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Gosavi S, Krishnan G, Acharya RV. Aspirin vs Clopidogrel: Antiplatelet Agent of Choice for Those With Recent Bleeding or at Risk for Gastrointestinal Bleed. Cureus 2023; 15:e37890. [PMID: 37213942 PMCID: PMC10199733 DOI: 10.7759/cureus.37890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 05/23/2023] Open
Abstract
Antiplatelet agents are used worldwide mainly for primary and secondary prevention of cardiovascular events on a long-term basis for mortality benefit. Gastrointestinal bleeding is a well-known adverse effect. Various factors are to be considered while choosing antiplatelet agents to prevent the risk of bleed and rebleed incidents. These range from deciding on the agent, timing of therapy, underlying indications, coadministration of proton pump inhibitor, etc. At the same time, one must weigh the risks of cardiovascular events secondary to the stoppage of antiplatelet therapy. With this review, we have tried to guide the clinician on decision-making regarding the care of patients on management of acute upper and lower gastrointestinal bleeding, stoppage, restarting of agents, and measures to prevent a recurrence. We have focused on aspirin and clopidogrel as they are among the most widely used antiplatelet agents.
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Affiliation(s)
- Siddharth Gosavi
- Department of Internal Medicine, Kasturba Medical College Manipal, Manipal, IND
| | - Gokul Krishnan
- Department of Internal Medicine, Kasturba Medical College Manipal, Manipal, IND
| | - Raviraja V Acharya
- Department of Internal Medicine, Kasturba Medical College Manipal, Manipal, IND
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Tseng ZF, Hsu PI, Peng NJ, Kao SS, Tsay FW, Cheng JS, Chen WC, Tsai KF, Tang SY, Chuah SK, Shie CB. Omeprazole vs famotidine for the prevention of gastroduodenal injury in high-risk users of low-dose aspirin: A randomized controlled trial. J Chin Med Assoc 2021; 84:19-24. [PMID: 33230059 DOI: 10.1097/jcma.0000000000000465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Low-dose aspirin is widely used in the prevention of cardiovascular diseases. However, the use of aspirin is associated with an increased risk of gastrointestinal injury. METHODS Low-dose aspirin users with a history of peptic ulcers who did not have gastroduodenal mucosal breaks at initial endoscopy were randomly assigned to receive famotidine (20 mg bid) or omeprazole (20 mg qd) for 6 months. Follow-up endoscopy was performed at the end of the sixth month and whenever epigastric discomfort, hematemesis, or melena occurred. The primary end point was the occurrence of gastroduodenal mucosal breaks. The secondary end points were (1) the occurrence of gastroduodenal ulcers and (2) the occurrence of gastroduodenal bleeding. RESULT Between November 2013 and June 2018, 170 patients were randomly assigned to receive either famotidine (n = 84) or omeprazole (n = 86). The incidence of gastroduodenal mucosal breaks was 33.8% among the patients receiving famotidine, and 19.8% among those receiving omeprazole (95% CI: 0.4%-27.5%; p = 0.045). The two patient groups had comparable incidence rates of gastroduodenal ulcers (20.0% vs 9.8%; p = 0.071), and gastroduodenal bleeding (2.5% vs 0%; p = 0.243). Multivariate analysis showed that use of the proton pump inhibitor was an independent protective factor (odds ratio: 0.47; 95% CI: 0.23-0.99; p = 0.047), and that smoking was a risk factor for mucosal breaks (odds ratio: 3.84; 95% CI: 1.52-9.71; p = 0.004). CONCLUSION Proton pump inhibitor was superior to histamine-2 receptor antagonist in the prevention of gastroduodenal mucosal breaks in high-risk users of low-dose aspirin, and smoking was an independent risk factor for developing gastroduodenal mucosal breaks.
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Affiliation(s)
- Zhi-Fu Tseng
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Ping-I Hsu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, An Nan Hospital, China Medical University, Tainan, Taiwan, ROC
| | - Nan-Jing Peng
- Department of Nuclear Medicine, Kaohsiung Veterans General Hospital and National Yang-Ming University, Kaohsiung, Taiwan, ROC
| | - Sung-Shuo Kao
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Feng-Woei Tsay
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Jin-Shiung Cheng
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Wen-Chi Chen
- Division of Gastroenterology and Hepatology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
| | - Kun-Feng Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, An Nan Hospital, China Medical University, Tainan, Taiwan, ROC
| | - Sheng-Yeh Tang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, An Nan Hospital, China Medical University, Tainan, Taiwan, ROC
| | - Seng-Kee Chuah
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan, ROC
| | - Chang-Bih Shie
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, An Nan Hospital, China Medical University, Tainan, Taiwan, ROC
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Parekh PJ, Oldfield EC, Johnson DA. Current Strategies to Reduce Gastrointestinal Bleeding Risk Associated with Antiplatelet Agents. Drugs 2015; 75:1613-25. [PMID: 26330139 DOI: 10.1007/s40265-015-0455-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Antiplatelet agents remain the cornerstone in the primary and secondary therapeutic intervention for cardiovascular disease. Some patients may be subjected to a year or more of dual antiplatelet therapy to reduce the risk of subsequent cardiovascular events. Patients on antiplatelet therapy have an increased risk of gastrointestinal bleeding; however, not all patients benefit from concomitant acid suppressive therapy. This review will provide an overview of the pharmacology of antiplatelet agents and outline patient risk profiles that ought to be considered when considering prophylactic therapy to reduce gastrointestinal toxicity. In addition, we discuss the current risk-reduction strategies intended to mitigate against the potential for related gastroduodenal injury.
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Affiliation(s)
- Parth J Parekh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tulane University, New Orleans, LA, USA
| | - Edward C Oldfield
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - David A Johnson
- Division of Gastroenterology, Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, 23510, USA.
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Peptic ulcer diseases: genetics, mechanism, and therapies. BIOMED RESEARCH INTERNATIONAL 2014; 2014:898349. [PMID: 25610875 PMCID: PMC4290999 DOI: 10.1155/2014/898349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 09/22/2014] [Indexed: 01/10/2023]
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Impact of blood type, functional polymorphism (T-1676C) of the COX-1 gene promoter and clinical factors on the development of peptic ulcer during cardiovascular prophylaxis with low-dose aspirin. BIOMED RESEARCH INTERNATIONAL 2014; 2014:616018. [PMID: 25243161 PMCID: PMC4163467 DOI: 10.1155/2014/616018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Accepted: 07/09/2014] [Indexed: 12/23/2022]
Abstract
Aims. To investigate the impact of blood type, functional polymorphism (T-1676C) of the COX-1 gene promoter, and clinical factors on the development of peptic ulcer during cardiovascular prophylaxis with low-dose aspirin. Methods. In a case-control study including 111 low-dose aspirin users with peptic ulcers and 109 controls (asymptomatic aspirin users), the polymorphism (T-1676C) of the COX-1 gene promoter was genotyped, and blood type, H pylori status, and clinical factors were assessed. Results. Univariate analysis showed no significant differences in genotype frequencies of the COX-1 gene at position -1676 between the peptic ulcer group and control group. Multivariate analysis revealed that blood type O, advanced age, history of peptic ulcer, and concomitant use of NSAID were the independent risk factors for the development of peptic ulcer with the odds ratios of the 2.1, 3.1, 27.6, and 2.9, respectively. Conclusion. The C-1676T polymorphism in the COX-1 gene promoter is not a risk factor for ulcer formation during treatment with low-dose aspirin. Blood type O, advanced age, history of peptic ulcer, and concomitant use of NSAID are of independent significance in predicting peptic ulcer development during treatment with low-dose aspirin.
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Sheu BS, Wu CY, Wu MS, Chiu CT, Lin CC, Hsu PI, Cheng HC, Lee TY, Wang HP, Lin JT. Consensus on control of risky nonvariceal upper gastrointestinal bleeding in Taiwan with National Health Insurance. BIOMED RESEARCH INTERNATIONAL 2014; 2014:563707. [PMID: 25197649 PMCID: PMC4147192 DOI: 10.1155/2014/563707] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 08/01/2014] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS To compose upper gastrointestinal bleeding (UGIB) consensus from a nationwide scale to improve the control of UGIB, especially for the high-risk comorbidity group. METHODS The steering committee defined the consensus scope to cover preendoscopy, endoscopy, postendoscopy, and overview from Taiwan National Health Insurance Research Database (NHIRD) assessments for UGIB. The expert group comprised thirty-two Taiwan experts of UGIB to conduct the consensus conference by a modified Delphi process through two separate iterations to modify the draft statements and to vote anonymously to reach consensus with an agreement ≥80% for each statement and to set the recommendation grade. RESULTS The consensus included 17 statements to highlight that patients with comorbidities, including liver cirrhosis, end-stage renal disease, probable chronic obstructive pulmonary disease, and diabetes, are at high risk of peptic ulcer bleeding and rebleeding. Special considerations are recommended for such risky patients, including raising hematocrit to 30% in uremia or acute myocardial infarction, aggressive acid secretory control in high Rockall scores, monitoring delayed rebleeding in uremia or cirrhosis, considering cycloxygenase-2 inhibitors plus PPI for pain control, and early resumption of antiplatelets plus PPI in coronary artery disease or stroke. CONCLUSIONS The consensus comprises recommendations to improve care of UGIB, especially for high-risk comorbidities.
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Affiliation(s)
- Bor-Shyang Sheu
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chun-Ying Wu
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Cheng-Tang Chiu
- Gastroenterology Endoscopy Center, Chang Gung Memorial Hospital, Linko, Taiwan
| | - Chun-Che Lin
- Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ping-I Hsu
- Department of Internal Medicine, Tainan Hospital, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hsiu-Chi Cheng
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Teng-Yu Lee
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsiu-Po Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jaw-Town Lin
- School of Medicine, Fu Jen Catholic University, No. 510 Zhongzheng Road, Xinzhuang District, New Taipei City 24205, Taiwan
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Diagnosis, treatment, and outcome in patients with bleeding peptic ulcers and Helicobacter pylori infections. BIOMED RESEARCH INTERNATIONAL 2014; 2014:658108. [PMID: 25101293 PMCID: PMC4101224 DOI: 10.1155/2014/658108] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 06/10/2014] [Indexed: 12/13/2022]
Abstract
Upper gastrointestinal (UGI) bleeding is the most frequently encountered complication of peptic ulcer disease. Helicobacter pylori (Hp) infection and nonsteroidal anti-inflammatory drug (NSAID) administration are two independent risk factors for UGI bleeding. Therefore, testing for and diagnosing Hp infection are essential for every patient with UGI hemorrhage. The presence of the infection is usually underestimated in cases of bleeding peptic ulcers. A rapid urease test (RUT), with or without histology, is usually the first test performed during endoscopy. If the initial diagnostic test is negative, a delayed 13C-urea breath test (UBT) or serology should be performed. Once an infection is diagnosed, antibiotic treatment is advocated. Sufficient evidence supports the concept that Hp infection eradication can heal the ulcer and reduce the likelihood of rebleeding. With increased awareness of the effects of Hp infection, the etiologies of bleeding peptic ulcers have shifted to NSAID use, old age, and disease comorbidity.
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Nanau RM, Delzor F, Neuman MG. Efficacy and safety of prasugrel in acute coronary syndrome patients. Clin Biochem 2014; 47:516-28. [DOI: 10.1016/j.clinbiochem.2014.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 03/09/2014] [Accepted: 03/13/2014] [Indexed: 12/11/2022]
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Prolonged acetylsalicylic-acid-supplementation-induced gastritis affects the chemical coding of the stomach innervating vagal efferent neurons in the porcine dorsal motor vagal nucleus (DMX). J Mol Neurosci 2014; 54:188-98. [PMID: 24643520 PMCID: PMC4156783 DOI: 10.1007/s12031-014-0274-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 02/25/2014] [Indexed: 02/07/2023]
Abstract
The main goal of our research was to study the possible alterations of the chemical coding of the dorsal motor vagal nucleus (DMX) neurons projecting to the porcine stomach prepyloric region following prolonged acetylsalicylic acid supplementation. Fast Blue (FB) was injected into the studied area of the stomach. Since the seventh day following the FB injection, acetylsalicylic acid (ASA) was given orally to the experimental gilts. All animals were euthanized on the 28th day after FB injection. Medulla oblongata sections were then processed for double-labeling immunofluorescence for choline acetyltransferase (ChAT), pituitary adenylate cyclase-activating peptide (PACAP), vasoactive intestinal polypeptide (VIP), nitric oxide synthase (NOS), galanin (GAL), substance P (SP), leu enkephalin (LENK), and cocaine- and amphetamine-regulated transcript (CART). In the control DMX, only PACAP was observed in 30.08 ± 1.97 % of the FB-positive neurons, while VIP, NOS, GAL, SP, LENK, and CART were found exclusively in neuronal processes running between FB-labeled perikarya. In the ASA DMX, PACAP was revealed in 49.53 ± 5.73 % of traced vagal perikarya. Moreover, we found de novo expression of VIP in 40.32 ± 7.84 %, NOS in 25.02 ± 6.08 %, and GAL in 3.37 ± 0.85 % of the FB-labeled neurons. Our results suggest that neuronal PACAP, VIP, NOS, and GAL are mediators of neural response to aspirin-induced stomach inflammatory state.
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Liang CC, Muo CH, Wang IK, Chang CT, Chou CY, Liu JH, Yen TH, Huang CC, Chung CJ. Peptic ulcer disease risk in chronic kidney disease: ten-year incidence, ulcer location, and ulcerogenic effect of medications. PLoS One 2014; 9:e87952. [PMID: 24498412 PMCID: PMC3912161 DOI: 10.1371/journal.pone.0087952] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 01/03/2014] [Indexed: 12/30/2022] Open
Abstract
Objectives We aimed at determining peptic ulcer disease (PUD) incidence among chronic kidney disease (CKD) patients during 1998–2008, compared to patients without CKD, and at examining associations between CKD and PUD. Methods Data for 1998–2008 were extracted from the National Health Insurance Research Database in Taiwan. The annual PUD incidence (cases per thousand persons per year) was calculated separately for patients with and without CKD. Characteristics of patients with newly diagnosed PUD (n = 16322) were compared to those of a control group without PUD (n = 32644). The 2 groups were matched for age, sex, and index year. Odds ratios (OR) and 95% confidence intervals (CI) were estimated by logistic regression. Results Over the 10-year period, the PUD incidence was ∼10–12 times higher in CKD patients than in those without CKD. Its incidence in elderly CKD patients increased rapidly over time. For CKD patients, most PUD events (>95%) were managed during hospitalization. Peptic ulcer risk, adjusted for all potential confounders, was much higher in CKD patients undergoing hemodialysis (adjusted OR, 9.74; 95% CI, 7.11–13.31). Maintenance hemodialysis patients were 2 times more likely to have gastric ulcers than duodenal ulcers, while CKD patients not on dialysis had similar risks for both. There were no significant interactions between medications and CKD status on the peptic ulcer risk. Unlike CKD patients on nonsteroidal anti-inflammatory drugs and clopidogrel, those on aspirin did not have a higher peptic ulcer risk (adjusted OR, 0.88; 95% CI, 0.44–1.77). Conclusions CKD patients have a substantially increased PUD risk, and the majority of CKD patients with PUD require hospital management. Further, peptic ulcer risk is affected by hemodialysis therapy, patient status (inpatient vs. outpatient), and ulcerogenic medications.
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Affiliation(s)
- Chih-Chia Liang
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chih-Hsin Muo
- Department of Public Health, China Medical University, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - I-Kuan Wang
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chiz-Tzung Chang
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Che-Yi Chou
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Jiung-Hsiun Liu
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Tzung-Hai Yen
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chiu-Ching Huang
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chi-Jung Chung
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
- Department of Health Risk Management, College of Public Health, China Medical University, Taichung, Taiwan
- * E-mail:
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Karolczak K, Kamysz W, Karafova A, Drzewoski J, Watala C. Homocysteine is a novel risk factor for suboptimal response of blood platelets to acetylsalicylic acid in coronary artery disease: A randomized multicenter study. Pharmacol Res 2013; 74:7-22. [DOI: 10.1016/j.phrs.2013.04.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 04/24/2013] [Accepted: 04/25/2013] [Indexed: 12/29/2022]
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Diener HC. Stroke Patients With Suspected Atrial Fibrillation Should Be Started on Anticoagulation Pending the Results of Long-Term Cardiac Monitoring. Stroke 2013; 44:298-9. [DOI: 10.1161/strokeaha.112.658252] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hans-Christoph Diener
- From the Department of Neurology and Stroke Center, University Hospital Essen, Germany
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