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Stahel PF, Belk KW, McInnis SJ, Holland K, Nanz R, Beals J, Gosnell J, Ogundele O, Mastriani KS. The Rothman Index predicts unplanned readmissions to intensive care associated with increased mortality and hospital length of stay: a propensity-matched cohort study. Patient Saf Surg 2024; 18:10. [PMID: 38454490 PMCID: PMC10921657 DOI: 10.1186/s13037-024-00391-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/16/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND Patients with unplanned readmissions to the intensive care unit (ICU) are at high risk of preventable adverse events. The Rothman Index represents an objective real-time grading system of a patient's clinical condition and a predictive tool of clinical deterioration over time. This study was designed to test the hypothesis that the Rothman Index represents a sensitive predictor of unanticipated ICU readmissions. METHODS A retrospective propensity-matched cohort study was performed at a tertiary referral academic medical center in the United States from January 1, 2022, to December 31, 2022. Inclusion criteria were adult patients admitted to an ICU and readmitted within seven days of transfer to a lower level of care. The control group consisted of patients who were downgraded from ICU without a subsequent readmission. The primary outcome measure was in-hospital mortality or discharge to hospice for end-of-life care. Secondary outcome measures were overall hospital length of stay, ICU length of stay, and 30-day readmission rates. Propensity matching was used to control for differences between the study cohorts. Regression analyses were performed to determine independent risk factors of an unplanned readmission to ICU. RESULTS A total of 5,261 ICU patients met the inclusion criteria, of which 212 patients (4%) had an unanticipated readmission to the ICU within 7 days. The study cohort and control group were stratified by propensity matching into equal group sizes of n = 181. Lower Rothman Index scores (reflecting higher physiologic acuity) at the time of downgrade from the ICU were significantly associated with an unplanned readmission to the ICU (p < 0.0001). Patients readmitted to ICU had a lower mean Rothman Index score (p < 0.0001) and significantly increased rates of mortality (19.3% vs. 2.2%, p < 0.0001) and discharge to hospice (14.4% vs. 6.1%, p = 0.0073) compared to the control group of patients without ICU readmission. The overall length of ICU stay (mean 8.0 vs. 2.2 days, p < 0.0001) and total length of hospital stay (mean 15.8 vs. 7.3 days, p < 0.0001) were significantly increased in patients readmitted to ICU, compared to the control group. CONCLUSION The Rothman Index represents a sensitive predictor of unanticipated readmissions to ICU, associated with a significantly increased mortality and overall ICU and hospital length of stay. The Rothman Index should be considered as a real-time objective measure for prediction of a safe downgrade from ICU to a lower level of care.
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Affiliation(s)
- Philip F Stahel
- Department of Surgery, East Carolina University, Brody School of Medicine, 27834, Greenville, NC, USA.
- Rocky Vista University, College of Osteopathic Medicine, 80134, Parker, CO, USA.
- Mission Health, HCA Healthcare North Carolina Division, 28803, Asheville, NC, USA.
| | - Kathy W Belk
- Spacelabs Healthcare, 98065, Snoqualmie, WA, USA
| | | | - Kathryn Holland
- Mission Health, HCA Healthcare North Carolina Division, 28803, Asheville, NC, USA
| | - Roy Nanz
- Mission Health, HCA Healthcare North Carolina Division, 28803, Asheville, NC, USA
| | - Joseph Beals
- Spacelabs Healthcare, 98065, Snoqualmie, WA, USA
| | - Jaclyn Gosnell
- Mission Health, HCA Healthcare North Carolina Division, 28803, Asheville, NC, USA
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Munawar I, Sarkar S, D'Adamo C, Ogundele O. UTILIZATION OF THE ROTHMAN INDEX AS A PREDICTOR OF ICU RECIDIVISM. Chest 2020. [DOI: 10.1016/j.chest.2020.08.1204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Fehintola AO, Fehintola FO, Loto OM, Fasubaa OB, Bakare B, Ogundele O. Pregnancy and fetal outcome of placental malaria parasitemia in Ile-Ife, Nigeria. Trop J Obstet Gynaecol 2016. [DOI: 10.4103/0189-5117.199811] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Kautza B, Gomez H, Escobar D, Corey C, Ataya B, Luciano J, Botero AM, Gordon L, Brumfield J, Martinez S, Holder A, Ogundele O, Pinsky M, Shiva S, Zuckerbraun BS. Inhaled, nebulized sodium nitrite protects in murine and porcine experimental models of hemorrhagic shock and resuscitation by limiting mitochondrial injury. Nitric Oxide 2015; 51:7-18. [PMID: 26410351 DOI: 10.1016/j.niox.2015.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 09/19/2015] [Accepted: 09/21/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The cellular injury that occurs in the setting of hemorrhagic shock and resuscitation (HS/R) affects all tissue types and can drive altered inflammatory responses. Resuscitative adjuncts hold the promise of decreasing such injury. Here we test the hypothesis that sodium nitrite (NaNO2), delivered as a nebulized solution via an inhalational route, protects against injury and inflammation from HS/R. METHODS Mice underwent HS/R to a mean arterial pressure (MAP) of 20 or 25 mmHg. Mice were resuscitated with Lactated Ringers after 90-120 min of hypotension. Mice were randomized to receive nebulized NaNO2 via a flow through chamber (30 mg in 5 mL PBS). Pigs (30-35 kg) were anesthetized and bled to a MAP of 30-40 mmHg for 90 min, randomized to receive NaNO2 (11 mg in 2.5 mL PBS) nebulized into the ventilator circuit starting 60 min into the hypotensive period, followed by initial resuscitation with Hextend. Pigs had ongoing resuscitation and support for up to four hours. Hemodynamic data were collected continuously. RESULTS NaNO2 limited organ injury and inflammation in murine hemorrhagic shock. A nitrate/nitrite depleted diet exacerbated organ injury, as well as mortality, and inhaled NaNO2 significantly reversed this effect. Furthermore, NaNO2 limited mitochondrial oxidant injury. In porcine HS/R, NaNO2 had no significant influence on shock induced hemodynamics. NaNO2 limited hypoxia/reoxia or HS/R-induced mitochondrial injury and promoted mitochondrial fusion. CONCLUSION NaNO2 may be a useful adjunct to shock resuscitation based on its limitation of mitochondrial injury.
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Affiliation(s)
| | - Hernando Gomez
- Department of Critical Care Medicine, USA; The Center for Critical Care Nephrology, USA
| | | | | | | | | | | | | | | | | | | | | | - Michael Pinsky
- Department of Critical Care Medicine, USA; The Center for Critical Care Nephrology, USA
| | - Sruti Shiva
- Department of Pharmacology & Chemical Biology, USA; Vascular Medicine Institute, University of Pittsburgh, USA.
| | - Brian S Zuckerbraun
- VA Pittsburgh Healthcare System, USA; Department of Surgery, USA; The Center for Critical Care Nephrology, USA; Vascular Medicine Institute, University of Pittsburgh, USA.
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Gomez H, Kautza B, Escobar D, Nassour I, Luciano J, Botero AM, Gordon L, Martinez S, Holder A, Ogundele O, Loughran P, Rosengart MR, Pinsky M, Shiva S, Zuckerbraun BS. Inhaled Carbon Monoxide Protects against the Development of Shock and Mitochondrial Injury following Hemorrhage and Resuscitation. PLoS One 2015; 10:e0135032. [PMID: 26366865 PMCID: PMC4569171 DOI: 10.1371/journal.pone.0135032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 07/16/2015] [Indexed: 01/08/2023] Open
Abstract
Aims Currently, there is no effective resuscitative adjunct to fluid and blood products to limit tissue injury for traumatic hemorrhagic shock. The objective of this study was to investigate the role of inhaled carbon monoxide (CO) to limit inflammation and tissue injury, and specifically mitochondrial damage, in experimental models of hemorrhage and resuscitation. Results Inhaled CO (250 ppm for 30 minutes) protected against mortality in severe murine hemorrhagic shock and resuscitation (HS/R) (20% vs. 80%; P<0.01). Additionally, CO limited the development of shock as determined by arterial blood pH (7.25±0.06 vs. 7.05±0.05; P<0.05), lactate levels (7.2±5.1 vs 13.3±6.0; P<0.05), and base deficit (13±3.0 vs 24±3.1; P<0.05). A dose response of CO (25–500 ppm) demonstrated protection against HS/R lung and liver injury as determined by MPO activity and serum ALT, respectively. CO limited HS/R-induced increases in serum tumor necrosis factor-α and interleukin-6 levels as determined by ELISA (P<0.05 for doses of 100–500ppm). Furthermore, inhaled CO limited HS/R induced oxidative stress as determined by hepatic oxidized glutathione:reduced glutathione levels and lipid peroxidation. In porcine HS/R, CO did not influence hemodynamics. However, CO limited HS/R-induced skeletal muscle and platelet mitochondrial injury as determined by respiratory control ratio (muscle) and ATP-linked respiration and mitochondrial reserve capacity (platelets). Conclusion These preclinical studies suggest that inhaled CO can be a protective therapy in HS/R; however, further clinical studies are warranted.
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MESH Headings
- Adenosine Triphosphate/metabolism
- Administration, Inhalation
- Animals
- Carbon Monoxide/administration & dosage
- Carbon Monoxide/pharmacology
- Carbon Monoxide/therapeutic use
- Cells, Cultured
- Interleukin-6/blood
- Lactic Acid/blood
- Male
- Mice
- Mice, Inbred C57BL
- Mitochondria, Liver/drug effects
- Mitochondria, Liver/metabolism
- Mitochondria, Muscle/drug effects
- Mitochondria, Muscle/metabolism
- Oxidative Stress
- Resuscitation
- Shock, Hemorrhagic/metabolism
- Shock, Hemorrhagic/prevention & control
- Shock, Hemorrhagic/therapy
- Swine
- Tumor Necrosis Factor-alpha/blood
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Affiliation(s)
- Hernando Gomez
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- The Center for Critical Care Nephrology University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Benjamin Kautza
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Daniel Escobar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Ibrahim Nassour
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jason Luciano
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Ana Maria Botero
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Lisa Gordon
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Silvia Martinez
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Andre Holder
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Olufunmilayo Ogundele
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Patricia Loughran
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Matthew R. Rosengart
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
- The Center for Critical Care Nephrology University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Michael Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Sruti Shiva
- Department of Pharmacology, University of Pittsburgh, Pittsburgh, PA, United States of America
- Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Brian S. Zuckerbraun
- The Center for Critical Care Nephrology University of Pittsburgh, Pittsburgh, PA, United States of America
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America
- Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
- VA Pittsburgh Healthcare System, Pittsburgh, PA, United States of America
- * E-mail:
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Haugaa H, Gómez H, Maberry DR, Holder A, Ogundele O, Quintero AMB, Escobar D, Tønnessen TI, Airgood H, Dezfulian C, Kenny E, Shiva S, Zuckerbraun B, Pinsky MR. Effects of inhalation of low-dose nitrite or carbon monoxide on post-reperfusion mitochondrial function and tissue injury in hemorrhagic shock swine. Crit Care 2015; 19:184. [PMID: 25899004 PMCID: PMC4422303 DOI: 10.1186/s13054-015-0903-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/30/2015] [Indexed: 01/29/2023]
Abstract
Introduction Tissue reperfusion following hemorrhagic shock may paradoxically cause tissue injury and organ dysfunction by mitochondrial free radical expression. Both nitrite and carbon monoxide (CO) may protect from this reperfusion injury by limiting mitochondrial free radial production. We explored the effects of very small doses of inhaled nitrite and CO on tissue injury in a porcine model of hemorrhagic shock. Methods Twenty pigs (mean wt. 30.6 kg, range 27.2 to 36.4 kg) had microdialysis catheters inserted in muscle, peritoneum, and liver to measure lactate, pyruvate, glucose, glycerol, and nitrite. Nineteen of the pigs were bled at a rate of 20 ml/min to a mean arterial pressure of 30 mmHg and kept between 30 and 40 mmHg for 90 minutes and then resuscitated. One pig was instrumented but not bled (sham). Hemorrhaged animals were randomized to inhale nothing (control, n = 7), 11 mg nitrite (nitrite, n = 7) or 250 ppm CO (CO, n = 5) over 30 minutes before fluid resuscitation. Mitochondrial respiratory control ratio was measured in muscle biopsies. Repeated measures from microdialysis catheters were analyzed in a random effects mixed model. Results Neither nitrite nor CO had any effects on the measured hemodynamic variables. Following inhalation of nitrite, plasma, but not tissue, nitrite increased. Following reperfusion, plasma nitrite only increased in the control and CO groups. Thereafter, nitrite decreased only in the nitrite group. Inhalation of nitrite was associated with decreases in blood lactate, whereas both nitrite and CO were associated with decreases in glycerol release into peritoneal fluid. Following resuscitation, the muscular mitochondrial respiratory control ratio was reduced in the control group but preserved in the nitrite and CO groups. Conclusions We conclude that small doses of nebulized sodium nitrite or inhaled CO may be associated with intestinal protection during resuscitation from severe hemorrhagic shock. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0903-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Håkon Haugaa
- Department of Critical Care Medicine, Cardiopulmonary Research Laboratory, University of Pittsburgh, 3501 Fifth Avenue, Pittsburgh, PA, 15260, USA. .,Department of Emergencies and Critical Care, Oslo University Hospital, Sognsvannsveien 27 0424, Oslo, Norway. .,Institute of Clinical Medicine, University of Oslo, Sognsvannsveien 20 0424, Oslo, Norway.
| | - Hernando Gómez
- Department of Critical Care Medicine, Cardiopulmonary Research Laboratory, University of Pittsburgh, 3501 Fifth Avenue, Pittsburgh, PA, 15260, USA. .,Center for Critical Care Nephrology, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - Donald R Maberry
- Department of Critical Care Medicine, Cardiopulmonary Research Laboratory, University of Pittsburgh, 3501 Fifth Avenue, Pittsburgh, PA, 15260, USA.
| | - Andre Holder
- Department of Critical Care Medicine, Cardiopulmonary Research Laboratory, University of Pittsburgh, 3501 Fifth Avenue, Pittsburgh, PA, 15260, USA.
| | - Olufunmilayo Ogundele
- Department of Critical Care Medicine, Cardiopulmonary Research Laboratory, University of Pittsburgh, 3501 Fifth Avenue, Pittsburgh, PA, 15260, USA.
| | - Ana Maria B Quintero
- Institute of Clinical Medicine, University of Oslo, Sognsvannsveien 20 0424, Oslo, Norway.
| | - Daniel Escobar
- Institute of Clinical Medicine, University of Oslo, Sognsvannsveien 20 0424, Oslo, Norway.
| | - Tor Inge Tønnessen
- Department of Emergencies and Critical Care, Oslo University Hospital, Sognsvannsveien 27 0424, Oslo, Norway. .,Institute of Clinical Medicine, University of Oslo, Sognsvannsveien 20 0424, Oslo, Norway.
| | - Hannah Airgood
- Department of Critical Care Medicine, Safar Center for Resuscitation Research University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - Cameron Dezfulian
- Department of Critical Care Medicine, Safar Center for Resuscitation Research University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - Elizabeth Kenny
- Department of Critical Care Medicine, Safar Center for Resuscitation Research University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, 15261, USA.
| | - Sruti Shiva
- Department of Pharmacology and Chemical Biology, Vascular Medicine Institute, Center for Metabolism and Mitochondrial Medicine, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA, 15261, USA.
| | - Brian Zuckerbraun
- Department of Surgery, University of Pittsburgh, 3380 Boulevard of the Allies 390, Pittsburgh, PA, 15213, USA.
| | - Michael R Pinsky
- Department of Critical Care Medicine, Cardiopulmonary Research Laboratory, University of Pittsburgh, 3501 Fifth Avenue, Pittsburgh, PA, 15260, USA.
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Haugaa H, Gomez H, Maberry D, Holder A, Ogundele O, Botero A, Escobar D, Gordon L, Shiva S, Dezfulian C, Kenney B, Tønnessen TI, Zuckerbraun B, Pinsky MR. Attenuation of ischemia-reperfusion injury in swine resuscitated for hemorrhagic shock by low-dose inhaled nitrite or carbon monoxide. Crit Care 2014. [PMCID: PMC4068305 DOI: 10.1186/cc13309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Lee JM, Ogundele O, Pike F, Pinsky MR. Effect of acute endotoxemia on analog estimates of mean systemic pressure. J Crit Care 2013; 28:880.e9-15. [PMID: 23731817 DOI: 10.1016/j.jcrc.2013.04.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 03/27/2013] [Accepted: 04/21/2013] [Indexed: 11/30/2022]
Abstract
Dynamic estimates of mean systemic pressure based on a Guytonian analog model (Pmsa) appear accurate under baseline conditions but may not remain so during septic shock because blood volume distribution and resistances between arterial and venous beds may change. Thus, we examined the effect of acute endotoxemia on the ability of Pmsa, estimated from steady-state cardiac output, right atrial pressure, and mean arterial pressure, to reflect our previously validated instantaneous venous return measure of mean systemic pressure (Pmsi), derived from beat-to-beat measures of right ventricular stroke volume and right atrial pressure during positive pressure ventilation. We studied 6 splenectomized pentobarbital-anesthetized close chested dogs. Right ventricular stroke volume was measured by a pulmonary arterial electromagnetic flow probe. Instantaneous venous return measure of mean systemic pressure and Pmsa were calculated during volume loading and removal (±100-mL bolus increments×5) both before (control) and 30 minutes after endotoxin infusion (endo). Cardiac output increased (2628±905 vs 3560±539 mL/min; P<.05) and mean arterial pressure decreased (107±16 vs 56±12 mm Hg; P<.01) during endo. Changes in Pmsi and Pmsa correlated during both control and endo (r2=0.7) with minimal bias by Bland-Altman analysis (mean difference±95% confidence interval, 0.47±5.04 mm Hg). We conclude that changes in Pmsa accurately tracts Pmsi under both control and endo.
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Affiliation(s)
- Jae Myeong Lee
- Cardiopulmonary Research Laboratory, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
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Gomez H, Escobar D, Ataya B, Gordon L, Ogundele O, Pinsky M, Shiva S, Zuckerbraun B. Inhaled carbon monoxide or nebulized sodium nitrite protect against hemorrhagic shock-induced mitochondrial dysfunction. Crit Care 2013. [PMCID: PMC3642532 DOI: 10.1186/cc12158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Fasina T, Ogundele O, Ejiah F, Dueke-Eze C. Biological Activity of Copper (II), Cobalt (II) and Nickel (II) Complexes of Schiff Base Derived from O-phenylenediamine and 5-bromosalicylaldehyde. ACTA ACUST UNITED AC 2011. [DOI: 10.3923/ijbc.2012.24.30] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Affiliation(s)
- Olufunmilayo Ogundele
- University of Pittsburgh Medical Center, Department of Critical Care Medicine, 606 D Scaife Hall, 3550 Terrace Street, University of Pittsburgh, Pittsburgh, PA 15261, USA
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