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Boil
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<h2 id="signs-and-symptoms">Signs and symptoms</h2> <p>Boils are bumpy, red, <a href="/facts/Pus/jzNHzM70">pus</a>-filled lumps around a hair follicle that are <a href="/facts/Tenderness_(medicine)/7So4qEoJ">tender</a>, warm, and painful. They range from pea-sized to golf ball-sized. A yellow or white point at the center of the lump can be seen when the boil is ready to drain or discharge pus. In a severe infection, an individual may experience <a href="/facts/Fever/waVxR2Ac">fever</a>, swollen <a href="/facts/Lymph_node/vkwfcQjH">lymph nodes</a>, and <a href="/facts/Fatigue_(medical)/C2oo4Hvg">fatigue</a>. A recurring boil is called chronic furunculosis.<a class="footnote-ref" id="fnref:4" href="#fn:4"><sup>4</sup></a><a class="footnote-ref" id="fnref:5" href="#fn:5"><sup>5</sup></a><a class="footnote-ref" id="fnref:6" href="#fn:6"><sup>6</sup></a><a class="footnote-ref" id="fnref:7" href="#fn:7"><sup>7</sup></a> Skin infections tend to be recurrent in many patients and often spread to other family members. Systemic factors that lower resistance commonly are detectable, including: <a href="/facts/Diabetes/2xeHXbsI">diabetes</a>, <a href="/facts/Obesity/RBF9y5Vl">obesity</a>, and <a href="/facts/Hematologic_disorder/QB4CeNEF">hematologic disorders</a>.<a class="footnote-ref" id="fnref:8" href="#fn:8"><sup>8</sup></a> </p><p>Boils may appear on the buttocks or near the anus, the back, the neck, the belly, the chest, the arms or legs, or even in the ear canal.<a class="footnote-ref" id="fnref:9" href="#fn:9"><sup>9</sup></a> Boils may also appear around the eye, where they are called <a href="/facts/Stye/KpnvMb0e">styes</a>.<a class="footnote-ref" id="fnref:10" href="#fn:10"><sup>10</sup></a> </p> <h3>Complications</h3> <p>The most common <a href="/facts/Complication_(medicine)/uJHvzqUt">complications</a> of boils are <a href="/facts/Scarring/XSQ92JoG">scarring</a> and <a href="/facts/Infection/182XrncP">infection</a> or <a href="/facts/Abscess/BW3TH8kb">abscess</a> of the <a href="/facts/Skin/4havlLzG">skin</a>, <a href="/facts/Spinal_cord/XbWLr917">spinal cord</a>, <a href="/facts/Brain/EKla9NkJ">brain</a>, <a href="/facts/Kidney/HBspPrv9">kidneys</a>, or other organs. Infections may also spread to the bloodstream (<a href="/facts/Bacteremia/J0C082Sg">bacteremia</a>) and become life-threatening.<a class="footnote-ref" id="fnref:11" href="#fn:11"><sup>11</sup></a><a class="footnote-ref" id="fnref:12" href="#fn:12"><sup>12</sup></a> <i>S. aureus</i> strains first infect the skin and its structures (for example, <a href="/facts/Sebaceous_gland/HKMXmv1Y">sebaceous glands</a>, <a href="/facts/Hair_follicle/SXsAKufM">hair follicles</a>) or invade damaged skin (cuts, abrasions). Sometimes the infections are relatively limited (such as a <a href="/facts/Stye/KpnvMb0e">stye</a>, boil, furuncle, or carbuncle), but other times they may spread to other skin areas (causing <a href="/facts/Cellulitis/hCIm7nzQ">cellulitis</a>, <a href="/facts/Folliculitis/6fPEDloP">folliculitis</a>, or <a href="/facts/Impetigo/hDuv14qE">impetigo</a>). Unfortunately, these bacteria can reach the bloodstream (<a href="/facts/Bacteremia/J0C082Sg">bacteremia</a>) and end up in many different body sites, causing infections (wound infections, abscesses, <a href="/facts/Osteomyelitis/FUzsmRPf">osteomyelitis</a>, <a href="/facts/Endocarditis/SlaH14C3">endocarditis</a>, <a href="/facts/Pneumonia/Jw0KquTA">pneumonia</a>)<a class="footnote-ref" id="fnref:13" href="#fn:13"><sup>13</sup></a> that may severely harm or kill the infected person. <i>S. aureus</i> strains also produce <a href="/facts/Enzymes/DSI1Fh7y">enzymes</a> and <a href="/facts/Exotoxins/j18H60P0">exotoxins</a> that likely cause or increase the severity of certain diseases. Such diseases include <a href="/facts/Food_poisoning/9lxqlJqg">food poisoning</a>, <a href="/facts/Septic_shock/yc9mgmrz">septic shock</a>, <a href="/facts/Toxic_shock_syndrome/JC3Ixna4">toxic shock syndrome</a>, and <a href="/facts/Staphylococcal_scalded_skin_syndrome/6l7aEwLg">scalded skin syndrome</a>.<a class="footnote-ref" id="fnref:14" href="#fn:14"><sup>14</sup></a> </p> <h2 id="causes">Causes</h2> <h3>Bacteria</h3> <p>Naturally the cause is bacteria such as <a href="/facts/Staphylococci/maRQMH6E">staphylococci</a> that are present on the skin. Bacterial colonisation begins in the <a href="/facts/Hair_follicle/SXsAKufM">hair follicles</a> and can cause local <a href="/facts/Cellulitis/hCIm7nzQ">cellulitis</a> and inflammation.<a class="footnote-ref" id="fnref:15" href="#fn:15"><sup>15</sup></a><a class="footnote-ref" id="fnref:16" href="#fn:16"><sup>16</sup></a><a class="footnote-ref" id="fnref:17" href="#fn:17"><sup>17</sup></a> <a href="/facts/Myiasis/3r6jFupl">Myiasis</a> caused by the <a href="/facts/Cordylobia_anthropophaga/l4CNGwXz">tumbu fly</a> in Africa usually presents with cutaneous furuncles.<a class="footnote-ref" id="fnref:18" href="#fn:18"><sup>18</sup></a> <a href="/facts/Risk_factor/N0YTUyer">Risk factors</a> for furunculosis include <a href="/facts/Bacteria/wC8xSCsU">bacterial</a> carriage in the nostrils, <a href="/facts/Diabetes_mellitus/2xeHXbsI">diabetes mellitus</a>, <a href="/facts/Obesity/RBF9y5Vl">obesity</a>, <a href="/facts/Lymphoproliferative_disorders/MHqV2ncT">lymphoproliferative</a> <a href="/facts/Neoplasm/K0ytzmPz">neoplasms</a>, <a href="/facts/Malnutrition/KasQy5MR">malnutrition</a>, and use of <a href="/facts/Immunosuppressive_drug/ctlB3Hda">immunosuppressive drugs</a>.<a class="footnote-ref" id="fnref:19" href="#fn:19"><sup>19</sup></a> </p> <h3>Family history</h3> <p>People with recurrent boils are as well more likely to have a positive family history, take antibiotics, and to have been hospitalised, <a href="/facts/Anemic/AgEPPmg8">anemic</a>, or diabetic; they are also more likely to have associated skin diseases and multiple lesions.<a class="footnote-ref" id="fnref:20" href="#fn:20"><sup>20</sup></a> </p> <h3>Other</h3> <p>Other causes include <a href="/facts/Immunodeficiency/CIEujXmc">poor immune system function</a> such as from <a href="/facts/HIV/AIDS/RqLIEMuJ">HIV/AIDS</a>, <a href="/facts/Diabetes/2xeHXbsI">diabetes</a>, <a href="/facts/Malnutrition/KasQy5MR">malnutrition</a>, or <a href="/facts/Alcoholism/KGPzpChp">alcoholism</a>.<a class="footnote-ref" id="fnref:21" href="#fn:21"><sup>21</sup></a> Poor hygiene and <a href="/facts/Obesity/RBF9y5Vl">obesity</a> have also been linked.<a class="footnote-ref" id="fnref:22" href="#fn:22"><sup>22</sup></a> It may occur following antibiotic use due to the development of resistance to the antibiotics used.<a class="footnote-ref" id="fnref:23" href="#fn:23"><sup>23</sup></a> An associated skin disease favors recurrence. This may be attributed to the persistent colonization of abnormal skin with <i>S. aureus</i> strains, such as is the case in persons with <a href="/facts/Atopic_dermatitis/DvmdVwWu">atopic dermatitis</a>.<a class="footnote-ref" id="fnref:24" href="#fn:24"><sup>24</sup></a> Boils which recur under the arm, breast or in the groin area may be associated with <a href="/facts/Hidradenitis_suppurativa/tuxkrNnu">hidradenitis suppurativa</a> (HS).<a class="footnote-ref" id="fnref:25" href="#fn:25"><sup>25</sup></a> </p> <h2 id="diagnosis">Diagnosis</h2> <p>Diagnosis is made through clinical evaluation by a physician, which may include culturing of the lesion.<a class="footnote-ref" id="fnref:26" href="#fn:26"><sup>26</sup></a> Evaluation can further include imaging, such as an ultrasound, to evaluate for formation of an abscess or other complications. </p> <h2 id="treatment">Treatment</h2> <p>A boil may clear up on its own without bursting, but more often it will need to be opened and drained. This will usually happen spontaneously within two weeks. Regular application of a <a href="/facts/Warm_moist_compress/cLeGLqBP">warm moist compress</a>, both before and after a boil opens, can help speed healing. The area must be kept clean, hands washed after touching it, and any dressings disposed of carefully, in order to avoid spreading the bacteria. A doctor may cut open or "<a href="/facts/Incision_and_drainage/feWC8Tfy">lance</a>" a boil to allow it to drain, but squeezing or cutting should not be attempted at home, as this may further spread the infection. <a href="/facts/Antibiotic/sF1kIfxg">Antibiotic</a> therapy may be recommended for large or recurrent boils or those that occur in sensitive areas (such as the groin, breasts, armpits, around or in the nostrils, or in the ear).<a class="footnote-ref" id="fnref:27" href="#fn:27"><sup>27</sup></a><a class="footnote-ref" id="fnref:28" href="#fn:28"><sup>28</sup></a><a class="footnote-ref" id="fnref:29" href="#fn:29"><sup>29</sup></a><a class="footnote-ref" id="fnref:30" href="#fn:30"><sup>30</sup></a> An antibiotic should not be used for longer than one month, with at least two months (preferably longer) between uses, otherwise it will lose its effectiveness.<a class="footnote-ref" id="fnref:31" href="#fn:31"><sup>31</sup></a> </p><p>Furuncles at risk of leading to serious complications should be incised and drained if antibiotics or steroid injections are not effective. These include furuncles that are unusually large, last longer than two weeks, or occur in the middle of the face or near the spine.<a class="footnote-ref" id="fnref:32" href="#fn:32"><sup>32</sup></a><a class="footnote-ref" id="fnref:33" href="#fn:33"><sup>33</sup></a> Fever and chills are signs of <a href="/facts/Sepsis/n52bkffJ">sepsis</a> and indicate immediate treatment.<a class="footnote-ref" id="fnref:34" href="#fn:34"><sup>34</sup></a> </p><p><i>Staphylococcus aureus</i> has the ability to acquire <a href="/facts/Antimicrobial_resistance/jsbAywgx">antimicrobial resistance</a> easily, making treatment difficult. Knowledge of the antimicrobial resistance of <i>S. aureus</i> is important in the selection of antimicrobials for treatment.<a class="footnote-ref" id="fnref:35" href="#fn:35"><sup>35</sup></a> </p> <h2 id="see-also">See also</h2> <ul><li><a href="/facts/Cutaneous_condition/Vkr5XpeG">Cutaneous condition</a></li> <li><a href="/facts/Nodule_(medicine)/BgCs3GNE">Nodule (medicine)</a></li></ul> <h2 id="external-links">External links</h2> Wikimedia Commons has media related to Furuncles. <ul><li><a href="/facts/DermAtlas/5gK8F9QF">DermAtlas</a> <i><a href="http://dermatlas.med.jhmi.edu/derm/result.cfm?Diagnosis=1817374494">1817374494</a></i></li></ul> <h2 id="references">References</h2> <ol> <li id="fn:1"><p>MedlinePlus Encyclopedia: Furuncle <a href="/wiki/MedlinePlus" target="_blank">/wiki/MedlinePlus</a> <a href="#fnref:1" class="footnote-back-ref">↩</a></p></li> <li id="fn:2"><p>"Causes and Cures of Skin". Healthguidance.org. Retrieved 26 July 2014. <a href="http://www.healthguidance.org/entry/11040/1/Causes-and-Cures-of-Skin-Boils.html" target="_blank">http://www.healthguidance.org/entry/11040/1/Causes-and-Cures-of-Skin-Boils.html</a> <a href="#fnref:2" class="footnote-back-ref">↩</a></p></li> <li id="fn:3"><p>MedlinePlus Encyclopedia: Carbuncle <a href="/wiki/MedlinePlus" target="_blank">/wiki/MedlinePlus</a> <a href="#fnref:3" class="footnote-back-ref">↩</a></p></li> <li id="fn:4"><p>MedlinePlus Encyclopedia: Furuncle <a href="/wiki/MedlinePlus" target="_blank">/wiki/MedlinePlus</a> <a href="#fnref:4" class="footnote-back-ref">↩</a></p></li> <li id="fn:5"><p>Blume JE, Levine EG, Heymann WR (2003). "Bacterial diseases". In Bolognia JL, Jorizzo JL, Rapini RP (eds.). Dermatology. Mosby. p. 1126. ISBN 0-323-02409-2. <a href="0-323-02409-2" target="_blank">0-323-02409-2</a> <a href="#fnref:5" class="footnote-back-ref">↩</a></p></li> <li id="fn:6"><p>Habif, TP (2004). "Furuncles and carbuncles". Clinical Dermatology: A Color Guide to Diagnosis and Therapy (4th ed.). Philadelphia PA: Mosby. <a href="#fnref:6" class="footnote-back-ref">↩</a></p></li> <li id="fn:7"><p>Wolf K; et al. (2005). "Section 22. Bacterial infections involving the skin". Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology (5th ed.). McGraw-Hill. <a href="#fnref:7" class="footnote-back-ref">↩</a></p></li> <li id="fn:8"><p>Steele RW, Laner SA, Graves MH (February 1980). "Recurrent staphylococcal infection in families". Arch Dermatol. 116 (2): 189–90. doi:10.1001/archderm.1980.01640260065016. hdl:1765/7628. PMID 7356349. <a href="http://repub.eur.nl/pub/7628" target="_blank">http://repub.eur.nl/pub/7628</a> <a href="#fnref:8" class="footnote-back-ref">↩</a></p></li> <li id="fn:9"><p>"Boils, Carbuncles and Furunculosis". Patient.info. Retrieved 26 July 2014. <a href="https://patient.info/health/boils-carbuncles-and-furunculosis" target="_blank">https://patient.info/health/boils-carbuncles-and-furunculosis</a> <a href="#fnref:9" class="footnote-back-ref">↩</a></p></li> <li id="fn:10"><p>"Boils, Kidshealth". 13 September 2011. Retrieved 26 July 2014. <a href="http://www.kidshealth.org.nz/boils" target="_blank">http://www.kidshealth.org.nz/boils</a> <a href="#fnref:10" class="footnote-back-ref">↩</a></p></li> <li id="fn:11"><p>Habif, TP (2004). "Furuncles and carbuncles". Clinical Dermatology: A Color Guide to Diagnosis and Therapy (4th ed.). Philadelphia PA: Mosby. <a href="#fnref:11" class="footnote-back-ref">↩</a></p></li> <li id="fn:12"><p>Wolf K; et al. (2005). "Section 22. Bacterial infections involving the skin". Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology (5th ed.). McGraw-Hill. <a href="#fnref:12" class="footnote-back-ref">↩</a></p></li> <li id="fn:13"><p>Lina G, Piémont Y, Godail-Gamot F, Bes M, Peter MO, Gauduchon V, Vandenesch F, Etienne J (November 1999). "Involvement of Panton-Valentine leukocidin-producing Staphylococcus aureus in primary skin infections and pneumonia". Clin Infect Dis. 29 (5): 1128–32. doi:10.1086/313461. PMID 10524952. <a href="https://doi.org/10.1086%2F313461" target="_blank">https://doi.org/10.1086%2F313461</a> <a href="#fnref:13" class="footnote-back-ref">↩</a></p></li> <li id="fn:14"><p>"Staph Infection Causes, Symptoms, Treatment – Staph Infection Diagnosis". eMedicineHealth. <a href="http://www.emedicinehealth.com/staphylococcus/page4_em.htm" target="_blank">http://www.emedicinehealth.com/staphylococcus/page4_em.htm</a> <a href="#fnref:14" class="footnote-back-ref">↩</a></p></li> <li id="fn:15"><p>MedlinePlus Encyclopedia: Furuncle <a href="/wiki/MedlinePlus" target="_blank">/wiki/MedlinePlus</a> <a href="#fnref:15" class="footnote-back-ref">↩</a></p></li> <li id="fn:16"><p>Habif, TP (2004). "Furuncles and carbuncles". Clinical Dermatology: A Color Guide to Diagnosis and Therapy (4th ed.). Philadelphia PA: Mosby. <a href="#fnref:16" class="footnote-back-ref">↩</a></p></li> <li id="fn:17"><p>Wolf K; et al. (2005). "Section 22. Bacterial infections involving the skin". Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology (5th ed.). McGraw-Hill. <a href="#fnref:17" class="footnote-back-ref">↩</a></p></li> <li id="fn:18"><p>Tamir J, Haik J, Schwartz E (2003). "Myiasis with Lund's fly (Cordylobia rodhaini) in travellers". J Travel Med. 10 (5): 293–95. doi:10.2310/7060.2003.2732. PMID 14531984. <a href="https://doi.org/10.2310%2F7060.2003.2732" target="_blank">https://doi.org/10.2310%2F7060.2003.2732</a> <a href="#fnref:18" class="footnote-back-ref">↩</a></p></li> <li id="fn:19"><p>Scheinfeld NS (2007). "Furunculosis". Consultant. 47 (2). Archived from the original on 23 November 2012. Retrieved 31 August 2009. <a href="https://web.archive.org/web/20121123092305/http://www.consultantlive.com/display/article/10162/36304" target="_blank">https://web.archive.org/web/20121123092305/http://www.consultantlive.com/display/article/10162/36304</a> <a href="#fnref:19" class="footnote-back-ref">↩</a></p></li> <li id="fn:20"><p>El-Gilany AH, Fathy H (January 2009). "Risk factors of recurrent furunculosis". Dermatol Online J. 15 (1): 16. doi:10.5070/D39NG6M0BN. PMID 19281721. <a href="http://dermatology.cdlib.org/1501/letters/furunculosis/elgilany.html" target="_blank">http://dermatology.cdlib.org/1501/letters/furunculosis/elgilany.html</a> <a href="#fnref:20" class="footnote-back-ref">↩</a></p></li> <li id="fn:21"><p>Demos, M; McLeod, MP; Nouri, K (October 2012). "Recurrent furunculosis: a review of the literature". The British Journal of Dermatology. 167 (4): 725–32. doi:10.1111/j.1365-2133.2012.11151.x. PMID 22803835. S2CID 25415894. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:21" class="footnote-back-ref">↩</a></p></li> <li id="fn:22"><p>Demos, M; McLeod, MP; Nouri, K (October 2012). "Recurrent furunculosis: a review of the literature". The British Journal of Dermatology. 167 (4): 725–32. doi:10.1111/j.1365-2133.2012.11151.x. PMID 22803835. S2CID 25415894. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:22" class="footnote-back-ref">↩</a></p></li> <li id="fn:23"><p>Laube S, Farrell M (2002). "Bacterial skin infection in the elderly: diagnosis and treatment". Drugs & Aging. 19 (5): 331–42. doi:10.2165/00002512-200219050-00002. PMID 12093320. S2CID 24264303. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:23" class="footnote-back-ref">↩</a></p></li> <li id="fn:24"><p>Laube S, Farrell M (2002). "Bacterial skin infection in the elderly: diagnosis and treatment". Drugs & Aging. 19 (5): 331–42. doi:10.2165/00002512-200219050-00002. PMID 12093320. S2CID 24264303. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:24" class="footnote-back-ref">↩</a></p></li> <li id="fn:25"><p>"What is this boil like abscess under your arm, breast or groin". The Hidradenitis Suppurativa Trust. Archived from the original on 29 September 2015. Retrieved 28 September 2015. <a href="https://web.archive.org/web/20150929010339/http://www.hstrust.org/info" target="_blank">https://web.archive.org/web/20150929010339/http://www.hstrust.org/info</a> <a href="#fnref:25" class="footnote-back-ref">↩</a></p></li> <li id="fn:26"><p>"Furuncles and Carbuncles". Merck Manuals Professional Edition. August 2017. Retrieved 29 April 2018. <a href="https://www.merckmanuals.com/professional/dermatologic-disorders/bacterial-skin-infections/furuncles-and-carbuncles" target="_blank">https://www.merckmanuals.com/professional/dermatologic-disorders/bacterial-skin-infections/furuncles-and-carbuncles</a> <a href="#fnref:26" class="footnote-back-ref">↩</a></p></li> <li id="fn:27"><p>MedlinePlus Encyclopedia: Furuncle <a href="/wiki/MedlinePlus" target="_blank">/wiki/MedlinePlus</a> <a href="#fnref:27" class="footnote-back-ref">↩</a></p></li> <li id="fn:28"><p>Blume JE, Levine EG, Heymann WR (2003). "Bacterial diseases". In Bolognia JL, Jorizzo JL, Rapini RP (eds.). Dermatology. Mosby. p. 1126. ISBN 0-323-02409-2. <a href="0-323-02409-2" target="_blank">0-323-02409-2</a> <a href="#fnref:28" class="footnote-back-ref">↩</a></p></li> <li id="fn:29"><p>Habif, TP (2004). "Furuncles and carbuncles". Clinical Dermatology: A Color Guide to Diagnosis and Therapy (4th ed.). Philadelphia PA: Mosby. <a href="#fnref:29" class="footnote-back-ref">↩</a></p></li> <li id="fn:30"><p>Wolf K; et al. (2005). "Section 22. Bacterial infections involving the skin". Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology (5th ed.). McGraw-Hill. <a href="#fnref:30" class="footnote-back-ref">↩</a></p></li> <li id="fn:31"><p>Mayo Clinic Archived 15 August 2012 at the Wayback Machine <a href="http://www.mayoclinic.com/health/boils-and-carbuncles/DS00466/DSECTION=symptoms" target="_blank">http://www.mayoclinic.com/health/boils-and-carbuncles/DS00466/DSECTION=symptoms</a> <a href="#fnref:31" class="footnote-back-ref">↩</a></p></li> <li id="fn:32"><p>MedlinePlus Encyclopedia: Furuncle <a href="/wiki/MedlinePlus" target="_blank">/wiki/MedlinePlus</a> <a href="#fnref:32" class="footnote-back-ref">↩</a></p></li> <li id="fn:33"><p>Wolf K; et al. (2005). "Section 22. Bacterial infections involving the skin". Fitzpatrick's Color Atlas & Synopsis of Clinical Dermatology (5th ed.). McGraw-Hill. <a href="#fnref:33" class="footnote-back-ref">↩</a></p></li> <li id="fn:34"><p>"Boils and carbuncles: Complications - MayoClinic.com". Archived from the original on 15 August 2012. Retrieved 14 August 2012. <a href="https://web.archive.org/web/20120815144700/http://www.mayoclinic.com/health/boils-and-carbuncles/DS00466/DSECTION%3Dcomplications" target="_blank">https://web.archive.org/web/20120815144700/http://www.mayoclinic.com/health/boils-and-carbuncles/DS00466/DSECTION%3Dcomplications</a> <a href="#fnref:34" class="footnote-back-ref">↩</a></p></li> <li id="fn:35"><p>Nagaraju U, Bhat G, Kuruvila M, Pai GS, Babu RP (2004). "Methicillin-resistant Staphylococcus aureus in community-acquired pyoderma". Int J Dermatol. 43 (6): 412–14. doi:10.1111/j.1365-4632.2004.02138.x. PMID 15186220. S2CID 38742158. <a href="/wiki/Doi_(identifier)" target="_blank">/wiki/Doi_(identifier)</a> <a href="#fnref:35" class="footnote-back-ref">↩</a></p></li> </ol>