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Hepatoprotective effect of the ethyl acetate fraction of Indonesian Artocarpus species against CCl4 induced liver injury in rat

Yıl 2024, Cilt: 28 Sayı: 4, 952 - 960, 28.06.2025

Fitrya Fitrya , Annisa Amriani , Rennie Puspa Novita , Venny Fatya Sahara Mella Rizki Meilita Rahma Muharni Muharni Fatma Sri Wahyuni

Öz

The liver—the center of metabolism and detoxification—is especially susceptible to damage from toxins and must be protected. This study aimed to evaluate the hepatoprotective effects of the ethyl acetate fraction from three Indonesian Artocarpus species (Artocarpus altilis, A. champeden, and A. heterophyllus) in rats with acute liver injury induced by carbon tetrachloride (CCl4). The hepatoprotective effect was assessed through biochemical parameters (AST, ALT, and ALP) and histological analysis of the liver of the test group and compared to the normal control group (Na CMC 0.5%) and the positive control group (silymarin 100 mg/kg). There was no significant difference between the AST, ALT, and ALP levels in the 500 mg dose group, the control and the silymarin group (p > 0.05). Histological analysis of the liver tissue showed a microscopic profile similar to that of the control and silymarin groups. This study showed that the ethyl acetate fraction of Artocarpus altilis, A. heterophyllus, and A. champeden has synergistic potential as a hepatoprotector against liver injury caused by CCl4. Consequently, the leaves of these species can be used as complementary medicine in treating acute liver damage.

Anahtar Kelimeler

Ethyl acetate fraction Artocarpus altilis Artocarpus heterophyllus Artocarpus champeden acute liver damage

Kaynakça

  • [1] Hashem MM, Salama MM, Mohammed FF, Tohamy AF, El Deeb KS. Metabolic profile and hepatoprotective effect of Aeschynomene elaphroxylon (Guill. & Perr.) PLoS ONE 14(1): e0210576. https://doi.org/10.1371/journal.pone.0210576
  • [2] Rakib A, Ahmed S, Islam MA, Haye A, Uddin SMN, Uddin MMN, Hossain MK, Paul A, Emran TB. Antipyretic and hepatoprotective potential of Tinospora crispa and investigation of possible lead compounds through in silico approaches. Food Sci Nutr. 2020;8:547–556. https://doi.org/10.1002/fsn3.1339
  • [3] Qu J, Huang P, Zhang L, Qiu Y, Qi H, Leng A, Shang D. Hepatoprotective effect of plant polysaccharides from natural resources: A review of the mechanisms and structure-activity relationship. Int J Biol Macromol. 2020;161:24–34. https://doi.org/10.1016/j.ijbiomac.2020.05.196
  • [4] Khan H, Ullah H, Nabavi SM. Mechanistic insights of hepatoprotective effects of curcumin: Therapeutic updates and future prospects. Food Chem Toxicol. 2019;124:182–191. https://doi.org/10.1016/j.fct.2018.12.002.
  • [5] Balitbangkes KKR. Laporan Nasional Riskesdas 2018. Jakarta, 2019, pp. 144-151.
  • [6] Palupi DHS, Retnoningrum DS, Iwo MI, Soemardji AA. Leaf extract of Artocarpus altilis [park.] fosberg has potency as antiinflammatory, antioxidant, and immunosuppressant. Rasayan J Chem. 2020;13(1):636–646. https://doi.org/10.31788/RJC.2020.1315519.
  • [7] Fakhrudin N, Pertiwi KK, Takubessi MI, Susiani EF, Nurrochmad A, Widyarini S, Sudarmanto A, Nugroho AA, Wahyuono S. A geranylated chalcone with antiplatelet activity from the leaves of breadfruit (Artocarpus altilis). Pharmacia 2020;67(4):173-180. https://doi.org/10.3897/pharmacia.67.e56788.
  • [8] Mat Saad H, Tan CH, Lim SH, Manickam S, Sim KS. Evaluation of anti-melanogenesis and free radical scavenging activities of five Artocarpus species for cosmeceutical applications. Ind Crops Prod. 2021;161: 113184. https://doi.org/10.1016/j.indcrop.2020.113184.
  • [9] Mahadi Abdul Jamil M, Ganeson S, Buhari Mammam H, Abdul Wahab R. Artocarpus altilis extract effect on cervical cancer cells. Mater Today Proc. 2018;5(7):15559-15566. https://doi.org/10.1016/j.matpr.2018.04.163.
  • [10] Zhang Y, Jin X, Arancon NQ, Borris RP. Two new geranylated biphenyl esters from Artocarpus altilis. Nat Prod Commun 2020;15(10). https://doi.org/10.1177/1934578X20968439.
  • [11] Sari DRAP, Ahmad FF, Djabir YY, Yulianty R. Breadfruit leaves extract (Artocarpus altilis) effect on pancreatic damage in diabetic type II animal model induced by alloxan–nicotinamide. Med Clin Pract. 2020;3(S1):1-4. https://doi.org/10.1016/j.mcpsp.2020.100099.
  • [12] Fitrya F, Amriani A, Novita RP, Salsabila A, Siregar SM, Anafisya Y. Evaluation of ethanol extracts from three species of Artocarpus as natural gastroprotective agents: In vivo and histopathological studies. J Complement Integr Med. 2022;19(4):967-974. https://doi.org/10.1515/jcim-2022-0105.
  • [13] Fitrya F, Amriani A, Novita RP, Gabriella R, Lestari SV, Agustina A. The diuretic effect of ethyl acetate fractions of Artocarpus altilis, Artocarpus champeden, and Artocarpus heterophyllus leaves in normotensive Wistar rats. J Ayurveda Integr Med. 2023;14(4): 100746. https://doi.org/10.1016/j.jaim.2023.100746.
  • [14] Chiu YJ, Chou SC, Chiu CS, Kao CP, Wu KC, Chen CJ, Tsai JC, Peng WH. Hepatoprotective effect of the ethanol extract of Polygonum orientale on carbon tetrachloride-induced acute liver injury in mice. J Food Drug Anal. 2018;26(1):369-379. https://doi.org/10.1016/j.jfda.2017.04.007.
  • [15] Oleshchuk O, Ivankiv Y, Falfushynska H, Mudra A, Lisnychuk N. Hepatoprotective effect of melatonin in toxic liver injury in rats. Medicina (Kaunas). 2019;55(6):304. https://doi.org/10.3390/medicina55060304.
  • [16] Meng X, Tang GY, Liu PH, Liu Q, Li H Bin, Zhao CJ. Antioxidant activity and hepatoprotective effect of 10 medicinal herbs on CCl4-induced liver injury in mice. World J Gastroenterol. 2020;26(37):5629-5645. https://doi.org/10.3748/wjg.v26.i37.5629.
  • [17] Meng X, Zhou J, Zhao CN, Gan RY, Li H Bin. Health benefits and molecular mechanisms of resveratrol: A narrative review. Foods. 2020;9(3):1-27. https://doi.org/10.3390/foods9030340.
  • [18] Song W, Wu J, Yu L, Peng Z. Evaluation of the pharmacokinetics and hepatoprotective effects of phillygenin in mouse. Biomed Res Int. 2018;2018: 7964318. https://doi.org/10.1155/2018/7964318.
  • [19] Airaodion AI, Ogbuagu EO, Ogbuagu U, Adeniji AR, Agunbiade AP, Airaodion EO. Hepatoprotective effect of Parkia biglobosa on acute ethanol-induced oxidative stress in Wistar rats. Int Res J Gastroenterol Hepatol. 2019;2(1):18-28.
  • [20] El-bakry K, Toson E, Serag M, Aboser M. Hepatoprotective effect of Moringa Oleifera leaves extract against carbon tetrachloride- ınduced liver. World J Pharm Pharm Sci. 2016;5(5):76-89. https://doi.org/10.20959/wjpps20165-6638.
  • [21] Lee YS, Cho IJ, Kim JW, Lee MK, Ku SK, Choi JS, Lee HJ. Hepatoprotective effects of blue honeysuckle on CCl4-induced acute liver damaged mice. Food Sci Nutr. 2019;7(1):322-338. https://doi.org/10.1002/fsn3.893.
  • [22] Ganda R, Panjaitan P, Handharyani E, Zakiah Z, Manalu W. Pengaruh Pemberian Karbon Tetraklorida Terhadap Fungsi Hati Dan Ginjal Tikus. Makara Kesehatan. 2007;11(1):11-16.
  • [23] Farid AS, El Shemy MA, Nafie E, Hegazy AM, Abdelhiee EY. Anti-inflammatory, anti-oxidant and hepatoprotective effects of lactoferrin in rats. Drug Chem Toxicol. 2021;44(3):286-293. https://doi.org/10.1080/01480545.2019.1585868.
  • [24] Vargas-Mendoza N, Madrigal-Santillán E, Morales-González Á, Esquivel-Soto J, Esquivel-Chirino C, García-Luna y González-Rubio MG, Gayosso-de-Lucio JA, Morales-González JA. Hepatoprotective effect of silymarin. World J Hepatol. 2014;6(3):144-149. https://doi.org/10.4254/wjh.v6.i3.144.
  • [25] Eidi A, Mortazavi P, Bazargan M, Zaringhalam J. Hepatoprotective activity of cinnamon ethanolic extract against CCL4-induced liver injury in rats. EXCLI J. 2012;11:495–507. https:/ /doi.org/10.17877/DE290R-4957.
  • [26] Ali M, Khan T, Fatima K, Ali Q ul A, Ovais M, Khalil AT, Ullah I, Raza A, Shinwari ZK, Idrees M. Selected hepatoprotective herbal medicines: Evidence from ethnomedicinal applications, animal models, and possible mechanism of actions. Phyther Res. 2018;32(2):199-215. https://doi.org/10.1002/ptr.5957.
  • [27] Bahtiar A, Miranda AJ, Arsianti A. The effect of Artocarpus altilis (parkinson) fosberg extract supplementation on kidney ischemia-reperfusion injury rat. Pharmacogn J. 2021;13(1):150-154. https://doi.org/10.5530/pj.2021.13.21.
  • [28] Wong SK, Tangah J, Chan HT, Chan EWC. Chemistry and pharmacology of artocarpin: An isoprenyl flavone from Artocarpus species. Syst Rev Pharm. 2018;9(1):58-63. https://doi.org/10.5530/srp.2018.1.12.
  • [29] Wei BL, Weng JR, Chiu PH, Hung CF, Wang JP, Lin CN. Antiinflammatory flavonoids from Artocarpus heterophyllus and Artocarpus communis. J Agric Food Chem. 2005;53(10):3867-3871. https://doi.org/10.1021/jf047873n.
  • [30] Baliga MS, Shivashankara AR, Haniadka R, Dsouza J, Bhat HP. Phytochemistry, nutritional and pharmacological properties of Artocarpus heterophyllus Lam (jackfruit): A review. Food Res Int. 2011;44(7):1800-1811. https://doi.org/10.1016/j.foodres.2011.02.035.
  • [31] Abdulla MA, Ahmed KAA, Al-Bayaty FH, Masood Y. Gastroprotective effect of Phyllanthus niruri leaf extract against ethanol-induced gastric mucosal injury in rats. Afr J Pharm Pharmacol. 2010;4(5):226-230. https://doi.org/10.5897/AJPP.9000160

Yıl 2024, Cilt: 28 Sayı: 4, 952 - 960, 28.06.2025

Fitrya Fitrya , Annisa Amriani , Rennie Puspa Novita , Venny Fatya Sahara Mella Rizki Meilita Rahma Muharni Muharni Fatma Sri Wahyuni

Öz

Kaynakça

  • [1] Hashem MM, Salama MM, Mohammed FF, Tohamy AF, El Deeb KS. Metabolic profile and hepatoprotective effect of Aeschynomene elaphroxylon (Guill. & Perr.) PLoS ONE 14(1): e0210576. https://doi.org/10.1371/journal.pone.0210576
  • [2] Rakib A, Ahmed S, Islam MA, Haye A, Uddin SMN, Uddin MMN, Hossain MK, Paul A, Emran TB. Antipyretic and hepatoprotective potential of Tinospora crispa and investigation of possible lead compounds through in silico approaches. Food Sci Nutr. 2020;8:547–556. https://doi.org/10.1002/fsn3.1339
  • [3] Qu J, Huang P, Zhang L, Qiu Y, Qi H, Leng A, Shang D. Hepatoprotective effect of plant polysaccharides from natural resources: A review of the mechanisms and structure-activity relationship. Int J Biol Macromol. 2020;161:24–34. https://doi.org/10.1016/j.ijbiomac.2020.05.196
  • [4] Khan H, Ullah H, Nabavi SM. Mechanistic insights of hepatoprotective effects of curcumin: Therapeutic updates and future prospects. Food Chem Toxicol. 2019;124:182–191. https://doi.org/10.1016/j.fct.2018.12.002.
  • [5] Balitbangkes KKR. Laporan Nasional Riskesdas 2018. Jakarta, 2019, pp. 144-151.
  • [6] Palupi DHS, Retnoningrum DS, Iwo MI, Soemardji AA. Leaf extract of Artocarpus altilis [park.] fosberg has potency as antiinflammatory, antioxidant, and immunosuppressant. Rasayan J Chem. 2020;13(1):636–646. https://doi.org/10.31788/RJC.2020.1315519.
  • [7] Fakhrudin N, Pertiwi KK, Takubessi MI, Susiani EF, Nurrochmad A, Widyarini S, Sudarmanto A, Nugroho AA, Wahyuono S. A geranylated chalcone with antiplatelet activity from the leaves of breadfruit (Artocarpus altilis). Pharmacia 2020;67(4):173-180. https://doi.org/10.3897/pharmacia.67.e56788.
  • [8] Mat Saad H, Tan CH, Lim SH, Manickam S, Sim KS. Evaluation of anti-melanogenesis and free radical scavenging activities of five Artocarpus species for cosmeceutical applications. Ind Crops Prod. 2021;161: 113184. https://doi.org/10.1016/j.indcrop.2020.113184.
  • [9] Mahadi Abdul Jamil M, Ganeson S, Buhari Mammam H, Abdul Wahab R. Artocarpus altilis extract effect on cervical cancer cells. Mater Today Proc. 2018;5(7):15559-15566. https://doi.org/10.1016/j.matpr.2018.04.163.
  • [10] Zhang Y, Jin X, Arancon NQ, Borris RP. Two new geranylated biphenyl esters from Artocarpus altilis. Nat Prod Commun 2020;15(10). https://doi.org/10.1177/1934578X20968439.
  • [11] Sari DRAP, Ahmad FF, Djabir YY, Yulianty R. Breadfruit leaves extract (Artocarpus altilis) effect on pancreatic damage in diabetic type II animal model induced by alloxan–nicotinamide. Med Clin Pract. 2020;3(S1):1-4. https://doi.org/10.1016/j.mcpsp.2020.100099.
  • [12] Fitrya F, Amriani A, Novita RP, Salsabila A, Siregar SM, Anafisya Y. Evaluation of ethanol extracts from three species of Artocarpus as natural gastroprotective agents: In vivo and histopathological studies. J Complement Integr Med. 2022;19(4):967-974. https://doi.org/10.1515/jcim-2022-0105.
  • [13] Fitrya F, Amriani A, Novita RP, Gabriella R, Lestari SV, Agustina A. The diuretic effect of ethyl acetate fractions of Artocarpus altilis, Artocarpus champeden, and Artocarpus heterophyllus leaves in normotensive Wistar rats. J Ayurveda Integr Med. 2023;14(4): 100746. https://doi.org/10.1016/j.jaim.2023.100746.
  • [14] Chiu YJ, Chou SC, Chiu CS, Kao CP, Wu KC, Chen CJ, Tsai JC, Peng WH. Hepatoprotective effect of the ethanol extract of Polygonum orientale on carbon tetrachloride-induced acute liver injury in mice. J Food Drug Anal. 2018;26(1):369-379. https://doi.org/10.1016/j.jfda.2017.04.007.
  • [15] Oleshchuk O, Ivankiv Y, Falfushynska H, Mudra A, Lisnychuk N. Hepatoprotective effect of melatonin in toxic liver injury in rats. Medicina (Kaunas). 2019;55(6):304. https://doi.org/10.3390/medicina55060304.
  • [16] Meng X, Tang GY, Liu PH, Liu Q, Li H Bin, Zhao CJ. Antioxidant activity and hepatoprotective effect of 10 medicinal herbs on CCl4-induced liver injury in mice. World J Gastroenterol. 2020;26(37):5629-5645. https://doi.org/10.3748/wjg.v26.i37.5629.
  • [17] Meng X, Zhou J, Zhao CN, Gan RY, Li H Bin. Health benefits and molecular mechanisms of resveratrol: A narrative review. Foods. 2020;9(3):1-27. https://doi.org/10.3390/foods9030340.
  • [18] Song W, Wu J, Yu L, Peng Z. Evaluation of the pharmacokinetics and hepatoprotective effects of phillygenin in mouse. Biomed Res Int. 2018;2018: 7964318. https://doi.org/10.1155/2018/7964318.
  • [19] Airaodion AI, Ogbuagu EO, Ogbuagu U, Adeniji AR, Agunbiade AP, Airaodion EO. Hepatoprotective effect of Parkia biglobosa on acute ethanol-induced oxidative stress in Wistar rats. Int Res J Gastroenterol Hepatol. 2019;2(1):18-28.
  • [20] El-bakry K, Toson E, Serag M, Aboser M. Hepatoprotective effect of Moringa Oleifera leaves extract against carbon tetrachloride- ınduced liver. World J Pharm Pharm Sci. 2016;5(5):76-89. https://doi.org/10.20959/wjpps20165-6638.
  • [21] Lee YS, Cho IJ, Kim JW, Lee MK, Ku SK, Choi JS, Lee HJ. Hepatoprotective effects of blue honeysuckle on CCl4-induced acute liver damaged mice. Food Sci Nutr. 2019;7(1):322-338. https://doi.org/10.1002/fsn3.893.
  • [22] Ganda R, Panjaitan P, Handharyani E, Zakiah Z, Manalu W. Pengaruh Pemberian Karbon Tetraklorida Terhadap Fungsi Hati Dan Ginjal Tikus. Makara Kesehatan. 2007;11(1):11-16.
  • [23] Farid AS, El Shemy MA, Nafie E, Hegazy AM, Abdelhiee EY. Anti-inflammatory, anti-oxidant and hepatoprotective effects of lactoferrin in rats. Drug Chem Toxicol. 2021;44(3):286-293. https://doi.org/10.1080/01480545.2019.1585868.
  • [24] Vargas-Mendoza N, Madrigal-Santillán E, Morales-González Á, Esquivel-Soto J, Esquivel-Chirino C, García-Luna y González-Rubio MG, Gayosso-de-Lucio JA, Morales-González JA. Hepatoprotective effect of silymarin. World J Hepatol. 2014;6(3):144-149. https://doi.org/10.4254/wjh.v6.i3.144.
  • [25] Eidi A, Mortazavi P, Bazargan M, Zaringhalam J. Hepatoprotective activity of cinnamon ethanolic extract against CCL4-induced liver injury in rats. EXCLI J. 2012;11:495–507. https:/ /doi.org/10.17877/DE290R-4957.
  • [26] Ali M, Khan T, Fatima K, Ali Q ul A, Ovais M, Khalil AT, Ullah I, Raza A, Shinwari ZK, Idrees M. Selected hepatoprotective herbal medicines: Evidence from ethnomedicinal applications, animal models, and possible mechanism of actions. Phyther Res. 2018;32(2):199-215. https://doi.org/10.1002/ptr.5957.
  • [27] Bahtiar A, Miranda AJ, Arsianti A. The effect of Artocarpus altilis (parkinson) fosberg extract supplementation on kidney ischemia-reperfusion injury rat. Pharmacogn J. 2021;13(1):150-154. https://doi.org/10.5530/pj.2021.13.21.
  • [28] Wong SK, Tangah J, Chan HT, Chan EWC. Chemistry and pharmacology of artocarpin: An isoprenyl flavone from Artocarpus species. Syst Rev Pharm. 2018;9(1):58-63. https://doi.org/10.5530/srp.2018.1.12.
  • [29] Wei BL, Weng JR, Chiu PH, Hung CF, Wang JP, Lin CN. Antiinflammatory flavonoids from Artocarpus heterophyllus and Artocarpus communis. J Agric Food Chem. 2005;53(10):3867-3871. https://doi.org/10.1021/jf047873n.
  • [30] Baliga MS, Shivashankara AR, Haniadka R, Dsouza J, Bhat HP. Phytochemistry, nutritional and pharmacological properties of Artocarpus heterophyllus Lam (jackfruit): A review. Food Res Int. 2011;44(7):1800-1811. https://doi.org/10.1016/j.foodres.2011.02.035.
  • [31] Abdulla MA, Ahmed KAA, Al-Bayaty FH, Masood Y. Gastroprotective effect of Phyllanthus niruri leaf extract against ethanol-induced gastric mucosal injury in rats. Afr J Pharm Pharmacol. 2010;4(5):226-230. https://doi.org/10.5897/AJPP.9000160
Toplam 31 adet kaynakça vardır.

Ayrıntılar

Birincil Dil İngilizce
Konular Eczacılık ve İlaç Bilimleri (Diğer)
Bölüm Articles
Yazarlar

Fitrya Fitrya 0000-0001-9778-8866

Annisa Amriani 0000-0001-5372-8079

Rennie Puspa Novita 0000-0002-3959-4681

Venny Fatya Sahara 0009-0000-0113-9897

Mella Rizki 0009-0004-3220-8313

Meilita Rahma 0009-0004-4173-1499

Muharni Muharni 0000-0002-8332-1031

Fatma Sri Wahyuni 0000-0002-2026-4156

Yayımlanma Tarihi 28 Haziran 2025
Yayımlandığı Sayı Yıl 2024 Cilt: 28 Sayı: 4

Kaynak Göster

APA Fitrya, F., Amriani, A., Puspa Novita, R., Fatya Sahara, V., vd. (2025). Hepatoprotective effect of the ethyl acetate fraction of Indonesian Artocarpus species against CCl4 induced liver injury in rat. Journal of Research in Pharmacy, 28(4), 952-960.
AMA Fitrya F, Amriani A, Puspa Novita R, Fatya Sahara V, Rizki M, Rahma M, Muharni M, Sri Wahyuni F. Hepatoprotective effect of the ethyl acetate fraction of Indonesian Artocarpus species against CCl4 induced liver injury in rat. J. Res. Pharm. Temmuz 2025;28(4):952-960.
Chicago Fitrya, Fitrya, Annisa Amriani, Rennie Puspa Novita, Venny Fatya Sahara, Mella Rizki, Meilita Rahma, Muharni Muharni, ve Fatma Sri Wahyuni. “Hepatoprotective Effect of the Ethyl Acetate Fraction of Indonesian Artocarpus Species Against CCl4 Induced Liver Injury in Rat”. Journal of Research in Pharmacy 28, sy. 4 (Temmuz 2025): 952-60.
EndNote Fitrya F, Amriani A, Puspa Novita R, Fatya Sahara V, Rizki M, Rahma M, Muharni M, Sri Wahyuni F (01 Temmuz 2025) Hepatoprotective effect of the ethyl acetate fraction of Indonesian Artocarpus species against CCl4 induced liver injury in rat. Journal of Research in Pharmacy 28 4 952–960.
IEEE F. Fitrya, A. Amriani, R. Puspa Novita, V. Fatya Sahara, M. Rizki, M. Rahma, M. Muharni, ve F. Sri Wahyuni, “Hepatoprotective effect of the ethyl acetate fraction of Indonesian Artocarpus species against CCl4 induced liver injury in rat”, J. Res. Pharm., c. 28, sy. 4, ss. 952–960, 2025.
ISNAD Fitrya, Fitrya vd. “Hepatoprotective Effect of the Ethyl Acetate Fraction of Indonesian Artocarpus Species Against CCl4 Induced Liver Injury in Rat”. Journal of Research in Pharmacy 28/4 (Temmuz 2025), 952-960.
JAMA Fitrya F, Amriani A, Puspa Novita R, Fatya Sahara V, Rizki M, Rahma M, Muharni M, Sri Wahyuni F. Hepatoprotective effect of the ethyl acetate fraction of Indonesian Artocarpus species against CCl4 induced liver injury in rat. J. Res. Pharm. 2025;28:952–960.
MLA Fitrya, Fitrya vd. “Hepatoprotective Effect of the Ethyl Acetate Fraction of Indonesian Artocarpus Species Against CCl4 Induced Liver Injury in Rat”. Journal of Research in Pharmacy, c. 28, sy. 4, 2025, ss. 952-60.
Vancouver Fitrya F, Amriani A, Puspa Novita R, Fatya Sahara V, Rizki M, Rahma M, Muharni M, Sri Wahyuni F. Hepatoprotective effect of the ethyl acetate fraction of Indonesian Artocarpus species against CCl4 induced liver injury in rat. J. Res. Pharm. 2025;28(4):952-60.