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Castrisos G, Hoff J, Hewerdine S, Ho YM, Lamparelli M. Non-healing parastomal ulcer: think nicorandil. ANZ J Surg 2021; 91:2837-2838. [PMID: 33788367 DOI: 10.1111/ans.16844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/22/2021] [Indexed: 11/30/2022]
Affiliation(s)
- George Castrisos
- General Surgery Department, Rockhampton Hospital, Rockhampton, Queensland, Australia.,General Surgery, The University of Queensland, Brisbane, Queensland, Australia
| | - Jai Hoff
- General Surgery Department, Rockhampton Hospital, Rockhampton, Queensland, Australia
| | - Shirley Hewerdine
- General Surgery Department, Rockhampton Hospital, Rockhampton, Queensland, Australia
| | - Yiu M Ho
- General Surgery Department, Rockhampton Hospital, Rockhampton, Queensland, Australia
| | - Michael Lamparelli
- General Surgery Department, Rockhampton Hospital, Rockhampton, Queensland, Australia
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Babic V, Petitpain N, Guy C, Trechot P, Bursztejn AC, Faillie JL, Vial T, Schmutz JL, Gillet P. Nicorandil-induced ulcerations: a 10-year observational study of all cases spontaneously reported to the French pharmacovigilance network. Int Wound J 2018; 15:508-518. [PMID: 29767853 PMCID: PMC7949779 DOI: 10.1111/iwj.12845] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 10/01/2017] [Indexed: 11/26/2022] Open
Abstract
Nicorandil-induced ulcers remain often poorly recognised, with a late diagnosis and an inadequate management. We aimed to provide a clinical overview of the 148 spontaneously reported cases of nicorandil-induced ulcers to the French pharmacovigilance network between 2005 and 2014 and to complete this picture with worldwide published cases over the same period. Spontaneously reported nicorandil-induced ulcers were mainly mucosal (oral and anal) with a previous trauma in 23·0% of patients, revealed by a severe complication in 12·8% of cases. The mean cumulative dose of nicorandil was higher in serious cases. The median delay between the start of nicorandil use and the onset of the ulcer was 23·4 months, and after the ulcer was diagnosed, the median time to incriminate nicorandil was still 3·3 months, being shorter for mucosal ulcerations than for cutaneous ulcerations (5·2 versus 14·0 months, P = 0·001). The anatomic distribution in the 199 published cases differed slightly, but delays were similar. The hypothesis of mechanism becomes more precise, leaving no doubt about the necessity to discontinue the treatment. Practitioners need to be aware that nicorandil-induced ulcers can occur in many locations, possibly multiple and complicated, and should be simply managed by discontinuing treatment with no further reintroduction of nicorandil.
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Affiliation(s)
- Valérie Babic
- Department of DermatologyUniversity HospitalVandoeuvre‐les‐NancyFrance
| | - Nadine Petitpain
- Regional Center of PharmacovigilanceUniversity HospitalNancyFrance
| | - Claire Guy
- Regional Center of PharmacovigilanceUniversity HospitalSaint‐EtienneFrance
| | - Philippe Trechot
- Regional Center of PharmacovigilanceUniversity HospitalNancyFrance
| | | | - Jean Luc Faillie
- Regional Center of Pharmacovigilance, Department of Medical Pharmacology and Toxicology, CHU MontpellierUniversity of MontpellierMontpellierFrance
| | - Thierry Vial
- Regional Center of PharmacovigilanceUniversity HospitalLyonFrance
| | - Jean Luc Schmutz
- Department of DermatologyUniversity HospitalVandoeuvre‐les‐NancyFrance
| | - Pierre Gillet
- Regional Center of PharmacovigilanceUniversity HospitalNancyFrance
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Nicorandil-induced penile ulcerations: A case report and review of the penile cutaneous circulation. JPRAS Open 2016. [DOI: 10.1016/j.jpra.2016.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Pisano U, Deosaran J, Leslie SJ, Rushworth GF, Stewart D, Ford I, Watson AJM. Nicorandil, Gastrointestinal Adverse Drug Reactions and Ulcerations: A Systematic Review. Adv Ther 2016; 33:320-44. [PMID: 26861848 DOI: 10.1007/s12325-016-0294-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Nicorandil is a popular anti-anginal drug in Europe and Japan. Apart from some common adverse drug reactions (ADR), its safety is satisfactory. Several reports have suggested a link between nicorandil, gastrointestinal (GI) ulceration and fistulas. The review aims to critically appraise, synthesize and present the available evidence of all known GI ADR per anatomical location. METHODS The study complied with the PRISMA statement. Literature and pharmacovigilance databases were used to provide rate and/or calculate parameters (median age, median dose, history of symptoms, length of therapy and healing time after withdrawal of the drug). Differences in distribution of quantitative variables were analyzed via Mann-Whitney test. Correlation between quantitative variables was assessed with a Spearman's correlation coefficient. A p value <0.05 was significant. RESULTS Oral ulcerations occur in 0.2% of the subjects, anal ulcerations are present between 0.07% and 0.37% of patients. Oral and distal GI involvements are the most common ADR (28-29% and 27-31% of all GI ADR, respectively). The hepatobiliary system, the pancreas and salivary glands are not affected by nicorandil exposure. The time to develop oral ulcerations is 74 weeks among people on <30 mg/day compared to only 7.5 weeks in individuals on higher regimens (p = 0.47). There is a significant correlation between dose and ulcer healing time (Spearman's 0.525, p < 0.001). CONCLUSIONS Ulcerative disease is a very commonly reported GI ADR. A delayed ulcerative tendency supports the hypothesis of an ulcerogenic metabolite. Nicorandil seems to act as a cause of the ulcerations, but appears to also work in synergy with other promoting factors. Whether the action of the metabolites relies on a specific mechanism or a simple chemical ulceration is still to be established.
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Affiliation(s)
- Umberto Pisano
- Department of General Surgery, Raigmore Hospital, Inverness, UK.
| | | | | | | | - Derek Stewart
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
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Use of nicorandil is Associated with Increased Risk for Gastrointestinal Ulceration and Perforation- A Nationally Representative Population-based study. Sci Rep 2015; 5:11495. [PMID: 26118431 PMCID: PMC4483775 DOI: 10.1038/srep11495] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 05/07/2015] [Indexed: 02/08/2023] Open
Abstract
Nicorandil is a vasodilatory drug used to relieve angina symptoms. Several healthcare products regulatory agencies have issued a warning associating the use of nicorandil and gastrointestinal (GI) ulceration. We aimed to evaluate the association between use of nicorandil and GI ulceration/perforation. A population-based cohort study involving 1 million randomly sampled participants in Taiwan’s National Health Insurance Research Database was carried out. We estimated the association between use of nicorandil and GI ulceration/perforation by a Cox proportional hazards regression model. A nicorandil-specific propensity score (PS) was also created for adjustment of 75 covariates and matching. 25.8% (183/710) of nicorandil-treated patients developed new GI ulcer events and 1.6% (20/1254) developed new GI perforation events in the three-year follow-up period, as compared to 9.3% (61,281/659,081) and 0.3% (2,488/770,537) in the general population comparator cohort. Patients treated with nicorandil were at significantly increased risk of GI ulcer (PS adjusted hazard ratio 1.43, 95% CI, 1.23 to 1.65, 6848 excess cases per 100,000 person years) or GI perforation (aHR 1.60, 95% CI 1.02–2.51, 315 excess cases per 100,000 person years) compared with the nicorandil unexposed population. Our finding may warn the clinicians to weigh the overall risk-benefit balance of nicorandil treatment in patients.
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Lee MTG, Lin HY, Lee SH, Lee SH, Chang SS, Chen SC, Lee CC. Risk of skin ulcerations associated with oral nicorandil therapy: a population-based study. Br J Dermatol 2015; 173:498-509. [PMID: 25939634 DOI: 10.1111/bjd.13884] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although healthcare products regulatory agencies have issued warnings on risk of ulceration associated with the use of nicorandil, a population-based study has not been carried out. OBJECTIVES To determine the relationship between use of nicorandil and skin ulceration. METHODS We carried out a population-based study using a cohort of 1 million people assembled from Taiwan's national health insurance database. The association between nicorandil use and skin ulcers was estimated by a Cox proportional hazards regression model adjusting for a nicorandil-specific propensity score (PS) comprising of 86 potential predictors (c-statistic = 0·91). RESULTS The prospective cohort was longitudinally followed from January 2005 to December 2009, during which 1268 new users of nicorandil and 771 136 nonusers were identified. A higher frequency of skin ulcers (29 of 1268; 2·3%) was observed for users of nicorandil compared with nonusers (3231 of 771 136; 0·4%). Compared with nonusers, the crude hazard ratio (HR) associating nicorandil use with skin ulcers was 5·52 [95% confidence interval (CI) 3·82-7·95] and the PS-adjusted HR was 1·85 (95% CI 1·27-2·69). A risk period analysis showed that the risk of skin ulceration among users of nicorandil was greatest in the first year. Subgroup analysis found that the interaction term reached statistical significance (P < 0·05) for age and diabetes. CONCLUSIONS Use of nicorandil was found to be associated with an increased risk for skin ulceration, especially in the first year after incident exposure. We suggest that regulatory agencies re-evaluate the risk for skin ulceration associated with use of nicorandil.
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Affiliation(s)
- M-T G Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - H-Y Lin
- Department of Dermatology, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan.,Hsin-Yi Lin Dermatological Clinic, Taipei, Taiwan
| | - S-H Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - S-H Lee
- Department of Rehabilitation and Physical Medicine, Taipei Veteran General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming University Hospital, Taipei, Taiwan
| | - S-S Chang
- Department of Family Medicine, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan.,College of Medicine, Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, 333, Taiwan
| | - S-C Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - C-C Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Douliou, 640, Taiwan.,Department of General Medicine, National Taiwan University Hospital Yunlin Branch, Douliou, 640, Taiwan
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McCormack P, Skelly R. A demonstration of peristomal ulceration in the setting of nicorandil therapy. BMJ Case Rep 2014; 2014:bcr-2014-206599. [PMID: 25391826 DOI: 10.1136/bcr-2014-206599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Paul McCormack
- Department of General Surgery, Causeway Hospital, Coleraine, UK
| | - Roderick Skelly
- Department of General Surgery, Causeway Hospital, Coleraine, UK
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Mandal A, Ferdanzi S, Paudel S, Klein M. Nicorandil-associated skin necrosis around a stoma site. Br J Hosp Med (Lond) 2014; 75:595. [DOI: 10.12968/hmed.2014.75.10.595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Adhip Mandal
- Specialist Registrar in General Surgery in the Department of Surgery, Colchester General Hospital, Colchester, Essex CO4 5JL
| | - Sharon Ferdanzi
- Community Stoma Nurse Therapist in the Department of Colorectal Surgery
| | | | - Martin Klein
- Consultant General Surgeon in the Department of Surgery, Chase Farm Hospital, Enfield
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Kapoor S. Nicorandil and its associated gastrointestinal side effects. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:662. [PMID: 23437973 DOI: 10.1111/pace.12105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Nicorandil-induced oral ulceration: report of 3 cases and review of the Japanese literature. ACTA ACUST UNITED AC 2011; 112:754-9. [DOI: 10.1016/j.tripleo.2011.05.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 05/16/2011] [Accepted: 05/24/2011] [Indexed: 11/23/2022]
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Yap T, Philippou P, Perry M, Lam W, Corbishley C, Watkin N. Nicorandil-induced penile ulcerations: a case series. BJU Int 2011; 107:268-71. [DOI: 10.1111/j.1464-410x.2010.09463.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
The management of wounds is a specialty in its infancy. Success requires more than the use of dressings. All wounds require a diagnosis, a point well illustrated by the management of these cases which depended solely on stopping nicorandil.
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Affiliation(s)
- Girish K Patel
- Department of Dermatology and Wound Healing, School of Medicine, Cardiff University, Cardiff, UK.
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McDaid J, Reichl C, Hamzah I, Fitter S, Harbach L, Savage AP. Diverticular fistulation is associated with nicorandil usage. Ann R Coll Surg Engl 2010. [PMID: 20819332 DOI: 10.1308/003588410x12699663904673] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We observed that a number of patients presenting to our clinic with diverticular fistulation were taking nicorandil for angina. Recognised side effects of nicorandil include gastrointestinal and genital ulceration. The aim of our study was to determine whether nicorandil is an aetiological agent in diverticular fistulation. PATIENTS AND METHODS We conducted a case-control study of patients with diverticular disease related enteric fistulae. Two patient groups were identified: a study group of patients with diverticular fistulae, and a control group with uncomplicated diverticular disease. The proportion of patients who had ever used nicorandil was compared between the two groups. RESULTS A total of 153 case notes were analysed, 69 patients with fistulae and 84 control patients with uncomplicated diverticular disease. Female to male ratio in both groups was 2:1. The mean age was 71 years in the fistula group and 69 years in the control diverticular disease group (P = ns). Of those with colonic fistulae, 16% were taking nicorandil compared with 2% of the control group (odds ratio 7.8; 95% confidence interval 1.5-39.1; P = 0.008). There was no significant difference in rates of ischaemic heart disease between fistula and control groups. CONCLUSIONS Nicorandil is associated with fistula formation in diverticular disease.
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Affiliation(s)
- James McDaid
- Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK.
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McDaid J, Reichl C, Hamzah I, Fitter S, Harbach L, Savage AP. Diverticular fistulation is associated with nicorandil usage. Ann R Coll Surg Engl 2010; 92:463-5. [DOI: 10.1308/rcsann.2010.92.6.463] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We observed that a number of patients presenting to our clinic with diverticular fistulation were taking nicorandil for angna. Recognised side effects of nicorandil include gastrointestinal and genital ulceration. The aim of our study was to determine whether nicorandil is an aetiological agent in diverticular fistulation. PATIENTS AND METHODS We conducted a case-control study of patients with diverticular disease related enteric fistulae. Two patient groups were identified: a study group of patients with diverticular fistulae, and a control group with uncomplicated diverticular disease. The proportion of patients who had ever used nicorandil was compared between the two groups. RESULTS A total of 153 case notes were analysed, 69 patients with fistulae and 84 control patients with uncomplicated diverticular disease. Female to male ratio in both groups was 2:1. The mean age was 71 years in the fistula group and 69 years in the control diverticular disease group (P = ns). Of those with colonic fistulae, 16% were taking nicorandil compared with 2% of the control group (odds ratio 7.8; 95% confidence interval 1.5–39.1; P = 0.008). There was no significant difference in rates of ischaemic heart disease between fistula and control groups. CONCLUSIONS Nicorandil is associated with fistula formation in diverticular disease.
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Affiliation(s)
- James McDaid
- Department of Surgery, Queen Elizabeth Hospital Birmingham, UK
| | - Claire Reichl
- Department of General Surgery, Russell's Hall Hospital Dudley, UK
| | - Ihsan Hamzah
- Department of Colorectal Surgery, Russell's Hall Hospital Dudley, UK
| | - Samantha Fitter
- Department of Clinical Audit, Russell's Hall Hospital Dudley, UK
| | - Laura Harbach
- Department of Clinical Audit, Russell's Hall Hospital Dudley, UK
| | - Adrian P Savage
- Department of Colorectal Surgery, Russell's Hall Hospital Dudley, UK
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Riddell AD, Minhas U, Williams GL, Harding KJ. The role of Nicorandil in non-healing surgical wounds. Ann R Coll Surg Engl 2010; 92:W16-8. [PMID: 20566033 DOI: 10.1308/147870810x12699662981113] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We report two patients with non-healing surgical wounds, which healed after the withdrawal of Nicorandil therapy. Nicorandil should be recognised as an aetiological factor for non-healing wounds or ulcers once other inflammatory and malignant causes have been excluded. This may avoid surgery for high-risk patients and may also reduce complications for patients who undergo surgery for non-healing wounds. As Nicorandil is used in patients with severe coronary artery disease, it is recommended that the advice of a cardiologist is sought prior to cessation or adjustment to its dose.
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Affiliation(s)
- A D Riddell
- Department of General Surgery, Royal Free Hospital, London, UK.
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Swinscoe MT, Savani R, Lobo AJ, Stephenson TJ, Shorthouse AJ. Nicorandil-induced terminal ileal ulceration--a probable link. BMJ Case Rep 2010; 2010:2010/may31_1/bcr0920092303. [PMID: 22751206 DOI: 10.1136/bcr.09.2009.2303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Nicorandil, a commonly prescribed anti-anginal agent, has been reported to be associated with ulceration in various parts of the gastrointestinal tract. A 68-year-old general practitioner presented with severe rectal bleeding and abdominal pain associated with terminal ileal ulceration diagnosed by colonoscopy. Capsule endoscopy revealed no other source of bleeding and CT was normal. Diclofenac and/or aspirin were assumed to be causative factors and discontinued. Aspirin was temporarily resumed then discontinued after a second massive, but self-limiting, haemorrhage and persistent abdominal pain. Repeat colonoscopy 5 weeks later confirmed that the previously documented terminal ileal ulceration had worsened. Histopathology was consistent with localised mucosal ischaemia. Nicorandil was withdrawn, after which no further episode of bleeding occurred and his pain settled. Repeat colonoscopy 3 months later confirmed complete healing. This report implicates nicorandil as a cause of terminal ileal ulceration leading to life-threatening rectal bleeding and abdominal pain.
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Fernandez SF, Tandar A, Boden WE. Emerging medical treatment for angina pectoris. Expert Opin Emerg Drugs 2010; 15:283-98. [DOI: 10.1517/14728210903544482] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Chan SK, Harris MD, Baldwin PJW, Sterling JC. Vulvovaginal ulceration during prolonged treatment with nicorandil. BJOG 2009; 116:1403-5. [DOI: 10.1111/j.1471-0528.2009.02259.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fake J, Skellet AM, Skipper G. A patient with nicorandil−induced peristomal ulceration. ACTA ACUST UNITED AC 2008. [DOI: 10.12968/gasn.2008.6.5.29574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
This leading article refers to the paper by Abdelrazeq AS, Owen C, Smith L, McAdam JG, Pearson HJ, Leveson SH. Nicorandil-associated para-stomal ulceration: case series Eur J Gastroenterol Hepatol 2006; 18:1293-1295. We apologise to all concerned for the dissociation between the two papers, which was due to an administrative error. Nicorandil is used widely in patients with coronary artery disease. Nicorandil is well tolerated with only minor side effects. Nicorandil's association with oral, anal, gastrointestinal ulceration, and more recently para-stomal ulceration has been reported. Medical awareness of nicorandil association with ulcerations should be high to help avoid unnecessary and harmful treatment as only cessation of the drug would heal the ulceration. Nicorandil is an antianginal drug used for the treatment of symptomatic coronary artery disease. It is characterized by an arterial and venous vasodilator effect with dual mechanism of action. Nicorandil is not a first-line agent in the management of angina but it is used in combination with other antianginal medications in stable and unstable angina. It is generally well tolerated with minor side effects such as headache, nausea, flushing and dizziness. The association of nicorandil with mouth and anal ulcers as well as the association with ulceration throughout the gastrointestinal tract has been reported, and recently, an association with para-stomal ulceration has also been described. Medical awareness of the association of nicorandil with ulceration in any part of the gastrointestinal tract should be highlighted among all medical professionals to help avoid delays in withdrawing the treatment and to avoid unnecessary and sometimes invasive and costly interventions.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2007. [DOI: 10.1002/pds.1376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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