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Brisinda G, Fico V, Tropeano G, Altieri G, Chiarello MM. Effectiveness and safety of botulinum toxin injection in the treatment of recurrent anal fissure following lateral internal sphincterotomy: cohort study. BJS Open 2024; 8:zrad156. [PMID: 38323879 PMCID: PMC10848301 DOI: 10.1093/bjsopen/zrad156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/03/2023] [Accepted: 11/18/2023] [Indexed: 02/08/2024] Open
Affiliation(s)
- Giuseppe Brisinda
- University Department of Translational Medicine and Surgery, Catholic School of Medicine, Rome, Italy
- Emergency and Trauma Surgery Unit, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, Rome, Italy
| | - Valeria Fico
- Emergency and Trauma Surgery Unit, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, Rome, Italy
| | - Giuseppe Tropeano
- Emergency and Trauma Surgery Unit, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, Rome, Italy
| | - Gaia Altieri
- Emergency and Trauma Surgery Unit, Department of Abdominal and Endocrine Metabolic Medical and Surgical Sciences, Fondazione Policlinico Universitario A Gemelli, IRCS, Rome, Italy
| | - Maria Michela Chiarello
- General Surgery Operative Unit, Department of Surgery, Provincial Health Authority, Cosenza, Italy
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Rezvani Habibabadi M, Safaee M, Rezaei A. The Assessment of Marcaine Versus Meperidine for Spinal Anesthesia in Anorectal Surgery: A Randomized Clinical Trial. Anesth Pain Med 2023; 13:e136871. [PMID: 38476991 PMCID: PMC10928446 DOI: 10.5812/aapm-136871] [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] [Received: 04/29/2023] [Revised: 07/24/2023] [Accepted: 08/05/2023] [Indexed: 03/14/2024] Open
Abstract
Background Spinal anesthesia (SA) for the surgical management of chronic anal fissures is favored by surgeons as it provides an early return to daily activities; however, the agents applied for SA to achieve the best outcomes with minimized adverse effects are a matter of debate. Objectives This study aimed to assess the utility of Marcaine versus meperidine for SA induction of anoderm surgery. Methods This randomized clinical trial (RCT) was conducted on 138 patients with chronic anal fissures who were candidates for surgical management in 2020. The patients were randomly assigned to two groups of SA using 2.5 mL of hyperbaric Marcaine 0.5% (n = 69) or 1 mg/kg of meperidine (n = 69). Pain severity (measured via Numerical Rating Scale (NRS)), anal sphincter tone manometry (measured at baseline and the end of the sphincterotomy), and drug-related adverse effects were compared between the groups. Results Both agents led to significant pain relief within 24 hours after SA (P < 0.05); nevertheless, pain severity was remarkably lower in meperidine-treated patients in different measurements performed during the first 24 hours after SA (P < 0.05). The sphincteric tone significantly decreased in both groups (P < 0.001), while the postoperative tone was significantly less in the Marcaine-treated patients (65.22 ± 3.02 versus 46.04 ± 1.97, P < 0.001). The two groups did not differ regarding the adverse effects (P > 0.05). Conclusions Meperidine for SA in anal fissure surgical management was relatively superior to Marcaine, as postoperative pain control was remarkably better achieved with meperidine. However, anal sphincter tone reached a normal range in Marcaine-treated cases, and the average tone in those anesthetized with meperidine was slightly above the normal limits.
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Affiliation(s)
- Mehran Rezvani Habibabadi
- Department of Anesthesiology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Masumeh Safaee
- Department of General Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Rezaei
- Department of General Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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Cheng Y, Mao M, Shang Y, Ying C, Guo L, Lu Y. Chemical sphincterotomy in posthemorrhoidectomy pain relief: a meta-analysis. BMC Surg 2023; 23:113. [PMID: 37161404 PMCID: PMC10169460 DOI: 10.1186/s12893-023-02025-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/03/2023] [Indexed: 05/11/2023] Open
Abstract
PURPOSE This study aims to evaluate the pain relief function of chemical sphincterotomy in patients undergoing haemorrhoid surgery and compare, through a meta-analysis, the different drugs used to treat this condition. METHODS We conducted a search in databases including PubMed, EMBASE and Web of Science. The methodological quality was evaluated using the Revised Cochrane risk-of-bias tool for randomized trials (ROB2). The pain score was assessed using a visual analogue scale (VAS) on day 1, day 2, and day 7, and a meta-analysis was conducted based on the use of random effects models. In addition, the subgroup analysis was evaluated based on the kind of experimental drugs. Heterogeneity and publication bias were assessed. RESULTS Fourteen studies with a total of 681 patients were included in this meta-analysis, and all studies were randomized controlled trials RCTs. Chemical sphincterotomy showed better pain relief function than placebo on day 1 (SMD: 1.16, 95% CI 0.52 to 1.80), day 2 (SMD: 2.12, 95% CI 1.37 to 2.87) and day 7 (SMD: 1.97, 95% CI 1.17 to 2.77) after surgery. In the subgroup meta-analysis, we found that different drugs for chemical sphincterotomy provided different pain relief. CONCLUSION Chemical sphincterotomy effectively relieves pain after haemorrhoidectomy, and calcium channel blockers have the best effect.
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Affiliation(s)
- Yifan Cheng
- Department of Gastrointestinal Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 150 Ximen Street, Linhai, Taizhou, 318000, Zhejiang, China
| | - Misha Mao
- Department of Surgical Oncology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yaqian Shang
- Department of Gastrointestinal Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 150 Ximen Street, Linhai, Taizhou, 318000, Zhejiang, China
| | - Chaomei Ying
- Department of Gastrointestinal Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 150 Ximen Street, Linhai, Taizhou, 318000, Zhejiang, China
| | - Linnan Guo
- Department of Gastrointestinal Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 150 Ximen Street, Linhai, Taizhou, 318000, Zhejiang, China
| | - Yong Lu
- Department of Gastrointestinal Surgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, No. 150 Ximen Street, Linhai, Taizhou, 318000, Zhejiang, China.
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Modified open posterior internal sphincterotomy with sliding skin graft for chronic anal fissure and anal stenosis: Low recurrence rate and no serious faecal incontinence postoperative complication. J Visc Surg 2021; 159:267-272. [PMID: 34303637 DOI: 10.1016/j.jviscsurg.2021.07.002] [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: 11/22/2022]
Abstract
AIM Lateral internal sphincterotomy (LIS) remains a standard for chronic anal fissure even though other surgical techniques have shown high efficacy. Faecal incontinence is a well-documented complication of LIS. We devised modified open posterior internal sphincterotomy (m-OPIS) with sliding skin graft (SSG), which is a combined procedure of OPIS and anal advancement flap. The aim of this study is to evaluate m-OPIS+SSG. METHODS This was a retrospective, observational, single-arm study. m-OPIS+SSG was performed for chronic anal fissure and anal stenosis. m-OPIS involved incision of the internal sphincter muscle at the posterior midline until four fingers could be passed. The incision wound was closed by anastomosis of the anoderm and skin. Then, an arcuate skin incision was created and the skin graft was advanced into the anal canal. Follow-up was conducted by clinical consultation and telephone interview. Faecal continence was assessed by Cleveland Clinic Faecal Incontinence (CCFI) score. RESULTS m-OPIS+SSG was performed in 143 patients. The mean patient age was 50±16 years. The success and overall recurrence rates after m-OPIS+SSG were 99% and 0.7%, respectively, with a median follow-up period of 16.3 years. One patient developed incontinence with liquid stools once during the 6-month period. None of the other patients suffered permanent faecal incontinence postoperatively. The postoperative CCFI score was 0.5±0.9. CONCLUSIONS We consider m-OPIS+SSG as one of the efficacious options of procedure for chronic anal fissure and anal stenosis, owing to its high success rate, low recurrence rate and no postoperative complication of serious faecal incontinence.
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Lee KH, Hyun K, Yoon SG, Lee JK. Minimal Lateral Internal Sphincterotomy (LIS): Is It Enough to Cut Less Than the Conventional Tailored LIS? Ann Coloproctol 2021; 37:275-280. [PMID: 34246204 PMCID: PMC8566144 DOI: 10.3393/ac.2020.00976.0139] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/15/2021] [Indexed: 11/05/2022] Open
Abstract
Purpose Anal fissure is a common anorectal condition, yet its pathogenesis remains unclear. Lateral internal sphincterotomy (LIS) is the gold standard treatment for chronic anal fissures that do not respond to conservative treatment; however, it has a risk of anal incontinence. We believe that fibrosis of the internal anal sphincter is an important factor in the pathogenesis of chronic anal fissure. In this study, we describe the minimal LIS method, a minimally invasive method where only the fibrotic portion of the internal anal sphincter is cut. We also describe the outcomes of this method. Methods We performed a retrospective review of 468 patients (270 male and 198 female) who underwent minimal LIS for chronic anal fissure in 2017 at Seoul Song Do Hospital. We analyzed the patients’ clinical characteristics, manometry data, complications, and outcomes of minimal LIS. The outcomes of the surgery were assessed via questionnaires during the postoperative outpatient visits, beginning 2 weeks postoperatively. Results The overall complication rate was 4.0% (19 patients). Delayed healing occurred in 14 patients (3.0%), perianal abscess was present in 3 patients (0.6%), and gas incontinence occurred in 2 patients (0.4%). All complications were improved with conservative treatment. Recurrence, defined as the recurrence of anal fissure more than 4 weeks after healing, was present in 6 patients (1.3%). Conclusion Minimal LIS is a safe and effective treatment option for patients with chronic anal fissure. Postoperative complications, especially incontinence and recurrence, are rare.
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Affiliation(s)
- Keun-Hee Lee
- Department of Surgery, Seoul Song Do Hospital, Seoul, Korea
| | - Keehoon Hyun
- Department of Surgery, Seoul Song Do Hospital, Seoul, Korea
| | - Seo-Gue Yoon
- Department of Surgery, Seoul Song Do Hospital, Seoul, Korea
| | - Jong-Kyun Lee
- Department of Surgery, Seoul Song Do Hospital, Seoul, Korea
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Sungurtekin U, Ozgen U, Sungurtekin H. "Prospective, Randomized, Controlled Trial of Ultra-modified Internal Sphincterotomy vs Closed Lateral Internal Sphincterotomy for Chronic Fissure-in-Ano". Am Surg 2021; 88:2388-2396. [PMID: 33861669 DOI: 10.1177/00031348211011104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Currently, the lateral internal sphincterotomy is the treatment of choice for a chronic anal fissure (CAF). However, the length of the internal sphincter incision varies, due to lack of standardization. Insufficient length increases the risk of recurrence. To compare a new ultra-modified internal sphincterotomy (UMIS) to the closed lateral internal sphincterotomy (CLIS) for treating CAF, based on internal anal sphincter function and postoperative complications. The primary endpoint was continence after UMIS. The secondary outcomes were CAF healing complications, visual analog scale pain scores, and sphincter pressures. METHODS This was a prospective, randomized, controlled trial (block randomization method). 200 patients with CAFs were randomly assigned to receive either UMIS (n = 100) or the closed lateral internal sphincterotomy (CLIS) (n = 100). Follow-up was 2 years. RESULTS: All (100%) patients in both groups showed clinical improvement at 1 month post-surgery. Recurrences were accompanied by deteriorations in Cleveland Clinic Florida Fecal Incontinence scores at 12 months and 2 years (P < .05). The groups showed significant differences in fissure healing rates and pain scores. After 1 and 2 years, incontinence rates were significantly higher, and patient satisfaction scores were significantly lower in the CLIS group than the UMIS group (P < .05). CONCLUSION UMIS provided a faster healing rate and fewer side effects than the CLIS for treating CAFs. These results might lead to a standardized treatment among surgeons.
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Affiliation(s)
- Ugur Sungurtekin
- Department of General Surgery, Division of Colon & Rectal Surgery, 64052Pamukkale University School of Medicine, Denizli, Turkey
| | - Utku Ozgen
- Department of General Surgery, Division of Colon & Rectal Surgery, 64052Pamukkale University School of Medicine, Denizli, Turkey
| | - Hulya Sungurtekin
- Department of Anesthesiology & Critical Care, 64052Pamukkale University School of Medicine, Denizli, Turkey
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Mosleh G, Hosseini SV, Azadi A, Bahrami F, Ghahramani L, Badr P, Zaeri M, Abolhassanzadeh Z, Mohagheghzadeh A. Erysimum cheiri and Rosa × damascena cerate vs. Diltiazem 2% gel in the treatment of acute anal fissure: A randomized, controlled clinical trial. Eur J Integr Med 2020. [DOI: 10.1016/j.eujim.2020.101230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Soltany S, Hemmati HR, Toussy JA, Salehi D, Toosi PA. Therapeutic properties of botulinum toxin on chronic anal fissure treatment and the patient factors role. J Family Med Prim Care 2020; 9:1562-1566. [PMID: 32509650 PMCID: PMC7266196 DOI: 10.4103/jfmpc.jfmpc_944_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/21/2020] [Accepted: 03/03/2020] [Indexed: 12/28/2022] Open
Abstract
Background: One of the most frequent distressing diseases which causes anal pain and bleeding after defecation is anal fissure. Despite a poorly understood pathogenesis, the internal anal sphincter spasm has been identified to play a central role in pathogenesis. Recently, botulinum toxin is being used increasingly for the treatment of chronic anal fissure to achieve chemical sphincterotomy and reduce internal sphincter tonicity. Based on the heterogeneity among the published studies, we aimed this study to evaluate its healing rate and for recognizing the factors of patients which may affect the outcome. Subjects and Methods: In a prospective case series medical research, 106 patients who suffer from chronic anal fissure were treated by botulinum toxin injections. All patients received 30 units of botulinum toxin and were physically examined every week for 2 months. They were evaluated for bleeding, pain, hematoma, thrombosis, infection, incontinence, and healing of the fissure. At the end of the follow-up period, the fissure healing rate and its relation to age, gender, prior topical therapy, duration of symptoms, and the position of the fissure were assessed. Results: At the end of the study (8 weeks), the healing rate was 84.9% (90 patients responded to injections). Healing rate was higher in females and in patients who experienced a shorter duration of symptoms before injection. The mean healing time was 4.68 weeks. In addition, patients with one fissure (anterior or posterior) demonstrated higher healing rate and shorter healing time compared to patients with two fissures (anterior and posterior). Conclusion: This study demonstrated that botulinum toxin injection is safe and effective for the treatment of chronic anal fissures, with a low complication rate. In addition, the healing rate was higher in females, patients with shorter duration of symptoms, and those with one fissure.
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Affiliation(s)
- Setareh Soltany
- Cancer Research Center, Kowsar Hospital, Semnan University of Medical Sciences, Semnan, Iran
| | - Hamid Reza Hemmati
- Department of Surgery, Kowsar Hospital, Semnan University of Medical Sciences, Semnan, Iran
| | - Jafar Alavy Toussy
- Department of Pathology, Semnan University of Medical Sciences, Semnan, Iran
| | - Dina Salehi
- Department of Medicine, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran
| | - Parisa Alavi Toosi
- Department of Medicine, School of Medicine, Semnan University of Medical Sciences, Semnan, Iran
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Hancke E, Suchan K, Völke K. Anokutaner Advancement-Flap zur sphinkterschonenden chirurgischen Therapie der chronischen Analfissur. COLOPROCTOLOGY 2020. [DOI: 10.1007/s00053-020-00449-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
PURPOSE OF REVIEW Anal fissures are very common. They are easy to diagnose and treat in the office setting. They may coexist with hemorrhoids. In fact 20% of patients with hemorrhoids have anal fissures also. The purpose of this review is to highlight current diagnosis and treatment of anal fissures using diet, ointments and botulinum toxin to enable healing. Medical treatment relies on reducing anal sphincter spasm to allow improved blood flow and healing. RECENT FINDINGS Many anorectal disorders can be managed in the office. Most anal fissures can be managed without the need for surgery. The need for anorectal examination, including use of anoscopy is stressed in the current literature. The use of calcium channel blockers in preference to nitroglycerin is highlighted as well as the use of botulinum toxin when ointments don't work. SUMMARY Anal fissure can be managed nonsurgically most of the time and gastroenterologists should be able to manage them. This article should help in preventing unnecessary surgery and its complications, mainly incontinence in a small but significant number. The search for more effective drugs and options for managing this disorder continues.
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Acar T, Acar N, Güngör F, Kamer E, Güngör H, Candan MS, Bağ H, Tarcan E, Dilek ON, Haciyanli M. Treatment of chronic anal fissure: Is open lateral internal sphincterotomy (LIS) a safe and adequate option? Asian J Surg 2019; 42:628-633. [DOI: 10.1016/j.asjsur.2018.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/04/2018] [Accepted: 10/02/2018] [Indexed: 12/18/2022] Open
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Ivanova NA, Trapani A, Franco CD, Mandracchia D, Trapani G, Franchini C, Corbo F, Tripodo G, Kolev IN, Stoyanov GS, Bratoeva KZ. In vitro and ex vivo studies on diltiazem hydrochloride-loaded microsponges in rectal gels for chronic anal fissures treatment. Int J Pharm 2018; 557:53-65. [PMID: 30580086 DOI: 10.1016/j.ijpharm.2018.12.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/17/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022]
Abstract
Diltiazem hydrochloride, topically applied at 2% concentration, is considered effective for the treatment of chronic anal fissures, although it involves several side effects among which anal pruritus and postural hypotension. To test the hypothesis that a sustained delivery system of diltiazem hydrochloride may be helpful for the treatment of chronic anal fissures, in the present study we evaluated the potential of gels containing diltiazem hydrochloride entrapped in microsponges. Such microsponges were based on Eudragit RS 100 and the effect of some formulation variables was assessed by a 23 full factorial screening design. An optimized formulation of diltiazem hydrochloride microsponges was dispersed in Methylcellulose 2% or Poloxamer 407 20% and the resulting gels (micro-l-diltiazem hydrochloride 2%) were subjected to in vitro drug release, ex vivo permeability and drug deposition after application on porcine rectal mucosa. The results showed a prolonged release up to 24 h from micro-l-diltiazem hydrochloride at 2% in the gels. The permeation tests revealed up to 18% higher drug retention on the mucosal tissue after 24 h by the micro-l-diltiazem hydrochloride 2% gels compared to conventional diltiazem hydrochloride gels at 2%. These results suggest that diltiazem hydrochloride-loaded microsponges dispersed in rectal gels may be useful to overcome some limitations of conventional local chronic anal fissure therapy.
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Affiliation(s)
- Nadezhda Antonova Ivanova
- Faculty of Pharmacy, Medical University, "Prof. Dr. Paraskev Stoyanov", 84 Tsar Osvoboditel str., Varna, Bulgaria
| | - Adriana Trapani
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Via Orabona, 4, 70125 Bari, Italy.
| | | | - Delia Mandracchia
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Via Orabona, 4, 70125 Bari, Italy
| | - Giuseppe Trapani
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Via Orabona, 4, 70125 Bari, Italy
| | - Carlo Franchini
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Via Orabona, 4, 70125 Bari, Italy
| | - Filomena Corbo
- Department of Pharmacy-Drug Sciences, University of Bari "Aldo Moro", Via Orabona, 4, 70125 Bari, Italy
| | - Giuseppe Tripodo
- Department of Drug Sciences, University of Pavia, Viale Taramelli, 12, 27100 Pavia, Italy
| | - Iliyan Nikolov Kolev
- Faculty of Pharmacy, Medical University, "Prof. Dr. Paraskev Stoyanov", 84 Tsar Osvoboditel str., Varna, Bulgaria
| | - Georgi Stoyanov Stoyanov
- Department of General and Clinical Pathology, Forensic Medicine and Deontology, Faculty of Medicine, Medical University, "Prof. Dr. Paraskev Stoyanov", 55 Marin Drinov str., Varna, Bulgaria; Faculty of Medicine, Medical University, "Prof. Dr. Paraskev Stoyanov", 55 Marin Drinov str., Varna, Bulgaria
| | - Kameliya Zhechkova Bratoeva
- Faculty of Medicine, Medical University, "Prof. Dr. Paraskev Stoyanov", 55 Marin Drinov str., Varna, Bulgaria
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