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Niżnik Ł, Jabłońska K, Orczyk M, Orzechowska M, Jasińska J, Smoliniec B, Hućko A, Kosowicz P, Klocek A, Słoma P, Roztoczyńska A, Toporowska-Kaźmierak J, Jurowski K. Hot-Water Immersion (HWI) or Ice-Pack Treatment (IPT) as First Aid for Human Envenomation by Marine Animals? Review of Literature. Toxins (Basel) 2024; 16:273. [PMID: 38922167 PMCID: PMC11209160 DOI: 10.3390/toxins16060273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 06/11/2024] [Accepted: 06/13/2024] [Indexed: 06/27/2024] Open
Abstract
Envenomation by marine animals poses a significant health concern globally, affecting both local residents and tourists in coastal regions. The primary objective of this review is to critically evaluate the existing scientific literature to determine the most effective first-aid treatment for envenomations caused by marine animals, specifically whether hot-water immersion (HWI) or ice-pack treatment (IPT) provides the best immediate care. This comprehensive review covers a wide range of marine envenomations, from jellyfish stings to stingray injuries. While our focus is primarily on the efficacy of HWI and IPT, we also explore the role of cold-water treatment as a result of its relevance and similarity to ice-pack applications. In addition, we examine other treatments mentioned in the literature, such as medications or vinegar, and highlight their findings where applicable. To provide a clear and structured overview, we summarised the articles in separate tables. These tables categorise the type of research conducted, the marine species studied, the region of origin of the marine species, and the key findings of each study. Our analysis of the available evidence indicates a general consensus in the scientific community on the effectiveness of HWI or IPT for envenomation by marine animals. However, when treating those injuries, it is crucial to consider all factors since there is no universally superior treatment due to the diverse nature of marine habitats.
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Affiliation(s)
- Łukasz Niżnik
- Department of Regulatory and Forensic Toxicology, Institute of Medical Expertise, Łódź, ul. Aleksandrowska 67/93, 91-205 Łódź, Poland
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland (A.K.)
| | - Karolina Jabłońska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland (A.K.)
| | - Michał Orczyk
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland (A.K.)
| | - Martyna Orzechowska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland (A.K.)
| | - Judyta Jasińska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland (A.K.)
| | - Barbara Smoliniec
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland (A.K.)
| | - Agnieszka Hućko
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland (A.K.)
| | - Piotr Kosowicz
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland (A.K.)
| | - Anna Klocek
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland (A.K.)
| | - Paweł Słoma
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland (A.K.)
| | - Aleksandra Roztoczyńska
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland (A.K.)
| | - Joanna Toporowska-Kaźmierak
- Toxicological Science Club ‘Paracelsus’, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland (A.K.)
| | - Kamil Jurowski
- Department of Regulatory and Forensic Toxicology, Institute of Medical Expertise, Łódź, ul. Aleksandrowska 67/93, 91-205 Łódź, Poland
- Laboratory of Innovative Toxicological Research and Analyses, Institute of Medical Sciences, Medical College, Rzeszów University, Al. mjr. W. Kopisto 2a, 35-959 Rzeszow, Poland
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Hughey SB, Kotler JA, Ozaki Y, Itani Y, Fukuzawa F, Yanagimoto T, Takamatsu K, Koito S, Suzuki H, Nishihira Y, Hughey AC, Nagata T. Marine Envenomation in Okinawa: Overview and Treatment Concept. Wilderness Environ Med 2024; 35:57-66. [PMID: 38379485 DOI: 10.1177/10806032231220401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Okinawa prefecture is a popular tourist destination due to its beaches and reefs. The reefs host a large variety of animals, including a number of venomous species. Because of the popularity of the reefs and marine activities, people are frequently in close contact with dangerous venomous species and, thus, are exposed to potential envenomation. Commonly encountered venomous animals throughout Okinawa include the invertebrate cone snail, sea urchin, crown-of-thorns starfish, blue-ringed octopus, box jellyfish, and fire coral. The vertebrates include the stonefish, lionfish, sea snake, and moray eel. Treatment for marine envenomation can involve first aid, hot water immersion, antivenom, supportive care, regional anesthesia, and pharmaceutical administration. Information on venomous animals, their toxins, and treatment should be well understood by prehospital care providers and physicians practicing in the prefecture.
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Affiliation(s)
- Scott B Hughey
- Naval Hospital Okinawa, Okinawa, Japan
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA
| | - Joshua A Kotler
- Naval Biotechnology Group, Naval Medical Center Portsmouth, Portsmouth, VA
- III Marine Expeditionary Force, Okinawa, Japan
| | | | | | | | | | | | - Shu Koito
- Naval Hospital Okinawa, Okinawa, Japan
| | | | | | | | - Takashi Nagata
- Department of Emergency Medicine, Japan Self-Defense Force Central Hospital, Tokyo, Japan
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Mouchbahani-Constance S, Choinière M, Sharif-Naeini R. Understanding the pain experience of lionfish envenomation. Pain Rep 2023; 8:e1090. [PMID: 38225957 PMCID: PMC10789455 DOI: 10.1097/pr9.0000000000001090] [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: 03/24/2023] [Revised: 05/01/2023] [Accepted: 05/05/2023] [Indexed: 01/17/2024] Open
Abstract
Introduction Stings from the lionfish (Pterois volitans) constitute one of the most painful wounds in the ocean. This species has invaded the Atlantic coast of the United States, Gulf of Mexico, Caribbean, and Mediterranean Sea. In addition to its ecological impact on local fish populations, stings from the lionfish pose a medical problem because of the debilitating nature of the pain they produce. However, there are no studies examining the human pain experience of lionfish stings. Objective To characterize the various aspects of the pain experience following a lionfish sting. Methods We developed a pain questionnaire that includes validated scales used with patients having acute or chronic pain to understand the pain variability, as well as the use of health care resources and treatments. Results We provide the first study of the pain experience from lionfish stings. Here, we show that the pain is intense from the start and peaks approximately 1 hour later, resolving itself in 7 days for most victims. Furthermore, pain intensity can be influenced by several factors, including (1) age of the victim, where older victims experience significantly higher pain intensities, (2) the number of spines involved, (3) and whether infection occurred at the injury site. However, pain intensity was not different between male and female participants. Conclusion These findings will inform the medical community on the pain experience and can be used by local authorities to better appreciate the impact of lionfish envenomations to develop programs aimed at curtailing the expansion of the lionfish.
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Affiliation(s)
- Stephanie Mouchbahani-Constance
- Department of Physiology and Cell Information Systems Group, McGill University, Montreal, QC, Canada
- Alan Edwards Center for Research on Pain, McGill University, Montreal, QC, Canada
| | - Manon Choinière
- Department of Anesthesiology and Pain Medicine, University of Montreal, Montreal, QC, Canada
| | - Reza Sharif-Naeini
- Department of Physiology and Cell Information Systems Group, McGill University, Montreal, QC, Canada
- Alan Edwards Center for Research on Pain, McGill University, Montreal, QC, Canada
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Paolino G, Di Nicola MR, Avella I, Mercuri SR. Venomous Bites, Stings and Poisoning by European Vertebrates as an Overlooked and Emerging Medical Problem: Recognition, Clinical Aspects and Therapeutic Management. Life (Basel) 2023; 13:1228. [PMID: 37374011 DOI: 10.3390/life13061228] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/17/2023] [Accepted: 05/20/2023] [Indexed: 06/29/2023] Open
Abstract
Europe presents a high number of venomous and poisonous animals able to elicit medically relevant symptoms in humans. However, since most of the accidents involving venomous or poisonous animals in Europe are unreported, their incidence and morbidity are severely overlooked. Here we provide an overview of the European vertebrate species of greatest toxicological interest, the clinical manifestations their toxins can cause, and their treatment. We report the clinical symptoms induced by envenomations and poisoning caused by reptiles, fishes, amphibians and mammals in Europe, ranging from mild, local symptoms (e.g., erythema, edema) to systemic and potentially deadly. The present work constitutes a tool for physicians to recognize envenomation/poisoning symptoms caused by the most medically relevant European vertebrates and to decide which approach is the most appropriate to treat them.
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Affiliation(s)
- Giovanni Paolino
- Unit of Dermatology and Cosmetology, I.R.C.C.S. San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
- Unit of Clinical Dermatology, Università Vita-Salute San Raffaele, Via Olgettina 60, 20132 Milan, Italy
| | - Matteo Riccardo Di Nicola
- Unit of Dermatology and Cosmetology, I.R.C.C.S. San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
- Asociación Herpetológica Española, Apartado de Correos 191, 28911 Leganés, Spain
| | - Ignazio Avella
- CIBIO, Centro de Investigação em Biodiversidade e Recursos Genéticos, InBIO Laboratório Associado, Campus de Vairão, Universidade do Porto, 4485-661 Vairão, Portugal
- Departamento de Biologia, Faculdade de Ciências, Universidade do Porto, 4099-002 Porto, Portugal
- BIOPOLIS Program in Genomics, Biodiversity and Land Planning, CIBIO, Campus de Vairão, 4485-661 Vairão, Portugal
| | - Santo Raffaele Mercuri
- Unit of Dermatology and Cosmetology, I.R.C.C.S. San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy
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Mathis S, Carla L, Duval F, Nadal L, Solé G, Le Masson G. Acute peripheral neuropathy following animal envenomation: A case report and systematic review. J Neurol Sci 2022; 442:120448. [PMID: 36244096 DOI: 10.1016/j.jns.2022.120448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 10/31/2022]
Abstract
Animal envenomation in humans is usually accidental or for defensive purposes. Depending on the venom composition and administration, different reactions can be observed. After reporting the first case of acute polyradiculitis in a 57-year-old healthy male after red lionfish envenomation, we propose to analyze rare similar cases of acute neuritis after animal envenomation published in the medical literature. Including our case, we found 54 patients who developed acute peripheral neuropathy after having been stung or bitten by various animals, mainly hymenoptera (in half of the cases) but also jellyfishes, snakes, corals or nonhooked arthropods. We observed two distinct patterns of peripheral neuropathy: more than half of them were polyneuropathy while the others were focal neuropathy. The prognosis was favorable in most cases. The pathophysiological mechanism associated with these rare complications remain unknown, although some hypotheses may be proposed. A direct action of certain components of the venom, such as phospholipase-A2, could explain the focal forms of peripheral neuropathy trough toxic reactions and/or vasculitis processes. The more diffuse clinical situations could be due to an allergy-triggered immune-mediated reaction (possibly linked to a molecular mimicry mechanism between venom proteins and some myelin proteins of the peripheral nervous system), or to the action of some venom components on membrane ionic channels particularly at the node of Ranvier. Even if acute peripheral neuropathies are rare after envenomation, they may occur after envenomation from various animals, and their usually favorable prognoses should be known by neurologists.
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Affiliation(s)
- Stéphane Mathis
- Department of Neurology, Nerve-Muscle Unit, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France; ALS Center, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France; AOC Neuromuscular Reference Center, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France.
| | - Louis Carla
- Department of Neurology, Nerve-Muscle Unit, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Fanny Duval
- Department of Neurology, Nerve-Muscle Unit, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France; AOC Neuromuscular Reference Center, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Louis Nadal
- Department of Neurology, Nerve-Muscle Unit, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Guilhem Solé
- Department of Neurology, Nerve-Muscle Unit, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France; AOC Neuromuscular Reference Center, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France
| | - Gwendal Le Masson
- Department of Neurology, Nerve-Muscle Unit, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France; ALS Center, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France; AOC Neuromuscular Reference Center, University Hospital (CHU) of Bordeaux (Pellegrin Hospital), 2 place Amélie Raba-Léon, 33000 Bordeaux, France
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Bédry R, de Haro L, Bentur Y, Senechal N, Galil BS. Toxicological risks on the human health of populations living around the Mediterranean Sea linked to the invasion of non-indigenous marine species from the Red Sea: A review. Toxicon 2021; 191:69-82. [PMID: 33359388 DOI: 10.1016/j.toxicon.2020.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 12/07/2020] [Accepted: 12/19/2020] [Indexed: 10/22/2022]
Abstract
The Mediterranean region is, by far, a prime travel destination, having hosted more than 330 million tourists in 2016, mostly for seaside holidays. A greatly increased influx of thermophilic Red Sea species, introduced through the Suez Canal in a process referred to as Lessepsian invasion (in honor of Ferdinand de Lesseps who instigated the building of the Suez Canal), have raised awareness among scientists, medical personnel, and the public, of health risks caused by some venomous and poisonous marine species. The main species of concern are the poisonous Lagocephalus sceleratus, and the venomous Plotosus lineatus, Siganus luridus, Siganus rivulatus, Pterois miles, Synancea verrucosa, Rhopilema nomadica, Macrorhynchia philippina and Diadema setosum. Recognizing that the main factors that drive the introduction and dispersal of Red Sea biota in the Mediterranean, i.e., Suez Canal enlargements and warming seawater, are set to increase, and international tourist arrivals are forecasted to increase as well, to 500 million in 2030, an increase in intoxications and envenomations by alien marine species is to be expected and prepared for.
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Affiliation(s)
- R Bédry
- UHSI, Pellegrin University Hospital, 33000, Bordeaux, France.
| | - L de Haro
- Centre Antipoison de Marseille, Hôpital Sainte Marguerite, 13009, Marseille, France
| | - Y Bentur
- Israel Poison Information Center, Rambam Health Care Campus, The Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - N Senechal
- Bordeaux University, UMR EPOC, 5805, Pessac, France
| | - B S Galil
- Steinhardt Museum of Natural History, Tel Aviv University, Tel Aviv, Israel
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Abstract
The lionfish (Pterois volitans) is a venomous invasive species found in the Caribbean and Northwestern Atlantic. It poses a growing health problem because of the increase in frequency of painful stings, for which no treatment or antidote exists, and the long-term disability caused by the pain. Understanding the venom's algogenic properties can help identify better treatment for these envenomations. In this study, we provide the first characterization of the pain and inflammation caused by lionfish venom and examine the mechanisms through which it causes pain using a combination of in vivo and in vitro approaches including behavioral, physiological, calcium imaging, and electrophysiological testing. Intraplantar injections of the venom produce a significant increase in pain behavior, as well as a marked increase in mechanical sensitivity for up to 24 hours after injection. The algogenic substance(s) are heat-labile peptides that cause neurogenic inflammation at the site of injection and induction of Fos and microglia activation in the superficial layers of the dorsal horn. Finally, calcium imaging and electrophysiology experiments show that the venom acts predominantly on nonpeptidergic, TRPV1-negative, nociceptors, a subset of neurons implicated in sensing mechanical pain. These data provide the first characterization of the pain and inflammation caused by lionfish venom, as well as the first insight into its possible cellular mechanism of action.
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Needleman RK, Neylan IP, Erickson TB. Environmental and Ecological Effects of Climate Change on Venomous Marine and Amphibious Species in the Wilderness. Wilderness Environ Med 2018; 29:343-356. [DOI: 10.1016/j.wem.2018.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 04/12/2018] [Accepted: 04/18/2018] [Indexed: 01/22/2023]
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de Haro L. Aspects cliniques des expositions aux toxines marines : de découvertes en redécouvertes. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2018. [DOI: 10.1016/j.toxac.2018.07.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Boucaud-Maitre D, Vernoux JP, Pelczar S, Daudens-Vaysse E, Aubert L, Boa S, Ferracci S, Garnier R. Incidence and clinical characteristics of ciguatera fish poisoning in Guadeloupe (French West Indies) between 2013 and 2016: a retrospective cases-series. Sci Rep 2018; 8:3095. [PMID: 29449664 PMCID: PMC5814543 DOI: 10.1038/s41598-018-21373-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 02/02/2018] [Indexed: 11/09/2022] Open
Abstract
This retrospective case study analysed the incidence and symptoms of ciguatera fish poisoning (ciguatera) in Guadeloupe (French West Indies) between 2013 and 2016. Cases attending the emergency departments of the two public hospitals and the reports received by the regional health authority in charge of monitoring (ARS) were compiled. Two hundred and thirty-four cases of poisoning were observed, with a mean annual incidence of 1.47/10,000 (95% CI): 1.29-1.66), i.e 5 times higher than the previously reported incidence (1996-2006). The main species described as being responsible for poisoning were fish from the Carangidae family (n = 47) (jack), followed by fish from the Lutjanidae family (n = 27) (snapper), Serranidae family (n = 15) (grouper), Sphyraenidae family (n = 12) (barracuda), and Mullidae family (n = 12) (goatfish). One case of lionfish ciguatera was observed. 93.9% of patients experienced gastrointestinal symptoms, 76.0% presented neurological signs (mainly paresthesia, dysesthesia and pruritus) and 40.3% presented cardiovascular symptoms (bradycardia and/or hypotension). A high frequency (61.4%) of hypothermia (body temperature <36.5 °C) was observed. This study reports for the first time the relatively high frequency of cardiac symptoms and low body temperature. The monitoring of ciguatera poisoning throughout the Caribbean region must be improved, notably after reef disturbance due to Irma and Maria major cyclones.
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Affiliation(s)
- Denis Boucaud-Maitre
- French West Indies Toxicovigilance Coordination, Basse-Terre Hospital, Basse-Terre, France.
| | - Jean-Paul Vernoux
- Research Unit EA 4651 Aliments Bioprocédés Toxicologie Environnements (ABTE), IFR146 ICORE, Normandie Université de Caen, Esplanade de la paix, Caen, France
| | - Stéphane Pelczar
- Department of Critical Care and Emergency Unit, Basse-Terre Hospital, Basse-Terre, France
| | - Elise Daudens-Vaysse
- Santé publique France, French national public health agency, Regional unit (Cire) Antilles, Saint-Maurice, France
| | - Lyderic Aubert
- Santé publique France, French national public health agency, Regional unit (Cire) Antilles, Saint-Maurice, France
| | - Sylvie Boa
- Agence Régionale de Santé Guadeloupe, Monitoring and health alert unit, Gourbeyre, France
| | - Serge Ferracci
- Department of Critical Care and Emergency Unit, Pointe-à-Pitre University Hospital, Pointe-à-Pitre, France
| | - Robert Garnier
- Poison and Toxicovigilance Centre, Fernand Widal Hospital, Paris, France
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Boucaud-Maitre D, Ferracci S, Pelczar S. Quels sont les facteurs pronostiques de recours des urgentistes aux centres antipoison et de toxicovigilance ? Étude rétrospective de cohorte en Guadeloupe entre 2013 et 2015. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2017. [DOI: 10.1016/j.toxac.2017.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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