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A Cost-Effective Analysis of Systematically Using Mapping Systems During Catheter Ablation Procedures in Children and Teenagers. Pediatr Cardiol 2018; 39:1581-1589. [PMID: 29948026 DOI: 10.1007/s00246-018-1933-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 06/07/2018] [Indexed: 10/14/2022]
Abstract
The aim of this study is to evaluate the cost-effectiveness of an extended use of 3D non-fluoroscopic mapping systems (NMSs) during paediatric catheter ablation (CA) in an adult EP Lab. This study includes 58 consecutive patients (aged between 8 and 18) who underwent CA from March 2005 to February 2015. We compare the fluoroscopy data of two groups: group I, patients who underwent CA from 2005 to 2008 using only fluoroscopy, and group II, patients who underwent CA from 2008 to 2015 performed also using NMSs. Two cost-effectiveness analyses were carried out: the first method was based on the alpha value (AV), and the second one was based on the value of a statistical life (VSL). For both methods, a children's correction factor was also considered. The reduction cost estimated from all these methods was compared to the real additional cost of using NMSs. The use of an NMS during a CA procedure has led to an effective dose reduction (ΔE) of 2.8 milli-Sievert. All presented methods are based on parameters with a wide range of values. The use of an NMS, applying directly AV values or VSL values, is not cost-effective for most countries. Only considering the children's correction factor, the CA procedure using an NMS seems to be cost-effective. The cost-effectiveness of a systematic use of NMSs during CA procedures in children and teenagers remains a challenging task. A positive result depends on which value of AV or VSL is considered and if the children's correction factor is applied or not.
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Casella M, Dello Russo A, Pelargonio G, Del Greco M, Zingarini G, Piacenti M, Di Cori A, Casula V, Marini M, Pizzamiglio F, Zucchetti M, Riva S, Russo E, Narducci ML, Soldati E, Panchetti L, Startari U, Bencardino G, Perna F, Santangeli P, Di Biase L, Cichocki F, Fattore G, Bongiorni M, Picano E, Natale A, Tondo C. Near zerO fluoroscopic exPosure during catheter ablAtion of supRavenTricular arrhYthmias: the NO-PARTY multicentre randomized trial. Europace 2016; 18:1565-1572. [PMID: 26559916 PMCID: PMC5072134 DOI: 10.1093/europace/euv344] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 09/13/2015] [Indexed: 11/17/2022] Open
Abstract
AIMS Aim of this study was to compare a minimally fluoroscopic radiofrequency catheter ablation with conventional fluoroscopy-guided ablation for supraventricular tachycardias (SVTs) in terms of ionizing radiation exposure for patient and operator and to estimate patients' lifetime attributable risks associated with such exposure. METHODS AND RESULTS We performed a prospective, multicentre, randomized controlled trial in six electrophysiology (EP) laboratories in Italy. A total of 262 patients undergoing EP studies for SVT were randomized to perform a minimally fluoroscopic approach (MFA) procedure with the EnSiteTMNavXTM navigation system or a conventional approach (ConvA) procedure. The MFA was associated with a significant reduction in patients' radiation dose (0 mSv, iqr 0-0.08 vs. 8.87 mSv, iqr 3.67-22.01; P < 0.00001), total fluoroscopy time (0 s, iqr 0-12 vs. 859 s, iqr 545-1346; P < 0.00001), and operator radiation dose (1.55 vs. 25.33 µS per procedure; P < 0.001). In the MFA group, X-ray was not used at all in 72% (96/134) of cases. The acute success and complication rates were not different between the two groups (P = ns). The reduction in patients' exposure shows a 96% reduction in the estimated risks of cancer incidence and mortality and an important reduction in estimated years of life lost and years of life affected. Based on economic considerations, the benefits of MFA for patients and professionals are likely to justify its additional costs. CONCLUSION This is the first multicentre randomized trial showing that a MFA in the ablation of SVTs dramatically reduces patients' exposure, risks of cancer incidence and mortality, and years of life affected and lost, keeping safety and efficacy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01132274.
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Affiliation(s)
- Michela Casella
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
| | - Antonio Dello Russo
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
| | | | | | - Gianluca Zingarini
- Ospedale Santa Maria della Misericordia, Azienda Ospedaliera di Perugia, Perugia, Italy
| | - Marcello Piacenti
- CNR, Institute of Clinical Physiology, Fondazione G. Monasterio, Pisa, Italy
| | - Andrea Di Cori
- Second Division of Cardiovascular Diseases, Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Victor Casula
- Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
- Department of Radiology, University of Oulu, Oulu, Finland
| | | | - Francesca Pizzamiglio
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
| | - Martina Zucchetti
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
| | - Stefania Riva
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
| | - Eleonora Russo
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
| | | | - Ezio Soldati
- Second Division of Cardiovascular Diseases, Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Luca Panchetti
- CNR, Institute of Clinical Physiology, Fondazione G. Monasterio, Pisa, Italy
| | - Umberto Startari
- CNR, Institute of Clinical Physiology, Fondazione G. Monasterio, Pisa, Italy
| | | | | | - Pasquale Santangeli
- Texas Cardiac Arrhythmia Institute at St Davis Medical Center, Austin, TX, USA
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute at St Davis Medical Center, Austin, TX, USA
| | | | - Giovanni Fattore
- Department of Policy Analysis and Public Management and CERGAS, Università Bocconi, Milan, Italy
| | - Mariagrazia Bongiorni
- Second Division of Cardiovascular Diseases, Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St Davis Medical Center, Austin, TX, USA
| | - Claudio Tondo
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino, IRCCS, Via Parea, 4, 20138 Milan, Italy
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Marini M, Del Greco M, Ravanelli D, Cima A, Coser A, Porcedda G, Guarracini F, Valentini A, Bonmassari R. The Benefit of a General, Systematic Use of Mapping Systems During Electrophysiological Procedures in Children and Teenagers: The Experience of an Adult EP Laboratory. Pediatr Cardiol 2016; 37:802-9. [PMID: 26932365 DOI: 10.1007/s00246-016-1354-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 02/09/2016] [Indexed: 12/17/2022]
Abstract
Standard imaging during electrophysiological procedures (EPs) uses fluoroscopy. The aim of this study was to evaluate the feasibility, efficacy, safety and effect of an extended use of non-fluoroscopic mapping systems (NMSs) for imaging during paediatric EPs in an adult EP laboratory focusing on the amount of X-ray exposure. This study is a retrospective analysis that includes consecutive young patients (83 pts, aged between 8 and 18) who underwent EPs from March 2005 to February 2015. We compare the fluoroscopy data of two groups of pts: Group I, pts who underwent EPs from 2005 to 2008 using only fluoroscopy and Group II, pts who underwent EPs from 2008 to 2015 performed also using NMSs. The use of an NMS resulted in reduced fluoroscopy time in Group II {median value 0.1 min (95 % CI [0.00-1.07])} compared to Group I {median value 3.55 min (95 % CI [1.93-7.83]) (MW test, P < 0.05)}. There was a complementary reduction in the total X-ray exposure from 2.53 Gy cm(2) (95 % CI [1.51-4.66]) in Group I to 0.05 Gy cm(2) in Group II (95 % CI [0.00-1.22]) (MW test, P < 0.05). Regarding ablation procedures, the median effective dose decreased from 3.04 mSv (95 % CI [1.22-6.89]) to 0.25 mSv (95 % CI [0.00-0.60]) (MW test, P < 0.05). The use of an NMS dramatically reduces fluoroscopy time and total X-ray exposure during EPs in children and teenagers in an adult EP laboratory. In our experience, this reduction is mainly related to the systematic day-to-day use of NMSs.
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Affiliation(s)
| | | | | | - Anna Cima
- Department of Cardiology, S. Maria del Carmine, Rovereto, TN, Italy
| | - Alessio Coser
- Department of Cardiology, S. Chiara Hospital, Trento, Italy
| | | | | | - Aldo Valentini
- Department of Physics, S. Chiara Hospital, Trento, Italy
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Giaccardi M, Del Rosso A, Guarnaccia V, Ballo P, Mascia G, Chiodi L, Colella A. Near-zero x-ray in arrhythmia ablation using a 3-dimensional electroanatomic mapping system: A multicenter experience. Heart Rhythm 2015; 13:150-6. [PMID: 26341606 DOI: 10.1016/j.hrthm.2015.09.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Radiation exposure related to conventional tachyarrhythmia radiofrequency catheter ablation (RFCA) carries small but not negligible stochastic and deterministic effects on health. These effects are cumulative and potentially more harmful in younger individuals. Nonfluoroscopic mapping systems can significantly reduce the radiological exposure and in some cases it can completely eliminate it. OBJECTIVE The aim of this study was to assess the safety, feasibility, and efficacy of a complete nonfluoroscopic approach for RFCA compared with ablation procedures performed under fluoroscopic guidance. METHODS RFCA was performed in 442 consecutive patients (mean age 58 ± 19 years). The first 145 patients (group 1) were treated only under fluoroscopic guidance, and the following 297 patients (group 2) were treated using a nonfluoroscopic electroanatomic mapping system (EnSite Velocity). RFCA was completely performed without fluoroscopy in 255 of 297 patients in group 2 (86%). RESULTS The acute success rate did not differ between group 1 and group 2 (97% vs 96%; P = .46), and there were no differences in either procedure time (87 ± 57 minutes vs 91 ± 52 minutes; P = .41) or complication rate. Fluoroscopic exposure in group 2 was significantly reduced in comparison with group 1 (14 ± 6 seconds vs 1159 ± 833 seconds; P < .0001). CONCLUSION Compared with the conventional fluoroscopic technique, the near-zero radiation (RX) approach provides similar outcomes and may significantly reduce or eliminate ionizing radiation exposure in RFCA. These reductions are achieved without altering the duration or compromising the safety and effectiveness of the procedure.
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Affiliation(s)
- Marzia Giaccardi
- Electrophysiology Unit, Department of Internal Medicine, San Giovanni di Dio Hospital, Florence, Italy.
| | - Attilio Del Rosso
- Electrophysiology Unit, Department of Internal Medicine, San Giuseppe Hospital, Empoli, Italy
| | - Vincenzo Guarnaccia
- Electrophysiology Unit, Department of Internal Medicine, San Giuseppe Hospital, Empoli, Italy
| | - Piercarlo Ballo
- Cardiology Unit, Department of Internal Medicine, Santa Maria Annunziata Hospital, Florence, Italy
| | - Giuseppe Mascia
- Cardiology Unit, Department of Internal Medicine, Santa Maria Nuova Hospital, Florence, Italy
| | - Leandro Chiodi
- Cardiology Unit, Department of Internal Medicine, Santa Maria Annunziata Hospital, Florence, Italy
| | - Andrea Colella
- Electrophysiology Unit, Department of Heart and Vessels, Careggi Hospital, Florence, Italy
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Radiofrequency catheter ablation of supraventricular tachycardia in pregnancy: Ablation without fluoroscopic exposure. Heart Rhythm 2015; 12:1057-61. [DOI: 10.1016/j.hrthm.2015.01.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Indexed: 11/22/2022]
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Kean AC, LaPage MJ, Yu S, Dick M, Bradley DJ. Patient and Procedural Correlates of Fluoroscopy Use During Catheter Ablation in the Pediatric and Congenital Electrophysiology Lab. CONGENIT HEART DIS 2014; 10:281-7. [DOI: 10.1111/chd.12213] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/06/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Adam C. Kean
- Pediatrix Cardiology Associates of New Mexico; Albuquerque NM USA
| | - Martin J. LaPage
- Division of Pediatric Cardiology; University of Michigan; Ann Arbor Mich USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology; University of Michigan; Ann Arbor Mich USA
| | - Macdonald Dick
- Division of Pediatric Cardiology; University of Michigan; Ann Arbor Mich USA
| | - David J. Bradley
- Division of Pediatric Cardiology; University of Michigan; Ann Arbor Mich USA
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Heidbuchel H, Wittkampf FHM, Vano E, Ernst S, Schilling R, Picano E, Mont L, Jais P, de Bono J, Piorkowski C, Saad E, Femenia F. Practical ways to reduce radiation dose for patients and staff during device implantations and electrophysiological procedures. Europace 2014; 16:946-64. [PMID: 24792380 DOI: 10.1093/europace/eut409] [Citation(s) in RCA: 212] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Despite the advent of non-fluoroscopic technology, fluoroscopy remains the cornerstone of imaging in most interventional electrophysiological procedures, from diagnostic studies over ablation interventions to device implantation. Moreover, many patients receive additional X-ray imaging, such as cardiac computed tomography and others. More and more complex procedures have the risk to increase the radiation exposure, both for the patients and the operators. The professional lifetime attributable excess cancer risk may be around 1 in 100 for the operators, the same as for a patient undergoing repetitive complex procedures. Moreover, recent reports have also hinted at an excess risk of brain tumours among interventional cardiologists. Apart from evaluating the need for and justifying the use of radiation to assist their procedures, physicians have to continuously explore ways to reduce the radiation exposure. After an introduction on how to quantify the radiation exposure and defining its current magnitude in electrophysiology compared with the other sources of radiation, this position paper wants to offer some very practical advice on how to reduce exposure to patients and staff. The text describes how customization of the X-ray system, workflow adaptations, and shielding measures can be implemented in the cath lab. The potential and the pitfalls of different non-fluoroscopic guiding technologies are discussed. Finally, we suggest further improvements that can be implemented by both the physicians and the industry in the future. We are confident that these suggestions are able to reduce patient and operator exposure by more than an order of magnitude, and therefore think that these recommendations are worth reading and implementing by any electrophysiological operator in the field.
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Affiliation(s)
- Hein Heidbuchel
- Department of Cardiovascular Medicine, University Hospital Gasthuisberg, University of Leuven, 3000 Leuven, Belgium
| | - Fred H M Wittkampf
- Heart Lung Center, Department of Cardiology, University Medical Center, 3584 CX Utrecht, The Netherlands
| | - Eliseo Vano
- Radiology Department, Medicine School, Complutense University and San Carlos Hospital, IdISSC, Madrid 28040, Spain
| | - Sabine Ernst
- NIHR Biomedical Research Unit and Royal Brompton and Harefield NHS Foundation Trust, Sydney Street, SW3 6NP, London, UK
| | - Richard Schilling
- Biomedical Research Unit, Bart's Health NHS Trust and the William Harvey Research Institute, London EC1A 7BE, UK
| | - Eugenio Picano
- CNR Biomedical Sciences Department, Institute of Clinical Physiology, 56124, Pisa, Italy
| | - Lluis Mont
- Department of Cardiology, Hospital Clínic, Universitat de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia 08036, Spain
| | - Pierre Jais
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Joseph de Bono
- Queen Elizabeth Medical Centre, Department of Cardiology, Birmingham, United Kingdom
| | | | - Eduardo Saad
- Hospital Pró-Cardíaco, Setor de Arritmia Invasiva, Rio de Janeiro, Brazil
| | - Francisco Femenia
- Biomedical Research Unit, Bart's Health NHS Trust and the William Harvey Research Institute, London EC1A 7BE, UK
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Stec S, Śledź J, Mazij M, Raś M, Ludwik B, Chrabąszcz M, Śledź A, Banasik M, Bzymek M, Młynarczyk K, Deutsch K, Labus M, Śpikowski J, Szydłowski L. Feasibility of implementation of a "simplified, No-X-Ray, no-lead apron, two-catheter approach" for ablation of supraventricular arrhythmias in children and adults. J Cardiovasc Electrophysiol 2014; 25:866-874. [PMID: 24654678 DOI: 10.1111/jce.12414] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Revised: 02/11/2014] [Accepted: 03/10/2014] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Although the "near-zero-X-Ray" or "No-X-Ray" catheter ablation (CA) approach has been reported for treatment of various arrhythmias, few prospective studies have strictly used "No-X-Ray," simplified 2-catheter approaches for CA in patients with supraventricular tachycardia (SVT). We assessed the feasibility of a minimally invasive, nonfluoroscopic (MINI) CA approach in such patients. METHODS Data were obtained from a prospective multicenter CA registry of patients with regular SVTs. After femoral access, 2 catheters were used to create simple, 3D electroanatomic maps and to perform electrophysiologic studies. Medical staff did not use lead aprons after the first 10 MINI CA cases. RESULTS A total of 188 patients (age, 45 ± 21 years; 17% <19 years; 55% women) referred for the No-X-Ray approach were included. They were compared to 714 consecutive patients referred for a simplified approach using X-rays (age, 52 ± 18 years; 7% <19 years; 55% women). There were 9 protocol exceptions that necessitated the use of X-rays. Ultimately, 179/188 patients underwent the procedure without fluoroscopy, with an acute success rate of 98%. The procedure times (63 ± 26 vs. 63 ± 29 minutes, P > 0.05), major complications (0% vs. 0%, P > 0.05) and acute (98% vs. 98%, P > 0.05) and long-term (93% vs. 94%, P > 0.05) success rates were similar in the "No-X-Ray" and control groups. CONCLUSIONS Implementation of a strict "No-X-Ray, simplified 2-catheter" CA approach is safe and effective in majority of the patients with SVT. This modified approach for SVTs should be prospectively validated in a multicenter study.
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Affiliation(s)
- Sebastian Stec
- Department of Cardiology, Medical Center for Postgraduate Education, Grochowski Hospital, Warsaw.,ELMedica EP-Network, Kielce.,Podkarpackie Center for Cardiovascular Interventions, Sanok
| | - Janusz Śledź
- ELMedica EP-Network, Kielce.,Carint Medica, Kraków.,Division of Interventional Cardiology, Center of Invasive Cardiology, Angiology and Electrotherapy in Ostrowiec, Poland
| | - Mariusz Mazij
- Department of Cardiology and Pediatric Cardiology, Research and Development Center, Wrovasc, Voivodship's Specialist Hospital, Wroclaw
| | - Małgorzata Raś
- Department of Cardiology and Pediatric Cardiology, Research and Development Center, Wrovasc, Voivodship's Specialist Hospital, Wroclaw
| | - Bartosz Ludwik
- Department of Cardiology and Pediatric Cardiology, Research and Development Center, Wrovasc, Voivodship's Specialist Hospital, Wroclaw
| | - Michał Chrabąszcz
- ELMedica EP-Network, Kielce.,Institute of Physics, Department of Atomic Physics, Jan Kochanowski University, Kielce
| | | | | | | | | | - Karol Deutsch
- Department of Cardiology, Medical Center for Postgraduate Education, Grochowski Hospital, Warsaw
| | - Michał Labus
- Department of Cardiology and Pediatric Cardiology, Research and Development Center, Wrovasc, Voivodship's Specialist Hospital, Wroclaw
| | - Jerzy Śpikowski
- Department of Cardiology and Pediatric Cardiology, Research and Development Center, Wrovasc, Voivodship's Specialist Hospital, Wroclaw
| | - Lesław Szydłowski
- Department of Pediatric Cardiology, Silesian Medical University, Katowice, Poland
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Giedrimas E, Goldberger JJ. Catheter ablation for supraventricular tachycardias: contemporary issues. Future Cardiol 2014; 9:581-96. [PMID: 23834697 DOI: 10.2217/fca.13.26] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The treatment of cardiac arrhythmias has evolved significantly over the last 30 years. Understanding of arrhythmia mechanisms has led to pharmacologic therapies, surgical interventions and the widely used percutaneous catheter ablation techniques. The focus of this review is centered on the current catheter ablation therapies available for supraventricular tachycardia. We will discuss current management strategies including challenges when considering catheter ablation therapy for management of supraventricular tachycardias: atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia utilizing an accessory pathway, atrial tachycardia and atrial flutter. Selected contemporary issues related to supraventricular tachycardia physiology, ablation approaches and ablation outcomes and complications will be discussed. Future goals for electrophysiologists are to continue to improve procedural safety and efficiency, while maintaining the impressive success rates that have been achieved.
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Affiliation(s)
- Evaldas Giedrimas
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 251 East Huron Street, Feinberg 8-503E, Chicago, IL 60611, USA
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FERNÁNDEZ-GÓMEZ JUANM, MORIÑA-VÁZQUEZ PABLO, MORALES ELENADELRIO, VENEGAS-GAMERO JOSÉ, BARBA-PICHARDO RAFAEL, CARRANZA MANUELHERRERA. Exclusion of Fluoroscopy Use in Catheter Ablation Procedures: Six Years of Experience at a Single Center. J Cardiovasc Electrophysiol 2014; 25:638-44. [DOI: 10.1111/jce.12385] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Revised: 01/26/2014] [Accepted: 01/29/2014] [Indexed: 12/13/2022]
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