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Povišani jetrni encimi so pogost pojav, s katerim se zdravniki srečujejo v klinični praksi. Vendar je za mnoge zdravnike ocena te težave pri pacientih, ki nimajo nobenih simptomov, lahko izziv. Čeprav so spremembe jetrnih encimov v nekaterih primerih lahko normalen fiziološki pojav, lahko pri drugih odražajo tudi morebitno poškodbo jeter, zaradi česar je potrebna njihova nadaljnja ocena in obravnava.[1]
Kaj so jetrni encimi in kaj pomeni povišana vrednost jetrnih encimov?
Jetrni encimi so beljakovine, ki pospešujejo kemične reakcije v telesu. Te kemične reakcije vključujejo proizvodnjo žolča in snovi, ki pospešujejo strjevanje krvi, razgradnjo hrane in toksinov ter boj proti okužbam.
Povišani jetrni encimi pogosto kažejo na vnetje ali poškodbo celic v jetrih. Pri vnetih ali poškodovanih jetrnih celicah se v krvni obtok sproščajo večje količine nekaterih kemikalij, vključno z jetrnimi encimi, kot je normalno, zato se jetrni encimi v krvnih testih zvišajo.
Najpogosteje ugotovljeni povišani jetrni encimi so:
alanin aminotrasferaza (ALT)
aspartat aminotransferaza (AST)
alkalna fosfataza (ALP)
Gama-glutamil transferaza (GGT)
Zvišane vrednosti jetrnih encimov se lahko odkrijejo med rutinskim testiranjem krvi. V večini primerov so vrednosti jetrnih encimov le rahlo in začasno povišane. Po navadi povišane vrednosti jetrnih encimov ne kažejo na kronične, resne težave z jetri.
Kako se zdravijo povišani jetrni encimi?
Zdravljenje je odvisno od vzroka povišanih jetrnih encimov. Pri približno tretjini ljudi s povišanimi jetrnimi encimi se bodo vrednosti jetrnih encimov po dveh do štirih tednih normalizirale. Če jetrni encimi ostanejo visoki, je treba opraviti več krvnih preiskav ali slikovnih preiskav, kot so ultrazvok, računalniška tomografija (CT) ali magnetna resonanca (MRI), da se ugotovi vzrok.
Izziv pri zdravljenju povišanih jetrnih encimov
Ocena odstopanj v vrednosti jetrnih encimov pri sicer zdravem pacientu je lahko izziv tudi za izkušenega zdravnika. Morda pa ni nujno, da se pri vseh abnormalnih rezultatih testov opravi obsežna preiskava, saj se s tem mnoge paciente izpostavi nepotrebnim tveganjem in stroškom postopka. Nasprotno pa lahko opustitev preiskave blagih ali zmernih povišanj jetrnih encimov pomeni, da zamudimo zgodnjo diagnozo potencialno življenjsko nevarnih, vendar ozdravljivih stanj. [1]
ŠTUDIJA PRIMERA: Asimptomatski pacient z abnormalnimi rezultati jetrnih testov
(Če so medicinske podrobnosti za vas prezahtevne, preskočite naslednje besedilo in nadaljujte z razpravo. Brez strokovnega nadzora sami ne uživajte nobenih zelišč.)
PREGLED
57-letni moški je prišel na mojo kliniko brez specifične glavne težave novembra 2020. Pred tem je že bil moj pacient maja 2019, ko se je zdravil zaradi napihnjenosti v trebuhu in smrdečega, tekočega blata, vendar nadaljnjih obiskov in zdravljenja ni opravil, dokler se ni ponovno zglasil več kot leto dni pozneje. Januarja 2021 je opravil krvni test s povišanimi vrednostmi bilirubina, AST, ALT, GGT, CEA in Ca19. Ker je že dvakrat obiskal mojo kliniko in je užival zelišča, ga prosim za več preteklih rezultatov krvnih testov, da bi izključila možnost poškodbe jeter zaradi zelišč. Izkazalo se je, da je imel pacient povišane jetrne encime že od leta 2019, številke pa so se ves čas zviševale.
SUBJEKTIVNI IN OBJEKTIVNI POGOJI
Pacient na začetku ni imel posebnih pritožb glede fizičnega ali psihološkega stanja. Trdil je, da se na splošno dobro počuti, le občasno ima motnje spanja. Odvajanje blata je redno in gladko, vendar je pogosto imel težave s smrdečimi plini. Zavrnil je anamnezo kroničnih bolezni. Pije občasno v družbi. Pacient je običajno grajen Slovenec, z blago centralno zamaščenostjo, vendar brez splošne debelosti.
27. 11. 2020
Pri diagnostiki po metodi TKM sem opazila, da je jezik rožnat s tanko belo oblogo. Njegov pulz je bil šibek, gibanje pulza pa težko in izrazito. Pulz črevesja je bil šibek, pulz ledvic in mehurja močan in izrazit, pulz vranice težak in izrazit z zmerno močjo. [Preberi več: Kaj nam lahko pove diagnostika jezika] [Preberi več: Diagnostika pulza]
Predpis zelišč:
Hei Zhi Ma (črni sezam), Di Gu Pi, Tu Fu Ling, Tao Ren, Chai Hu, Gan Cao, Sheng Jiang, Yi Mu Cao
10. 12. 2020
Pacient se je vrnil brez simptomov. Pulzna dianostika je pokazala, da ledvični pulz ni več močan, temveč globoko izčrpanost. Na receptu zelišč sta bila odstranjena Tu Fu Ling in Tao Ren, dodan je bil Hu Tao Ren.
8. 1. 2021
Pacient je opravil rutinsko preiskavo krvi in ugotovil višjo sedimentacijo in povišane jetrne encime, vendar ni pokazal dejanskih številk. Predlagane so bile nadaljnje preiskave. Zelišča so ostala nespremenjena, dokler se ne pregledajo rezultati krvnih preiskav.
22. 1. 2021
Njegovo zadnje poročilo krvnih preiskav je pokazalo povišane vrednosti bilirubina, AST, ALT, GGT, CEA in Ca19. Še vedno je bil brez simptomov. Pri moških pacientih je precej pogosto, da pri svojih zdravnikih ne izrazijo svojih skrbi in potreb. Zato ponovno začnem s pogovorom o življenjskem slogu in prehranjevalnih navadah ter prosim za predhodna zdravniška poročila. Pozneje izvem, da od leta 2019 opaža povišane jetrne encime in da je pred kratkim začel uživati kurkumo in cimet zaradi številnih zdravstvenih trditev, ki jih je našel na internetu.
Naročila sem mu, naj preneha uporabljati vsa nepredpisana zdravila, bodisi naravna bodisi kemična. Predlagala sem tudi prilagoditev življenjskega sloga in prehrane. Pulzna diagnostika je pokazala močan in oviran pulz jeter ter močan in gost pulz v desnem "chi" položaju. [Preberi več: Kdaj jeste je prav tako pomembno kot to, kaj jeste] [Preberi več: Cirkadiani ritmi in telesna ura kitajske medicine]
Predpis zelišč:
Sheng Di Huang, Jin Qian Cao, Chai Hu, Gan Cao, Sheng Jiang, Yi Mu Cao, Yin Chen, Long Dan Cao
5. 2. 2021
Pacient se je pritoževal zaradi bolečin v levi rami in zapestju ter rahlo zmehčanega blata. Pulz kaže manj oviran pulz jeter, še vedno močan, leva chi pozicija močna.
Predpis zelišč:
Sheng Di Huang, Da Huang (Sheng), Chai Hu, Gan Cao, Sheng Jiang, Yi Mu Cao, Yin Chen, Long Dan Cao
18. 2. 2021
Pacientovi simptomi so se umirili. Pulz je pokazal globoko napetost v jetrih, oba chi sta bila močna in spolzka, vranica debela in preplavljena. Jezik je rožnat z gostim svetlo rumeno oblogo zadaj. Recept zelišč nespremenjen in dodan Huang Bai.
5. 3. 2021
Krvni test je pokazal zmanjšanje vrednosti jetrnih encimov, vendar je še vedno abnormalen. Pulz je pokazal, da sta oba chi močna, jetra in vranica pa delujejo gladkeje kot prej. Jezik je rožnat s svetlo rumeno oblogo zadaj.
Predpis zelišč:
Sheng Di Huang, Da Huang (Sheng), Zhi Zi (Shan), Da Qing Ye, Sheng Jiang, Bai Shao, Long Dan Cao, Huang Bai, Wei Ling Xian
19. 3. 2021
Pulz je pokazal, da je levi chi zmerno močan in spolzek, jetra imajo globok in močan pulz.
Predpis zelišč:
Sheng Di Huang, Da Huang (Sheng), Zhi Zi (Shan), Da Qing Ye, Sheng Jiang, Bai Shao, Long Dan Cao, Tu Fu Ling, Yin Chen
9. 4. 2021
Vse vrednosti jetrnih encimov so bile normalne.
Pacient je nadaljeval z delom za nadaljnje izboljšanje. Do 8. 12. 2021 so vse vrednosti jetrnih encimov ostale normalne, CEA in Ca19 normalna, vendar sta bila holesterol in LDL povišana.
RAZPRAVA
Ta primer predstavlja nekaj izzivov pri diagnosticiranju in zdravljenju. Kot prvo, pacient je prišel z zelo pomanjkljivo verbalno komunikacijo in je posredoval zelo malo podrobnosti o svojem zdravstvenem stanju in težavah. To je v Sloveniji še posebej pogosto. Čeprav nismo našli nobene uradne študije o moškem zdravstvenem upoštevanju ali iskanju pomoči pri TKM, obstaja sistematični pregled, ki kaže, da moški res redkeje poiščejo pomoč na področju duševnega zdravja.[2] Ker sta tako duševno zdravje kot zdravstvena preventiva v TKM bolj subtilni in neopaženi obliki zdravstvene problematike, bi lahko pojava logično povezali. Druga ovira za jasno in odprto komunikacijo v praksi TKM bi lahko bil problem razumevanja in sprejemanja TKM. Pri mnogih Slovencih ostaja TKM še vedno neznana ali napačno razumljena. Zaradi tega so pacienti skeptični in nezaupljivi glede zdravljenja s TKM. [Preberi več: TKM vs. zahodna medicina] [Preberi več: Vaše telo je ekosistem, ne stroj]
Drugi izziv je posledica prvega. Ker je bilo posredovanih malo podrobnosti, je bilo običajno razlikovanje sindromov TKM oteženo. Razlikovanje sindromov je pogosto uporabljena metodologija in praksa v TKM, ki usmerja diagnosticiranje in zdravljenje bolezni. Edinstven sistem diagnosticiranja in zdravljenja TKM zahteva celovito analizo pacientovih simptomov. Toda v asimtomatskem primeru ali če pacient noče, ne more opisati simptomov, je naloga diangnoze TKM skoraj v celoti na zdravniku. V takem primeru mora zdravnik posvetiti posebno pozornost neverbalnim podrobnostim, kot so videz, vonj, izraz obraza, logično spraševanje in predvsem diagnostika jezika in pulza.
V tej študiji primera je pulzna diagnostika ključni element, ki usmerja celoten postopek zdravljenja. Ob prvem obisku je bilo sicer opaziti majhen pulz, ki običajno kaže na pomanjkanje ali šibkost, vendar je tekstura pulza in več lokacij pokazalo nasprotujoče si ugotovitve. Zdravniki TKM ne smemo prehitro začeti z agresivnimi tonizirajočimi formulami. Pravzaprav se je treba izogibati vnaprej pripravljenim formulam oziroma jih narediti čim bolj preproste. Nekatera zelišča v formuli morda niso najprimernejša v dani situaciji. Individualizirano predpisovanje in redne prilagoditve bodo zagotovile najboljšo prilagodljivost in natančnost uporabe zelišč ter tako povečale učinkovitost in zmanjšale toksičnost.
Medtem ko sodobna medicina teži k odpravljanju subjektivnosti, se pri TKM združujeta objektivnost in subjektivnost. Odločitev, da se odločimo za prečiščevalna zelišča in ne za tonizirajoča, je večinoma zdravnikova osebna presoja, ki temelji na izkušnjah. V sodobnem času je bolj verjetno, da se srečamo s pacienti s prekomernim tipom kot s pomanjkljivim tipom kar se tiče sistema jeter in ledvic, ali pa vsaj z mešanim vzorcem. Čisto pomanjkanje ledvičnega jina ali janga, kot je opisano v starodavnih besedilih, je dandanes izjemno redko. Vidno majhen pulz bi lahko kazal na izjemno preveliko količino toksinov, zlasti vlage, ki zavira normalen pretok qija in krvi. Zato je pomembno, da preverimo tudi teksturo pulza. Namesto učbeniškega opisa spolzkega pulza je veliko pogosteje opaziti gost pulz. Predstavljajte si, da je normalen pulz kot voda, ki kroži v posodi, gost pulz pa je v njej med ali surovo olje.
Tretji in največji izziv pri obravnavi povišanih jetrnih encimov s pomočjo TKM je slabo upoštevanje priporočil zdravnika. Kot je prikazano v tej študiji primera, je začetna faza zdravljenja trajala 3 mesece, celotno zdravljenje pa lahko traja eno leto, včasih tudi več. V resnični praksi niso vsi pacienti primerni za očiščevalna zelišča že od samega začetka ali pa imajo nekateri od njih težave pri prilagajanju življenjskega sloga in prehrane. Vsi ti dejavniki lahko zavlečejo postopek ali zmanjšajo učinkovitost zdravljenja. Zanimanja za alternativno zdravljenje ne manjka, vendar pa je po podatkih moje klinike več kot 80 % pacientov opustilo zdravljenje v prvih treh obiskih. Uspeh iz študije primera je sicer redek, vendar ga je ob upoštevanju ustreznih navodil in zdravljenja povsem mogoče ponoviti. Upam, da bi z deljenjem te podrobne študije primera (in še nekaj prihodnjih) lahko izboljšali razumevanje in zaupanje zdravnikov in pacientov v zdravljenje s TKM.
Viri:
Malakouti M, Kataria A, Ali SK, Schenker S. Elevated Liver Enzymes in Asymptomatic Patients - What Should I Do? J Clin Transl Hepatol. 2017 Dec 28;5(4):394-403. doi: 10.14218/JCTH.2017.00027. Epub 2017 Sep 21. PMID: 29226106; PMCID: PMC5719197.
Sagar-Ouriaghli I, Godfrey E, Bridge L, Meade L, Brown JSL. Improving Mental Health Service Utilization Among Men: A Systematic Review and Synthesis of Behavior Change Techniques Within Interventions Targeting Help-Seeking. Am J Mens Health. 2019 May-Jun;13(3):1557988319857009. doi: 10.1177/1557988319857009. PMID: 31184251; PMCID: PMC6560805.
Elevated liver enzymes- A real case with TCM treatment
Elevated liver enzymes are a common scenario encountered by physicians in clinical practice. For many physicians, however, evaluation of such a problem in patients presenting with no symptoms can be challenging. Although alterations of liver enzymes could be a normal physiological phenomenon in certain cases, it may also reflect potential liver injury in others, necessitating its further assessment and management.[1]
What are liver enzymes and what does it mean with elevated liver enzymes?
Liver enzymes are proteins that speed up chemical reactions in our body. These chemical reactions include producing bile and substances that facilitates blood clot, breaking down food and toxins, and fighting infection.
Elevated liver enzymes often indicate inflammation or damage to cells in the liver. Inflamed or injured liver cells leak higher than normal amounts of certain chemicals, including liver enzymes, into the bloodstream, elevating liver enzymes on blood tests.
The elevated liver enzymes most commonly found are:
Alanine transaminase (ALT)
Aspartate transaminase (AST)
Alkaline phosphatase (ALP)
Gamma-glutamyl transpeptidase (GGT)
Elevated liver enzymes might be discovered during routine blood testing. In most cases, liver enzyme levels are only mildly and temporarily elevated. Most of the time, elevated liver enzymes don't signal a chronic, serious liver problem.
How are elevated liver enzymes treated?
Treatment depends on what is causing the liver enzymes to be elevated. About one-third of people with elevated liver enzymes will have normal liver enzyme levels after two to four weeks. If the liver enzymes stay high, more blood tests, or imaging tests such as ultrasound, CT scan or MRI should be carried out to find out the cause.
The challenge in treating elevated liver enzymes
Evaluation of abnormal liver enzyme levels in an otherwise healthy patient can pose a challenge to even an experienced clinician. It may not be necessary to pursue extensive evaluation for all abnormal test results, however, as it would expose many patients to unnecessary procedural risks and expenses. Conversely, failure to investigate mild or moderate liver enzyme elevations could mean missing the early diagnosis of potential life-threatening yet treatable conditions. 1
CASE STUDY: Asymptomatic Patient With Abnormal Liver Test Results
(Please skip the following and jump to the discussion if the medical details are too much. Do not consume any herbs on your own without professional supervision.)
OVERVIEW
A 57-year-old male came to my clinic with no specific chief complaint in 11.2020. He was my patient once in 5.2019 complaining about abdominal bloatedness and smelly, runny stool but no further visits and treatment were carried out until he revisited more than a year later. In 1.2021, he revealed a blood test with elevated bilirubin, AST, ALT, GGT, CEA and Ca19. Since he was already visiting my clinic for 2 times and consumed herbal prescription, I request for more past blood test results to rule out the possibility of herb-induced liver injury. As it turned out, the patient had elevated liver enzymes since 2019 and the numbers kept rising.
SUBJECTIVE AND OBJECTIVE CONDITIONS
The patient initially came with no specific complaints about any physical or psychological conditions. He claimed to be generally well with an occasional disturbed sleep. Bowel movement is regular and smooth but he often felt gassy and the gas was smelly. He declined a history of chronic illness. A social drinker. The patient is a regular built Slovenia man, mild central fat but no general obesity.
27.11.2020
In the TCM diagnostics, I observed pink tongue with thin white fur. His pulse is small and the movement of pulse is heavy and thick. The intestine pulse is small, kidney and bladder pulse is strong and thick, spleen pulse is heavy and thick with moderate power. [Read more: What Tongue Diagnosis can tell you] [Read more: Pulse diagnostic]
Prescription of herbs:
Hei Zhi Ma (black sesame), Di Gu Pi, Tu Fu Ling, Tao Ren, Chai Hu, Gan Cao, Sheng Jiang, Yi Mu Cao
10.12.2020
The patient returned with no symtoms. Pulse dianostics showed the kidney pulse is not strong anymore but a deep hallowness. In the prescription, Tu Fu Ling and Tao Ren were removed, Hu Tao Ren was added.
8.1.2021
The patient had a routine blood test and found higher sedimentation and liver enzymes but did not show the actual numbers. Further investigations were suggested. Herbs remained unchanged until blood test results are reviewed.
22.1.2021
His latest blood test report showed elevated bilirubin, AST, ALT, GGT, CEA and Ca19. He was still asymptomatic. It is rather common in male patients that they do not express their concerns and needs with their physicans. Therefore I restart my interview of lifestyle and dietary habits, and request for previous medical reports. Later I relieved that he has been noticing elevated liver enzymes since 2019 and recently started consuming turmeric and cinnamon due to many health claims he found on the internet.
I instructed him to stop all unprescribed remedies, whether natural or chemical. Lifestyle and dietary adjustments were also suggested. Pulse diagnostics showed strong and suppressed liver pulse, strong and thick pulse in right “chi” position. [Read more: When you eat is just as important as what you eat] [Read more: Circadian Rhythms and the Chinese Medicine Body Clock]
Prescription of herbs:
Sheng Di Huang, Jin Qian Cao, Chai Hu, Gan Cao, Sheng Jiang, Yi Mu Cao, Yin Chen, Long Dan Cao
5.2.2021
The patient complained about left shoulder and wrist pain, mild loose stool. Pulse show less suppressed liver pulse, still strong, left chi position strong.
Prescription of herbs:
Sheng Di Huang, Da Huang (Sheng), Chai Hu, Gan Cao, Sheng Jiang, Yi Mu Cao, Yin Chen, Long Dan Cao
18.2.2021
The patient’s symptoms were relieved. Pulse showed deep liver tension, both chi strong and slippery, spleen thick and overflows. Tongue is pink with dense light yellow fur at the back. Prescription unchanged and added Huang Bai.
5.3.2021
Blood test showed a decrease in number in liver enzymes, but still abnormal. Pulse showed both chi strong, liver and spleen smoother than before. Tongue is pink with light yellow fur at the back.
Prescription of herbs:
Sheng Di Huang, Da Huang (Sheng), Zhi Zi (Shan), Da Qing Ye, Sheng Jiang, Bai Shao, Long Dan Cao, Huang Bai, Wei Ling Xian
19.3.2021
Pulse showed left chi moderate strong and slippery, liver deep level strong.
Prescription of herbs:
Sheng Di Huang, Da Huang (Sheng), Zhi Zi (Shan), Da Qing Ye, Sheng Jiang, Bai Shao, Long Dan Cao, Tu Fu Ling, Yin Chen
9.4.2021
All liver enzymes readings were normal.
The patient continued working for further improvement. By 8.12.2021, all liver enzymes remained normal, CEA and Ca19 normal, but cholesterol and LDL were high.
DISCUSSION
This case poses a couple of challenges in diagnosis and treatment. First of all, the patient came with very little verbal communication and provided very little details about his health condition and concerns. This is particularly common in Slovenia. Even though no formal studies in men’s medical adherance or help-seeking in TCM are found, there is a systematic review showing that men indeed seek help less often in mental health.[2] As both mental health and TCM health prevention are more subtle and unnoticed forms of health issue, we could logically link the phenomena. Another obstacle for a clear and open communication in the TCM practice could be a problem of the understanding and acceptance of TCM. TCM remains unheard of or misunderstood with many Slovenians. This makes patients skeptical and unconfident about TCM treatment. [Read more: TCM vs Western Medicine] [Read more: Your Body as a Garden]
The second challenge is the result of the first. Since little details were provided, the regular TCM syndrome differentiation could be difficult. Syndrome differentiation is a commonly used methodology and practice in TCM guiding the diagnosis and treatment of diseases. The unique TCM diagnosis and treatment system requires a comprehensive analysis of a patient’s symptoms. But in the asymptomatic case, or if the patient is unwilling, unable to tell the symptoms, then the challenge of TCM diagnosis lays almost completely on the practitioner. In such case, the practitioner must pay extra attention to the non-verbal details like the appearance, smell, facial expression, logical questioning and most importantly tongue and pulse diagnostics.
In this case study, the pulse diagnostics is the key component that guides the whole treatment process. In his first visit, although a small pulse is noticed, and it usually indicates a deficiency or weakness, but the texture of the pulse and several locations showed contradictory findings. Practitioners must not jump too fast into any aggressive tonifying formula. In fact, a per made formula should be avoided or made as simple as possible. Certain herbs in the formula might not be best suited in the situation. Individualized prescription and periodic adjustments will provide the best flexibility and accuracy of herbs usage thus enhancing the effectiveness and reducing toxicity.
While modern medicine tends to eliminate subjectivity, TCM is about blending objectivity and subjectivity. The decision to go towards cleansing herbs rather than tonifying herbs is mostly the practitioner’s personal judgment based on experience. In the modern times, it is more likely to encounter an excessive type of patients rather than a deficient type of patient in the liver and kidney system, or at least a mixed pattern. The pure kidney Yin or Yang deficiency as described in ancient text is now extremely rare. The seeingly small pulse could indicate an extremely excessive toxins, particularly the dampness, suppressing the normal Qi and Blood flow. Therefore, it is important to also examine the texture of the pulse. Instead of the textbook description of slippery pulse, it is a lot more common to notice a thick pulse. Imagine a normal pulse is like water circulating inside the vessel, a thick pulse is honey or cruel oil inside.
The third and biggest challenge for managing elevated liver enzymes with TCM is the low medical adherence and compliance. As shown in this case study, the initial phase of treatment took 3 months, and the whole treatment could last for a year, sometime more. In real life practice, not every patients are suitable for the cleansing herbs right from the start, or some of them could have difficulties in the lifestyle an dietary adjustment. All these factors could delay the process or lower the effectiveness of treatment. There is no shortage of interest in alternative treatment, however, in my own clinic’s record, more than 80% of patients dropped out of treatment within the first 3 visits. The success of the case study is rare, but completely repetiable given the suitable guidance and treatment are followed. I hope by sharing this detailed case study (and a few more to come) could improve the understanding and confidence of TCM treatment among practitioners and patients.
Reference:
Malakouti M, Kataria A, Ali SK, Schenker S. Elevated Liver Enzymes in Asymptomatic Patients - What Should I Do? J Clin Transl Hepatol. 2017 Dec 28;5(4):394-403. doi: 10.14218/JCTH.2017.00027. Epub 2017 Sep 21. PMID: 29226106; PMCID: PMC5719197.
Sagar-Ouriaghli I, Godfrey E, Bridge L, Meade L, Brown JSL. Improving Mental Health Service Utilization Among Men: A Systematic Review and Synthesis of Behavior Change Techniques Within Interventions Targeting Help-Seeking. Am J Mens Health. 2019 May-Jun;13(3):1557988319857009. doi: 10.1177/1557988319857009. PMID: 31184251; PMCID: PMC6560805.
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