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Elheet AA, Elhadidy AF, Farrag MH, Mahmoud MA, Ibrahim AA, AlAbdali AM, Kazim H, Elganainy MN. Ultrasound-Facilitated, Catheter-Directed Thrombolysis for Acute Pulmonary Embolism. Cureus 2024; 16:e57345. [PMID: 38690498 PMCID: PMC11060753 DOI: 10.7759/cureus.57345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Acute pulmonary embolism (APE) poses a significant risk to patient health, with treatment options varying in efficacy and safety. Ultrasound-facilitated catheter-directed thrombolysis (USCDT) has emerged as a potential alternative to conventional catheter-directed thrombolysis (CDT) for patients with intermediate to high-risk APE. This study aimed to compare the efficacy and safety of USCDT versus conventional CDT in patients with intermediate to high-risk APE. METHODS This observational retrospective study was conducted at the Armed Forces Hospital, Al-Hada, Taif, the Kingdom of Saudi Arabia (KSA), on 135 patients diagnosed with APE and treated with either USCDT or CDT (58 underwent CDT, while 77 underwent USCDT). The primary efficacy outcome was the change in the right ventricle to the left ventricle (RV/LV) diameter ratio. Secondary outcomes included changes in pulmonary artery systolic pressure and the Miller angiographic obstruction index score. Safety outcomes focused on major bleeding events. RESULTS Both USCDT and CDT significantly reduced RV/LV diameter ratio (from 1.35 ± 0.14 to 1.05 ± 0.17, P < 0.001) and systolic pulmonary artery pressure (SPAP) (from 55 ± 7 mmHg to 38 ± 7 mmHg, P < 0.001) at 48- and 12-hours post-procedure, respectively, with no significant differences between treatments. However, USCDT was associated with a significantly lower rate of major bleeding events compared to CDT (0% vs. 3.4%, P = 0.008). Multivariate logistic regression analysis revealed that USCDT was associated with a 71.9% risk reduction of bleeding (OR = 0.281, 95% CI = 0.126 - 0.627, P = 0.002). CONCLUSIONS USCDT is a safe and effective alternative to CDT for the treatment of intermediate to high-risk APE, as it significantly reduces the risk of major bleeding.
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Affiliation(s)
- Ahmed A Elheet
- Cardiovascular Disease, Mahalla Cardiac Center, Tanta, EGY
- Cardiovascular Disease, Al Hada Armed Forces Hospital, Taif, SAU
| | | | - Mohamad H Farrag
- Cardiovascular Medicine, Al Hada Armed Force Hospital, Taif, SAU
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Ventenilla J, Rushing T, Ngu B, Shavelle D, Rai N. Ultrasound-Assisted Catheter-Directed Thrombolysis for the Management of Pulmonary Embolism: A Single Center Experience in a Community Hospital. J Cardiovasc Pharmacol Ther 2024; 29:10742484241238656. [PMID: 38483845 DOI: 10.1177/10742484241238656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Current guidelines recommend anticoagulation alone for low-risk pulmonary embolism (PE) with the addition of systemic thrombolysis for high-risk PE. However, treatment recommendations for intermediate-risk PE are not well-defined. Due to bleeding risks associated with systemic thrombolysis, ultrasound-assisted catheter-directed thrombolysis (USAT) has evolved as a promising treatment modality. USAT is thought to decrease the rate of major bleeding by using localized delivery with lower thrombolytic dosages. Currently, there is little guidance on the implementation of USAT in the real-world clinical setting. This study was designed to evaluate our experience with USAT at this single community hospital with a newly initiated Pulmonary Embolism Response Team (PERT). All patients identified by the PERT with an acute PE diagnosed by a computed tomography (CT) scan from January 2021 to January 2023 were included. During the study period, there were 89 PERT activations with 40 patients (1 high-risk and 37 intermediate-risk PE) receiving USAT with alteplase administered at a fixed rate of 1 mg/h per catheter for 6 h. The primary efficacy outcome was the change in Pulmonary Embolism Severity Index (PESI) score within 48 h after USAT. The primary safety outcome was major bleeding within 72 h. The mean age was 57.4 ± 17.4 years and 50% (n = 20) were male, 17.5% (n = 7) had active malignancy, and 20% (n = 8) had a history of prior deep vein thrombosis (DVT) or PE. The mean PESI score decreased from baseline to 48 h post-USAT (84.7 vs 74.9; p = 0.025) and there were no major bleeding events. The overall hospital length of stay was 7.5 ± 9.8 days and ICU length of stay was 2.2 ± 2.8 days. This study outlined our experience at this single community hospital which resulted in an improvement in PESI scores and no major bleeding events observed.
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Affiliation(s)
- Jasmine Ventenilla
- Department of Pharmacy, MemorialCare Long Beach Medical Center, Long Beach, CA, USA
| | - Todd Rushing
- Department of Pharmacy, MemorialCare Long Beach Medical Center, Long Beach, CA, USA
| | - Becky Ngu
- Department of Pharmacy, MemorialCare Long Beach Medical Center, Long Beach, CA, USA
| | - David Shavelle
- Department of Cardiology, MemorialCare Heart and Vascular Institute, Long Beach Medical Center, Long Beach, CA, USA
| | - Neepa Rai
- Department of Pharmacy, MemorialCare Long Beach Medical Center, Long Beach, CA, USA
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Sun B, Chen RR. A comparison of the efficacy and safety between anticoagulation alone and combined with catheter-directed thrombolysis for treatment of pulmonary embolism on outcome: A systematic review and meta-analysis. Perfusion 2023:2676591231211753. [PMID: 37902217 DOI: 10.1177/02676591231211753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
BACKGROUND Catheter-directed thrombolysis (CDT) is one of the newest treatment options for submassive pulmonary embolism (sPE). This study will compare the efficacy and safety of catheter-directed thrombolysis (CDT) combine with anticoagulation versus anticoagulation alone (AC) in patients with PE. METHODS A database search was conducted using PubMed, EMBASE, Cochrane Library, and Clinicaltrials.gov for trials that compared CDT with AC in patients with pulmonary embolism. The primary outcomes was1-year mortality. The secondary outcomes were in-hospital, 30 days, 90 days mortality, in-hospital major and minor bleeding (Thrombolysis in Myocardial Infarction (TIMI) classification), length of hospital stay (LOS), reduction of pulmonary arterial systolic pressure (PASP) and RV/LV diameter ratio. RESULTS A total of 16 articles (3 RCTs and 13 non-RCTs) and 10595 patients were included in this study. 2237 patients were in the CDT group and 8358 patients were in the AC group. CDT group was associated with significantly lower in-hospital mortality (2.1% vs 6.2%,OR:0.36, 95%CI:0.26-0.51, p < .00001,I2 = 0%), 30 days mortality (3.1% vs 8.6%,OR:0.39,95%CI:0.23-0.66, p = .0005, I2 = 0%), 90 days mortality (3.8% vs 7.7%,OR:0.49,95%CI:0.29-0.80,p = .005,I2 = 7%), 1-year mortality (6.1% vs 11%, OR:0.51, 95%CI:0.35-0.76, p = .0008,I2 = 36%) compared to AC group, especially in ultrasound-assisted thrombolysis (USAT) subgroup. There were no differences on major bleeding between two groups (1.8% vs 2.2%, OR:1.10, 95%CI:0.61-1.98, p = .75, I2 = 0%). Minor bleeding was significantly higher in CDT group than AC group (6.2% vs 3.8%, OR:1.93,95%CI:1.27-2.94.66, p = .002, I2 = 1%). CDT group significantly reduced PASP (WMD:11.90,95%CI:6.45-17.35, p < .0001, I2 = 72%) and RV/LV (WMD:0.17,95%CI:0.04-0.30, p = .009, I2 = 69%) rapidly than AC group after treatment. LOS was similar between two groups (WMD:0.02,95%CI: -0.68-0.73, p = .95, I2 = 51%). CONCLUSION Results thus confirmed that CDT reduced in-hospital, 30 days, 90 days and 1-year all-cause mortality in patients with sPE compared to AC, particularly in USAT subgroup. Nonetheless, CDT group was associated with a higher risk of minor bleeding.
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Affiliation(s)
| | - Rui Rui Chen
- Department of Cardiology, Tang Du Hospital, Air Force Medical University, Shaanxi, China
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Balakrishna AM, Kalathil RAM, Pusapati S, Atreya A, Mehta A, Bansal M, Aggarwal V, Basir MB, Kochar A, Truesdell AG, Vallabhajosyula S. Comparative Outcomes of Catheter-Directed Thrombolysis Plus Systemic Anticoagulation Versus Systemic Anticoagulation Alone in the Management of Intermediate-Risk Pulmonary Embolism in a Systematic Review and Meta-Analysis. Am J Cardiol 2023; 205:249-258. [PMID: 37619491 DOI: 10.1016/j.amjcard.2023.07.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 08/26/2023]
Abstract
There are limited and conflicting data on the initial management of intermediate-risk (or submassive) pulmonary embolism (PE). This study sought to compare the outcomes of catheter-directed thrombolysis (CDT) in combination with systemic anticoagulation (SA) to SA alone. A systematic search was conducted in MEDLINE, EMBASE, PubMed, and the Cochrane databases from inception to March 1, 2023 for studies comparing the outcomes of CDT + SA versus SA alone in intermediate-risk PE. The outcomes were in-hospital, 30-day, 90-day, and 1-year mortality; bleeding; blood transfusion; right ventricular recovery; and length of stay. Random-effects models was used to calculate the pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs). A total of 15 (2 randomized and 13 observational) studies with 10,549 (2,310 CDT + SA and 8,239 SA alone) patients were included. Compared with SA, CDT + SA was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.001), 30-day mortality (RR 0.34, 95% CI 0.18 to 0.67, p = 0.002), 90-day mortality (RR 0.34, 95% CI 0.17 to 0.67, p = 0.002), and 1-year mortality (RR 0.58, 95% CI 0.34 to 0.97, p = 0.04). There were no significant differences between the 2 cohorts in the rates of major bleeding (RR 1.39, 95% CI 0.72 to 2.68, p = 0.56), minor bleeding (RR 1.83, 95% CI 0.97 to 3.46, p = 0.06), and blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p = 0.08). In conclusion, CDT + SA is associated with significantly lower short-term and long-term all-cause mortality, without any differences in major/minor bleeding, in patients with intermediate-risk PE.
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Affiliation(s)
| | | | - Suma Pusapati
- Department of Medicine, Creighton University School of Medicine, Omaha, Nebraska
| | - Auras Atreya
- Division of Cardiovascular Medicine, Department of Medicine, University of Arkansas School of Medicine, Little Rock, Arkansas
| | - Aryan Mehta
- Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Mridul Bansal
- Department of Medicine, East Carolina Brody School of Medicine, Greenville, North Carolina
| | - Vikas Aggarwal
- Section of Cardiovascular Medicine, Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Mir B Basir
- Section of Cardiovascular Medicine, Department of Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Ajar Kochar
- Section of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | | | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina.
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Ishisaka Y, Watanabe A, Fujisaki T, Iwagami M, So M, Steiger D, Aoi S, Secemsky EA, Wiley J, Kuno T. Comparison of interventions for intermediate to high-risk pulmonary embolism: A network meta-analysis. Catheter Cardiovasc Interv 2023. [PMID: 37269229 DOI: 10.1002/ccd.30745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/20/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Multiple interventions, including catheter-directed therapy (CDT), systemic thrombolysis (ST), surgical embolectomy (SE), and therapeutic anticoagulation (AC) have been used to treat intermediate to high-risk pulmonary embolism (PE), but the most effective and safest treatment remains unclear. Our study aimed to investigate the efficacy and safety outcomes of each intervention. METHODS We queried PubMed and EMBASE in January 2023 and performed a network meta-analysis of observational studies and randomized controlled trials (RCT), including high or intermediate-risk PE patients, and comparing AC, CDT, SE, and ST. The primary outcomes were in-hospital mortality and major bleeding. The secondary outcomes included long-term mortality (≥6 months), recurrent PE, minor bleeding, and intracranial hemorrhage. RESULTS We identified 11 RCTs and 42 observational studies involving 157,454 patients. CDT was associated with lower in-hospital mortality than ST (odds ratio [OR] [95% confidence interval (CI)]: 0.41 [0.31-0.55]), AC (OR [95% CI]: 0.33 [0.20-0.53]), and SE (OR [95% CI]: 0.61 [0.39-0.96]). Recurrent PE in CDT was lower than ST (OR [95% CI]: 0.66 [0.50-0.87]), AC (OR [95% CI]: 0.36 [0.20-0.66]), and trended lower than SE (OR [95% CI]: 0.71 [0.40-1.26]). Notably, ST had higher major bleeding risks than CDT (OR [95% CI]: 1.51 [1.19-1.91]) and AC (OR [95% CI]: 2.21 [1.53-3.19]). By rankogram analysis, CDT presented the highest p-score in in-hospital mortality, long-term mortality, and recurrent PE. CONCLUSION In this network meta-analysis of observational studies and RCTs involving patients with intermediate to high-risk PE, CDT was associated with improved mortality outcomes compared to other therapies, without significant additional bleeding risk.
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Affiliation(s)
- Yoshiko Ishisaka
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA
| | - Atsuyuki Watanabe
- Division of Hospital Medicine, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
| | - Tomohiro Fujisaki
- Department of Cardiovascular Medicine, University of Kumamoto, Kumamoto, Japan
| | - Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Matsuo So
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA
| | - David Steiger
- Department of Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA
| | - Shunsuke Aoi
- Division of Cardiology, Billings Clinic, Billing, Montana, USA
| | - Eric A Secemsky
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jose Wiley
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York, USA
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Sun B, Yang JX, Wang ZK, Zhou HJ, Chu Y, Li Y, Chen RR. Clinical efficacy and safety of ultrasound-assisted thrombolysis vs. standard catheter-directed thrombolysis in patients with acute pulmonary embolism: A study level meta-analysis of clinical trials. Front Cardiovasc Med 2022; 9:967786. [PMID: 36277787 PMCID: PMC9581227 DOI: 10.3389/fcvm.2022.967786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Aim To compare the clinical efficacy of ultrasound-assisted thrombolysis (USAT) vs. standard catheter-directed thrombolysis (SCDT) in patients with acute pulmonary embolism (aPE). Methods This study analyzed the clinical outcomes of patients with non-low-risk aPE who received USAT or SCDT. The primary outcomes were all-cause death, total bleeding, and major bleeding. Secondary outcomes included pulmonary thrombotic load score (Miller), improvement in right ventricular-to-left ventricular ratio (RV/LV), dose and duration of the thrombolytic drug tissue plasminogen activator (tPA), length of stay (LOS) in the ICU, and total LOS in the hospital. Results A total of seven articles and 451 patients were included in this study. 241 patients were in the USAT group and 210 patients were in the SCDT group. There were no significant differences in all-cause mortality, total bleeding, and major bleeding between the two groups. Miller scores for pulmonary thrombus also showed no difference between the two groups, but pulmonary artery systolic pressure (PASP) was lower in the SCDT group after-treatment. The reduction of RV/LV from baseline was more pronounced in the SCDT group than in the USAT group (OR: -0.14, 95%CI: -0.20 to 0.07, P < 0.0001, I 2 = 0%). Total dose of tPA and duration of infusion in the USAT group were lower than those in the SCDT group, but there was no significant statistical difference. LOS in the ICU was similar between the two groups, while LOS in the hospital was lower in the SCDT group. Conclusion This study did not detect any differences in all-cause mortality, total bleeding, and major bleeding between non-low-risk aPE patients treated with USAT or SCDT. Improvement in right ventricular function was better in the SCDT group, and hospital LOS was lower in the SCDT group.
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Meta-Analysis Comparing Catheter-Directed Thrombolysis Versus Systemic Anticoagulation Alone for Submassive Pulmonary Embolism. Am J Cardiol 2022; 178:154-162. [PMID: 35778309 DOI: 10.1016/j.amjcard.2022.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/21/2022] [Accepted: 06/01/2022] [Indexed: 12/12/2022]
Abstract
The optimal therapy for submassive pulmonary embolism (sPE), defined by right ventricular dysfunction without hemodynamic instability, is uncertain. We conducted a systematic review and meta-analysis to compare the outcomes of catheter-directed thrombolysis (CDT) versus systemic anticoagulation (SA) alone in patients with sPE. We searched PubMed, EMBASE, Cochrane, ClinicalTrials.gov, and Google Scholar (from inception through May 2022) for studies comparing outcomes of CDT versus SA in sPE. Studies were identified, and data were extracted by 2 independent reviewers. We used a random-effects model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Outcomes included in-hospital, 30-day, 90-day, and 1-year mortality, major and minor bleeding, and need for blood transfusion. A total of 12 studies (1 randomized, 11 observational) with 9,789 patients were included. Compared with SA, CDT was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.00001), 30-day mortality (RR 0.37, 95% CI 0.18 to 0.73, p = 0.004), 90-day mortality (RR 0.36, 95% CI 0.17 to 0.72, p = 0.004), and a tendency toward lower 1-year mortality (RR 0.56, 95% CI 0.29 to 1.05, p = 0.07). The risks of major bleeding (RR 1.31, 95% CI 0.57 to 3.01, p = 0.53), minor bleeding (RR 1.67, 95% CI 0.77 to 3.63, p = 0.20), and the rates of blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p = 0.08) were similar between the 2 strategies. In conclusion, in patients with sPE, CDT is associated with significantly lower in-hospital, 30-day, and 90-day mortality and a tendency toward lower 1-year mortality with similar bleeding rates compared with SA. This study expands the evidence supporting CDT as first-line therapy for sPE, and randomized controlled trials are indicated to confirm our findings.
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Bradley M, Bull T, Hountras P, MacLaren R. Pragmatic Use of Catheter-Directed Thrombolysis in Venous Thromboembolism and a Comparative Evaluation With Traditional Therapies in Submassive Pulmonary Embolism. J Pharm Pract 2021; 35:738-746. [PMID: 33823705 DOI: 10.1177/08971900211004833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Catheter-directed thrombolysis (CDT) is a novel treatment for venous thromboembolism (VTE). Limited data describe pragmatic use of CDT and compare CDT to other VTE therapies. OBJECTIVE Assess the use of CDT and comparatively evaluate CDT, anticoagulation, and systemic thrombolysis in submassive pulmonary embolism (PE). METHODS Retrospective, single-center, chart audit. Part 1 described all patients who received CDT for VTE. Part 2 matched patients with submassive PE who received CDT, heparin, or systemic thrombolysis and assessed length of stay (LOS), bleeding, all cause in-hospital mortality, and escalation of care. RESULTS For part 1, 70 CDT patients were identified; 42 with DVT and 28 with PE. ICU LOS was longer (2.5 ± 2.9 vs. 4.9 ± 8.4 days, p = 0.07), escalation of care more frequent (0% vs. 35.7%, p < 0.0001), and hospital mortality greater (2.4% vs. 21.4%, p = 0.014) in the PE group. For part 2, 21 CDT patients were matched to 21 heparin and 21 systemic thrombolysis patients. All CDT and tPA patients were admitted to the ICU versus only 6 (28.6%, p < 0.001) heparin patients. ICU LOS was significantly longer in the CDT group versus systemic tPA and systemic anticoagulation (80.7 ± 64.1 vs. 48.2 ± 27.7 vs. 24.9 ± 59.1 hours; p = 0.0048). More IVC filters and thrombectomies were performed in the CDT group. CONCLUSIONS CDT is frequently used for both DVT and PE and requires ICU admission. Escalation of care is common when CDT is used for PE. For submassive PE, CDT is associated with prolonged ICU LOS compared to heparin or systemic thrombolysis. Resource utilization with CDT requires further evaluation.
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Affiliation(s)
- Mary Bradley
- Department of Clinical Pharmacy, 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.,Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
| | - Todd Bull
- Division of Pulmonary Sciences & Critical Care Medicine, Department of Medicine, Pulmonary Vascular Disease Center, University of Colorado School of Medicine, Aurora, CO, USA
| | - Peter Hountras
- Division of Pulmonary Sciences & Critical Care Medicine, Department of Medicine, Pulmonary Vascular Disease Center, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert MacLaren
- Department of Clinical Pharmacy, 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA.,Department of Pharmacy, University of Colorado Hospital, Aurora, CO, USA
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