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Beygui, F., Castren, M., Brunetti, N. D., Rosell-Ortiz, F., Christ, M., Zeymer, U., . . . Goldstein, P. (2017). Gestione pre-ospedaliera dei pazienti con dolore toracico e/o dispnea di origine cardiaca[Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin]. Recenti progressi in medicina, 108(1), 27-51.
Open this publication in new window or tab >>Gestione pre-ospedaliera dei pazienti con dolore toracico e/o dispnea di origine cardiaca[Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin]
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2017 (Italian)In: Recenti progressi in medicina, ISSN 2038-1840, Vol. 108, no 1, 27-51 p.Article in journal (Refereed) Published
Abstract [en]

Chest pain and acute dyspnoea are frequent causes of emergency medical services activation. The pre-hospital management of these conditions is heterogeneous across different regions of the world and Europe, as a consequence of the variety of emergency medical services and absence of specific practical guidelines. This position paper focuses on the practical aspects of the pre-hospital treatment on board and transfer of patients taken in charge by emergency medical services for chest pain and dyspnoea of suspected cardiac aetiology after the initial assessment and diagnostic work-up. The objective of the paper is to provide guidance, based on evidence, where available, or on experts' opinions, for all emergency medical services' health providers involved in the pre-hospital management of acute cardiovascular care.

Abstract [it]

Dolore toracico e dispnea acuta sono cause frequenti di attivazione dei servizi medici di emergenza. La gestione pre-ospedaliera di tali condizioni è estremamente eterogenea nelle diverse regioni del mondo e d’Europa, a causa delle differenze dei servizi medici di emergenza e dell’assenza di linee-guida sull’argomento. Questo position paper intende pertanto occuparsi degli aspetti pratici del trattamento pre-ospedaliero a bordo delle autoambulanze e durante il trasferimento dei pazienti in carico ai servizi di emergenza medica per dolore toracico e dispnea di sospetta eziologia cardiaca, dopo la valutazione diagnostica iniziale. L’obiettivo è quello di fornire indicazioni, basate su evidenze, quando disponibili, o sull’opinione degli esperti, per tutte le figure professionali coinvolte nella gestione dei servizi sanitari medici di emergenza e nella gestione pre-ospedaliera delle patologie acute cardiovascolari.

Place, publisher, year, edition, pages
Il Pensiero Scientifico Editore, 2017
Keyword
Chest pain, dyspnoea, pre-hospital management, Dispnea, dolore toracico, gestione pre-ospedaliera
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-139127 (URN)10.1701/2624.26982 (DOI)28151526 (PubMedID)2-s2.0-85019553787 (Scopus ID)
Available from: 2017-07-03 Created: 2017-07-03 Last updated: 2017-08-09Bibliographically approved
Panayi, G., Wieringa, W. G., Alfredsson, J., Carlsson, J., Karlsson, J.-E., Persson, A., . . . Swahn, E. (2016). Computed tomography coronary angiography in patients with acute myocardial infarction and normal invasive coronary angiography. BMC Cardiovascular Disorders, 16(78).
Open this publication in new window or tab >>Computed tomography coronary angiography in patients with acute myocardial infarction and normal invasive coronary angiography
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2016 (English)In: BMC Cardiovascular Disorders, ISSN 1471-2261, E-ISSN 1471-2261, Vol. 16, no 78Article in journal (Refereed) Published
Abstract [en]

Background: Three to five percent of patients with acute myocardial infarction (AMI) have normal coronary arteries on invasive coronary angiography (ICA). The aim of this study was to assess the presence and characteristics of atherosclerotic plaques on computed tomography coronary angiography (CTCA) and describe the clinical characteristics of this group of patients. Methods: This was a multicentre, prospective, descriptive study on CTCA evaluation in thirty patients fulfilling criteria for AMI and without visible coronary plaques on ICA. CTCA evaluation was performed head to head in consensus by two experienced observers blinded to baseline patient characteristics and ICA results. Analysis of plaque characteristics and plaque effect on the arterial lumen was performed. Coronary segments were visually scored for the presence of plaque. Seventeen segments were differentiated, according to a modified American Heart Association classification. Echocardiography performed according to routine during the initial hospitalisation was retrieved for analysis of wall motion abnormalities and left ventricular systolic function in most patients. Results: Twenty-five patients presented with non ST-elevation myocardial infarction (NSTEMI) and five with ST-elevation myocardial infarction (STEMI). Mean age was 60.2 years and 23/30 were women. The prevalence of risk factors of coronary artery disease (CAD) was low. In total, 452 coronary segments were analysed. Eighty percent (24/30) had completely normal coronary arteries and twenty percent (6/30) had coronary atherosclerosis on CTCA. In patients with atherosclerotic plaques, the median number of segments with plaque per patient was one. Echocardiography was normal in 4/22 patients based on normal global longitudinal strain (GLS) and normal wall motion score index (WMSI); 4/22 patients had normal GLS with pathological WMSI; 3/22 patients had pathological GLS and normal WMSI; 11/22 patients had pathological GLS and WMSI and among them we could identify 5 patients with a Takotsubo pattern on echo. Conclusions: Despite a diagnosis of AMI, 80 % of patients with normal ICA showed no coronary plaques on CTCA. The remaining 20 % had only minimal non-obstructive atherosclerosis. Patients fulfilling clinical criteria for AMI but with completely normal ICA need further evaluation, suggestively with magnetic resonance imaging (MRI).

Place, publisher, year, edition, pages
BIOMED CENTRAL LTD, 2016
Keyword
Acute myocardial infarction; Normal coronary arteries; Computed tomography coronary angiography; MINCA
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-129496 (URN)10.1186/s12872-016-0254-y (DOI)000376723200001 ()27142217 (PubMedID)
Note

Funding Agencies|Swedish Heart and Lung Foundation [20120449]; Region of Ostergotland [437491]; European Union FP 7 [223615]; Medical Research Council of Southeast Sweden [157921]

Available from: 2016-06-20 Created: 2016-06-20 Last updated: 2017-11-28
Holm, A., Sederholm-Lawesson, S., Swahn, E. & Alfredsson, J. (2016). Gender difference in prognostic impact of in-hospital bleeding after myocardial infarction - data from the SWEDEHEART registry.. European heart journal. Acute cardiovascular care, 6, 463-472.
Open this publication in new window or tab >>Gender difference in prognostic impact of in-hospital bleeding after myocardial infarction - data from the SWEDEHEART registry.
2016 (English)In: European heart journal. Acute cardiovascular care, ISSN 2048-8734, Vol. 6, 463-472 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Bleeding complications increase mortality in myocardial infarction patients. Potential gender difference in bleeding regarding prevalence and prognostic impact is still controversial.

OBJECTIVES: Gender comparison regarding incidence and prognostic impact of bleeding in patients hospitalised with myocardial infarction during 2006-2008.

METHODS: Observational study from the SWEDEHEART register. Outcomes were in-hospital bleedings, in-hospital mortality and one-year mortality in hospital survivors.

RESULTS: A total number of 50,399 myocardial infarction patients were included, 36.6% women. In-hospital bleedings were more common in women (1.9% vs. 3.1%, p<0.001) even after multivariable adjustment (odds ratio (OR) 1.17, 95% confidence interval (CI) 1.01-1.37). The increased risk for women was found in ST-elevation myocardial infarction (OR 1.46, 95% CI 1.10-1.94) and in those who underwent percutaneous coronary intervention (OR 1.80, 95% CI 1.45-2.24). In contrast the risk was lower in medically treated women (OR 0.79, 95% CI 0.62-1.00). After adjustment, in-hospital bleeding was associated with higher risk of one-year mortality in men (OR 1.35, 95% CI 1.04-1.74), whereas this was not the case in women (OR 0.97, 95% CI 0.72-1.31).

CONCLUSIONS: Female gender is an independent risk factor of in-hospital bleeding after myocardial infarction. A higher bleeding risk in women appeared to be restricted to invasively treated patients and ST-elevation myocardial infarction patients. Even though women have higher short- and long-term mortality, there was no difference between the genders among bleeders. After multivariable adjustment the prognostic impact of bleeding complications was higher in men.

Keyword
Myocardial infarction; bleeding; gender; prognosis
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-124287 (URN)10.1177/2048872615610884 (DOI)26450782 (PubMedID)
Available from: 2016-01-25 Created: 2016-01-25 Last updated: 2017-01-17
Venetsanos, D., Alfredsson, J., Segelmark, M., Swahn, E. & Lawesson, S. (2015). Glomerular filtration rate (GFR) during and after STEMI: a single-centre, methodological study comparing estimated and measured GFR. BMJ Open, 5(9), 1-8, Article ID e007835.
Open this publication in new window or tab >>Glomerular filtration rate (GFR) during and after STEMI: a single-centre, methodological study comparing estimated and measured GFR
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2015 (English)In: BMJ Open, ISSN 2044-6055, E-ISSN 2044-6055, Vol. 5, no 9, 1-8 p., e007835Article in journal (Refereed) Published
Abstract [en]

Objectives: To validate the performance of the most commonly used formulas for estimation of glomerular filtration rate (GFR) against measured GFR during the index hospitalisation for ST-elevation myocardial infarction (STEMI). Setting: Single centre, methodological study. Participants: 40 patients with percutaneous coronary intervention-treated STEMI were included between November 2011 and February 2013. Patients on dialysis, cardiogenic shock or known allergy to iodine were excluded. Outcome measures: Creatinine and cystatin C were determined at admission and before discharge in 40 patients with STEMI. Clearance of iohexol was measured (mGFR) before discharge. We evaluated and compared the Cockcroft-Gault (CG), the Modification of Diet in Renal Disease (MDRD-IDMS), the Chronic Kidney Disease Epidemiology (CKD-EPI) and the Grubb relative cystatin C (rG-CystC) with GFR regarding correlation, bias, precision and accuracy (P30). Agreement between eGFR and mGFR to discriminate CKD was assessed by Cohens. statistics. Results: MDRD-IDMS and CKD-EPI demonstrated good performance to estimate GFR (correlation 0.78 vs 0.81%, bias -1.3% vs 1.5%, precision 17.9 vs 17.1 mL/min 1.73 m(2) and P30 82.5% vs 82.5% for MDRD-IDMS vs CKD-EPI). CKD was best classified by CKD-EPI (. 0.83). CG showed the worst performance (correlation 0.73%, bias -1% to 3%, precision 22.5 mL/min 1.73 m(2) and P30 75%). The rG-CystC formula had a marked bias of -17.8% and significantly underestimated mGFR (p=0.03). At arrival, CKD-EPI and rG-CystC had almost perfect agreement in CKD classification (kappa=0.87), whereas at discharge agreement was substantially lower (kappa=0.59) and showed a significant discrepancy in CKD classification (p=0.02). Median cystatin C concentration increased by 19%. Conclusions: In acute STEMI, CKD-EPI showed the best CKD-classification ability followed by MDRD-IDMS, whereas CG performed the worst. STEMI altered the performance of the cystatin C equation during the acute phase, suggesting that other factors might be involved in the rise of cystatin C.

Place, publisher, year, edition, pages
BMJ PUBLISHING GROUP, 2015
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-122794 (URN)10.1136/bmjopen-2015-007835 (DOI)000363484000021 ()26399570 (PubMedID)
Available from: 2015-11-23 Created: 2015-11-23 Last updated: 2017-12-01
Trzebiatowska-Krzynska, A., Driessen, M., Sieswerda, G. T., Wallby, L., Swahn, E. & Meijboom, F. (2015). Knowledge-based 3D reconstruction of the right ventricle: comparison with cardiac magnetic resonance in adults with congenital heart disease. Echo research and practice, 2(4), 109-116.
Open this publication in new window or tab >>Knowledge-based 3D reconstruction of the right ventricle: comparison with cardiac magnetic resonance in adults with congenital heart disease
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2015 (English)In: Echo research and practice, ISSN 2055-0464, Vol. 2, no 4, 109-116 p.Article in journal (Refereed) Published
Abstract [en]

AIM: Assessment of right ventricular (RV) function is a challenge, especially in patients with congenital heart disease (CHD). The aim of the present study is to assess whether knowledge-based RV reconstruction, used in the everyday practice of an echo-lab for adult CHD in a tertiary referral center, is accurate when compared to cardiac magnetic resonance (CMR) examination.

SUBJECTS AND METHODS: Adult patients who would undergo CMR for assessment of the RV were asked to undergo an echo of the heart for further knowledge-based reconstruction (KBR). Echocardiographic images were acquired in standard views using a predefined imaging protocol. RV volumes and ejection fraction (EF) calculated using knowledge-based technology were compared with the CMR data of the same patient.

RESULTS: Nineteen consecutive patients with congenital right heart disease were studied. Median age of the patients was 28 years (range 46 years). Reconstruction was possible in 16 out of 19 patients (85%). RV volumes assessed with this new method were smaller than with CMR. Indexed end diastolic volumes were 114±17 ml vs 121±19 ml, P<0.05 and EFs were 45±8% vs 47±9%, P<0.05 respectively. The correlation between the methods was good with an intraclass correlation of 0.84 for EDV and 0.89 for EF, P value <0.001 in both cases.

CONCLUSION: KBR enables reliable measurement of RVs in patients with CHDs and can be used in clinical practice for analysis of volumes and EFs.

Keyword
congenital heart disease; knowledge-based reconstruction; right ventricle volume; ventripoint system
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-124289 (URN)10.1530/ERP-15-0029 (DOI)26796613 (PubMedID)
Available from: 2016-01-25 Created: 2016-01-25 Last updated: 2016-04-12
Alfredsson, J., Lindahl, T. L., Gustafsson, K. M., Janzon, M., Jonasson, L., Logander, E., . . . Swahn, E. (2015). Large early variation of residual platelet reactivity in Acute Coronary Syndrome patients treated with clopidogrel: Results from Assessing Platelet Activity in Coronary Heart Disease (APACHE).. Thrombosis Research, 136(2), 335-340.
Open this publication in new window or tab >>Large early variation of residual platelet reactivity in Acute Coronary Syndrome patients treated with clopidogrel: Results from Assessing Platelet Activity in Coronary Heart Disease (APACHE).
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2015 (English)In: Thrombosis Research, ISSN 0049-3848, E-ISSN 1879-2472, Vol. 136, no 2, 335-340 p.Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION: There is a large inter-individual variation in response to clopidogrel treatment and previous studies have indicated higher risk of thrombotic events in patients with high residual platelet reactivity (HRPR), but the optimal time-point for testing is not established. The aim of this study was to investigate the optimal time-point for aggregometry testing and the risk of major adverse cardiac events associated with HRPR.

METHOD AND RESULTS: We included 125 patients with ACS (73 with STEMI, and 71 received abciximab). The prevalence of HRPR varied substantially over time. The rate of HRPR in patients treated and not treated with abciximab were 43% vs 67% (p=0.01) before, 2% vs 23% (p=0.001) 6-8h after, 8% vs 9% (p=0.749) 3days after, and 23% vs 12% (p=0.138) 7-9 days after loading dose of clopidogrel. We found HRPR in 18% of the patients but only four ischemic events during 6months follow-up, with no significant difference between HRPR patients compared to the rest of the population. There were 3 TIMI major bleedings, all of which occurred in the low residual platelet reactivity (LRPR) group.

CONCLUSION: There is a large variation in platelet reactivity over time, also depending on adjunctive therapy, which has a large impact on optimal time-point for assessment. We found HRPR in almost 1 in 5 patients, but very few MACE, and not significantly higher in HRPR patients. In a contemporary ACS population, with low risk for stent thrombosis, the predictive value of HRPR for ischemic events will probably be low.

Place, publisher, year, edition, pages
Pergamon Press, 2015
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-119644 (URN)10.1016/j.thromres.2015.05.021 (DOI)000363953000026 ()26033398 (PubMedID)
Note

Funding agencies: Linkoping University; County Council of Ostergotland

Available from: 2015-06-24 Created: 2015-06-23 Last updated: 2017-12-04
Sederholm Lawesson, S., Alfredsson, J., Szummer, K., Fredrikson, M. & Swahn, E. (2015). Prevalence and prognostic impact of chronic kidney disease in STEMI from a gender perspective: data from the SWEDEHEART register, a large Swedish prospective cohort.. BMJ open, 5(6), e008188.
Open this publication in new window or tab >>Prevalence and prognostic impact of chronic kidney disease in STEMI from a gender perspective: data from the SWEDEHEART register, a large Swedish prospective cohort.
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2015 (English)In: BMJ open, ISSN 2044-6055, Vol. 5, no 6, e008188- p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: Gender differences in prevalence and prognostic impact of chronic kidney disease (CKD) in ST segment elevation myocardial infarction (STEMI) have been poorly evaluated. In STEMI, female gender has been independently associated with an increased risk of mortality. CKD has been found to be an important prognostic marker in myocardial infarction. The aim of this study was to evaluate gender differences in prevalence and prognostic impact of CKD on short-term and long-term mortality.

DESIGN: Prospective observational cohort study.

SETTING: The national quality register SWEDEHEART was used. In the beginning of the study period, 94% of the Swedish coronary care units contributed data to the register, which subsequently increased to 100%. The glomerular filtration rate was estimated (eGFR) according to Modification of Diet in Renal Disease Study (MDRD) and Cockcroft-Gault (CG).

PARTICIPANTS: All patients with STEMI registered in SWEDEHEART from the years 2003-2009 were included (37,991 patients, 66% men).

MAIN RESULTS: Women had 1.6 (MDRD) to 2.2 (CG) times higher multivariable adjusted risk of CKD. Half of the women had CKD according to CG. CKD was associated with 2-2.5 times higher risk of in-hospital mortality and approximately 1.5 times higher risk of long-term mortality in both genders. Each 10 mL/min decline of eGFR was associated with an increased risk of in-hospital and long-term mortality (22-33% and 9-16%, respectively) and this did not vary significantly by gender. Both in-hospital and long-term mortality were doubled in women. After multivariable adjustment including eGFR, there was no longer any gender difference in early outcome and the long-term outcome was better in women.

CONCLUSIONS: Among patients with STEMI, female gender was independently associated with CKD. Reduced eGFR was a strong independent risk factor for short-term and long-term mortality without a significant gender difference in prognostic impact and seems to be an important reason why women have higher mortality than men with STEMI.

National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:liu:diva-120388 (URN)10.1136/bmjopen-2015-008188 (DOI)000363479900096 ()26105033 (PubMedID)
Note

Funding text: National Board of Health and Welfare; Swedish Society of Cardiology; Swedish Association of Local Authorities and Regions

Available from: 2015-08-04 Created: 2015-08-04 Last updated: 2015-11-23
Szymanowski, A., Alfredsson, J., Janzon, M., Lindahl, T. L., Swahn, E., Jonasson, L. & Nilsson, L. (2015). Soluble markers of apoptosis in myocardial infarction patients during acute phase and 6-month follow up. .
Open this publication in new window or tab >>Soluble markers of apoptosis in myocardial infarction patients during acute phase and 6-month follow up
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2015 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Objectives

The aim of the study was to investigate circulating markers of apoptosis in the acute phase and at follow8up in patients with ST8elevation myocardial infarction (STEMI) or non8ST8elevation myocardial infarction (NSTEMI).

Background

Myocardial cell death during acute MI results from necrosis, apoptosis and autophagy. An elevated rate of apoptosis can continue for several days after the acute event, contributing to an increased final infarct size. Moreover, a lower but still increased apoptosis can continue for months resulting in left ventricular (LV) dysfunction and heart failure. Few studies have analysed markers of apoptosis longitudinally in MI patients.  Also, it is not known whether STEMI and NSTEMI patients differ in regard to these markers. 

Methods

This study is a prespecified substudy of the APACHE trial. We included 61 STEMI and 40 NSTEMI patients. Blood samples for analysis of soluble tumor necrosis factor receptor (sTNFR) 1, sTNFR2, sFas, sFas ligand (sFasL) and IL86 were collected at baseline prior to PCI, at 3 days and at 6 months. High sensitivity troponin T (hsTnT) was measured at 688 hours and echocardiography was performed at 283 days after admission to hospital.

Results

STEMI compared to NSTEMI patients showed very similar temporal patterns for each of the markers of apoptosis analyzed. Levels of sTNFRs increased from baseline to day 3 and the absolute increase as well as day 3 levels correlated significantly with TnT. At 6 months, sTNFR1 had returned to baseline whereas levels of sTNFR2 were still elevated. Soluble Fas and sFasL did not change from baseline to day 3, and both markers were significantly lower in the acute phase compared to 6 months. Indeed, sFas at day 3 correlated negatively with TnT. At all time points, plasma sTNFRs were significantly higher in patients with reduced LV function, whereas no such associations with sFas or sFasL was observed. 

Conclusions

The TNF and Fas/FasL pathways of apoptosis, as reflected by soluble markers, show markedly different temporal changes after an acute MI, indicating diverse roles of these two systems. STEMI compared to NSTEMI patients showed very similar temporal patterns for all the analyzed markers, suggesting apoptosis to be equally involved in myocardial damage of either infarct type.

Keyword
Apoptosis, ST-elevation myocardial infarction, non- ST-elevation myocardial infarction
National Category
Cardiac and Cardiovascular Systems Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:liu:diva-121116 (URN)
Available from: 2015-09-07 Created: 2015-09-07 Last updated: 2016-04-14Bibliographically approved
Eriksson, M., Isaksson, R.-M., Swahn, E., Hellström-Ängerud, K., Eriksson, M., Logander, E., . . . Thylén, I. (2014). Differences in symptom presentation in STEMI patients, with or without a previous history of hypertension; a survey report from the SymTime study group.. In: : . Paper presented at ESC Congress, Barcelona, September, 2014. .
Open this publication in new window or tab >>Differences in symptom presentation in STEMI patients, with or without a previous history of hypertension; a survey report from the SymTime study group.
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2014 (English)Conference paper, Poster (with or without abstract) (Refereed)
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-114049 (URN)
Conference
ESC Congress, Barcelona, September, 2014
Available from: 2015-02-05 Created: 2015-02-05 Last updated: 2015-03-30
Thylén, I., Isaksson, R.-M., Swahn, E., Hellström-Ängerud, K., Eriksson, M., Logander, E. & Lawesson, S. (2014). First medical contact in STEMI patients; utilization of healthcare advice via telephone in the acute phase - a survey report from the SymTime study group.. In: : . Paper presented at ESC Congress, Barcelona, September, 2014. .
Open this publication in new window or tab >>First medical contact in STEMI patients; utilization of healthcare advice via telephone in the acute phase - a survey report from the SymTime study group.
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2014 (English)Conference paper, Poster (with or without abstract) (Refereed)
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-114047 (URN)
Conference
ESC Congress, Barcelona, September, 2014
Available from: 2015-02-05 Created: 2015-02-05 Last updated: 2015-03-31
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-2608-2062

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