1
|
Skajaa N, Laugesen K, Lauffenburger JC, Schwamm LH, Sørensen HT, Patorno E. Trends in the Use of Medications for Secondary Ischemic Stroke Prevention in Denmark, 2005-2021. Neurology 2024; 102:e209309. [PMID: 38648572 PMCID: PMC11226314 DOI: 10.1212/wnl.0000000000209309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/29/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Understanding trends in the use of medications for secondary stroke prevention is crucial for identifying areas for improvement in stroke care. We examined the use of lipid-lowering, antihypertensive, glucose-lowering, oral anticoagulant, and antiplatelet medications after ischemic stroke hospitalization, from 2005 to 2021. METHODS Using nationwide registries in Denmark, we identified a cohort of patients discharged from hospital with a first-time or recurrent ischemic stroke (N = 150,744). Stratified by calendar year, we ascertained the 180-day probability of filling a prescription for the abovementioned medications after discharge. We further assessed factors associated with medication use. RESULTS From 2005 to 2021, lipid-lowering medication use increased from 58.3% to 82.0%; atorvastatin use rose from 2.1% to 64.8% and simvastatin use decreased from 55.7% to 8.6%. Antihypertensive medication use remained stable, at approximately 89%, and various antihypertensive classes were used comparably. Glucose-lowering medication use increased from 71.5% in 2005 to 84.1% in 2021, driven primarily by an increase in metformin use (from 28.0% to 59.5%). Use of glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter-2 inhibitors continually increased (from 1.7% to 17.5% and from 0.5% to 17.3%, respectively) between 2015 and 2021. Anticoagulant medication use rose from 45.9% in 2005 to 87.0% in 2021, primarily because of increased use of direct oral anticoagulant medications starting around 2010 and a decline in warfarin use. Antiplatelet use remained consistently high, at approximately 95%. Trends were consistent across subgroups of interest; however, overall medication use was lower in older patients (65 years and older), patients with severe stroke, and patients with neurologic and psychiatric comorbidities. DISCUSSION Despite increasing trends in the use of 3 of 5 medication classes, the overall use of lipid-lowering, glucose-lowering, and oral anticoagulant medications was somewhat lower than expected according to clinical guidelines, particularly among older patients with more severe stroke and other comorbidities. The relatively low use in these subgroups may signify appropriate clinical decision making in consideration of frequent contraindications and reduced life expectancy or highlight potential areas of improvement for the care of patients with recent ischemic stroke.
Collapse
Affiliation(s)
- Nils Skajaa
- From the Departments of Clinical Epidemiology and Clinical Medicine (N.S., K.L., H.T.S.), Aarhus University; Department of Clinical Biochemistry (K.L.), Aarhus University Hospital, Denmark; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (J.C.L., E.P.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Yale School of Medicine (L.H.S.), New Haven, CT
| | - Kristina Laugesen
- From the Departments of Clinical Epidemiology and Clinical Medicine (N.S., K.L., H.T.S.), Aarhus University; Department of Clinical Biochemistry (K.L.), Aarhus University Hospital, Denmark; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (J.C.L., E.P.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Yale School of Medicine (L.H.S.), New Haven, CT
| | - Julie C Lauffenburger
- From the Departments of Clinical Epidemiology and Clinical Medicine (N.S., K.L., H.T.S.), Aarhus University; Department of Clinical Biochemistry (K.L.), Aarhus University Hospital, Denmark; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (J.C.L., E.P.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Yale School of Medicine (L.H.S.), New Haven, CT
| | - Lee H Schwamm
- From the Departments of Clinical Epidemiology and Clinical Medicine (N.S., K.L., H.T.S.), Aarhus University; Department of Clinical Biochemistry (K.L.), Aarhus University Hospital, Denmark; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (J.C.L., E.P.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Yale School of Medicine (L.H.S.), New Haven, CT
| | - Henrik T Sørensen
- From the Departments of Clinical Epidemiology and Clinical Medicine (N.S., K.L., H.T.S.), Aarhus University; Department of Clinical Biochemistry (K.L.), Aarhus University Hospital, Denmark; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (J.C.L., E.P.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Yale School of Medicine (L.H.S.), New Haven, CT
| | - Elisabetta Patorno
- From the Departments of Clinical Epidemiology and Clinical Medicine (N.S., K.L., H.T.S.), Aarhus University; Department of Clinical Biochemistry (K.L.), Aarhus University Hospital, Denmark; Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine (J.C.L., E.P.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA; and Yale School of Medicine (L.H.S.), New Haven, CT
| |
Collapse
|
2
|
Characterisation of recent trends in cardiovascular risk factors in young and middle-aged patients with ischaemic stroke and/or transient ischaemic attack. J Neurol Sci 2020; 418:117115. [PMID: 32916515 DOI: 10.1016/j.jns.2020.117115] [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: 06/22/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Strokes in the young and middle-aged are associated with a disproportionately large economic and social impact in addition to their clinical effects. Standard Modifiable Cardiovascular Risk Factors (SMuRFs; hypercholesterolaemia, hypertension, diabetes mellitus and smoking) are key drivers of cardiovascular disease including strokes, however recent temporal trends in the younger stroke population have not been well characterised. We aimed to evaluate recent trends of SMuRFs in a cohort of younger patients with ischaemic stroke. METHODS Consecutive patients aged <65 years with clinical and/or radiological diagnosis of ischaemic stroke or transient ischaemic attack in a tertiary referral centre (2013-2017) were retrospectively appraised. The demographic and clinical comorbidities of these patients were assessed including their SMuRF profile. The prevalence over time and clinical associations of patients with no SMuRFs were studied and compared to patients with SMuRFs. RESULTS Of 487 patients (53.49 ± 9.13 yrs., 60% men) analysed, 23% did not have SMuRFs. The proportion of "non-SMuRF" patients increased over time (p < 0.01) and this trend was not influenced by age (p = 0.48) or gender (p = 0.68). The presence of SMuRFs was not associated with in-hospital outcomes, however patients without SMuRFs were significantly less likely to be discharged on blood pressure (p < 0.01) and lipid-lowering therapies (p = 0.03). CONCLUSIONS The proportion of younger stroke patients without SMuRFs is substantial and has increased over time. Our findings highlight the need for further research to better understand the mechanisms underlying stroke development in this population and whether less risk factor treatment in this population could impact longer term outcomes.
Collapse
|
3
|
Ung D, Dalli LL, Lopez D, Sanfilippo FM, Kim J, Andrew NE, Thrift AG, Cadilhac DA, Anderson CS, Kilkenny MF. Assuming one dose per day yields a similar estimate of medication adherence in patients with stroke: An exploratory analysis using linked registry data. Br J Clin Pharmacol 2020; 87:1089-1097. [PMID: 32643250 DOI: 10.1111/bcp.14468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 06/12/2020] [Accepted: 06/22/2020] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Prescribed daily dose (PDD), the number of doses prescribed to be taken per day, is used to calculate medication adherence using pharmacy claims data. PDD can be substituted by (i) one dose per day (1DD), (ii) an estimate based on the 75th percentile of days taken by patients to refill a script (PDD75 ) or (iii) the World Health Organization's defined daily dose (DDD). We aimed to compare these approaches for estimating the duration covered by medications and whether this affects calculated 1-year adherence to antihypertensive medications post-stroke. METHODS We conducted a retrospective review of prospective cohort data from the ongoing Australian Stroke Clinical Registry linked with pharmacy claims data. Adherence was calculated as the proportion of days covered (PDC) for 1DD, PDD75 and DDD. Differences were assessed using Wilcoxon rank-sum tests. RESULTS Among 12 628 eligible patients with stroke, 10 057 (80%) were prescribed antihypertensive medications in the year after hospital discharge (78.2% aged ≥65 years, 45.2% female). Overall, the 75th percentile of patient time until next medication refill was 39 days. The greatest variations in dose regimens, estimated using person- and dose-level refill times, were for beta blockers (11.4% taking two tablets/day). There were comparable levels of adherence between 1DD and the PDD75 (median PDC 91.0% vs 91.2%; P = 0.70), but adherence was slightly higher using DDD (92.3%; both P < 0.001). However, this would represent a clinically nonsignificant difference. CONCLUSION Adherence to antihypertensive medications shows similar estimates across standard measures of dosage in patients during the first year after an acute stroke.
Collapse
Affiliation(s)
- David Ung
- Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Lachlan L Dalli
- Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Derrick Lopez
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Joosup Kim
- Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Nadine E Andrew
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
| | - Amanda G Thrift
- Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Dominique A Cadilhac
- Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| | - Craig S Anderson
- Neurology Department, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,The George Institute for Global Health China at Peking University Health Science Center, China.,The George Institute for Global Health Australia, Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research Group, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia
| |
Collapse
|
4
|
Gattellari M, Goumas C, Jalaludin B, Worthington J. Measuring stroke outcomes for 74 501 patients using linked administrative data: System-wide estimates and validation of 'home-time' as a surrogate measure of functional status. Int J Clin Pract 2020; 74:e13484. [PMID: 32003055 DOI: 10.1111/ijcp.13484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/20/2020] [Accepted: 01/27/2020] [Indexed: 01/06/2023] Open
Abstract
AIMS Administrative data offer cost-effective, whole-of-population stroke surveillance yet the lack of validated measures of functional status is a shortcoming. The number of days spent living at home after stroke ('home-time') is a patient-centred outcome that can be objectively ascertained from administrative data. Population-based validation against both severity and outcome measures and for all subtypes is lacking. We aimed to report representative 'home-time' estimates and validate 'home-time' as a surrogate measure of functional status after stroke. METHODS Stroke hospitalisations from a state-wide census in New South Wales, Australia, from January 1, 2005 to March 31, 2014 were linked to prehospital data, poststroke admissions and deaths. We correlated 90-day 'home-time' with Glasgow Coma Scale (GCS) scores, measured upon a patient's initial contact with paramedics and Functional Independence Measure (FIM) scores, measured upon entry to rehabilitation after the acute hospital stroke admission. Negative binomial regressions identified predictors of 'home-time'. RESULTS Patients with stroke (N = 74 501) spent a median of 53 days living at home 90 days after the event. Median 'home-time' was 60 days after ischaemic stroke, 49 days after subarachnoid haemorrhage and 0 days after intracerebral haemorrhage. GCS and FIM scores significantly correlated with 'home-time' (P < .001). Women spent significantly less time at home compared with men after stroke, although being married increased 'home-time' after ischaemic stroke and subarachnoid haemorrhage. CONCLUSIONS These findings underscore the immediate and adverse impact of stroke. 'Home-time' measured using administrative data is a robust, replicable and valid patient-centred outcome enabling inexpensive population-based surveillance and system-wide quality assessment.
Collapse
Affiliation(s)
- Melina Gattellari
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Chris Goumas
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Bin Jalaludin
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- Population Health Intelligence, Healthy People and Places Unit, South Western Sydney Local Health District, Sydney, NSW, Australia
- School of Public Health, The University of New South Wales, Sydney, NSW, Australia
| | - John Worthington
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia
| |
Collapse
|
5
|
Gattellari M, Goumas C, Jalaludin B, Worthington JM. Population-based stroke surveillance using big data: state-wide epidemiological trends in admissions and mortality in New South Wales, Australia. Neurol Res 2020; 42:587-596. [PMID: 32449879 DOI: 10.1080/01616412.2020.1766860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Epidemiological trends for major causes of death and disability, such as stroke, may be monitored using administrative data to guide public health initiatives and service delivery. METHODS We calculated admissions rates for ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage between 1 January 2005 and December 31st, 2013 and rates of 30-day mortality and 365-day mortality in 30-day survivors to 31 December 2014 for patients aged 15 years or older from New South Wales, Australia. Annual Average Percentage Change in rates was estimated using negative binomial regression. RESULTS Of 81,703 eligible admissions, 64,047 (78.4%) were ischaemic strokes and 13,302 (16.3%) and 4,778 (5.8%) were intracerebral and subarachnoid haemorrhages, respectively. Intracerebral haemorrhage admissions significantly declined by an average of 2.2% annually (95% Confidence Interval = -3.5% to -0.9%) (p < 0.001). Thirty-day mortality rates significantly declined for ischaemic stroke (Average Percentage Change -2.9%, 95% Confidence Interval = -5.2% to -1.0%) (p = 0.004) and subarachnoid haemorrhage (Average Percentage Change = -2.6%, 95% Confidence Interval = -4.8% to -0.2%) (p = 0.04). Mortality at 365-days amongst 30-day survivors of ischaemic stroke and intracerebral haemorrhage was stable over time and increased in subarachnoid haemorrhage (Annual Percentage Change 6.2%, 95% Confidence Interval = -0.1% to 12.8%), although not significantly (p = 0.05). DISCUSSION Improved prevention may have underpinned declining intracerebral haemorrhage rates while survival gains suggest that innovations in care are being successfully translated. Mortality in patients surviving the acute period is unchanged and may be increasing for subarachnoid haemorrhage warranting investment in post-discharge care and secondary prevention.
Collapse
Affiliation(s)
- Melina Gattellari
- Ingham Institute for Applied Medical Research , Liverpool (Sydney), Australia.,Department of Neurology, Royal Prince Alfred Hospital , Camperdown (Sydney), Australia
| | - Chris Goumas
- Ingham Institute for Applied Medical Research , Liverpool (Sydney), Australia.,School of Public Health, the University of Sydney , Sydney, Australia
| | - Bin Jalaludin
- Ingham Institute for Applied Medical Research , Liverpool (Sydney), Australia.,Population Health Intelligence, Healthy People and Places Unit, South Western Sydney Local Health District , Liverpool, Sydney, Australia.,School of Public Health and Community Medicine, The University of New South Wales , Sydney, Australia
| | - John M Worthington
- Ingham Institute for Applied Medical Research , Liverpool (Sydney), Australia.,Department of Neurology, Royal Prince Alfred Hospital , Camperdown (Sydney), Australia.,School of Public Health and Community Medicine, The University of New South Wales , Sydney, Australia.,South Western Sydney Clinical School, The University of New South Wales , Liverpool, Sydney, Australia
| |
Collapse
|
6
|
Ung D, Kim J, Thrift AG, Cadilhac DA, Andrew NE, Sundararajan V, Kapral MK, Reeves M, Kilkenny MF. Promising Use of Big Data to Increase the Efficiency and Comprehensiveness of Stroke Outcomes Research. Stroke 2020; 50:1302-1309. [PMID: 31009352 DOI: 10.1161/strokeaha.118.020372] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David Ung
- From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (D.U., J.K., A.G.T., D.A.C., N.E.A., M.F.K.)
| | - Joosup Kim
- From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (D.U., J.K., A.G.T., D.A.C., N.E.A., M.F.K.).,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| | - Amanda G Thrift
- From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (D.U., J.K., A.G.T., D.A.C., N.E.A., M.F.K.)
| | - Dominique A Cadilhac
- From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (D.U., J.K., A.G.T., D.A.C., N.E.A., M.F.K.).,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| | - Nadine E Andrew
- From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (D.U., J.K., A.G.T., D.A.C., N.E.A., M.F.K.).,Peninsula Clinical School, Central Clinical School, Monash University, Frankston, VIC, Australia (N.E.A.)
| | - Vijaya Sundararajan
- La Trobe University, Melbourne, VIC, Australia (V.S.).,Department of Public Health, School of Psychology and Public Health, College of Science Health and Engineering, La Trobe University, Bundoora, VIC, Australia (V.S.)
| | - Moira K Kapral
- Division of General Internal Medicine, Department of Medicine, University of Toronto, ON, Canada (M.K.K.)
| | - Mathew Reeves
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, MI (M.R.)
| | - Monique F Kilkenny
- From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia (D.U., J.K., A.G.T., D.A.C., N.E.A., M.F.K.).,Stroke Division, The Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (J.K., D.A.C., M.F.K.)
| |
Collapse
|
7
|
Bembenek JP, Karlinski M, Kurkowska-Jastrzebska I, Czlonkowska A. Changes in pre-hospital management of vascular risk factors among patients admitted due to recurrent stroke in Poland from 1995 to 2013. Arch Med Sci 2016; 12:754-9. [PMID: 27482236 PMCID: PMC4947623 DOI: 10.5114/aoms.2016.60963] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/01/2016] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The aim of this study was to investigate long-term trends in secondary stroke prevention through management of vascular risk factors directly before hospital admission for recurrent stroke. MATERIAL AND METHODS This is a retrospective registry-based analysis of consecutive recurrent acute stroke patients from a highly urbanized area (Warsaw, Poland) admitted to a single stroke center between 1995 and 2013 with previous ischemic stroke. We compared between four consecutive time periods: 1995-1999, 2000-2004, 2005-2009 and 2010-2013. RESULTS During the study period, 894 patients with recurrent strokes were admitted (18% of all strokes), including 867 with previous ischemic stroke (our study group). Among those patients, the proportion of recurrent ischemic strokes (88.1% to 93.9%) (p = 0.319) and males (44% to 49.7%) (p = 0.5) remained stable. However, there was a rising trend in patients' age (median age of 73, 74, 76 and 77 years, respectively). There was also an increase in the use of antihypertensives (from 70.2% to 83.8%) (p = 0.013), vitamin K antagonists (from 4.8% to 15.6%) (p = 0.012) and statins (from 32.5% to 59.4%) (p < 0.001). Nonetheless, 21% of patients did not receive any antithrombotic prophylaxis. Tobacco smoking pattern remained unchanged. CONCLUSIONS Our data indicate a clear overall improvement of secondary stroke prevention. However, persistent use of antithrombotic drugs and tobacco smoking after the first ischemic stroke is constantly suboptimal.
Collapse
Affiliation(s)
- Jan P. Bembenek
- Department of Neurophysiology, Institute of Psychiatry and
Neurology, Warsaw, Poland
| | - Michał Karlinski
- 2 Department of Neurology, Institute of Psychiatry and
Neurology, Warsaw, Poland
| | - Iwona Kurkowska-Jastrzebska
- 2 Department of Neurology, Institute of Psychiatry and
Neurology, Warsaw, Poland
- Department of Experimental and Clinical Pharmacology, Medical
University of Warsaw, Warsaw, Poland
| | - Anna Czlonkowska
- 2 Department of Neurology, Institute of Psychiatry and
Neurology, Warsaw, Poland
- Department of Experimental and Clinical Pharmacology, Medical
University of Warsaw, Warsaw, Poland
| |
Collapse
|