Loading…

Self-assembled insulin and nanogels polyelectrolyte complex (Ins/NGs-PEC) for oral insulin delivery: characterization, lyophilization and in-vivo evaluation

Insulin is given by injection, because when administered orally, it would be destroyed by enzymes in the digestive system, hence only about 0.1% reaches blood circulation. The purpose of the present study was to use pH sensitive polyelectrolyte methyl methacrylate (MMA)/itaconic acid (IA) nanogels a...

Full description

Saved in:
Bibliographic Details
Published in:International journal of nanomedicine 2019-01, Vol.14, p.4895-4909
Main Authors: Mudassir, Jahanzeb, Darwis, Yusrida, Muhamad, Suriani, Khan, Arshad Ali
Format: Article
Language:English
Subjects:
Citations: Items that cite this one
Online Access:Get full text
Tags: Add Tag
No Tags, Be the first to tag this record!
cited_by cdi_FETCH-LOGICAL-c542t-c24c17c7dca662b7639fdb6997e1432a3a8839aa782d9f9cbcc554e599f9c0403
cites
container_end_page 4909
container_issue
container_start_page 4895
container_title International journal of nanomedicine
container_volume 14
creator Mudassir, Jahanzeb
Darwis, Yusrida
Muhamad, Suriani
Khan, Arshad Ali
description Insulin is given by injection, because when administered orally, it would be destroyed by enzymes in the digestive system, hence only about 0.1% reaches blood circulation. The purpose of the present study was to use pH sensitive polyelectrolyte methyl methacrylate (MMA)/itaconic acid (IA) nanogels as carriers in an attempt to improve absorption of insulin administered orally. Insulin (Ins) was incorporated into the MMA/IA nanogels (NGs) using the polyelectrolyte complexation (PEC) method to form Ins/NGs-PEC. Several parameters, including Ins:NGs ratio, pH, incubation time and stirring rate were optimized during preparation of InsNGs-PEC. The prepared formulations were characterized in terms of particle size (PS), polydispersity index (PdI), zeta potential (ZP) and percent entrapment efficiency (% EE). The optimized InF12 nanogels had a PS, PdI, ZP and %EE of 190.43 nm, 0.186, -16.70 mV and 85.20%, respectively. The InF12 nanogels were lyophilized in the presence of different concentrations of trehalose as cryoprotectant. The lyophilized InF12 containing 2%w/v trahalose (InF12-Tre2 nanogels) was chosen as final formulation which had a PS, PdI, ZP and %EE of 430.50 nm, 0.588, -16.50 mv and 82.10, respectively. The in vitro release of insulin from InF12-Tre2 nanogels in the SGF and SIF were 28.71% and 96.53%, respectively. The stability study conducted at 5±3°C for 3 months showed that lnF12-Tre2 nanogels were stable. The SDS-PAGE assay indicated that the primary structure of insulin in the lnF12-Tre2 nanogels was intact. The in-vivo study in the diabetic rats following oral administration of InF12-Tre2 nanogels at a dose of 100 IU/kg body weight reduced blood glucose level significantly to 51.10% after 6 hours compared to the control groups. The pH sensitive MMA/IA nanogels are potential carriers for oral delivery of insulin as they enhanced the absorption of the drug.
doi_str_mv 10.2147/IJN.S199507
format article
fullrecord <record><control><sourceid>gale_doaj_</sourceid><recordid>TN_cdi_doaj_primary_oai_doaj_org_article_45170065504c4022aea2b8f595474e3a</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><galeid>A602106566</galeid><doaj_id>oai_doaj_org_article_45170065504c4022aea2b8f595474e3a</doaj_id><sourcerecordid>A602106566</sourcerecordid><originalsourceid>FETCH-LOGICAL-c542t-c24c17c7dca662b7639fdb6997e1432a3a8839aa782d9f9cbcc554e599f9c0403</originalsourceid><addsrcrecordid>eNptkk1vEzEQhlcIREvgxB2txKUINrW9tnfNAamKSgmqClLhbHm9s4kjx07t3YjwW_ixOB-EFiEfPB6_fsYzerPsJUZjgml1Pv18M77FQjBUPcpOMa7qgiBcPr4Xn2TPYlwgxKqai6fZSYkp47zkp9mvW7BdoWKEZWOhzY2LgzUuV67NnXJ-BjbmK283YEH3IQU95NovVxZ-5GdTF89vrmLx9XLyJu98yH1Q9showZo1hM37XM9VULqHYH6q3nj3Lrcbv5obezjvyhlXrM3a57BWdtiln2dPOmUjvDjso-z7x8tvk0_F9Zer6eTiutCMkr7QhGpc6arVinPSVLwUXdtwISrAtCSqVHVdCqWqmrSiE7rRmjEKTGwPiKJylE333NarhVwFs1RhI70ycpfwYSZV6I22ICnDFUKcMUQ1RYQoUKSpOyYYrSiUKrE-7FmroVlCq8H1aSYPoA9vnJnLmV_L9HVUE5EAZwdA8HcDxF4uTdRgrXLghygJqXFNa15WSfr6H-nCD8GlUSUVq4XgmNd_VTOVGjCu86mu3kLlBUcEp26SF0bZ-D-qtFpYGu0ddCblHzx4u3-gg48xQHfsESO5NaZMxpQHYyb1q_tjOWr_OLH8De663xc</addsrcrecordid><sourcetype>Open Website</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2258996168</pqid></control><display><type>article</type><title>Self-assembled insulin and nanogels polyelectrolyte complex (Ins/NGs-PEC) for oral insulin delivery: characterization, lyophilization and in-vivo evaluation</title><source>PubMed (Medline)</source><source>Taylor &amp; Francis Journals Open Access</source><source>Publicly Available Content (ProQuest)</source><creator>Mudassir, Jahanzeb ; Darwis, Yusrida ; Muhamad, Suriani ; Khan, Arshad Ali</creator><creatorcontrib>Mudassir, Jahanzeb ; Darwis, Yusrida ; Muhamad, Suriani ; Khan, Arshad Ali</creatorcontrib><description>Insulin is given by injection, because when administered orally, it would be destroyed by enzymes in the digestive system, hence only about 0.1% reaches blood circulation. The purpose of the present study was to use pH sensitive polyelectrolyte methyl methacrylate (MMA)/itaconic acid (IA) nanogels as carriers in an attempt to improve absorption of insulin administered orally. Insulin (Ins) was incorporated into the MMA/IA nanogels (NGs) using the polyelectrolyte complexation (PEC) method to form Ins/NGs-PEC. Several parameters, including Ins:NGs ratio, pH, incubation time and stirring rate were optimized during preparation of InsNGs-PEC. The prepared formulations were characterized in terms of particle size (PS), polydispersity index (PdI), zeta potential (ZP) and percent entrapment efficiency (% EE). The optimized InF12 nanogels had a PS, PdI, ZP and %EE of 190.43 nm, 0.186, -16.70 mV and 85.20%, respectively. The InF12 nanogels were lyophilized in the presence of different concentrations of trehalose as cryoprotectant. The lyophilized InF12 containing 2%w/v trahalose (InF12-Tre2 nanogels) was chosen as final formulation which had a PS, PdI, ZP and %EE of 430.50 nm, 0.588, -16.50 mv and 82.10, respectively. The in vitro release of insulin from InF12-Tre2 nanogels in the SGF and SIF were 28.71% and 96.53%, respectively. The stability study conducted at 5±3°C for 3 months showed that lnF12-Tre2 nanogels were stable. The SDS-PAGE assay indicated that the primary structure of insulin in the lnF12-Tre2 nanogels was intact. The in-vivo study in the diabetic rats following oral administration of InF12-Tre2 nanogels at a dose of 100 IU/kg body weight reduced blood glucose level significantly to 51.10% after 6 hours compared to the control groups. The pH sensitive MMA/IA nanogels are potential carriers for oral delivery of insulin as they enhanced the absorption of the drug.</description><identifier>ISSN: 1178-2013</identifier><identifier>ISSN: 1176-9114</identifier><identifier>EISSN: 1178-2013</identifier><identifier>DOI: 10.2147/IJN.S199507</identifier><identifier>PMID: 31456636</identifier><language>eng</language><publisher>New Zealand: Dove Medical Press Limited</publisher><subject>Acids ; acrylic monomers ; Biomedical materials ; Blood glucose ; Body weight ; Diabetes ; Diabetes therapy ; Enzymes ; Glucose ; Hypoglycemia ; Hypoglycemic agents ; hypoglycemic effect ; Insulin ; Insulin aspart ; lyophilization ; Nanoparticles ; Original Research ; Peptides ; peptides self assembly ; Pharmacy ; Polyelectrolytes ; Polyesters ; polymeric nanogels ; Polymerization ; Proteins</subject><ispartof>International journal of nanomedicine, 2019-01, Vol.14, p.4895-4909</ispartof><rights>COPYRIGHT 2019 Dove Medical Press Limited</rights><rights>2019. This work is licensed under https://creativecommons.org/licenses/by-nc/3.0/ (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>2019 Mudassir et al. 2019 Mudassir et al.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c542t-c24c17c7dca662b7639fdb6997e1432a3a8839aa782d9f9cbcc554e599f9c0403</citedby></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://www.proquest.com/docview/2258996168/fulltextPDF?pq-origsite=primo$$EPDF$$P50$$Gproquest$$Hfree_for_read</linktopdf><linktohtml>$$Uhttps://www.proquest.com/docview/2258996168?pq-origsite=primo$$EHTML$$P50$$Gproquest$$Hfree_for_read</linktohtml><link.rule.ids>230,314,727,780,784,885,25753,27924,27925,37012,37013,44590,53791,53793,75126</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/31456636$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Mudassir, Jahanzeb</creatorcontrib><creatorcontrib>Darwis, Yusrida</creatorcontrib><creatorcontrib>Muhamad, Suriani</creatorcontrib><creatorcontrib>Khan, Arshad Ali</creatorcontrib><title>Self-assembled insulin and nanogels polyelectrolyte complex (Ins/NGs-PEC) for oral insulin delivery: characterization, lyophilization and in-vivo evaluation</title><title>International journal of nanomedicine</title><addtitle>Int J Nanomedicine</addtitle><description>Insulin is given by injection, because when administered orally, it would be destroyed by enzymes in the digestive system, hence only about 0.1% reaches blood circulation. The purpose of the present study was to use pH sensitive polyelectrolyte methyl methacrylate (MMA)/itaconic acid (IA) nanogels as carriers in an attempt to improve absorption of insulin administered orally. Insulin (Ins) was incorporated into the MMA/IA nanogels (NGs) using the polyelectrolyte complexation (PEC) method to form Ins/NGs-PEC. Several parameters, including Ins:NGs ratio, pH, incubation time and stirring rate were optimized during preparation of InsNGs-PEC. The prepared formulations were characterized in terms of particle size (PS), polydispersity index (PdI), zeta potential (ZP) and percent entrapment efficiency (% EE). The optimized InF12 nanogels had a PS, PdI, ZP and %EE of 190.43 nm, 0.186, -16.70 mV and 85.20%, respectively. The InF12 nanogels were lyophilized in the presence of different concentrations of trehalose as cryoprotectant. The lyophilized InF12 containing 2%w/v trahalose (InF12-Tre2 nanogels) was chosen as final formulation which had a PS, PdI, ZP and %EE of 430.50 nm, 0.588, -16.50 mv and 82.10, respectively. The in vitro release of insulin from InF12-Tre2 nanogels in the SGF and SIF were 28.71% and 96.53%, respectively. The stability study conducted at 5±3°C for 3 months showed that lnF12-Tre2 nanogels were stable. The SDS-PAGE assay indicated that the primary structure of insulin in the lnF12-Tre2 nanogels was intact. The in-vivo study in the diabetic rats following oral administration of InF12-Tre2 nanogels at a dose of 100 IU/kg body weight reduced blood glucose level significantly to 51.10% after 6 hours compared to the control groups. The pH sensitive MMA/IA nanogels are potential carriers for oral delivery of insulin as they enhanced the absorption of the drug.</description><subject>Acids</subject><subject>acrylic monomers</subject><subject>Biomedical materials</subject><subject>Blood glucose</subject><subject>Body weight</subject><subject>Diabetes</subject><subject>Diabetes therapy</subject><subject>Enzymes</subject><subject>Glucose</subject><subject>Hypoglycemia</subject><subject>Hypoglycemic agents</subject><subject>hypoglycemic effect</subject><subject>Insulin</subject><subject>Insulin aspart</subject><subject>lyophilization</subject><subject>Nanoparticles</subject><subject>Original Research</subject><subject>Peptides</subject><subject>peptides self assembly</subject><subject>Pharmacy</subject><subject>Polyelectrolytes</subject><subject>Polyesters</subject><subject>polymeric nanogels</subject><subject>Polymerization</subject><subject>Proteins</subject><issn>1178-2013</issn><issn>1176-9114</issn><issn>1178-2013</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2019</creationdate><recordtype>article</recordtype><sourceid>PIMPY</sourceid><recordid>eNptkk1vEzEQhlcIREvgxB2txKUINrW9tnfNAamKSgmqClLhbHm9s4kjx07t3YjwW_ixOB-EFiEfPB6_fsYzerPsJUZjgml1Pv18M77FQjBUPcpOMa7qgiBcPr4Xn2TPYlwgxKqai6fZSYkp47zkp9mvW7BdoWKEZWOhzY2LgzUuV67NnXJ-BjbmK283YEH3IQU95NovVxZ-5GdTF89vrmLx9XLyJu98yH1Q9showZo1hM37XM9VULqHYH6q3nj3Lrcbv5obezjvyhlXrM3a57BWdtiln2dPOmUjvDjso-z7x8tvk0_F9Zer6eTiutCMkr7QhGpc6arVinPSVLwUXdtwISrAtCSqVHVdCqWqmrSiE7rRmjEKTGwPiKJylE333NarhVwFs1RhI70ycpfwYSZV6I22ICnDFUKcMUQ1RYQoUKSpOyYYrSiUKrE-7FmroVlCq8H1aSYPoA9vnJnLmV_L9HVUE5EAZwdA8HcDxF4uTdRgrXLghygJqXFNa15WSfr6H-nCD8GlUSUVq4XgmNd_VTOVGjCu86mu3kLlBUcEp26SF0bZ-D-qtFpYGu0ddCblHzx4u3-gg48xQHfsESO5NaZMxpQHYyb1q_tjOWr_OLH8De663xc</recordid><startdate>20190101</startdate><enddate>20190101</enddate><creator>Mudassir, Jahanzeb</creator><creator>Darwis, Yusrida</creator><creator>Muhamad, Suriani</creator><creator>Khan, Arshad Ali</creator><general>Dove Medical Press Limited</general><general>Taylor &amp; Francis Ltd</general><general>Dove</general><general>Dove Medical Press</general><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7X7</scope><scope>7XB</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>8G5</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>GNUQQ</scope><scope>GUQSH</scope><scope>K9.</scope><scope>M0S</scope><scope>M2O</scope><scope>MBDVC</scope><scope>PIMPY</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>Q9U</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20190101</creationdate><title>Self-assembled insulin and nanogels polyelectrolyte complex (Ins/NGs-PEC) for oral insulin delivery: characterization, lyophilization and in-vivo evaluation</title><author>Mudassir, Jahanzeb ; Darwis, Yusrida ; Muhamad, Suriani ; Khan, Arshad Ali</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c542t-c24c17c7dca662b7639fdb6997e1432a3a8839aa782d9f9cbcc554e599f9c0403</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2019</creationdate><topic>Acids</topic><topic>acrylic monomers</topic><topic>Biomedical materials</topic><topic>Blood glucose</topic><topic>Body weight</topic><topic>Diabetes</topic><topic>Diabetes therapy</topic><topic>Enzymes</topic><topic>Glucose</topic><topic>Hypoglycemia</topic><topic>Hypoglycemic agents</topic><topic>hypoglycemic effect</topic><topic>Insulin</topic><topic>Insulin aspart</topic><topic>lyophilization</topic><topic>Nanoparticles</topic><topic>Original Research</topic><topic>Peptides</topic><topic>peptides self assembly</topic><topic>Pharmacy</topic><topic>Polyelectrolytes</topic><topic>Polyesters</topic><topic>polymeric nanogels</topic><topic>Polymerization</topic><topic>Proteins</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Mudassir, Jahanzeb</creatorcontrib><creatorcontrib>Darwis, Yusrida</creatorcontrib><creatorcontrib>Muhamad, Suriani</creatorcontrib><creatorcontrib>Khan, Arshad Ali</creatorcontrib><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Proquest Health &amp; Medical Complete</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>Research Library (Alumni Edition)</collection><collection>ProQuest Central (Alumni)</collection><collection>ProQuest Central</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Central Student</collection><collection>Research Library Prep</collection><collection>ProQuest Health &amp; Medical Complete (Alumni)</collection><collection>Health &amp; Medical Collection (Alumni Edition)</collection><collection>Research Library (ProQuest)</collection><collection>Research Library (Corporate)</collection><collection>Publicly Available Content (ProQuest)</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>ProQuest Central Basic</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>International journal of nanomedicine</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Mudassir, Jahanzeb</au><au>Darwis, Yusrida</au><au>Muhamad, Suriani</au><au>Khan, Arshad Ali</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Self-assembled insulin and nanogels polyelectrolyte complex (Ins/NGs-PEC) for oral insulin delivery: characterization, lyophilization and in-vivo evaluation</atitle><jtitle>International journal of nanomedicine</jtitle><addtitle>Int J Nanomedicine</addtitle><date>2019-01-01</date><risdate>2019</risdate><volume>14</volume><spage>4895</spage><epage>4909</epage><pages>4895-4909</pages><issn>1178-2013</issn><issn>1176-9114</issn><eissn>1178-2013</eissn><abstract>Insulin is given by injection, because when administered orally, it would be destroyed by enzymes in the digestive system, hence only about 0.1% reaches blood circulation. The purpose of the present study was to use pH sensitive polyelectrolyte methyl methacrylate (MMA)/itaconic acid (IA) nanogels as carriers in an attempt to improve absorption of insulin administered orally. Insulin (Ins) was incorporated into the MMA/IA nanogels (NGs) using the polyelectrolyte complexation (PEC) method to form Ins/NGs-PEC. Several parameters, including Ins:NGs ratio, pH, incubation time and stirring rate were optimized during preparation of InsNGs-PEC. The prepared formulations were characterized in terms of particle size (PS), polydispersity index (PdI), zeta potential (ZP) and percent entrapment efficiency (% EE). The optimized InF12 nanogels had a PS, PdI, ZP and %EE of 190.43 nm, 0.186, -16.70 mV and 85.20%, respectively. The InF12 nanogels were lyophilized in the presence of different concentrations of trehalose as cryoprotectant. The lyophilized InF12 containing 2%w/v trahalose (InF12-Tre2 nanogels) was chosen as final formulation which had a PS, PdI, ZP and %EE of 430.50 nm, 0.588, -16.50 mv and 82.10, respectively. The in vitro release of insulin from InF12-Tre2 nanogels in the SGF and SIF were 28.71% and 96.53%, respectively. The stability study conducted at 5±3°C for 3 months showed that lnF12-Tre2 nanogels were stable. The SDS-PAGE assay indicated that the primary structure of insulin in the lnF12-Tre2 nanogels was intact. The in-vivo study in the diabetic rats following oral administration of InF12-Tre2 nanogels at a dose of 100 IU/kg body weight reduced blood glucose level significantly to 51.10% after 6 hours compared to the control groups. The pH sensitive MMA/IA nanogels are potential carriers for oral delivery of insulin as they enhanced the absorption of the drug.</abstract><cop>New Zealand</cop><pub>Dove Medical Press Limited</pub><pmid>31456636</pmid><doi>10.2147/IJN.S199507</doi><tpages>15</tpages><oa>free_for_read</oa></addata></record>
fulltext fulltext
identifier ISSN: 1178-2013
ispartof International journal of nanomedicine, 2019-01, Vol.14, p.4895-4909
issn 1178-2013
1176-9114
1178-2013
language eng
recordid cdi_doaj_primary_oai_doaj_org_article_45170065504c4022aea2b8f595474e3a
source PubMed (Medline); Taylor & Francis Journals Open Access; Publicly Available Content (ProQuest)
subjects Acids
acrylic monomers
Biomedical materials
Blood glucose
Body weight
Diabetes
Diabetes therapy
Enzymes
Glucose
Hypoglycemia
Hypoglycemic agents
hypoglycemic effect
Insulin
Insulin aspart
lyophilization
Nanoparticles
Original Research
Peptides
peptides self assembly
Pharmacy
Polyelectrolytes
Polyesters
polymeric nanogels
Polymerization
Proteins
title Self-assembled insulin and nanogels polyelectrolyte complex (Ins/NGs-PEC) for oral insulin delivery: characterization, lyophilization and in-vivo evaluation
url http://sfxeu10.hosted.exlibrisgroup.com/loughborough?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-01-06T01%3A57%3A02IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-gale_doaj_&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Self-assembled%20insulin%20and%20nanogels%20polyelectrolyte%20complex%20(Ins/NGs-PEC)%20for%20oral%20insulin%20delivery:%20characterization,%20lyophilization%20and%20in-vivo%20evaluation&rft.jtitle=International%20journal%20of%20nanomedicine&rft.au=Mudassir,%20Jahanzeb&rft.date=2019-01-01&rft.volume=14&rft.spage=4895&rft.epage=4909&rft.pages=4895-4909&rft.issn=1178-2013&rft.eissn=1178-2013&rft_id=info:doi/10.2147/IJN.S199507&rft_dat=%3Cgale_doaj_%3EA602106566%3C/gale_doaj_%3E%3Cgrp_id%3Ecdi_FETCH-LOGICAL-c542t-c24c17c7dca662b7639fdb6997e1432a3a8839aa782d9f9cbcc554e599f9c0403%3C/grp_id%3E%3Coa%3E%3C/oa%3E%3Curl%3E%3C/url%3E&rft_id=info:oai/&rft_pqid=2258996168&rft_id=info:pmid/31456636&rft_galeid=A602106566&rfr_iscdi=true