51
|
Andersen C, Mellemkjær S, Hilberg O, Bendstrup E. NT-proBNP <95 ng/l can exclude pulmonary hypertension on echocardiography at diagnostic workup in patients with interstitial lung disease. Eur Clin Respir J 2016; 3:32027. [PMID: 27478030 PMCID: PMC4967712 DOI: 10.3402/ecrj.v3.32027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/07/2016] [Indexed: 12/03/2022] Open
Abstract
Background Pulmonary hypertension (PH) is a serious complication to interstitial lung disease (ILD) and has a poor prognosis. PH is often diagnosed by screening with echocardiography followed by right heart catheterisation. A previous study has shown that a value of NT-pro-brain natriuretic peptide (NT-proBNP) <95 ng/l could be used to rule out PH in patients with ILD. Aim To evaluate this rule-out test for PH in a new cohort of incident patients with ILD. Methods An established database with data from 148 consecutive patients referred from January 2012 to October 2014 was used to identify patients and obtain data from echocardiography, NT-proBNP, diagnosis and lung function. Signs of PH on echocardiography were defined as a tricuspid pressure gradient (TR) ≥40 mmHg, decreased right ventricular systolic function or dilatation. Sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of NT-proBNP >95 ng/l for signs of PH on echocardiography were calculated. The study was approved by the Danish Health Authority. Results In 118 patients, data from both echocardiography and measurements of NT-proBNP were available. Eleven of these were screened positive for PH on echocardiography. Sensitivity, specificity, NPV and PPV of NT-proBNP <95 ng/l for PH were 100, 44, 16 and 100%, respectively. Furthermore, no patients with left heart failure as the cause of dyspnoea were missed using this cut-off value. Conclusion NT-proBNP <95 ng/l precludes a positive echocardiographic screen for PH in ILD patients at referral for diagnostic workup.
Collapse
Affiliation(s)
- Charlotte Andersen
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark;
| | - Søren Mellemkjær
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Ole Hilberg
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Elisabeth Bendstrup
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
52
|
Suntharalingam J, Ross RM, Easaw J, Robinson G, Coghlan G. Who should be referred to a specialist pulmonary -hypertension centre - a referrer's guide. Clin Med (Lond) 2016; 16:135-41. [PMID: 27037382 PMCID: PMC4952966 DOI: 10.7861/clinmedicine.16-2-135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The introduction of pulmonary hypertension (PH)-specific drugs has allowed certain forms of PH to become more treatable. However, patients with these diseases can present to a number of medical specialties and can be challenging to identify, particularly in a non-specialist setting. This article provides guidance on who should be investigated and referred on to a specialist centre, highlighting the potential pitfalls during assessment.
Collapse
Affiliation(s)
| | | | - Jacob Easaw
- Cardiology Department, Royal United Hospital, Bath, UK
| | | | | |
Collapse
|
53
|
Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2015; 46:903-75. [DOI: 10.1183/13993003.01032-2015] [Citation(s) in RCA: 1929] [Impact Index Per Article: 214.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Guidelines summarize and evaluate all available evidence on a particular issue at the time of the writing process, with the aim of assisting health professionals in selecting the best management strategies for an individual patient with a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines and recommendations should help health professionals to make decisions in their daily practice. However, the final decisions concerning an individual patient must be made by the responsible health professional(s) in consultation with the patient and caregiver as appropriate.
Collapse
|
54
|
Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2015; 37:67-119. [DOI: 10.1093/eurheartj/ehv317] [Citation(s) in RCA: 3916] [Impact Index Per Article: 435.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
|
55
|
Klok F, Tesche C, Rappold L, Dellas C, Hasenfuß G, Huisman M, Konstantinides S, Lankeit M. External validation of a simple non-invasive algorithm to rule out chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Thromb Res 2015; 135:796-801. [DOI: 10.1016/j.thromres.2014.12.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 12/03/2014] [Accepted: 12/06/2014] [Indexed: 01/21/2023]
|
56
|
Jacobs W, Konings TC, Heymans MW, Boonstra A, Bogaard HJ, van Rossum AC, Vonk Noordegraaf A. Noninvasive identification of left-sided heart failure in a population suspected of pulmonary arterial hypertension. Eur Respir J 2015; 46:422-30. [PMID: 25837029 DOI: 10.1183/09031936.00202814] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 02/19/2015] [Indexed: 11/05/2022]
Abstract
Exclusion of pulmonary hypertension secondary to left-sided heart disease (left heart failure (LHF)) is pivotal in the diagnosis of pulmonary arterial hypertension (PAH). In case of doubt, invasive measurements are recommended. The aim of the present study was to investigate whether it is possible to diagnose LHF using noninvasive parameters in a population suspected of PAH.300 PAH and 80 LHF patients attended our pulmonary hypertension clinic before August 2010, and were used to build the predictive model. 79 PAH and 55 LHF patients attended our clinic from August 2010, and were used for prospective validation.A medical history of left heart disease, S deflection in V1 plus R deflection in V6 in millimetres on ECG, and left atrial dilation or left valvular heart disease that is worse than mild on echocardiography were independent predictors of LHF. The derived risk score system showed good predictive characteristics: R(2)=0.66 and area under the curve 0.93. In patients with a risk score ≥72, there is 100% certainty that the cause of pulmonary hypertension is LHF. Using this risk score system, the number of right heart catheterisations in LHF may be reduced by 20%.In a population referred under suspicion of PAH, a predictive model incorporating medical history, ECG and echocardiography data can diagnose LHF noninvasively in a substantial percentage of cases.
Collapse
Affiliation(s)
- Wouter Jacobs
- Dept of Pulmonology, VU University Medical Center, Amsterdam, The Netherlands Dept of Pulmonology, Martini Hospital, Groningen, The Netherlands
| | - Thelma C Konings
- Dept of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | - Martijn W Heymans
- Dept of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands
| | - Anco Boonstra
- Dept of Pulmonology, VU University Medical Center, Amsterdam, The Netherlands
| | - Harm Jan Bogaard
- Dept of Pulmonology, VU University Medical Center, Amsterdam, The Netherlands
| | - Albert C van Rossum
- Dept of Cardiology, VU University Medical Center, Amsterdam, The Netherlands
| | | |
Collapse
|
57
|
Charalampopoulos A, Howard LS, Tzoulaki I, Gin-Sing W, Grapsa J, Wilkins MR, Davies RJ, Nihoyannopoulos P, Connolly SB, Gibbs JSR. Response to pulmonary arterial hypertension drug therapies in patients with pulmonary arterial hypertension and cardiovascular risk factors. Pulm Circ 2015; 4:669-78. [PMID: 25610602 DOI: 10.1086/678512] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 05/07/2014] [Indexed: 12/11/2022] Open
Abstract
The age at diagnosis of pulmonary arterial hypertension (PAH) and the prevalence of cardiovascular (CV) risk factors are increasing. We sought to determine whether the response to drug therapy was influenced by CV risk factors in PAH patients. We studied consecutive incident PAH patients (n = 146) between January 1, 2008, and July 15, 2011. Patients were divided into two groups: the PAH-No CV group included patients with no CV risk factors (obesity, systemic hypertension, type 2 diabetes mellitus, permanent atrial fibrillation, mitral and/or aortic valve disease, and coronary artery disease), and the PAH-CV group included patients with at least one. The response to PAH treatment was analyzed in all the patients who received PAH drug therapy. The PAH-No CV group included 43 patients, and the PAH-CV group included 69 patients. Patients in the PAH-No CV group were younger than those in the PAH-CV group (P < 0.0001). In the PAH-No CV group, 16 patients (37%) improved on treatment and 27 (63%) did not improve, compared with 11 (16%) and 58 (84%) in the PAH-CV group, respectively (P = 0.027 after adjustment for age). There was no difference in survival at 30 months (P = 0.218). In conclusion, in addition to older age, CV risk factors may predict a reduced response to PAH drug therapy in patients with PAH.
Collapse
Affiliation(s)
- Athanasios Charalampopoulos
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare National Health Service (NHS) Trust, London, United Kingdom
| | - Luke S Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare National Health Service (NHS) Trust, London, United Kingdom
| | - Ioanna Tzoulaki
- Imperial College London, London, United Kingdom ; University of Ioannina, Ioannina, Greece
| | - Wendy Gin-Sing
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare National Health Service (NHS) Trust, London, United Kingdom
| | - Julia Grapsa
- Imperial College London, London, United Kingdom ; King's Lynn and Papworth Hospitals, Cambridge, United Kingdom ; Echocardiography Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Rachel J Davies
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare National Health Service (NHS) Trust, London, United Kingdom
| | - Petros Nihoyannopoulos
- Imperial College London, London, United Kingdom ; Echocardiography Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Susan B Connolly
- Cardiology Department, Imperial College Healthcare NHS Trust, London, United Kingdom ; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - J Simon R Gibbs
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare National Health Service (NHS) Trust, London, United Kingdom ; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| |
Collapse
|
58
|
Alkukhun L, Baumgartner M, Budev M, Dweik RA, Tonelli AR. Electrocardiographic differences between COPD patients evaluated for lung transplantation with and without pulmonary hypertension. COPD 2014; 11:670-80. [PMID: 24983839 DOI: 10.3109/15412555.2014.898047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is an indicator of poor prognosis in COPD patients; particularly in those with mean pulmonary artery pressure ≥ 40 mm Hg. Electrocardiography (ECG) might be useful for screening of this condition. METHODS Retrospective study of COPD patients evaluated for lung transplantation in whom we analyzed the 12-lead ECG performed closest to the time of right heart catheterization. RESULTS We included 142 patients. PH was present in 90 patients (63%) and 16 (11%) had a mean PAP ≥ 40 mmHg. The PR interval was longer in PH patients (151 (29) versus 139 (22) ms, p = 0.01) and T wave axis had a left shift (56.9 (32) versus 68.7 (19) degrees, p = 0.006). PR interval was longer (178.5 (35) versus 142.2 (23) ms, p = 0.001), T wave axis had a leftward deflection (63.6 (24) versus 42.8 (46) degrees, p = 0.005) and S wave in lead I was larger (0.19 (0.13) versus 0.12 (0.12) mV, p = 0.03) in patients with mean PAP ≥ 40 mmHg. A PR interval > 137 ms and S wave in DI > 0.02 mV had a sensitivity of 100% and a specificity of 59.5% to identify COPD patients with a mean PAP ≥ 40 mmHg. CONCLUSION There are significant ECG differences between advanced COPD patients with and without PH; however the ECG is an inadequate tool to differentiate between the groups. A prolonged PR interval suggests the presence of severe PH.
Collapse
Affiliation(s)
- Laith Alkukhun
- Department of Pulmonary, Allergy and Critical Care Medicine. Respiratory Institute , Cleveland Clinic, Cleveland, OH , USA
| | | | | | | | | |
Collapse
|
59
|
Nonaka DF, Grichnik KP, Whitener GB. Pulmonary Hypertension and Thoracic Surgery: Diagnostics and Advances in Therapy and Intraoperative Management. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0053-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
|
60
|
Tonelli AR, Baumgartner M, Alkukhun L, Minai OA, Dweik RA. Electrocardiography at diagnosis and close to the time of death in pulmonary arterial hypertension. Ann Noninvasive Electrocardiol 2013; 19:258-65. [PMID: 24372670 DOI: 10.1111/anec.12125] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Scarce information exits on the electrocardiographic (ECG) characteristics of pulmonary arterial hypertension (PAH) patients close to their death and whether observed abnormalities progress from the time of PAH diagnosis. METHODS We analyzed the characteristics of the ECG performed at initial diagnosis, during the course of the disease and close to the time of death on consecutive PAH patients followed at our institution between June 2008 and December 2010. RESULTS We included 50 patients with PAH (76% women) with mean (SD) age of 58 (14) years. Median heart rate (83 vs 89 bpm, P = 0.001), PR interval (167 vs 176 ms, P = 0.03), QRS duration (88 vs 90 ms, P = 0.02), R/S ratio in lead V1 (1 vs 2, P = 0.01), and QTc duration (431 vs 444 ms, P = 0.02) significantly increased from the initial to the last ECG. In addition, the frontal QRS axis rotated to the right (97 vs 112 degrees, P = 0.003) and we more commonly observed right bundle branch block (5% vs 8%, P = 0.03) and negative T waves in inferior leads (31% vs 60%, P = 0.004). No patient had normal ECG at the time of death. CONCLUSIONS Significant changes progressively occur in a variety of ECG parameters between the time of the initial PAH diagnosis and close to death.
Collapse
Affiliation(s)
- Adriano R Tonelli
- Department of Pulmonary, Allergy, and Critical Care Medicine, Respiratory Institute, Cleveland, OH
| | | | | | | | | |
Collapse
|
61
|
Predictors of diastolic-to-wedge gradient in patients evaluated for pulmonary hypertension. PLoS One 2013; 8:e76461. [PMID: 24124561 PMCID: PMC3790694 DOI: 10.1371/journal.pone.0076461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 08/23/2013] [Indexed: 12/02/2022] Open
Abstract
Background Differentiation of pulmonary arterial hypertension (PAH) and pulmonary venous hypertension (PVH) often requires right heart catheterization (RHC). We sought to determine whether a combination of clinical and echocardiographic variables could predict the pulmonary diastolic to wedge (PAd-PWP) gradient and thus differentiate patients with PAH and PVH. Methods We prospectively enrolled 108 patients presenting for PH evaluation. We developed a multivariate model to predict PAd-PWP gradient and validated this model using bootstrapping technique. Results PAH patients had worse hemodynamics and were more likely to have evidence of right ventricular dilation and dysfunction whereas patients with PVH were older and more likely to have features of the metabolic syndrome. PAd-PWP gradient of ≥ 6mmHg accurately discriminated patients with PAH compared to PVH. Our model including clinical and echocardiographic variables was highly accurate for the prediction of PAd-PWP gradient with a slope 0.89 (slope of 1 represents perfect prediction). Conclusions In this prospective study of patients referred for PH evaluation, a model of readily available clinical parameters and simple echocardiographic measurements accurately predicted the PAd-PWP gradient, allowing discrimination of patients with PAH and PVH. This model requires validation in a larger cohort, but may afford clinicians more parsimony with referral for invasive testing in the evaluation of PH.
Collapse
|
62
|
Andersen CU, Mellemkjær S, Nielsen-Kudsk JE, Bendstrup E, Simonsen U, Hilberg O. Diagnostic and prognostic role of biomarkers for pulmonary hypertension in interstitial lung disease. Respir Med 2012; 106:1749-55. [DOI: 10.1016/j.rmed.2012.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 08/17/2012] [Accepted: 09/11/2012] [Indexed: 11/30/2022]
|
63
|
Lammi MR, Panetta N, Vega ME. Airway bypass stents for emphysema, algorithm to exclude precapillary pulmonary hypertension, and sildenafil for pulmonary hypertension in heart failure with preserved ejection fraction. Am J Respir Crit Care Med 2012; 185:1323-4. [PMID: 22707735 DOI: 10.1164/rccm.201202-0235rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Matthew R Lammi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Temple University School of Medicine, 3401 N. Broad Street, Philadelphia, PA 19140, USA.
| | | | | |
Collapse
|
64
|
Hammerstingl C, Schueler R, Bors L, Momcilovic D, Pabst S, Nickenig G, Skowasch D. Diagnostic value of echocardiography in the diagnosis of pulmonary hypertension. PLoS One 2012; 7:e38519. [PMID: 22685577 PMCID: PMC3369879 DOI: 10.1371/journal.pone.0038519] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 05/05/2012] [Indexed: 01/13/2023] Open
Abstract
AIMS To determine the value of echocardiography including tissue Doppler imaging (TDI) and right ventricular (RV) speckle tracking analysis for the diagnosis of pulmonary hypertension (PH) and discrimination between pre- and postcapillary PH. METHODS AND RESULTS 155 consecutive patients (mean age 70.5±13.0 years, 81 [52%] male gender, BMI 27.2±6.1 kg/m(2)) with PH undergoing right heart catheterization (RHC) and transthoracic echocardiography (TTE) with TDI between January 2008 and December 2009 were retrospectively evaluated including offline speckle tracking analysis of RV contractility. After RHC 23.2% of patients (36) were diagnosed with precapillary PH. Invasive results from RHC were significantly correlated to TTE measurements (E/é, postcapillary wedge pressure [PCWP], r=0.61, P<0.001; mean, systolic pulmonary arterial pressure [mPAP, sPAP], r=0.43, P<0.001). Single echocardiographic parameters were of good predictive value for final PH-diagnosis (sPAP, area under the curve [AUC] 0.63, P=0.025; lateral apical RV longitudinal strain [RVaSl)], AUC 0.76, P=0.001; E/é, AUC 0.84, P<0.001) which could be increased by combining most predictive parameters after receiver operating curves (ROC) cut off analysis (sPAP>69 mmHg, E/é<12, RVaSl ≥-8.4%). TTE had a sensitivity of 33.33% and a specificity of 100% to identify patients with precapillary PH, and a negative predictive value of 84.72% to rule out precapilary PH. CONCLUSION Echocardiography allows feasible and reliable estimation of PH and seems helpful to distinguish between pre-and postcapillary PH. Further prospective studies on patients with different manifestations of PH must validate the predictive value of echocardiography in this clinical setting.
Collapse
Affiliation(s)
- Christoph Hammerstingl
- Department of Internal Medicine II, Cardiology/Pneumology, University of Bonn, Bonn, Germany
| | - Robert Schueler
- Department of Internal Medicine II, Cardiology/Pneumology, University of Bonn, Bonn, Germany
| | - Lisa Bors
- Department of Internal Medicine II, Cardiology/Pneumology, University of Bonn, Bonn, Germany
| | - Diana Momcilovic
- Department of Internal Medicine II, Cardiology/Pneumology, University of Bonn, Bonn, Germany
| | - Stefan Pabst
- Department of Internal Medicine II, Cardiology/Pneumology, University of Bonn, Bonn, Germany
| | - Georg Nickenig
- Department of Internal Medicine II, Cardiology/Pneumology, University of Bonn, Bonn, Germany
| | - Dirk Skowasch
- Department of Internal Medicine II, Cardiology/Pneumology, University of Bonn, Bonn, Germany
| |
Collapse
|
65
|
Grünig E, Barner A, Bell M, Claussen M, Dandel M, Dumitrescu D, Gorenflo M, Holt S, Kovacs G, Ley S, Meyer JF, Pabst S, Riemekasten G, Saur J, Schwaiblmair M, Seck C, Sinn L, Sorichter S, Winkler J, Leuchte HH. Non-invasive diagnosis of pulmonary hypertension: ESC/ERS Guidelines with Updated Commentary of the Cologne Consensus Conference 2011. Int J Cardiol 2011; 154 Suppl 1:S3-12. [DOI: 10.1016/s0167-5273(11)70488-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
|