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Turner JV, Garratt D, Barwick A, McLindon LA, Spark MJ, Smith A. Congenital and Fetal Effects After Mifepristone Exposure and Continuation of Pregnancy: A Systematic Review. Clin Pharmacol Ther 2024. [PMID: 39049612 DOI: 10.1002/cpt.3392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 07/09/2024] [Indexed: 07/27/2024]
Abstract
Mifepristone is an anti-progestational drug that is the first component of the standard medical abortion regimen. For women who take mifepristone and then do not take misoprostol, which is the second component of the medical abortion regimen, it is possible that their pregnancy may continue to live birth. Since mifepristone is commonly used for medical abortion up to 9-10 weeks gestation, any adverse or teratogenic effects on the developing embryo/fetus must be considered, given exposure during the critical time of its development and organogenesis. Toxicology and teratology reports have cited studies demonstrating teratogenic effect of mifepristone in some animals. Current clinical guidelines for women exposed to mifepristone in the first trimester of pregnancy state that it is not known to be teratogenic based on limited published evidence from humans. The aim of this narrative systematic review was to investigate embryonic/fetal exposure to mifepristone and any association with congenital or fetal anomalies. This study was conducted by systematic searches of health databases from inception to February 2024. The references of relevant citations were manually searched to retrieve any additional citations not captured in database searching. Congenital anomalies and adverse outcomes were encountered at various doses of mifepristone exposure. A number of the congenital anomalies encountered in this review were explained by circumstances other than exposure to mifepristone. The present systematic review did not find data to support mifepristone being implicated as a teratogen.
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Affiliation(s)
- Joseph V Turner
- School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Deborah Garratt
- School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | - Anna Barwick
- School of Health-Pharmacy, University of New England, Armidale, New South Wales, Australia
| | - Lucas A McLindon
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - M Joy Spark
- School of Health-Pharmacy, University of New England, Armidale, New South Wales, Australia
| | - Angela Smith
- Hunter New England Local Health District, NSW Health, Newcastle, New South Wales, Australia
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2
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Cirucci CA. Self-Managed Medication Abortion: Implications for Clinical Practice. LINACRE QUARTERLY 2023; 90:273-289. [PMID: 37841380 PMCID: PMC10566489 DOI: 10.1177/00243639221128389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Medication abortion represents more than 50 percent of abortions in the United States (US). Since its approval in the US in 2000, the Food and Drug Administration (FDA) has progressively relaxed the prescribing requirements such that currently, no office visit, in-person dispensing, or ultrasound is required. Obtaining medication for abortion online without medical supervision or evaluation is also possible. This article reviews the complications of medication abortion by examining major studies and delineates the risks specific to self-managed abortion to inform clinicians in caring for women. Summary Medication abortion has become the most common abortion method in the United States. This document provides a detailed history of the relaxation requirements on medication abortion and reviews the major studies on medication abortion complications including a discussion of their limitations. Finally, the paper delineates the ease of access to medication abortion without a health care provider and the risks associated with self-managed abortion. This paper is intended to provide information for clinicians who likely will be encountering increasing number of patients with such complications.
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Cirucci CA, Aultman KA, Harrison DJ. Mifepristone Adverse Events Identified by Planned Parenthood in 2009 and 2010 Compared to Those in the FDA Adverse Event Reporting System and Those Obtained Through the Freedom of Information Act. Health Serv Res Manag Epidemiol 2022; 8:23333928211068919. [PMID: 34993274 PMCID: PMC8724996 DOI: 10.1177/23333928211068919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 11/15/2022] Open
Abstract
Background As part of the accelerated approval of mifepristone as an abortifacient in 2000, the Food and Drug Administration (FDA) required prescribers to report all serious adverse events (AEs) to the manufacturer who was required to report them to the FDA. This information is included in the FDA Adverse Event Reporting System (FAERS) and is available to the public online. The actual Adverse Event Reports (AERs) can be obtained through the Freedom of Information Act (FOIA). Methods We compared the number of specific AEs and total AERs for mifepristone abortions from January 1, 2009 to December 31, 2010 from 1. Planned Parenthood abortion data published by Cleland et al. 2. FAERS online dashboard, and 3. AERs provided through FOIA and analyzed by Aultman et al. Results Cleland identified 1530 Planned Parenthood mifepristone cases with specific AEs for 2009 and 2010. For this period, FAERS online dashboard includes a total (from all providers) of only 664, and the FDA released only 330 AERs through FOIA. Cleland identified 1158 ongoing pregnancies in 2009 and 2010. FAERs dashboard contains only 95, and only 39 were released via FOIA. Conclusions There are significant discrepancies in the total number of AERs and specific AEs for 2009 and 2010 mifepristone abortions reported in 1. Cleland's documentation of Planned Parenthood AEs, 2. FAERS dashboard, and 3. AERs provided through FOIA. These discrepancies render the FAERS inadequate to evaluate the safety of mifepristone abortions.
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Affiliation(s)
| | | | - Donna J Harrison
- American Association of Pro-Life Obstetricians and Gynecologists, USA
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Pharmacological Abortion in a Pandemic: An Italian Medico-Legal Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212043. [PMID: 34831795 PMCID: PMC8619535 DOI: 10.3390/ijerph182212043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 11/17/2022]
Abstract
The limitations caused by the spread of the SARS-CoV2 virus have had repercussions on the voluntary termination of pregnancy. During the pandemic, Italy issued updated guidelines regarding voluntary termination of pregnancy by means of mifepristone and prostaglandin. This included news concerning the time limit and location in which this procedure could be accessed: updates partially recognize women’s needs, and they are into line with the European parliament’s recent exhortations. However, these updates do not change the previously provided responsibilities that lie with doctors. This article aimed to compare regulations concerning medical abortion in Italy and other countries, with a focus on recent Italian updates in the context of pandemic.
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Miech RP. Pathopharmacology of Excessive Hemorrhage in Mifepristone Abortions. Ann Pharmacother 2016; 41:2002-7. [DOI: 10.1345/aph.1k351] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To explain a pathopharmacologic mechanism that initiates an increase in hemorrhage following medical abortions with mifepristone. Data Sources: MEDLINE, PubMed, and Google Scholar databases were searched (1990–July 2007). Key search terms were mifepristone, RU486, medical abortion hemorrhage, bleeding, inflammation, innate immune system, phagocytes, macrocytes, cytokines, interleukins, and nitric oxide. Study Selection and Data Extraction: All articles identified from the data sources were evaluated and all information deemed relevant was included for the information related to the development of the understanding of the pathopharmacology of mifepristone as the initiating cause of increased hemorrhage in medical abortions. Mifepristone's blockade of glucocorticoid receptors, prolonged generation of nitric oxide (NO), and postabortion vasodilatation of uterine vasculature by NO that favors excessive hemontiage were the criteria used to determine whether information was relevant for inclusion. Data Synthesis: Inescapable bacterial contamination of the decidua accompanies spontaneous, surgical, and mifepristone abortions and is routinely overcome by activation of the innate immune system. The combination of the induction of NO synthase (NOS) and local production of NO is one of the key features of the activation of the innate immune system's phagocytes. NO is a potent vasodilator and is associated with menstrual menorrhagia. Glucocorticoids prevent the overproduction of NOS and NO and thereby contribute to the control of hemorrhage in the postabortion phase. Conclusions: Blockade of the glucocorticoid receptors by mifepristone can result in an excess of NO that is theorized to be the cause of excessive hemorrhage seen in mifepristone abortions.
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Affiliation(s)
- Ralph P Miech
- Department of Molecular Pharmacology (Box GB3), Warren Alpert Medical School, Brown University, Providence, RI 02912
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Svedas E, Maciulaitis R, Stakisaitis D. Comment: Analysis of Severe Adverse Events Related to the Use of Mifepristone as an Abortifacient. Ann Pharmacother 2016; 40:784; author reply 784-5. [PMID: 16595574 DOI: 10.1345/aph.1g481a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Kanhere AV, Kanhere VM. Pregnancy After Cardiac Surgery. J Obstet Gynaecol India 2016; 66:10-5. [PMID: 26924901 DOI: 10.1007/s13224-016-0841-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 01/09/2016] [Indexed: 10/22/2022] Open
Abstract
Heart disease is one of the common, indirect obstetric causes of maternal death. Management of these cases may challenge the entire team providing care to the mother and fetus. Advances in cardiac surgery has improved quality of life and level of functioning of cardiovascular system of patients with congenital or acquired heart disease. These diseases complicate 0.1-4 % pregnancies. Maternal complications in the form of thromboembolic, hemorrhagic episode and heart failure may occur. The fetus is in danger of effects of oral anticoagulation therapy and other medications given to the patient in order to support cardiovascular system, intrauterine growth restriction and danger of hypoxia. In recent era, we are facing more pregnant patients with previous history of surgical correction of congenital or rheumatic heart disease. In this review, we have attempted to draw a management protocol of such patients based on the available literature and various international guidelines. In pregnant women with mechanical heart valves, recent data support warfarin use throughout pregnancy, followed by a switch to heparin and planned induction of labor. However, the complexity of this situation demands a cafeteria approach where the patient herself can choose from the available options that are supported by evidence-based information. Preconception counseling, evaluation and antenatal high-risk management protocol with the help of cardiologist and cardiac surgeon improves maternal and neonatal outcome.
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Affiliation(s)
- Anjali Vivek Kanhere
- Department of Obstetrics and Gynecology, Chirayu Medical College and Hospital, Bhopal-Indore Highway, Near Bairagarh, Bhopal, Bhopal, MP 462030 India
| | - Vivek Madhav Kanhere
- Department of Cardiothoracic Surgery, Chirayu Cardiac Center, Chirayu Medical College and Hospital, Bhopal, Bhopal-Indore Highway, Near Bairagarh, Bhopal, MP 462030 India
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Affiliation(s)
- J Aznar
- Institute of Life Sciences, Catholic University of Valencia , Valencia , Spain
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Clark W, Shannon C, Winikoff B. Misoprostol for uterine evacuation in induced abortion and pregnancy failure. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17474108.2.1.67] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Tzeng CR, Hwang JL, Au HK, Chien LW. Sonographic patterns of the endometrium in assessment of medical abortion outcomes. Contraception 2013; 88:153-9. [DOI: 10.1016/j.contraception.2012.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 09/02/2012] [Accepted: 09/24/2012] [Indexed: 10/27/2022]
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Han XH, Du CX, Zhang CL, Zheng CL, Wang L, Li D, Feng Y, DuPont HL, Jiang ZD, Shi YK. Clostridium difficile infection in hospitalized cancer patients in Beijing, China is facilitated by receipt of cancer chemotherapy. Anaerobe 2013; 24:82-4. [PMID: 23770543 DOI: 10.1016/j.anaerobe.2013.05.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 03/29/2013] [Accepted: 05/11/2013] [Indexed: 02/04/2023]
Abstract
The purpose of this study was to determine the presence of Clostridium difficile infection (CDI) and risk factors for infection in hospitalized patients with diarrhea in a cancer hospital in Beijing, China. A total of 277 patients with hospital-associated diarrhea (HAD) were studied of which 41 (15%) were positive for fecal C. difficile toxin A/B. For each CDI case identified, a control with HAD but negative C. difficile specimen was enrolled to look for CDI risk factors. Receipt of cancer chemotherapy occurred in 20 (49%) patients with CDI and 9 (22.0%) patients with non-CDI HAD (OR3.39, 95%CI 1.78-10.05). Median length of chemotherapy before HAD developed was 39 days for those with CDI and 22 days for patients with CDI-negative HAD (P = 0.0391). The study found that CDI is commonly seen in cancer patients in China with increasing risk for patients who receive chemotherapy.
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Affiliation(s)
- X H Han
- Cancer Institute/Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Clinical Study on Anticancer Molecular Targeted Drugs, Beijing, China
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Bernard N, Elefant E, Carlier P, Tebacher M, Barjhoux CE, Bos-Thompson MA, Amar E, Descotes J, Vial T. Continuation of pregnancy after first-trimester exposure to mifepristone: an observational prospective study. BJOG 2013; 120:568-74. [DOI: 10.1111/1471-0528.12147] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2012] [Indexed: 11/28/2022]
Affiliation(s)
- N Bernard
- Centre Régional de Pharmacovigilance; Hospices Civils de Lyon; Lyon; France
| | - E Elefant
- Centre de Référence sur les Agents Tératogènes; Hôpital Trousseau; Paris; France
| | - P Carlier
- Centre Régional de Pharmacovigilance; Hôpital Fernand Widal; Paris; France
| | - M Tebacher
- Centre Régional de Pharmacovigilance; Hôpital Civil; Strasbourg; France
| | - CE Barjhoux
- Centre Régional de Pharmacovigilance; Centre Hospitalo-Universitaire; Grenoble; France
| | - MA Bos-Thompson
- Centre Régional de Pharmacovigilance; Hôpital Lapeyronie; Montpellier; France
| | - E Amar
- Registre des malformations en Rhône-Alpes; Lyon; France
| | - J Descotes
- Centre Régional de Pharmacovigilance; Hospices Civils de Lyon; Lyon; France
| | - T Vial
- Centre Régional de Pharmacovigilance; Hospices Civils de Lyon; Lyon; France
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Mifepristone (RU 486) induces vasodilation and inhibits platelet aggregation: nongenomic and genomic action to cause hemorrhage. Contraception 2011; 84:169-77. [PMID: 21757059 DOI: 10.1016/j.contraception.2010.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2010] [Revised: 12/16/2010] [Accepted: 12/22/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND The regimen mifepristone/misoprostol is an established and highly effective method for early termination of pregnancy. However, its side effects such as a significantly long bleeding time and hemorrhage have been scantly studied. STUDY DESIGN Human umbilical artery (HUA) from pregnant women undergoing elective cesarean section at term and rat thoracic aorta (RTA) were isometrically recorded. The vasorelaxing effect of mifepristone was analyzed on the contractile responses induced by KCl or serotonin (5-HT); moreover, the potential response of mifepristone on adenosine diphosphate (ADP)-induced human platelet aggregation was also evaluated. RESULTS This study describes that mifepristone elicits (1) rapid and reversible vasorelaxation on KCl- or 5-HT-induced contraction in HUA and RTA with and without endothelium and (2) immediate prevention of ADP-induced human platelet aggregation. CONCLUSIONS These effects seem to be responsible for increased and prolonged hemorrhage. Since mifepristone-prevented platelet aggregation was observed in the anucleate platelets, and mifepristone-induced vasorelaxation remained unaffected in de-endothelized tissues, by inhibitors of transcription and translation and a nitric oxide (NO) synthase inhibitor, a nongenomic endothelium- and NO-independent mechanism was revealed. Additionally, the results indicated a blockade of voltage- and receptor-operated calcium channels. The antiglucocorticoid genomic action of mifepristone, by inducing an excess of NO, may also contribute to exacerbated hemorrhage.
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Harrison DJ, Mitroka JG. Defining reality: the potential role of pharmacists in assessing the impact of progesterone receptor modulators and misoprostol in reproductive health. Ann Pharmacother 2010; 45:115-9. [PMID: 21177418 DOI: 10.1345/aph.1p608] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Medical abortion is increasingly heralded as an ideal method for decreasing maternal mortality in health-care resource-deprived areas and as an answer to the shrinking pool of physicians willing to perform abortions. The advent of progesterone receptor modulators (PRMs) and the recent approval by the Food and Drug Administration of ella (ulipristal) as an emergency contraceptive put pharmacists in the center of abortion controversy. Pharmacists, worldwide, need to be aware of the controversy surrounding the introduction of PRMs, particularly with regard to the effect on health policy, their mechanism of action, associated adverse events, and common off-label uses. Once understood, genuine opportunity exists for pharmacists to serve a fundamental role in positively shaping public health policy.
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Affiliation(s)
- Donna J Harrison
- American Association of Pro-Life Obstetricians and Gynecologists, Holland, MI, USA.
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Sitruk-Ware R. Mifepristone and misoprostol sequential regimen side effects, complications and safety. Contraception 2006; 74:48-55. [PMID: 16781261 DOI: 10.1016/j.contraception.2006.03.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Revised: 03/13/2006] [Accepted: 03/20/2006] [Indexed: 11/24/2022]
Abstract
Exhibiting a strong affinity to the progesterone and the glucocorticoid receptors, mifepristone exert competitive antagonism to these hormones both in in vitro and in animal experiments. Due to its antiprogesterone activity, it was proposed that mifepristone be used for the termination of early human pregnancy. Mifepristone, at a dose of 600 mg initially used alone, was then used with a subsequent low dose of prostaglandin that led to a success rate of 95% as a medical method for early termination of pregnancy (TOP), and the occurrence of continuing pregnancy was reduced to <or=1%. Its use was extended to other indications, such as cervical dilatation prior to surgical TOP in the first trimester, therapeutic TOP for medical reasons beyond the first trimester and for labor induction in case of fetal death in utero. The efficacy and safety of this treatment have been confirmed based on its use for over 15 years since its first approval in France and with close adherence to the approved recommendations. This article describes the toxicology studies conducted in animals as well as the safety follow-up and side effects reported with use of the compound when used with misoprostol in the main indication that is currently approved in 31 countries. Special emphasis is given to the rare but relevant safety issues, that is, heavy uterine bleeding, pelvic infections and continuing pregnancies. The rationale for warnings and contraindications for use of the product are also explained.
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Affiliation(s)
- Regine Sitruk-Ware
- Center for Biomedical Research, Population Council, Rockefeller University, New York, NY 10021, USA.
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Shannon CS. Comment: analysis of severe adverse events related to the use of mifepristone as an abortifacient. Ann Pharmacother 2006; 40:1215-6; author reply 1216-7. [PMID: 16735658 DOI: 10.1345/aph.1g481d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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17
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Hausknecht RU. Comment: analysis of severe adverse events related to the use of mifepristone as an abortifacient. Ann Pharmacother 2006; 40:785-6; author reply 786. [PMID: 16569806 DOI: 10.1345/aph.1g481c] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1181] [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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