional ability, contribute to falls and significant health and social care costs | ||
| | | | ||
*ADEM | *[[ADEM, Acute disseminated encephalomyelitis entities|ADEM]] | ||
* [[Ataxia]] | * [[Ataxia]] | ||
* [[Vertigo]] or Dizziness | * [[Vertigo]] or Dizziness | ||
Line 49: | Line 54: | ||
* [[VZV, Varicella Zoster Virus|VZV]] for vertigo | * [[VZV, Varicella Zoster Virus|VZV]] for vertigo | ||
* [[STLE, St Louis Encephalitis|STLE]] for dizziness | * [[STLE, St Louis Encephalitis|STLE]] for dizziness | ||
|[[Gels, Gelsemium sempervirens|Gels]] | |||
[[Alum, Alumina|Alum]] | |||
|- | |- | ||
|Autonomic MS | | rowspan="4" |'''<big>Autonomic MS</big>''' | ||
|<br />Cardiovascular / Thermoregulatory function during exercise | |||
Due to Hypothalamus temperature regulation disorder. | |||
| | | | ||
*Uhthoff's | *[[Uhthoff's sign]]: Agg from higher than usual temperatures | ||
* Attenuated | * Attenuated elevations in blood pressure during exercise can negatively impact blood flow to skeletal muscle. | ||
* | * Diminished sweating during exercise | ||
| | | | ||
*ADEM / SSPE | *[[ADEM, Acute disseminated encephalomyelitis entities|ADEM]] / [[Subacute sclerosing panencephalitis|SSPE]] | ||
* [[Thermoregulatory disorder|Thermoregulation impaired]] | * [[Thermoregulatory disorder|Thermoregulation impaired]] | ||
|[[RBOL, Measles, rubeola|RBOL]] | |[[RBOL, Measles, rubeola|RBOL]] | ||
| | |||
|- | |||
|Bowel MS: | |||
Bowel accidents can also be caused by reduced sensation in back passage, so he dose not recognize the urge to go to the toilet, and reduced control of the muscles at the bottom of his anus. | |||
| | |||
*[[Constipation]] due to Decreased or slowed Bowel motility. | |||
* Hard plug of impacted stool builds up in the back passage, | |||
* Overflow incontinence: A loose, watery stool can leak out | |||
| | |||
* [[Constipation]] | |||
* Involuntary stool | |||
| | |||
* [[HSV-1, Herpes Simplex Virus|HSV-1]] | |||
* [[HSV-2, Herpes Simplex Virus|HSV-2]] | |||
|[[Alum, Alumina|Alum]] | |||
|- | |||
|'''Bladder MS:'''Urge incontinence (8%): Spastic/ Overactive bladder: | |||
| | |||
*Incontinence: Unable to hold urine | |||
* Frequency / Urgency | |||
* Hesitancy / Difficulty in starting urination | |||
| | |||
* ADEM / Brain-stem | |||
* Incontinence | |||
* Frequency / Urgency | |||
| | |||
* [[HTLV-1, Human T lymphotropic virus type 1|HTLV-1]] | |||
* [[STLE, St Louis Encephalitis|STLE]] | |||
|[[Caust, Causticum|Caust]] | |||
|- | |||
|'''Bladder MS:''' | |||
Overflow | |||
* Bladder that does not empty properly | |||
* Nocturia | |||
|Bladder does not empty properly (retains some urine in it) | |||
| | |||
* [[ADEM, Acute disseminated encephalomyelitis entities|ADEM]] | |||
* Bladder/Atonia | |||
|[[HSV-1, Herpes Simplex Virus|HSV-1]] | |||
| | |||
|- | |- | ||
|[[ | |[[Upper motor neuron, UMN|'''<big>UMN</big>''']] | ||
MS | '''<big>MS</big>''' | ||
|Corticospinal tract involvement | |Corticospinal tract involvement | ||
| | | | ||
Line 78: | Line 125: | ||
* [[HTLV-1, Human T lymphotropic virus type 1|HTLV-1]] | * [[HTLV-1, Human T lymphotropic virus type 1|HTLV-1]] | ||
* HIV | * HIV | ||
| | |||
* Arg-n | |||
* Lat-s | |||
* Plb | |||
* [[Pic-ac, Picricum Acidum|Pic-ac]] | |||
|- | |- | ||
|'''Cerebellar MS''' | |'''<big>Cerebellar MS</big>''' | ||
| | | | ||
| | | | ||
Line 85: | Line 137: | ||
*ADEM | *ADEM | ||
* Tremor | * Tremor | ||
* [[Cerebellar ataxia | * [[Cerebellar ataxia|Cerebellar Ataxia]] | ||
* [[Dysarthria]] | * [[Dysarthria]] | ||
| | | | ||
* [[CXA, CXB, ECH, Coxsackie viruses & Echoviruses|CXB]] | * [[CXA, CXB, ECH, Coxsackie viruses & Echoviruses|CXB]] | ||
* [[VZV, Varicella Zoster Virus|VZV]] | * [[VZV, Varicella Zoster Virus|VZV]] | ||
|Alum | |||
Con | |||
|- | |- | ||
|''' | |'''<big>Visual MS</big>''' | ||
|Sudden visual loss | |Sudden visual loss | ||
| | | | ||
Line 124: | Line 155: | ||
* [[HTLV-1, Human T lymphotropic virus type 1|HTLV-1]] | * [[HTLV-1, Human T lymphotropic virus type 1|HTLV-1]] | ||
* [[RBOL, Measles, rubeola|RBOL]] | * [[RBOL, Measles, rubeola|RBOL]] | ||
|Gels | |||
[[Phys, Physostigma Venenosum|Phys]] | |||
|- | |- | ||
| | |'''<big>Cognitive MS</big>''' | ||
| | | | ||
*40-65 % Cognition skills such as | *40-65 % Cognition skills such as | ||
Line 140: | Line 170: | ||
* Verbal Fluency: Word-Hunting or mixing words | * Verbal Fluency: Word-Hunting or mixing words | ||
| | | | ||
* ADEM / SSPE | * [[ADEM, Acute disseminated encephalomyelitis entities|ADEM]] / SSPE | ||
* Cognition | * Cognition | ||
* Concentration | * Concentration | ||
* Memory | * Memory | ||
* Aphasia | * [[Aphasia]] | ||
| | | | ||
* VZV | * VZV | ||
Line 150: | Line 180: | ||
* INFL | * INFL | ||
* MMP | * MMP | ||
| | |||
|- | |||
|'''<big>Painful MS</big>''' | |||
|Central sensitization and second Hyper Stasia | |||
| | |||
* There are two different form first . It seems that both of them have same maiasmatic origin. | |||
* Central sensitization and sensory MS could be explained commonly. | |||
| | |||
*Hyper Stasia | |||
*Dysesthesia | |||
| | |||
*HSV-1 | |||
*HSV-2 | |||
* HTLV-1 | |||
|[[Ox-ac, Oxalicum Acidum|Ox-ac]] | |||
[[Pic-ac, Picricum Acidum|Pic-ac]] | |||
|} | |} | ||
== | == Related disease == | ||
=== [[RBD, Rapid Eye Movement Sleep Behavior Disoder|RBD]] === | |||
* | * Rapid eye movement sleep behavior disorder (RBD) is a parasomnia characterized by brief recurrent episodes of loss of muscle atonia during rapid eye movement sleep, with enacted dreams that cause sleep disruption. | ||
* MS patients have an increased risk compared with the general population to be affected by a sleep disturbance, including RBD. Patients affected, however, uncommonly can present RBD as the first clinical manifestation of MS without other neurologic deficits. These clinical presentations have usually been attributed to inflammatory lesions in the pedunculopontine nuclei, located in the dorsal pons. We present a case of RBD in a 38-year-old woman who was later diagnosed as having MS due to imaging findings and development of focal neurologic deficits. MS should be considered among the differential diagnoses in patients who present with symptoms of RBD, particularly if they are young and female.<ref>Enriquez-Marulanda A, Quintana-Peña V, Takeuchi Y, Quiñones J. ''Case Report:'' Rapid Eye Movement Sleep Behavior Disorder as the First Manifestation of Multiple Sclerosis: A Case Report and Literature Review. Int J MS Care. 2018 Jul-Aug;20(4):180-184. doi: 10.7224/1537-2073.2017-001. PMID: 30150902; PMCID: PMC6107341.</ref> | |||
=== | === [[ADEM, Acute disseminated encephalomyelitis entities|ADEM]] === | ||
== Remedies == | |||
{| class="wikitable" | |||
|+ | |||
! | |||
! | |||
! | |||
* | ! | ||
** | |- | ||
* | | rowspan="2" |'''<big>Prominent Eye Symptoms</big>''' | ||
| | |||
=== [[Phys, Physostigma Venenosum|Phys]] === | |||
| | |||
* Dim vision, Blurred vision | |||
* Partial loss of vision | |||
* Trembling of vision | |||
| | |||
* C30 | |||
* | * Pain over orbits, cannot bear to rise eyelids. | ||
* Spasm of ciliary muscles + Irritability after using eyes. | |||
|- | |||
| rowspan="2" | | |||
=== [[Gels, Gelsemium sempervirens|Gels]] === | |||
* | * After [[Influenza]] | ||
* [[Optic neuritis]] | |||
* Orbital neuralgia | |||
* In-Coordination/ Imbalance | |||
* Bladder paralysis | |||
* '''Ptosis''' | |||
* Eyes Muscles paralysis | |||
| | |||
* [[Optic neuritis]]: Blurred/ Foggy / Smoky vision | |||
* Varying degree of vision loss | |||
* Dim sighted, pupils dilated and insensible to light. Blurring and discomfort in eyes even after accurately adjusted glasses. | |||
| | |||
*Orbital neuralgia: Pain in the eyes | |||
*Contraction and twitching of muscles. | |||
*'''Ptosis, eyelids heavy, patient can hardly open them with double vision.''' | |||
*C200 | |||
|- | |||
| rowspan="2" |'''<big>Difficulty in</big>''' | |||
'''<big>Balance /</big>''' | |||
'''<big>[[Incoordination]] /</big>''' | |||
'''<big>[[Ataxia]]</big>''' | |||
| | |||
* Lack of muscle Coordination/ Balance | |||
* Gait is slow and unsteady. | |||
* Loss of balance while walking | |||
* Varying degrees of motor paralysis. | |||
=== | * Paralysis: Eyes Muscles, throat, larynx, extremities | ||
* Muscular weakness. Loss of power of muscular control | |||
| | |||
*Intense '''Dizziness''' /'''Drowsiness / Dullness''' | |||
* General prostration + '''Trembling''' | |||
* Muscular weakness / Complete relaxation. | |||
* Cramps in muscles | |||
* Profuse, clear, watery urine | |||
* Chilliness | |||
* Tremulousness. | |||
* Partial paralysis of bladder | |||
|- | |||
| | |||
=== [[Alum, Alumina|Alum]] === | |||
* [[ | * Locomotor [[ataxia]] | ||
* | | | ||
* Locomotor [[ataxia]] | |||
* Sluggish and staggering gait | |||
* Numbness and a bandaged feeling in legs. | |||
* [[Constipation]] | |||
| | |||
*C200 | |||
* Staggers on walking. Spinal degeneration and paralysis of lower limbs | |||
* [[Romberg test]] positive: Tottering and falling on closing the eyes | |||
|- | |||
| rowspan="2" |'''<big>Numbness, [[Paresthesia|Tingling]], Pin/ Needle-like Sensations</big>''' | |||
| | |||
=== [[Ox-ac, Oxalicum Acidum|Ox-ac]] === | |||
* | * '''Spot pain''' starting from spine | ||
| | |||
* Extremities are involved in MS. | |||
* Numbness extends from shoulders to finger tips. | |||
* [[Low back pain|Backache]] with numbness: Pain Drawing/ Sharp / Shooting/ Lancinating / '''Spot pain''' starting from spine and extend through limbs. | |||
| | |||
*Muscular prostration: Weakness and coldness in the lower limbs | |||
* '''Thinking about pain, agg.''' | |||
* Weak trembling Hands / Feet. | |||
* C30 | |||
|- | |||
| | |||
=== [[Pic-ac, Picricum Acidum|Pic-ac]] === | |||
* | * Spinal burning | ||
** | | | ||
** | * Feel pin and needle pricks in their limbs. | ||
* Marked Prostration/ Weakness / Tired / Heavy all over the body muscles | |||
* Spasms from MS | |||
| | |||
* C 30 | |||
* | * Worn out persons, both mentally and physically. | ||
* Burning sensation along the spine. | |||
* Weakness agg with exertion. | |||
|- | |||
| rowspan="3" |'''<big>Weakness in</big>''' | |||
'''<big>Lower Limbs</big>''' | |||
| | |||
=== [[Con, Conium Maculatum|Con]] === | |||
=== | * MS + Vertigo | ||
* Begins in | |||
* lower limb | |||
| | |||
* MS + muscular weakness, esp lower limbs. | |||
* Weak and weary legs /Unsteady walk, Sudden loss of strength in walking | |||
* Difficult gait / Stiffness / Heaviness in legs | |||
* Weakness in calf muscles, [[Rigidity]] in calves | |||
* Positive Romberg test | |||
* Trembling of all the limbs esp legs | |||
* Numbness of fingers and toes. | |||
* Ms from Grief | |||
| | |||
*C200 | |||
*Old age problems of Weakness/ Debility | |||
* Urinary troubles, | |||
* Weak memory | |||
* Eye troubles: Dim sighted agg in artificial lights. | |||
* Paralysis of ocular muscles. | |||
* Heavy, weary, paralyzed and trembling unsteady hands. | |||
|- | |||
| | |||
=== [[Arg-n, Argentum Nitricum|Arg-n]] === | |||
| | |||
* With softening of spinal cord. ([[Myelomalacia]]) | |||
* Weakness, [[rigidity]], or twisting in calf muscles. | |||
* Walks and stands unsteadily. Legs stiffness | |||
* Trembling and numbness of limbs + General debility. | |||
| | |||
*N'''eurotic effects''' | |||
* '''In-coordination, loss of control''' /'''Imbalance''' | |||
* '''Trembling''' in affected parts | |||
* Great desire for sweets. | |||
* [[Eye floaters|Spots before eyes]]. Eye strain from sewing worse in warm room. Blurred vision. | |||
|- | |||
| | |||
=== [[Plb, Plumbum Metallicum|Plb]] === | |||
* | * [[Twitching, Jerking|Twitching]] | ||
** Hyper | * [[Tremor]] | ||
** | * Hyperesthesia | ||
* Pain in atrophied muscles | |||
| | |||
* Paralysis of lower limbs. | |||
* Paralysis of single muscles, chiefly of extensor, forearm or upper limb from canter to periphery. Cannot raise arms, can’t lift anything. Extension is difficult. | |||
* Partial anesthesia or Excessive hyperesthesia preceded by pain. | |||
* [[Twitching, Jerking|Twitching]]/ [[Tremor]] / Cramps in calves | |||
| | |||
* C200 | |||
* Localized neuralgic pains with [[Neuralgia , Neurologic pain remedies|neuritis]]. | |||
* Eyes: Sudden loss of sight after fainting. | |||
* Paralysis from overexertion of extensor muscles in piano players. | |||
* [[Constipation]] | |||
* Pain in atrophied muscles + Colic | |||
* Stinging/ Tearing / Tingling/ Numbness | |||
|- | |||
| rowspan="2" |<big>'''[[Spasticity]]'''</big> | |||
| | |||
=== [[Lat-s, Lathyrus Sativus|Lat-s]] === | |||
| | |||
* [[Spasticity]] is most marked in the legs. | |||
* [[Rigidity]], with a spastic gait. | |||
* Trembling or tottering gait. | |||
* Cramps in the legs | |||
* Lower limbs and Gluteal muscles emaciation | |||
| | |||
* C30 | |||
* MS with spastic paralysis of lower limbs. | |||
* [[Hyper reflexia|Reflexes are increased]]. | |||
* MS with softening of spinal cord. | |||
|- | |||
| | |||
=== [[Nat-m, Natrium muriaticum|Nat-m]] === | |||
| | |||
* '''MS with painful contractions of thigh muscle''' | |||
* Ankles weak and sprain easily. | |||
* Coldness of legs with congestion of head, chest and stomach. | |||
* '''Eyelid heavy.''' | |||
* Ms from Grief | |||
| | |||
*'''[[Eye floaters|See sparks]]. Fiery zigzag lines running'''. | |||
* Great weakness and [[emaciation]]. | |||
* Psychic causes of diseases and ill effects of grief, fright and anger. | |||
* Consolation agg | |||
|- | |||
|[[Urinary incontinence|'''<big>Urinary</big>''']] | |||
[[Urinary incontinence|'''<big>incontinence</big>''']] | |||
| | |||
=== [[Caust, Causticum|Caust]] === | |||
| | |||
* C 200 | |||
* Involuntary passage of urine, on coughing , walking, blowing nose or sneezing | |||
* Urine dribbles or passes slowly. | |||
* Paralysis of bladder + Involuntary urination on sneezing and coughing. | |||
* Unsteady walking and easily falling. | |||
=== | * Weakness and progressive loss of muscular strength, causing paralysis of single organs | ||
[[ | * Ms from Grief | ||
| | |||
* | *Tearing/ Drawing pains + Severe weakness. | ||
* | * '''Local paralysis''': Vocal cords, tongue, eyelids, face, bladder '''+ Single parts of extremities + Dull, tearing pains + Loss of sensation'''. | ||
* Impaired vision + [[Eye floaters|Sparks/ Dark spots before eyes]]. | |||
* '''Ptosis''' + Paralysis of extra ocular muscles. | |||
* [[Restless legs syndrome|Restless legs]] at night + Weak ankles. | |||
* Amel by warmth esp heat of bed. | |||
|- | |||
| | |||
| | |||
=== [[Phos, Phosphorus|Phos]] === | |||
| | |||
*Marked prostration + Trembling + Numbness + Complete paralysis | |||
* Sensory and motor paralysis from ends of fingers and toes. | |||
* Weakness and trembling from every exertion. | |||
* Arms and hands become numb. | |||
* Can scarcely hold anything. | |||
| | |||
*'''[[Eye floaters|Black points seem to float]] before the eyes.''' | |||
* [[Eye Fatigue remedies|Fatigue of eyes]] and head with hands. | |||
* Sensitives to external impressions like light, sound, touch and thunders. | |||
* Ms from [[Grief]] | |||
|- | |||
| | |||
=== Other remedies === | |||
| | |||
*[[Zinc, Zincum Metallicum|Zinc]] | |||
* [[Cupr, Cuprum metallicum|Cupr]] | |||
* [[Syph, Syphilinum|Syph]] | |||
* [[Cic, Cicuta Virosa|Cic]] | |||
| | |||
| | |||
|} | |||
Homeopathic medicines are selected on the basis of symptoms, cause, family history and constitution of the person affected. Considering all these factors any of the above (or some other) homeopathic medicine may be indicated and helpful in a case of Multiple Sclerosis. |
Latest revision as of 10:23, 6 February 2024
Clinic
- MS is a demyelinating autoimmune disease of nervous system.
Specific symptoms: | Related disease | MS types |
---|---|---|
|
I think MS is an umbrella covering a list of demyelinating disease. I suggest a new classification Considering sign / Symptoms which equals the localization of demyelination.
|
Miasmatic analysis
In order to find appropriate miasm, I need to know series of miasms which could cause Encephalomyelitis. Then the localized involvement could specialized the miasm. ADEM could be a good choice.
MS types |
Pathology | Sign / Symptoms | Entities | Miasms | Suggested
Remedies |
---|---|---|---|---|---|
Vestibular MS
(49–59%) |
Intra-pontine 8th nerve fascicle involvement= Acute Vestibular Syndrome (AVS) |
|
Gels | ||
Autonomic MS | Cardiovascular / Thermoregulatory function during exercise Due to Hypothalamus temperature regulation disorder. |
|
RBOL | ||
Bowel MS:
Bowel accidents can also be caused by reduced sensation in back passage, so he dose not recognize the urge to go to the toilet, and reduced control of the muscles at the bottom of his anus. |
|
|
Alum | ||
Bladder MS:Urge incontinence (8%): Spastic/ Overactive bladder: |
|
|
Caust | ||
Bladder MS:
Overflow
|
Bladder does not empty properly (retains some urine in it) |
|
HSV-1 | ||
UMN
MS |
Corticospinal tract involvement |
|
|
| |
Cerebellar MS |
|
Alum
Con | |||
Visual MS | Sudden visual loss | ADEM / SSPE
Optic neuritis/Atrophy |
Gels | ||
Cognitive MS |
|
|
|
||
Painful MS | Central sensitization and second Hyper Stasia |
|
|
|
Ox-ac |
Related disease
RBD
- Rapid eye movement sleep behavior disorder (RBD) is a parasomnia characterized by brief recurrent episodes of loss of muscle atonia during rapid eye movement sleep, with enacted dreams that cause sleep disruption.
- MS patients have an increased risk compared with the general population to be affected by a sleep disturbance, including RBD. Patients affected, however, uncommonly can present RBD as the first clinical manifestation of MS without other neurologic deficits. These clinical presentations have usually been attributed to inflammatory lesions in the pedunculopontine nuclei, located in the dorsal pons. We present a case of RBD in a 38-year-old woman who was later diagnosed as having MS due to imaging findings and development of focal neurologic deficits. MS should be considered among the differential diagnoses in patients who present with symptoms of RBD, particularly if they are young and female.[1]
ADEM
Remedies
Prominent Eye Symptoms |
Phys |
|
|
Gels
|
|
| |
Difficulty in
Balance / Incoordination / Ataxia |
|
| |
Alum
|
|
| |
Numbness, Tingling, Pin/ Needle-like Sensations |
Ox-ac
|
|
|
Pic-ac
|
|
| |
Weakness in
Lower Limbs |
Con
|
|
|
Arg-n |
|
| |
Plb |
| ||
Spasticity |
Lat-s |
|
|
Nat-m |
|
| |
Urinary |
Caust |
|
|
Phos |
|
| |
Other remedies |
Homeopathic medicines are selected on the basis of symptoms, cause, family history and constitution of the person affected. Considering all these factors any of the above (or some other) homeopathic medicine may be indicated and helpful in a case of Multiple Sclerosis.
- ↑ Enriquez-Marulanda A, Quintana-Peña V, Takeuchi Y, Quiñones J. Case Report: Rapid Eye Movement Sleep Behavior Disorder as the First Manifestation of Multiple Sclerosis: A Case Report and Literature Review. Int J MS Care. 2018 Jul-Aug;20(4):180-184. doi: 10.7224/1537-2073.2017-001. PMID: 30150902; PMCID: PMC6107341.