Shared and differential cortical functional abnormalities associated with inhibitory control in patients with schizophrenia and bipolar disorder

ABSTRACT Schizophrenia (SZ) and bipolar I disorder (BD-I) share genetic risk factors and cognitive impairments, but these conditions may exhibit differences in cortical functioning

associated with inhibitory control. We measured hemodynamic responses during a stop-signal task using near-infrared spectroscopy (NIRS) in 20 patients with SZ, 21 patients with BD-I and 18

healthy controls (HCs). We used stop-signal reaction time (SSRT) to estimate behavioural inhibition. Compared with HCs, patients with either SZ or BD-I exhibited significantly reduced

activation in the bilateral inferior, middle and superior frontal gyri. Furthermore, patients with BD-I showed inactivation of the right superior temporal gyri compared with patients with SZ

or HCs. Patients with SZ or BD-I demonstrated significant negative correlations between SSRT and hemodynamic responses of the right inferior frontal gyrus. Moreover, patients with SZ

exhibited correlations in the middle and superior frontal gyri. Our findings suggest that right inferior frontal abnormalities mediate behavioural inhibition impairments in individuals with

SZ or BD-I. Differential patterns of orbitofrontal or superior temporal functional abnormalities may reflect important differences in psychopathological features between these disorders.

SIMILAR CONTENT BEING VIEWED BY OTHERS REDUCED TEMPORAL VARIABILITY OF CORTICAL EXCITATION/INHIBITION RATIO IN SCHIZOPHRENIA Article Open access 18 February 2025 AN ERP STUDY ON PROACTIVE

AND REACTIVE RESPONSE INHIBITION IN INDIVIDUALS WITH SCHIZOTYPY Article Open access 16 April 2021 REDUCTION OF INTRACORTICAL INHIBITION (ICI) CORRELATES WITH COGNITIVE PERFORMANCE AND

PSYCHOPATHOLOGY SYMPTOMS IN SCHIZOPHRENIA Article Open access 14 September 2024 INTRODUCTION Although the traditional diagnostic classification in psychiatry cuts across the natural

boundaries between schizophrenia (SZ) and bipolar I disorder (BD-I), recent epidemiological and molecular evidence supports shared genetic contributions between these disorders1. In

addition, these psychiatric disorders share cognitive impairments that may be linked to structural and functional alterations in the frontotemporal cortex2,3. Deficits in inhibitory control,

a major subcomponent of executive function, have been described in both SZ and BD-I. Inhibitory control is the ability to override, interrupt, or abort ongoing processes, especially when

these processes are well engrained3. The stop-signal task can estimate the time required by an individual to withhold ongoing responses, as measured by stop-signal reaction time (SSRT)4.

Compared with healthy controls (HCs), SSRTs are longer (i.e. suggesting impaired behavioural inhibition) in individuals with SZ5 or BD-I6,7. Neuroimaging studies indicate that inhibitory

processes involve the frontal cortex, particularly the right inferior frontal gyrus and presupplementary motor area8,9,10,11. Previous neuroimaging studies have found structural and

functional abnormalities in these regions in individuals with SZ12,13,14 or BD-I7,15,16. In addition, functional magnetic resonance imaging (fMRI) studies have reported associations between

behavioural inhibition and functional abnormalities of these brain regions in individuals with SZ13,14 or BD-I17,18. These neuroimaging studies suggest overlapping neural abnormalities in

inhibitory processes between SZ or BD-I; however, it remains unclear to what extent these abnormalities have similar profiles or to what degree they differ between the two psychiatric

disorders. Near-infrared spectroscopy (NIRS) is a non-invasive optical technique for monitoring hemodynamic changes related to cortical neural activity by measuring relative changes in

haemoglobin (Hb). Previous NIRS studies have reported functional abnormalities in the prefrontal cortex during a cognitive task in patients with SZ19,20 and BD-I (mainly individuals with

bipolar II disorder)21. Recent studies have also reported that, compared with HCs, individuals with SZ show functional abnormalities of the bilateral prefrontal cortex during Go/No Go22 and

stop-signal tasks23. Additionally, patients with bipolar II disorder show decreased oxygenated haemoglobin (oxy-Hb) changes in the bilateral orbitofrontal and left prefrontal cortices during

the Iowa Gambling Task24. However, to our knowledge, no NIRS studies to date have directly compared functional abnormalities associated with inhibitory control in patients with SZ or BD-I

relative to HCs. In the current study, we investigated differences in cortical frontotemporal functional abnormalities associated with inhibitory control between patients with SZ or BD-I and

HCs. We hypothesised that patients with SZ or BD-I possess shared–as well as different–cortical function patterns. These functional abnormalities appear to be directly associated with

observed cognitive and clinical features, and these associations may characterise important differences in psychopathology between the two disorders. RESULTS DEMOGRAPHIC CHARACTERISTICS The

study participants consisted of patients with SZ (n = 20), BD-I (n = 21) and 18 HCs. Participants’ demographic data are shown in Table 1. TASK PERFORMANCE SSRTs differed significantly across

the SZ, BD-I and HC groups (P = 0.015; Table 1). Patients with SZ demonstrated longer SSRTs than HCs (P = 0.011). No significant differences were observed between with patients BD-I and HCs

(P = 0.26) or between patients with SZ and BD-I (P = 0.30). COGNITIVE ACTIVATION WITHIN GROUPS HCs showed significantly increased mean oxy-Hb levels between the pre-task baseline and the

inhibitory control task period in 45 of 52 channels (‘ch’) (ch1–5, ch8–9, ch11–16, ch18–20, ch22–30, ch32–41 and ch43–52; t = −8.27 to −2.28; maximum false discovery rate (FDR)-corrected P 

< 0.05, corrected for 52 channels). Thus, widespread frontotemporal cortical activation related to oxy-Hb was induced by the inhibitory control task in HCs. Patients with SZ showed

significantly increased mean oxy-Hb levels in 14 of 52 channels (ch19, ch29–30, ch34–36, ch38–39, ch44–47 and ch49–50; t = −4.22 to −2.76; FDR-corrected P < 0.05, corrected for 52

channels). By contrast, patients with BD-I did not show significant changes in oxy-Hb levels in any channel (FDR-corrected P < 0.05, corrected for 52 channels). Figure 1 summarises the

cognitive activation results for all three groups. REGIONAL DIFFERENCES IN TASK-RELATED OXY-HB CHANGES AMONG GROUPS Task-related oxy-Hb changes differed significantly among the SZ, BD-I and

HC groups in 21 channels (ch4–5, ch12, ch14–15, ch18, ch24–25, ch34–37, ch39, ch43–46, ch48–51; F = 4.23–11.18; FDR-corrected P < 0.05, corrected for 52 channels). Compared with HCs, the

SZ group exhibited significantly smaller task-related oxy-Hb changes in 11 channels (ch5, ch14–15, ch18, ch25, ch36–37, ch39, ch46 and ch48–49; p = 0.009–0.049), whereas the BD group

exhibited significantly smaller changes in 21 channels (ch4–5, ch12, ch14–15, ch18, ch24–25, ch34–37, ch39, ch43–46 and ch48–51; P = 0.000–0.044; Fig. 2). Thus, both patient groups produced

significantly smaller task-related changes in oxy-Hb levels in the bilateral middle frontal, inferior frontal and superior frontal gyri compared with HCs (Table 2). Furthermore, patients

with BD-I demonstrated significantly smaller task-related changes in oxy-Hb levels than patients with SZ or HCs in three channels (ch43–45; P = 0.015–0.036) located in the middle temporal

and superior temporal gyri. In addition, analysis of covariance (ANCOVA) revealed that task-related oxy-Hb changes differed significantly among the SZ, BD-I and HC groups in 9 channels (ch5,

ch34–35, ch43–46, ch49 and ch51; F = 5.41–11.59; FDR-corrected P < 0.05, corrected for 52 channels). The BD group exhibited significantly smaller task-related oxy-Hb changes in 9

channels in comparison to HCs (ch5, ch34–35, ch43–46, ch49 and ch51; P = 0.000–0.010) and in 3 channels in comparison to the SZ group (ch43–45; P = 0.004–0.021). However, ANCOVA did not show

any significance between the SZ and HC groups after FDR correction. Figure 3 summarises the results of regional differences in task-related changes in oxy-Hb levels in patients with SZ or

BD-I. In brief, reduced hemodynamic responses in the bilateral middle frontal, inferior frontal and superior frontal (including orbitofrontal region) gyri are a shared feature in SZ and

BD-I. However, the reduction in the right superior temporal gyrus is specific to patients with BD-I. CORRELATION ANALYSIS Significant negative correlations between individual SSRT and

task-related oxy-Hb changes were observed in the SZ group at four channels (ch36 and ch46–48; r = −0.71 to −0.64; FDR-corrected P < 0.05, corrected for 52 channels) located in the right

middle frontal, inferior frontal and left superior frontal gyri, as well as in the BD-I group at one channel (ch45; r = −0.70; FDR-corrected P < 0.05, corrected for 52 channels) located

in the right inferior frontal gyrus. There were no significant correlations between SSRT and task-related oxy-Hb changes in HCs. Figure 4 summarises the correlation analysis in patients with

SZ or BD-I. We observed significant negative correlations between the Global Assessment of Functioning (GAF) scale score and task-related oxy-Hb changes in the BD-I group at two channels

(ch43–44; r = −0.72 to −0.68; FDR-corrected P < 0.05, corrected for 52 channels) located in the right middle and superior temporal gyri. No significant correlations were observed between

task-related oxy-Hb changes and any other clinical variable in the SZ, BD-I, or HC groups, including antipsychotic or antidepressant dosage. No significant correlations were observed between

task-related oxy-Hb changes and HAMD or YMRS scores in the BD-I group. DISCUSSION To our knowledge, this is the first NIRS study to directly compare regional cortical hemodynamic responses

associated with inhibitory control among patients with SZ or BD-I and HCs. Patients with SZ or BD-I exhibited functional abnormalities associated with inhibitory control in the right

inferior frontal gyrus. The differential abnormalities associated with behavioural inhibition were observed in the right middle and superior frontal gyri in patients with SZ and in the right

superior temporal gyrus of patients with BD-I. Our findings suggest that differential patterns of frontotemporal functional abnormalities may reflect an important difference in

psychopathology between schizophrenia and bipolar disorder. Compared with HCs, patients with SZ or BD-I showed significantly reduced hemodynamic responses in the bilateral inferior frontal,

middle frontal and superior frontal gyri. These results are consistent with previous SZ or BD-I neuroimaging studies that reported functional abnormalities in these regions7,12,13,14,15,16.

The right inferior frontal gyrus is known to play a general role in attentional control, rapidly adapting inhibitory control responses to current salient stimuli25,26,27. Previous

neuroimaging studies of HCs reported activation of the right inferior frontal and superior temporal gyri during a response inhibition task28. By contrast, studies have reported significant

associations between poor inhibitory control and the volume of damage to grey matter in the right inferior frontal gyrus in patients with lesions of the right frontal lobe29 and reduced

white matter fractional anisotropy in this region in patients with methamphetamine dependence30. Our results indicate that poor inhibitory control is associated with reduced hemodynamic

responses in the right inferior frontal gyrus of patients with SZ or BD-I. These individuals have specific patterns of cerebral alterations in the right inferior frontal gyrus; this region

may therefore be a neural substrate of impaired behavioural inhibition. Our findings suggest that right inferior frontal abnormalities mediate deficits in inhibitory control that are shared

across patients with either SZ or BD-I. In addition, the results of the current study suggest that patients with SZ exhibited deficits in inhibitory control associated with reduced

hemodynamic responses in the right middle frontal and left superior frontal gyri, including the orbitofrontal region (channels 47–48). Previous studies on individuals with SZ indicated that

structural or functional abnormalities in the orbitofrontal cortex were strongly associated with impulsive aggression or suicidal behavior31,32,33. Furthermore, alterations of orbitofrontal

areas associated with SZ have been linked to positive and negative symptom profiles in previous structural neuroimaging studies34,35. Taken together, these studies suggest that functional

abnormalities in the orbitofrontal region impair inhibition during impulsive or aggressive expression of symptoms in patients with SZ. Further, the alteration in this region may be related

to the specific psychopathology of SZ. Our findings suggest that orbitofrontal functional abnormalities related to impaired behavioural inhibition are a neural substrate of the impulsive or

aggressive clinical features associated with SZ. By contrast, patients with BD-I demonstrated reduced hemodynamic responses in the right superior temporal gyrus, which was unique to this

group. Moreover, patients with BD-I exhibited negative associations between SSRT and hemodynamic responses in this region. The superior temporal cortex (gyrus and sulcus) is part of a

complex face-processing system involved in the perception of emotions36 and regulating responses to negative visual social stimuli37. Recent structural neuroimaging studies in patients with

BD-I have found abnormally reduced thickness of the right superior temporal cortex38 or abnormally reduced fractional anisotropy in the right temporal lobe39. One investigation suggested

that reduced activation in the superior temporal sulcus may indicate disturbances in affect-processing circuitry, leading to abnormalities in mood and social cognition40. These findings

suggest that the superior temporal gyrus is an important neural substrate of emotion regulation and reward processing, and that alterations in this region may produce some of the cognitive

symptoms and social impairments associated with BD-I. Moreover, functional abnormalities in this region may result in impaired emotional control inhibition in individuals with BD-I. This

hypothesis is partly supported by the results of the current study, which showed an association between impaired global functioning and abnormal right temporal region hemodynamic responses

in patients with BD-I. Our findings suggest that the functional abnormalities related to inhibitory control in the right superior temporal gyrus are characteristic of BD-I. In addition,

patients with SZ showed significantly longer SSRTs compared to patients with BD-I or HCs. This is consistent with previous evidence associating SZ with response inhibition deficits2,5. By

contrast, no such difference in mean SSRT was observed patients with BD-I or HCs, consistent with the notion that neurocognitive functioning in individuals with BD-I is impaired relative to

HCs but better than in patients with SZ41,42. An alternative explanation for this difference between SZ and BD-I groups is that the current mood state in patients with BD-I influenced SSRT,

whereas the deficits persisted across all phases of BD-I6,7,43. A further explanation is that neuroimaging techniques, including the NIRS signal, are more sensitive than SSRT at detecting

differences between the BD-I and HC groups, especially given small sample sizes. This observation has been reported in previous neuroimaging studies17,18. In the current study, we considered

observed differences in hemodynamic responses among patients with SZ or BD-I and HCs to be activated by the stop-signal task. There are several potential limitations to our study. First,

our sample size was small, which may have limited the statistical power to produce reliable findings, i.e. ANCOVA did not show any significant differences between the SZ and HC groups after

FDR correction. This could also explain why associations between SSRT and task-related oxy-Hb changes were not observed in HCs. In addition, the NIRS signal might be more sensitive, allowing

greater detection of cortical functional abnormalities in patients with psychiatric diagnoses. This speculation is partly supported by previous NIRS studies that did not detect brain

regions associated with task performances in HCs during Go/No Go22 and stop-signal tasks23. Further studies with larger sample sizes are needed to verify our findings. Second, we cannot

exclude the possibility of medication effects on hemodynamic responses in patients with SZ and BD-I. However, it should be noted that the dosage of antidepressants or antipsychotics was not

correlated with hemodynamic responses in any channels, suggesting a minimal confounding effect of medication. In addition, previous NIRS studies have reported no significant effect of

psychotropic medications on neural activity in patients with SZ or BD19,20,21,22,23. Lastly, NIRS has lower spatial resolution to detect cortical activity from the scalp surface than other

neuroimaging techniques such as fMRI. However, this limitation should be within an acceptable range because differences in hemodynamic responses in patients with SZ or BD-I and HCs were

clearly observed in our study, as they have been in other NIRS studies23,24,44. In addition, we used a virtual spatial registration method to define the spatial information for each channel

using data45,46,47. This method was used in most recent NIRS studies and may be useful for replicating our findings. CONCLUSION This study demonstrated shared and differential patterns of

hemodynamic responses in the frontotemporal cortex among patients with SZ or BD-I and HCs. Our findings suggest that differential patterns in frontotemporal functional abnormalities may

reflect important differences in the psychopathological features of SZ or BD-I. NIRS is a non-invasive neuroimaging modality with easy applicability and high ecological validity. This makes

NIRS particularly suitable for use with patients with psychiatric diagnoses who may be afraid of enclosed spaces or exhibit motor restlessness that interferes with motion-sensitive imaging

methods45. Therefore, NIRS has the potential to be a powerful and specific diagnostic tool for use among individuals with SZ or BD-I. METHODS PARTICIPANTS The diagnosis of SZ or BD-I was

made according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition48 criteria using the Mini International Neuropsychiatric Interview (MINI)49. HCs were also

screened using the MINI and excluded if there was any history of psychiatric disorders or heritable neurological diseases among first- or second-order relatives. Exclusion criteria for the

study groups were as follows: a history of head trauma with loss of consciousness for more than 5 min, current or previous neurological disease, current or previous endocrine disease, a

history of electroconvulsive therapy and/or alcohol/substance abuse or addiction. Psychiatric symptoms were assessed using the Positive and Negative Syndrome Scale (PANSS)50. Global

functioning was assessed with GAF48. Depression severity was evaluated using the 17-item Hamilton depression rating scale administered using a structured interview guide51. Manic symptoms

were assessed using the Young mania rating scale (YMRS)52. Premorbid IQ was estimated using the Japanese version of the National Adult Reading Test53. Handedness was evaluated according to

the Edinburgh Inventory54. The chlorpromazine-equivalent dose of antipsychotics was calculated for each patient55. After providing a complete description of the study, written informed

consent was obtained from all participants. This study complied with the Declaration of Helsinki and was approved by the Ethics Committee of the Kindai University Faculty of Medicine. All

data generated or analysed during this study are included in this article. NIRS METHODOLOGY We used a 52-channel NIRS device (ETG-4000 Optical Topography System; Hitachi Medical Co., Tokyo,

Japan) to measure relative changes in oxy-Hb and deoxygenated haemoglobin (deoxy-Hb) at two wavelengths (694 and 830 nm) of near-infrared light (indicated as mM) based on the modified

Beer–Lambert law56. The NIRS probes were fixed using 3 × 11 thermoplastic shells with 17 emitters and 16 detectors. The distance between each source and detector probe was 30 mm and the area

analysed between the probes was defined as a ‘channel’. The probes of the NIRS device were placed on the frontotemporal region of each participant, with the lowermost probes located along

the T3-Fp1-Fpz-Fp2-T4 line, in accordance with the International 10–20 Placement System used for electroencephalography. The NIRS device can measure Hb values bilaterally from the prefrontal

and temporal surface regions at depths of 20–30 mm from the scalp, which correspond with the surface of the cerebral cortex. The spatial information for each channel was estimated using

data from the Functional Brain Science Laboratory at Jichi Medical University, Japan45,46. According to the LONI Probabilistic Brain Atlas (LPBA40)47, NIRS channels can record functional

hemodynamics within the bilateral frontal, temporal and parietal cortices. We anatomically labelled NIRS channels only after the LPBA40 region of highest probability was determined (Fig. 5).

We recorded relative mean changes in Hb concentrations from baseline in mM because NIRS cannot measure the absolute path length from the emitter to the detector. NIRS signals were acquired

with a time resolution of 0.1 s. We set the moving average window to 5 s to remove high frequency noise such as heartbeat and small bodily movements. Channel records with low signal-to-noise

ratios or motion artefacts were excluded, and there was no difference in the number of samples at each channel, including the channels that indicated significant differences among study

groups. In the present study, we focused on changes in oxy-Hb. Animal studies indicate that oxy-Hb is the most sensitive indicator of regional cerebral blood flow because the direction of

change in deoxy-Hb is determined by the degree of change in venous blood oxygenation and volume57. Pre-task baseline was determined as the mean across the last 10 s of the 30 s pre-task

segment. The obtained oxy-Hb data were averaged for each participant during each baseline and task period. The task-related oxy-Hb changes (task minus baseline) were used for statistical

analysis. STOP-SIGNAL TASK We used a variation on the classic stop-signal task4 (SST) to assess inhibitory control58. The original task design has been described in detail58,59. In brief,

across the task period, participants viewed the shape of a ‘go’ stimulus (circle or square) that appeared on screen in rapid succession. Occasionally, an auditory stop signal was presented

at a short, variable delay after the onset of the go stimulus. PROCEDURE The cognitive activation task used in this study had a one-block design and included 1) a pre-task baseline period

and 2) a stop-signal task period (Fig. 6A). During a 30 s pre-task period, participants were instructed to alternatively tap with their right and left index fingers every 1 s as accurately

as they could, using the left and right buttons on a keyboard. The task consisted of a block of 64 trials; stop-signal trials (75% of trials) and non-stop-signal trials (25% of trials) were

randomly presented. Each trial started with the presentation of a fixation sign on a computer monitor, which was replaced by the primary task stimulus after 250 ms. Stop-signal delay was

initially set at 250 ms and continuously adjusted with the staircase tracking procedure (range of 250–1050 ms). When inhibition was successful, the stop-signal delay increased by 50 ms; when

inhibition was unsuccessful, it decreased by 50 ms. Response registration continued during stop-signal presentation. In stop-signal trials, the go stimulus was followed by a stop signal

(750 Hz, 75 ms) after a variable stop-signal delay. In both no-stop-signal trials and stop-signal trials, the go stimulus remained on screen until subjects responded or the maximal reaction

time (RT; 1,250 ms) had elapsed. The inter-trial interval was 2,000 ms and independent of RT. Participants were instructed to respond as quickly and accurately as possible to the go stimulus

in non-stop-signal trials. In stop-signal trials, participants were instructed to try to withhold their response as required until the auditory stop signal occurred (Fig. 6B). STATISTICAL

ANALYSIS Demographic and clinical variables were compared among the study groups using the χ2 test, _t_-test and one-way ANOVA followed by Tukey’s _post hoc_ test. Statistical significance

was assumed at P < 0.05 (two-tailed). To identify regional differences in frontotemporal hemodynamic activation associated with the inhibitory control task, we compared mean oxy-Hb

changes during the pre-task (baseline) and task periods for every channel within individual subjects using the paired _t_-test. Task-related oxy-Hb changes were compared among the study

groups using ANOVA followed by Tukey’s _post hoc_ test. Because Tukey’s _post hoc_ test focused on NIRS channels where the hemodynamic response was shown to be significant after FDR

correction, no further correction for multiple comparisons was applied for the post hoc test and responses were considered significant at _P_ < 0.0523. Complementary analyses were

performed to identify between-group differences in activation associated with inhibitory control using ANCOVA with age, gender (dummy parameterised, male = 0, female = 1) and SSRT as

covariates. Furthermore, to examine the relationships between task-related oxy-Hb changes and clinical variables, we calculated Pearson’s correlation coefficients. We set the value of q

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NIRS. _Neuroimage_ 33, 542–549, https://doi.org/10.1016/j.neuroimage.2006.06.047 (2006). Article  PubMed  Google Scholar  Download references ACKNOWLEDGEMENTS This work was partly supported

by Grants-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (No. 25461792 and No. 16K10229). AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Department of

Neuropsychiatry, Kindai University Faculty of Medicine, Osaka, Japan Noa Tsujii, Wakako Mikawa, Toru Adachi, Tomoyuki Hirose & Osamu Shirakawa Authors * Noa Tsujii View author

publications You can also search for this author inPubMed Google Scholar * Wakako Mikawa View author publications You can also search for this author inPubMed Google Scholar * Toru Adachi

View author publications You can also search for this author inPubMed Google Scholar * Tomoyuki Hirose View author publications You can also search for this author inPubMed Google Scholar *

Osamu Shirakawa View author publications You can also search for this author inPubMed Google Scholar CONTRIBUTIONS N.T. designed the study, wrote the protocol, collected the data, undertook

the statistical analyses and wrote the manuscript. W.M. and T.A. collected the data. T.H. critically revised the text for important intellectual content. O.S. is the head of our laboratory

and designed the study, wrote the protocol and was involved in working on all drafts of the manuscript. All authors contributed to and have approved the final manuscript. CORRESPONDING

AUTHOR Correspondence to Noa Tsujii. ETHICS DECLARATIONS COMPETING INTERESTS Dr. Shirakawa has received honoraria from Pfizer, GlaxoSmithKline and Eli Lilly. The other authors report no

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THIS ARTICLE CITE THIS ARTICLE Tsujii, N., Mikawa, W., Adachi, T. _et al._ Shared and differential cortical functional abnormalities associated with inhibitory control in patients with

schizophrenia and bipolar disorder. _Sci Rep_ 8, 4686 (2018). https://doi.org/10.1038/s41598-018-22929-y Download citation * Received: 26 April 2017 * Accepted: 05 March 2018 * Published: 16

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