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Is Misoprostol Vaginal Insert Safe for the Induction of Labor in High-Risk Pregnancy Obese Women? Healthcare (Basel) 2021; 9:healthcare9040464. [PMID: 33919898 PMCID: PMC8070889 DOI: 10.3390/healthcare9040464] [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] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/07/2021] [Accepted: 04/12/2021] [Indexed: 11/21/2022] Open
Abstract
Induction of labor (IOL) is an event that occurs in up to 25% of pregnancies. In Europe, the misoprostol vaginal insert (MVI—Misodel®) was approved for labor induction in 2013. Studies on the outcomes and safety of IOL in obese pregnant women are scarce; no data are available on MVI IOL in high-risk pregnancy obese women (HRPO—late-term, hypertension, diabetes). As the obesity rates are growing steadily in pregnant women, we aimed to evaluate the failure rate for induction and the safety of a 200 μg MVI in obese (body mass index (BMI) >30 kg/m2) HRPO compared to that for obese non-high-risk pregnancies (non-HRPO). For this purpose, we conducted a cross-sectional study in “Filantropia” Clinical Hospital, Bucharest, Romania, from June 2017—the date of the initiation of the MVI IOL protocol in our clinic—to September 2019. The primary outcomes were the failure rate, measured by cesarean section (CS) ratio, and secondarily, the safety profile of MVI, analyzed by one-way ANOVA. Out of a total of 11,096 registered live births, IOL was performed on 206 obese patients. Of these, 74 obese pregnant women had their labor induced with MVI (HRPO, n = 57, and non-HRPO, n = 17). The average maternal age was 29.9 ± 4.8 years (19–44 years). Across the groups, the rate of CS was 29.8% (n = 17) in the HRPO group compared to 23.5% (n = 4) in the non-HRPO group (p = non significant). In the vaginally birth subgroups, the median time from drug administration to delivery was shorter in the HRPO group compared to the non-HRPO group (16.9 ± 6.0 h 95% confidence interval (CI) 15.0–18.8 vs. 19.4 ± 9.2 h 95% CI 13.8–25.0, p = 0.03). No significant differences were found regarding the maternal outcomes among the studied groups; in terms of perinatal outcomes of safety, 5.4% (n = 4) of the cases of vaginal delivery for HRPO were associated with neonatal intensive care unit (NICU) admissions. The MVI seems to be an efficient labor induction agent in high-risk pregnancy obese women with good maternal outcomes and low perinatologic complications.
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Hokkila E, Kruit H, Rahkonen L, Timonen S, Mattila M, Laatio L, Ordén MR, Uotila J, Luukkaala T, Tihtonen K. The efficacy of misoprostol vaginal insert compared with oral misoprostol in the induction of labor of nulliparous women: A randomized national multicenter trial. Acta Obstet Gynecol Scand 2019; 98:1032-1039. [PMID: 30771243 DOI: 10.1111/aogs.13580] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/09/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Our objective was to compare the efficacy of a 200-μg misoprostol vaginal insert vs oral misoprostol regarding the cesarean section rate and the time interval to vaginal delivery in nulliparous women with unfavorable cervix. MATERIAL AND METHODS In this prospective multicenter trial, 283 nulliparous women at term with Bishop score <6 were randomized to induction of labor with either a misoprostol vaginal insert (n = 140) or oral misoprostol (n = 143). In the oral misoprostol group, a 50-μg dose of oral misoprostol was administered every 4 hours up to three times during the first day; during the second day, the dose was increased to 100-μg every 4 hours up to three times during the first day, if necessary. Primary outcome was the cesarean section rate. Secondary outcomes were the time from induction of labor to vaginal delivery, the rate of other induction methods needed, labor augmentation with oxytocin and/or amniotomy, use of tocolytics and adverse neonatal and maternal events. RESULTS In the misoprostol vaginal insert group, median time to vaginal delivery was shorter (24.5 hours vs 44.2 hours, P < 0.001), whereas no difference was found in the cesarean section rate (33.8% vs 29.6%, odds ratio [OR] 1.21, 95% confidence interval [CI] 0.66-1.91, P = 0.67). Other induction methods and labor augmentation with oxytocin and/or amniotomy were less frequent in the misoprostol vaginal insert group (OR 0.32, 95% CI 0.18-0.59 and OR 0.56, 95% CI 0.32-0.99, respectively). Need for tocolysis and meconium-stained amniotic fluid were more common in the misoprostol vaginal insert group (OR 3.63, 95% CI 1.12-11.79 and OR 2.38, 95% CI 1.32-4.29, respectively). Maternal and neonatal adverse events did not differ between groups. CONCLUSIONS Misoprostol vaginal insert proved to shorten the time to vaginal delivery and to reduce the use of other methods of labor induction and augmentation, but it did not reduce the cesarean section rate compared with oral misoprostol. The benefit of more rapid delivery associated with misoprostol vaginal insert should be weighed against the greater risks for uterine hyperstimulation and meconium-stained amniotic fluid.
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Affiliation(s)
- Emma Hokkila
- Department of Obstetrics and Gynecology, Lapland Central Hospital, Rovaniemi, Finland
| | - Heidi Kruit
- Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland.,Helsinki University, Helsinki, Finland
| | - Leena Rahkonen
- Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki, Finland.,Helsinki University, Helsinki, Finland
| | - Susanna Timonen
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland
| | - Mirjami Mattila
- Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland
| | - Liisa Laatio
- Department of Obstetrics and Gynecology, Oulu University Hospital, Oulu, Finland
| | - Maija-Riitta Ordén
- Department of Obstetrics and Gynecology, Kuopio University Hospital, Kuopio, Finland
| | - Jukka Uotila
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
| | - Tiina Luukkaala
- Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, Finland.,Research, Development and Innovation Center, Tampere University Hospital, Tampere, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynecology, Tampere University Hospital, Tampere, Finland
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Patte C, Deruelle P. A critical appraisal of the misoprostol removable, controlled-release vaginal delivery system of labor induction. Int J Womens Health 2015; 7:889-99. [PMID: 26648758 PMCID: PMC4648618 DOI: 10.2147/ijwh.s62372] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Induction of labor is a major issue in pregnancy management. Finding strategies to increase rate and decrease time to vaginal delivery is an important goal, but maternal or neonatal safety must remain the primary objective. Misoprostol is a synthetic analogue of prostaglandin used off label to ripen the cervix and induce labor. The misoprostol vaginal insert (MVI) was designed to allow a controlled-release delivery of misoprostol (from 50 to 200 μg) with a removal tape. The objective of this review was to make a critical appraisal of this device referring to the literature. METHODS A literature search was performed in the PubMed and Cochrane databases using the keywords "vaginal misoprostol insert". RESULTS Several studies compared different doses of MVI (50, 100, 150, and 200 μg) with the 10 mg dinoprostone insert. The 100 μg MVI compared with the dinoprostone vaginal insert (DVI) showed similar efficacy and no significant differences in cesarean delivery rate. MVI 200 μg compared with DVI showed a reduced time to vaginal delivery and oxytocin need but had an increased risk of uterine hyperstimulation. The rate of hyperstimulation syndrome was two to three times more frequent with the 200 μg MVI than the 100 μg. CONCLUSION Current data suggest that the 100 μg MVI would provide the best balance between efficacy and safety. Further studies should be performed to evaluate this dose, especially in high-risk situations needing induction of labor.
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Affiliation(s)
- Charlotte Patte
- Lille University Hospital, Jeanne De Flandre Maternity, Université Lille 2, Lille, France
| | - Philippe Deruelle
- Lille University Hospital, Jeanne De Flandre Maternity, Université Lille 2, Lille, France ; UPRES EA 4489, Environnement périnatal et santé, Faculté de médecine Henri Warembourg, Université Lille 2, Lille, France
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Abstract
Labor-induction rates have increased considerably in the United States as well as around the world. With up to half of all induced labors requiring cervical ripening, prostaglandins have been utilized to increase induction success and achieve vaginal delivery. Misoprostol, a synthetic prostaglandin E1 analog has the ability to mimic the changes of spontaneous labor and has been used off label for over 30 years as a labor-induction agent. In the following article, cervical ripening and induction of labor with misoprostol will be discussed. The risks and benefits of misoprostol for ripening and induction and routes of administration will be reviewed, as well as future directions and new developments for its use.
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Affiliation(s)
- Megan L Stephenson
- Department of Obstetrics and Gynecology, University of California, 101 The City Drive South, Building 56, Suite 800, Orange, Irvine, CA.
| | - Deborah A Wing
- Department of Obstetrics and Gynecology, University of California, 101 The City Drive South, Building 56, Suite 800, Orange, Irvine, CA
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Stephenson ML, Wing DA. A novel misoprostol delivery system for induction of labor: clinical utility and patient considerations. Drug Des Devel Ther 2015; 9:2321-7. [PMID: 25960635 PMCID: PMC4410824 DOI: 10.2147/dddt.s64227] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Induction of labor is one of the most commonly performed obstetric procedures and will likely become more common as the reproductive population in developed nations changes. As the proportion of women undergoing induction grows, there is a constant search for more efficacious ways to induce labor while maintaining fetal and maternal safety as well as patient satisfaction. With almost half of induced labors requiring cervical ripening, methods for achieving active labor and vaginal delivery are constantly being investigated. Prostaglandins have been shown to be effective induction agents, and specifically vaginal misoprostol, used off-label, have been widely utilized to initiate cervical ripening and active labor. The challenge is to administer this medication accurately while maintaining the ability to discontinue the medication when needed. The misoprostol vaginal insert initiates cervical ripening utilizing a delivery system that controls medication release and can be rapidly removed. This paper reviews the design, development, and clinical utility of the misoprostol vaginal insert for induction of labor as well as patient considerations related to the delivery system.
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Affiliation(s)
- Megan L Stephenson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Irvine Medical Center, Orange, CA, USA
| | - Deborah A Wing
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Irvine Medical Center, Orange, CA, USA
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Stephenson ML, Hawkins JS, Powers BL, Wing DA. Misoprostol vaginal insert for induction of labor: a delivery system with accurate dosing and rapid discontinuation. ACTA ACUST UNITED AC 2014; 10:29-36. [PMID: 24328596 DOI: 10.2217/whe.13.49] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Labor induction and cervical ripening are widely utilized and new methods are constantly being investigated. Prostaglandins have been shown to be effective labor induction agents and, in particular, were compared with other prostaglandin preparations; vaginal misoprostol used off-label was associated with reduced failure to achieve vaginal delivery. The challenge is to provide this medication with the correct dosing for this indication and with the ability to discontinue the medication if needed, all while ensuring essential maternal and neonatal safety. The misoprostol vaginal insert initiates cervical ripening using a delivery system that controls misoprostol release and can be rapidly removed. This article reviews the development, safety and efficacy of the misoprostol vaginal insert for induction of labor and cervical ripening, and will focus on vaginally administered prostaglandins.
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Affiliation(s)
- Megan L Stephenson
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of California Irvine Medical Center, 101 The City Drive South, Building 56, Suite 800, Orange, CA 92868, USA
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Yang M, Yu T, Wang YY, Lai SK, Zeng Q, Miao B, Tang BC, Simons BW, Ensign LM, Liu G, Chan KW, Juang CY, Mert O, Wood J, Fu J, McMahon MT, Wu TC, Hung CF, Hanes J. Vaginal delivery of paclitaxel via nanoparticles with non-mucoadhesive surfaces suppresses cervical tumor growth. Adv Healthc Mater 2014; 3:1044-52. [PMID: 24339398 DOI: 10.1002/adhm.201300519] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 11/21/2013] [Indexed: 12/29/2022]
Abstract
Local delivery of chemotherapeutics in the cervicovaginal tract using nanoparticles may reduce adverse side effects associated with systemic chemotherapy, while improving outcomes for early-stage cervical cancer. It is hypothesized here that drug-loaded nanoparticles that rapidly penetrate cervicovaginal mucus (CVM) lining the female reproductive tract will more effectively deliver their payload to underlying diseased tissues in a uniform and sustained manner compared with nanoparticles that do not efficiently penetrate CVM. Paclitaxel-loaded nanoparticles are developed, composed entirely of polymers used in FDA-approved products, which rapidly penetrate human CVM and provide sustained drug release with minimal burst effect. A mouse model is further employed with aggressive cervical tumors established in the cervicovaginal tract to compare paclitaxel-loaded poly(lactic-co-glycolic acid) (PLGA) nanoparticles (conventional particles, or CP) and similar particles coated with Pluronic F127 (mucus-penetrating particles, or MPP). CP are mucoadhesive and, thus, aggregated in mucus, while MPP achieve more uniform distribution and close proximity to cervical tumors. Paclitaxel-MPP suppress tumor growth more effectively and prolong median survival of mice compared with unencapsulated paclitaxel or paclitaxel-CP. Histopathological studies demonstrate minimal toxicity to the cervicovaginal epithelia, suggesting paclitaxel-MPP may be safe for intravaginal use. These results demonstrate the in vivo advantages of polymer-based MPP for treatment of tumors localized to a mucosal surface.
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Affiliation(s)
- Ming Yang
- Center for Nanomedicine, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
- Department of Biomedical Engineering; Johns Hopkins University School of Medicine; 720 Rutland Avenue Baltimore MD 21205 USA
| | - Tao Yu
- Center for Nanomedicine, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
- Department of Biomedical Engineering; Johns Hopkins University School of Medicine; 720 Rutland Avenue Baltimore MD 21205 USA
| | - Ying-Ying Wang
- Center for Nanomedicine, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
- Department of Biomedical Engineering; Johns Hopkins University School of Medicine; 720 Rutland Avenue Baltimore MD 21205 USA
| | - Samuel K. Lai
- Center for Nanomedicine, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
- Department of Chemical and Biomolecular Engineering; Johns Hopkins University; 3400 N Charles Street Baltimore MD 21218 USA
- Eshelman School of Pharmacy; University of North Carolina at Chapel; Hill, 120 Mason Farm Road Chapel Hill NC 27599 USA
| | - Qi Zeng
- Department of Pathology; Johns Hopkins University School of Medicine; 600 N Wolfe Street Baltimore MD 21287 USA
| | - Bolong Miao
- Department of Chemical and Biomolecular Engineering; Johns Hopkins University; 3400 N Charles Street Baltimore MD 21218 USA
| | - Benjamin C. Tang
- Center for Nanomedicine, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
- Department of Chemical and Biomolecular Engineering; Johns Hopkins University; 3400 N Charles Street Baltimore MD 21218 USA
- Koch Institute for Integrated Cancer Research; Massachusetts Institute of Technology; 77 Massachusetts Avenue Cambridge MA 02139 USA
| | - Brian W. Simons
- Department of Molecular and Comparative Pathobiology; Johns Hopkins University School of Medicine; 1550 Orleans Street Baltimore MD 21231 USA
| | - Laura M. Ensign
- Center for Nanomedicine, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
- Department of Chemical and Biomolecular Engineering; Johns Hopkins University; 3400 N Charles Street Baltimore MD 21218 USA
- Department of Ophthalmology; The Wilmer Eye Institute, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
| | - Guanshu Liu
- F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute; 707 N Broadway Baltimore MD 21205 USA
- The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine; 600 N Wolfe Street Baltimore MD 21287 USA
| | - Kannie W.Y. Chan
- F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute; 707 N Broadway Baltimore MD 21205 USA
- The Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine; 600 N Wolfe Street Baltimore MD 21287 USA
| | - Chih-Yin Juang
- Center for Nanomedicine, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
| | - Olcay Mert
- Department of Chemical and Biomolecular Engineering; Johns Hopkins University; 3400 N Charles Street Baltimore MD 21218 USA
| | - Joseph Wood
- Department of Biomedical Engineering; Johns Hopkins University School of Medicine; 720 Rutland Avenue Baltimore MD 21205 USA
| | - Jie Fu
- Center for Nanomedicine, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
- Department of Ophthalmology; The Wilmer Eye Institute, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
| | - Michael T. McMahon
- Center for Nanomedicine, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
| | - T.-C. Wu
- Center for Nanomedicine, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
- Department of Pathology; Johns Hopkins University School of Medicine; 600 N Wolfe Street Baltimore MD 21287 USA
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins University School of Medicine; 600 N Wolfe Street Baltimore MD 21287 USA
| | - Chien-Fu Hung
- Center for Nanomedicine, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
- Department of Pathology; Johns Hopkins University School of Medicine; 600 N Wolfe Street Baltimore MD 21287 USA
- Department of Obstetrics and Gynecology; Johns Hopkins University School of Medicine; 600 N Wolfe Street Baltimore MD 21287 USA
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins University School of Medicine; 600 N Wolfe Street Baltimore MD 21287 USA
| | - Justin Hanes
- Center for Nanomedicine, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
- Department of Biomedical Engineering; Johns Hopkins University School of Medicine; 720 Rutland Avenue Baltimore MD 21205 USA
- Department of Chemical and Biomolecular Engineering; Johns Hopkins University; 3400 N Charles Street Baltimore MD 21218 USA
- Department of Ophthalmology; The Wilmer Eye Institute, Johns Hopkins University School of Medicine; 400 N Broadway Baltimore MD 21231 USA
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center; Johns Hopkins University School of Medicine; 600 N Wolfe Street Baltimore MD 21287 USA. Center for Cancer Nanotechnology Excellence; Institute for NanoBioTechnology, Johns Hopkins University; 3400 N Charles Street Baltimore MD 21218 USA
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Comparative efficacy of uterotonic agents: in vitro contractions in isolated myometrial strips of labouring and non-labouring women. Can J Anaesth 2014; 61:808-18. [DOI: 10.1007/s12630-014-0190-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 05/21/2014] [Indexed: 11/26/2022] Open
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Pevzner L, Alfirevic Z, Powers BL, Wing DA. Cardiotocographic abnormalities associated with misoprostol and dinoprostone cervical ripening and labor induction. Eur J Obstet Gynecol Reprod Biol 2011; 156:144-8. [DOI: 10.1016/j.ejogrb.2011.01.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Revised: 01/05/2011] [Accepted: 01/23/2011] [Indexed: 10/18/2022]
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Neves JD, Santos B, Teixeira B, Dias G, Cunha T, Brochado J. Vaginal drug administration in the hospital setting. Am J Health Syst Pharm 2008; 65:254-9. [DOI: 10.2146/ajhp070093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- José das Neves
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Porto, Portugal, and Compounding Pharmacist and Clinical Pharmacist, Pharmacy Department, Santo António General Hospital (HGSA), Porto
| | - Bárbara Santos
- Abel Salazar Institute of Biomedical Sciences, Porto, and Clinical Pharmacist, Pharmacy Department, HGSA
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