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Publications (10 of 12) Show all publications
Svenmarker, S., Claesson Lingehall, H., Malmqvist, G. & Appelblad, M. (2024). Plasma hyperosmolality during cardiopulmonary bypass is a risk factor for postoperative acute kidney injury: results from double blind randomised controlled trial. Perfusion
Open this publication in new window or tab >>Plasma hyperosmolality during cardiopulmonary bypass is a risk factor for postoperative acute kidney injury: results from double blind randomised controlled trial
2024 (English)In: Perfusion, ISSN 0267-6591, E-ISSN 1477-111XArticle in journal (Refereed) Epub ahead of print
Abstract [en]

Introduction: The study objective was to investigate whether a Ringer’s acetate based priming solution with addition of Mannitol and sodium concentrate increases the risk of cardiac surgery associated kidney injury (CSA-AKI).

Methods: This is a double blind, prospective randomized controlled trial from a single tertiary teaching hospital in Sweden including patients aged ≥65 years (n = 195) admitted for routine cardiac surgery with cardiopulmonary bypass. Patients in the study group received Ringer’s acetate 1000 mL + 400 mL Mannitol (60 g) + sodium chloride 40 mL (160 mmol) and heparin 2 mL (10 000 IU) 966 mOsmol (n = 98), while patients in the control group received Ringer’s acetate 1400 mL + heparin 2 mL (10 000 IU), 388 mOsmol (n = 97) as pump prime. Acute kidney injury was analysed based on the Kidney Disease Improving Outcomes (KDIGO 1-3) definition.

Results: The overall incidence of CSA-AKI (KDIGO stage 1) was 2.6% on day 1 in the ICU and 5.6% on day 3, postoperatively. The serum creatinine level did not show any postoperative intergroup differences, when compared to baseline preoperative values. Six patients in the Ringer and five patients in the Mannitol group developed CSA-AKI (KDIGO 1-3), all with glomerular filtration rates <60 mL/min/1.73 m2. These patients showed significantly higher plasma osmolality levels compared to preoperative values. Hyperosmolality together with patient age and the duration of the surgery were independent risk factors for postoperative acute kidney injury (KDIGO 1-3).

Conclusions: The use of a hyperosmolar prime solution did not increase the incidence of postoperative CSA-AKI in this study, while high plasma osmolality alone increased the associated risk by 30%. The data suggests further examination of plasma hyperosmolality as a relative risk factor of CSA-AKI.

Place, publisher, year, edition, pages
Sage Publications, 2024
Keywords
acute kidney injury, cardiac surgery, cardiopulmonary bypass, heart-lung machine, osmolar concentration, priming solution
National Category
Surgery Urology and Nephrology Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-222876 (URN)10.1177/02676591241240726 (DOI)001189813600001 ()38513672 (PubMedID)2-s2.0-85188462002 (Scopus ID)
Available from: 2024-04-12 Created: 2024-04-12 Last updated: 2024-04-12
Claesson Lingehall, H., Gustafson, Y., Svenmarker, S., Appelblad, M., Davidsson, F., Holmner, F., . . . Olofsson, B. (2023). Is a hyperosmolar pump prime for cardiopulmonary bypass a risk factor for postoperative delirium?: A double blinded randomised controlled trial. Scandinavian Cardiovascular Journal, 57(1), Article ID 2186326.
Open this publication in new window or tab >>Is a hyperosmolar pump prime for cardiopulmonary bypass a risk factor for postoperative delirium?: A double blinded randomised controlled trial
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2023 (English)In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 57, no 1, article id 2186326Article in journal (Refereed) Published
Abstract [en]

Objective: Postoperative delirium (POD) is common after cardiac surgery. We have previously identified plasma sodium concentration and the volume of infused fluids during surgery as possible risk factors. Both are linked to the selection and composition of the pump prime used for cardiopulmonary bypass (CPB). Present study aims to examine whether hyperosmolality increases the risk for POD.

Design: Patients ≥65 years (n = 195) scheduled for cardiac surgery were prospectively enrolled into this double blinded randomised clinical trial. Study group received a pump prime containing mannitol and ringer-acetate (966 mOsmol) (n = 98) vs. ringer-acetate (388 mOsmol) (n = 97) in the control group. Postoperative delirium was defined according to DSM-5 criteria based on a test-battery pre- and postoperatively (days 1–3). Plasma osmolality was measured on five occasions and coordinated with the POD assessments. The primary outcome was the POD incidence related to hyperosmolality as the secondary outcome.

Results: The incidence of POD was 36% in the study group and 34% in the control group, without intergroup difference (p=.59). The plasma osmolality was significantly higher in the study group, both on days 1 and 3 and after CPB (p<.001). Post hoc analysis indicated that high osmolality levels increased the risk for delirium on day 1 by 9% (odds ratio (OR) 1.09, 95% CI 1.03–1.15) and by 10% on day 3 (OR 1.10, 95% CI 1.04–1.16).

Conclusions: Use of a prime solution with high osmolality did not increase the incidence of POD. However, the influence of hyperosmolality as a risk factor for POD warrants further investigation.

Place, publisher, year, edition, pages
Taylor & Francis, 2023
Keywords
Cardiac surgery, cardiopulmonary bypass, delirium, mannitol, osmolality
National Category
Cardiac and Cardiovascular Systems Nursing Surgery
Identifiers
urn:nbn:se:umu:diva-206772 (URN)10.1080/14017431.2023.2186326 (DOI)000962391200001 ()37009834 (PubMedID)2-s2.0-85151638529 (Scopus ID)
Funder
Region VästerbottenUmeå University
Available from: 2023-04-26 Created: 2023-04-26 Last updated: 2023-04-26Bibliographically approved
Andersen, L., Appelblad, M., Wiklund, U., Sundström, N. & Svenmarker, S. (2023). Our initial experience of monitoring the autoregulation of cerebral blood flow during cardiopulmonary bypass. The journal of extra-corporeal technology, 55(4), 209-217
Open this publication in new window or tab >>Our initial experience of monitoring the autoregulation of cerebral blood flow during cardiopulmonary bypass
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2023 (English)In: The journal of extra-corporeal technology, ISSN 0022-1058, Vol. 55, no 4, p. 209-217Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Cerebral blood flow (CBF) is believed to be relatively constant within an upper and lower blood pressure limit. Different methods are available to monitor CBF autoregulation during surgery. This study aims to critically analyze the application of the cerebral oxygenation index (COx), one of the commonly used techniques, using a reference to data from a series of clinical registrations.

METHOD: CBF was monitored using near-infrared spectroscopy, while cerebral blood pressure was estimated by recordings obtained from either the radial or femoral artery in 10 patients undergoing cardiopulmonary bypass. The association between CBF and blood pressure was calculated as a moving continuous correlation coefficient. A COx index > 0.4 was regarded as a sign of abnormal cerebral autoregulation (CA). Recordings were examined to discuss reliability measures and clinical feasibility of the measurements, followed by interpretation of individual results, identification of possible pitfalls, and suggestions of alternative methods.

RESULTS AND CONCLUSION: Monitoring of CA during cardiopulmonary bypass is intriguing and complex. A series of challenges and limitations should be considered before introducing this method into clinical practice.

Place, publisher, year, edition, pages
EDP Sciences, 2023
Keywords
Autoregulation, Cardiopulmonary bypass, Cerebral blood flow, Monitoring, Near-infrared spectroscopy
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-218633 (URN)10.1051/ject/2023032 (DOI)38099638 (PubMedID)2-s2.0-85179772071 (Scopus ID)
Available from: 2023-12-27 Created: 2023-12-27 Last updated: 2023-12-27Bibliographically approved
Eriksson, J., Fowler, P., Appelblad, M., Lindholm, L. & Sund, M. (2022). Productivity in relation to organization of a surgical department: a retrospective observational study. BMC Surgery, 22(1), Article ID 114.
Open this publication in new window or tab >>Productivity in relation to organization of a surgical department: a retrospective observational study
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2022 (English)In: BMC Surgery, ISSN 1471-2482, E-ISSN 1471-2482, Vol. 22, no 1, article id 114Article in journal (Refereed) Published
Abstract [en]

Background: Responsible and efficient resource utilization are important factors in healthcare. The aim of this study was to investigate how total case time differs between two differently organized surgical departments. Methods: This is a retrospective observational study of a cohort of patients undergoing elective surgery for breast cancer or malignant melanoma in a university hospital setting in Sweden. All patients were operated on by the same set of surgeons but in two different surgical departments: a general surgery (GS) and a cardiothoracic (CT) surgery department. Patients were selected to the two departments from a waiting list in the order of referral for surgery. The effect of being operated on at the CT department compared to the GS department was estimated by linear regression. Results: The final study cohort comprised 349 patients in the GS department and 177 patients in the CT department. Both groups were similar regarding surgical procedures, American Society of Anesthesiologists' score, body mass index, age, sex, and the skill level of the operating surgeon. These covariates were included in the linear regression model. The total case time, defined by the Procedural Time Glossary as room set-up start to room clean-up finish, was significantly shorter for the patients who underwent a surgical procedure at the CT department compared to the GS department, even after adjusting for the background characteristics of the patients and surgeon. After adjusting for the selected covariates, the average difference in total case time between the two departments was − 30.67 min (p = 0.001). Conclusions: A significantly shorter total case time was measured for operations in the CT department. Plausible explanations may be more beneficial organizational factors, such as staffing ratio, skill mix in the operating room team, and working behavioral aspects regarding resource utilization.

Place, publisher, year, edition, pages
BioMed Central (BMC), 2022
Keywords
Logistics, Operating room, Perioperative management
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:umu:diva-193705 (URN)10.1186/s12893-022-01563-6 (DOI)000780283900001 ()35331217 (PubMedID)2-s2.0-85127042081 (Scopus ID)
Funder
Region Västerbotten
Available from: 2022-04-25 Created: 2022-04-25 Last updated: 2023-06-08Bibliographically approved
Nilsson, S., Appelblad, M. & Svenmarker, S. (2020). Can We Rely on the Activated Clotting Time to Measure Heparin Anticoagulation? A Clinical Evaluation of Two ACT Monitors. The journal of extra-corporeal technology, 52(3), 212-217
Open this publication in new window or tab >>Can We Rely on the Activated Clotting Time to Measure Heparin Anticoagulation? A Clinical Evaluation of Two ACT Monitors
2020 (English)In: The journal of extra-corporeal technology, ISSN 0022-1058, Vol. 52, no 3, p. 212-217Article in journal (Refereed) Published
Abstract [en]

The sensitivity to heparin during cardiopulmonary bypass (CPB) is determined by patient-specific characteristics and is assessed by the whole blood activated clotting time (ACT). We aimed to examine reliability measures between two different ACT monitors using Bland-Altman analysis: bias should not exceed 50 ± 50 seconds for measurements performed during CPB or 10 ± 10 seconds before and after CPB. The ACT response should be linear in relation to the concentration of heparin in plasma. Twenty patients (n = 20) aged 20-80 years and admitted for coronary artery bypass surgery were enrolled to this clinical observational study. ACT values and antifactor Xa were sampled: 1) before induction of anesthesia, 2) after heparin bolus, 3) during CPB at the start of rewarming, 4) at weaning from CPB, and 5) after heparin reversal. The evaluation comprised the Hemostasis Management System Plus™ (HMS, Medtronic Inc., Minneapolis, MN) and i-STAT™ (Abbott, Point of Care Inc., Princeton, NJ). Bias for the HMS Plus™ vs. i-STAT™ was +105 ± 119 seconds for measurements during CPB and +2.8 ± 11.7 seconds before and after CPB. Associated limits of agreement for the observed bias were ±235 and ±23 seconds, respectively. Inter-device correlation of ACT values was .46 (p < .001) during CPB; otherwise .48 (p = .02). Both devices produced ACT values unrelated (<10%) to the measured heparin concentration. The use of multivariable regression analysis demonstrated an independent association between the ACT measurement and hematocrit, however, not with the plasma concentration of heparin. ACT monitors demonstrate unacceptable bias differences, combined with wide limits of agreement. The ACT response correlated with hematocrit, but not with the actual heparin concentration.

Place, publisher, year, edition, pages
American Society of Extra-Corporeal Technology, 2020
Keywords
activated clotting time, anticoagulation, cardiopulmonary bypass, heparin and heparin concentration, point of care
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-197862 (URN)10.1182/ject-2000005 (DOI)32981959 (PubMedID)2-s2.0-85091809692 (Scopus ID)
Available from: 2022-07-07 Created: 2022-07-07 Last updated: 2023-05-22
Karlsson, M., Hannuksela, M., Appelblad, M., Hällgren, O., Johagen, D., Wahba, A. & Svenmarker, S. (2020). Cardiopulmonary bypass and dual antiplatelet therapy: a strategy to minimise transfusions and blood loss. Perfusion, 35(3), 236-245
Open this publication in new window or tab >>Cardiopulmonary bypass and dual antiplatelet therapy: a strategy to minimise transfusions and blood loss
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2020 (English)In: Perfusion, ISSN 0267-6591, E-ISSN 1477-111X, Vol. 35, no 3, p. 236-245Article in journal (Refereed) Published
Abstract [en]

Background: Patients with preoperative dual antiplatelet therapy prior to coronary artery bypass surgery are at risk of bleeding and blood component transfusion. We hypothesise that an optimised cardiopulmonary bypass strategy reduces postoperative blood loss and transfusions.

Methods: In total, 60 patients admitted for coronary artery bypass grafting with ticagrelor and aspirin medication withdrawn <96 hours before surgery were prospectively randomised into two equal sized groups. Cardiopulmonary bypass combined a closed Cortiva (R) heparin-coated circuit with low systemic heparinisation (activated clotting time < 250 seconds) and intraoperative cell salvage in the study group, whereas the control group used a Balance (R) coated open circuit, full systemic heparinisation (activated clotting time > 480 seconds) and conventional cardiotomy suction. This perfusion strategy was evaluated by the chest drain volume after 24 hours, perioperative haemoglobin and platelet loss accompanied by global coagulation assessments.

Results: Patients in the study group demonstrated significantly better outcomes signified by lower blood loss 554 +/- 224 versus 1,100 +/- 989 mL (p < 0.001), reduced packed red cell transfusion 7% versus 53% (p < 0.001), reduced haemoglobin -28 +/- 15 versus -40 +/- 14 g/L (p = 0.004) and platelet loss -35 +/- 36 versus -82 +/- 67 x 10(9)/L (p = 0.001). Indices of rotational thromboelastometry indicated shorter clotting times within the internal and external pathways. Adenosine diphosphate activated platelet function was within normal range based on Multiplate (R) aggregometry, while ROTEM (R) platelet analyses indicated inhibited function both preoperatively and post-bypass. Platelet inhibition by aspirin was verified throughout the perioperative period. Platelet function showed no intergroup differences.

Conclusion: A stringent perfusion strategy reduced blood loss and transfusions in dual antiplatelet therapy patients requiring urgent surgery.

Place, publisher, year, edition, pages
Sage Publications, 2020
Keywords
cardiopulmonary bypass, platelet inhibitors, blood loss
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-164540 (URN)10.1177/0267659119867005 (DOI)000483493800001 ()31446845 (PubMedID)2-s2.0-85071554803 (Scopus ID)
Available from: 2019-11-14 Created: 2019-11-14 Last updated: 2023-04-26Bibliographically approved
Malmqvist, G. & Appelblad, M. (2020). Fluid shifts due to the law of osmosis [Letter to the editor]. Acta Anaesthesiologica Scandinavica, 64(1), 137-137
Open this publication in new window or tab >>Fluid shifts due to the law of osmosis
2020 (English)In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 64, no 1, p. 137-137Article in journal, Letter (Refereed) Published
Place, publisher, year, edition, pages
Wiley-Blackwell Publishing Inc., 2020
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-165672 (URN)10.1111/aas.13485 (DOI)000490017500001 ()31549409 (PubMedID)2-s2.0-85074347424 (Scopus ID)
Available from: 2019-12-06 Created: 2019-12-06 Last updated: 2023-04-26Bibliographically approved
Malmqvist, G., Claesson Lingehall, H., Appelblad, M. & Svenmarker, S. (2019). Cardiopulmonary bypass prime composition: beyond crystalloids versus colloids. Perfusion, 34(2), 130-135
Open this publication in new window or tab >>Cardiopulmonary bypass prime composition: beyond crystalloids versus colloids
2019 (English)In: Perfusion, ISSN 0267-6591, E-ISSN 1477-111X, Vol. 34, no 2, p. 130-135Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: In the literature addressing cardiopulmonary bypass (CPB) prime composition, there is a considerable lack of discussion concerning plasma osmolality changes induced by using a hyperosmolar prime. With this study, we try to determine the magnitude and temporal relationship of plasma osmolality changes related to the use of a hyperosmolar CPB prime.

METHOD: In this prospective observational study performed in a university hospital setting, we enrolled thirty patients scheduled for elective coronary bypass surgery. Plasma osmolality was analysed on eight occasions. A hyperosmolar CPB prime was used.

RESULTS: Analyses of the perioperative plasma osmolality on eight occasions gave the following results: the preoperative osmolality level was normal (297±4 mOsm/kg); a significant increase to 322±17 mOsm/kg (p<0.001) was observed at the commencement of CPB and remained elevated after 30 minutes (310±4 mOsm/kg) and throughout the procedure (309±4 mOsm/kg); the osmolality level returned to 291±5 mOsm/kg on day 1 postoperatively and remained normal the following day (291±6 mOsm/kg).

CONCLUSIONS: Use of hyperosmolar CPB prime resulted in a dramatic and instant elevation of the plasma osmolality. Rapid changes in plasma osmolality are associated with organ dysfunction (e.g. osmotic demyelination syndrome), therefore, effects on plasma osmolality related to the CPB prime composition should be recognised. Influence on organ function and clinical outcome warrants further investigations. - Clinical Trials.gov (NCT03060824). Changes in Plasma Osmolality Related to the Use of Cardiopulmonary Bypass With Hyperosmolar Prime. URL: https://clinicaltrials.gov/ct2/show/NCT03060824?term=cpb&cond=osmolality&rank=1.

Place, publisher, year, edition, pages
Sage Publications, 2019
Keywords
cardiac surgery, cardiopulmonary bypass, osmolality, osmolarity, priming solutions
National Category
Nursing
Identifiers
urn:nbn:se:umu:diva-151324 (URN)10.1177/0267659118793249 (DOI)000458887400006 ()30114960 (PubMedID)2-s2.0-85052595962 (Scopus ID)
Available from: 2018-08-31 Created: 2018-08-31 Last updated: 2023-04-26Bibliographically approved
Smulter, N., Lingehall, H. C., Gustafson, Y., Olofsson, B., Engström, K. G., Appelblad, M. & Svenmarker, S. (2018). Disturbances in Oxygen Balance During Cardiopulmonary Bypass: A Risk Factor for Postoperative Delirium. Journal of Cardiothoracic and Vascular Anesthesia, 32(2), 684-690
Open this publication in new window or tab >>Disturbances in Oxygen Balance During Cardiopulmonary Bypass: A Risk Factor for Postoperative Delirium
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2018 (English)In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 32, no 2, p. 684-690Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of this study was to determine risk factors for postoperative delirium after cardiac surgery, specifically associated with the conduct of cardiopulmonary bypass (CPB).

Design: Prospective observational study.

Setting: Heart Centre, University Hospital.

Participants: The study included 142 patients aged 70 years and older scheduled for elective cardiac surgery with CPB.

Interventions: Risk factor analysis comprised information collected from the hospital clinical and CPB dedicated databases in addition to the medical chart. Delirium was diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision criterion using the Mini Mental State Examination and the Organic Brain Syndrome scale.

Measurements and Main Results: Assessments of delirium diagnosis were executed preoperatively and on the following first and fourth postoperative days. Delirium occurred in 55% (78/142) of the patients. Patients with delirium were identified with significantly higher body weight and body surface area preoperatively, accompanied with longer CPB time, higher positive fluid balance per CPB, and lower systemic pump flow related to body surface area. Furthermore, the duration of the mixed venous oxygen saturation (SvO2) below 75% was significantly longer during CPB. The result from the multivariable logistic regression analysis included the duration of SvO2 below 75%, fluid balance per CPB and patient age as independent risk factors for postoperative delirium.

Conclusions: The influence of the SvO2 level during CPB, fluid balance, and patient age should be recognized as risk factors for postoperative delirium after cardiac surgery in patients 70 years and older.

Place, publisher, year, edition, pages
Saunders Elsevier, 2018
Keywords
cardiac surgery, cardiopulmonary bypass, mixed venous oxygen saturation, postoperative delirium, risk factors
National Category
Nursing Cardiac and Cardiovascular Systems Respiratory Medicine and Allergy Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:umu:diva-144659 (URN)10.1053/j.jvca.2017.08.035 (DOI)000429083200014 ()29153931 (PubMedID)2-s2.0-85034429683 (Scopus ID)
Available from: 2018-02-09 Created: 2018-02-09 Last updated: 2023-04-26Bibliographically approved
Hällgren, O., Svenmarker, S. & Appelblad, M. (2017). Implementing a Statistical Model for Protamine Titration: Effects on Coagulation in Cardiac Surgical Patients. Journal of Cardiothoracic and Vascular Anesthesia, 31(2), 516-521
Open this publication in new window or tab >>Implementing a Statistical Model for Protamine Titration: Effects on Coagulation in Cardiac Surgical Patients
2017 (English)In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 31, no 2, p. 516-521Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: To implement a statistical model for protamine titration. DESIGN: Prospective randomized trial. SETTING: University hospital. PARTICIPANTS: Sixty (n = 30+30) patients scheduled for elective coronary artery bypass surgery were randomly assigned to 2 groups. INTERVENTIONS: Protamine dose calculated according to an algorithm established from a statistical model or to a fixed protamine-heparin dose ratio (1:1). MEASUREMENTS AND MAIN RESULTS: Both groups demonstrated comparable patient demographics and intraoperative data. Coagulation effects were evaluated using rotational thromboelastometry. Using the statistical model reduced (p<0.01) the protamine dose from 426±43 mg to 251±66 mg, followed by significantly (p<0.01) shorter intrinsic clotting time (208±29 seconds versus 244±52 seconds) and stronger clot firmness (p = 0.01), and effects on indices of extrinsic or fibrinogen coagulation pathways were insignificant. Test of residual heparin was negative in all patients after protamine administration, aligned with insignificant (p = 0.27) intergroup heparinase-verified clotting time differences. CONCLUSIONS: The statistical model for protamine titration is clinically feasible and protects the patient from exposure to excessive doses of protamine, with advantageous effects on coagulation as measured using rotational thromboelastometry. Significance regarding clinical outcome is yet to be defined.

Keywords
cardiac surgery, cardiopulmonary bypass, heparin, protamine, statistical model
National Category
Clinical Medicine
Identifiers
urn:nbn:se:umu:diva-134742 (URN)10.1053/j.jvca.2016.07.018 (DOI)000400794400018 ()27712970 (PubMedID)2-s2.0-85000444159 (Scopus ID)
Available from: 2017-05-11 Created: 2017-05-11 Last updated: 2023-04-26Bibliographically approved
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ORCID iD: ORCID iD iconorcid.org/0000-0002-8171-7227

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