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  • 1
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    Association between antihypertensive treatment and adverse events: systematic review and meta-analysis
    BMJ ; 2021
    In:  BMJ
    Details
    In: BMJ, BMJ
    Abstract: To examine the association between antihypertensive treatment and specific adverse events. Design Systematic review and meta-analysis. Eligibility criteria Randomised controlled trials of adults receiving antihypertensives compared with placebo or no treatment, more antihypertensive drugs compared with fewer antihypertensive drugs, or higher blood pressure targets compared with lower targets. To avoid small early phase trials, studies were required to have at least 650 patient years of follow-up. Information sources Searches were conducted in Embase, Medline, CENTRAL, and the Science Citation Index databases from inception until 14 April 2020. Main outcome measures The primary outcome was falls during trial follow-up. Secondary outcomes were acute kidney injury, fractures, gout, hyperkalaemia, hypokalaemia, hypotension, and syncope. Additional outcomes related to death and major cardiovascular events were extracted. Risk of bias was assessed using the Cochrane risk of bias tool, and random effects meta-analysis was used to pool rate ratios, odds ratios, and hazard ratios across studies, allowing for between study heterogeneity (τ 2 ). Results Of 15 023 articles screened for inclusion, 58 randomised controlled trials were identified, including 280 638 participants followed up for a median of 3 (interquartile range 2-4) years. Most of the trials (n=40, 69%) had a low risk of bias. Among seven trials reporting data for falls, no evidence was found of an association with antihypertensive treatment (summary risk ratio 1.05, 95% confidence interval 0.89 to 1.24, τ 2 =0.009). Antihypertensives were associated with an increased risk of acute kidney injury (1.18, 95% confidence interval 1.01 to 1.39, τ 2 =0.037, n=15), hyperkalaemia (1.89, 1.56 to 2.30, τ 2 =0.122, n=26), hypotension (1.97, 1.67 to 2.32, τ 2 =0.132, n=35), and syncope (1.28, 1.03 to 1.59, τ 2 =0.050, n=16). The heterogeneity between studies assessing acute kidney injury and hyperkalaemia events was reduced when focusing on drugs that affect the renin angiotensin-aldosterone system. Results were robust to sensitivity analyses focusing on adverse events leading to withdrawal from each trial. Antihypertensive treatment was associated with a reduced risk of all cause mortality, cardiovascular death, and stroke, but not of myocardial infarction. Conclusions This meta-analysis found no evidence to suggest that antihypertensive treatment is associated with falls but found evidence of an association with mild (hyperkalaemia, hypotension) and severe adverse events (acute kidney injury, syncope). These data could be used to inform shared decision making between doctors and patients about initiation and continuation of antihypertensive treatment, especially in patients at high risk of harm because of previous adverse events or poor renal function. Registration PROSPERO CRD42018116860.
    Type of Medium: Online Resource
    ISSN: 1756-1833
    URL: Article
    DOI: 10.1136/bmj.n189
    Language: English
    Publisher: BMJ
    Publication Date: 2021
    detail.hit.zdb_id: 1479799-9
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  • 2
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    National trends in heart failure mortality in men and women, United Kingdom , 2000–2017
    Wiley ; 2021
    In:  European Journal of Heart Failure Vol. 23, No. 1 ( 2021-01), p. 3-12
    Details
    In: European Journal of Heart Failure, Wiley, Vol. 23, No. 1 ( 2021-01), p. 3-12
    Abstract: To understand gender differences in the prognosis of women and men with heart failure, we compared mortality, cause of death and survival trends over time. Methods and results We analysed UK primary care data for 26 725 women and 29 234 men over age 45 years with a new diagnosis of heart failure between 1 January 2000 and 31 December 2017 using the Clinical Practice Research Datalink, inpatient Hospital Episode Statistics and the Office for National Statistics death registry. Age‐specific overall survival and cause‐specific mortality rates were calculated by gender and year. During the study period 15 084 women and 15 822 men with heart failure died. Women were on average 5 years older at diagnosis (79.6 vs. 74.8 years). Median survival was lower in women compared to men (3.99 vs. 4.47 years), but women had a 14% age‐adjusted lower risk of all‐cause mortality [hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.84–0.88]. Heart failure was equally likely to be cause of death in women and men (HR 1.03, 95% CI 0.96–1.12). There were modest improvements in survival for both genders, but these were greater in men. The reduction in mortality risk in women was greatest for those diagnosed in the community (HR 0.83, 95% CI 0.80–0.85). Conclusions Women are diagnosed with heart failure older than men but have a better age‐adjusted prognosis. Survival gains were less in women over the last two decades. Addressing gender differences in heart failure diagnostic and treatment pathways should be a clinical and research priority.
    Type of Medium: Online Resource
    ISSN: 1388-9842 , 1879-0844
    URL: Issue
    URL: Article
    DOI: 10.1002/ejhf.v23.1
    DOI: 10.1002/ejhf.1996
    Language: English
    Publisher: Wiley
    Publication Date: 2021
    detail.hit.zdb_id: 1500332-2
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  • 3
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    Associations between statins and adverse events in primary prevention of cardiovascular disease: systematic review with pairwise, network, and dose-response meta-analyses
    BMJ ; 2021
    In:  BMJ
    Details
    In: BMJ, BMJ
    Abstract: To assess the associations between statins and adverse events in primary prevention of cardiovascular disease and to examine how the associations vary by type and dosage of statins. Design Systematic review and meta-analysis. Data sources Studies were identified from previous systematic reviews and searched in Medline, Embase, and the Cochrane Central Register of Controlled Trials, up to August 2020. Review methods Randomised controlled trials in adults without a history of cardiovascular disease that compared statins with non-statin controls or compared different types or dosages of statins were included. Main outcome measures Primary outcomes were common adverse events: self-reported muscle symptoms, clinically confirmed muscle disorders, liver dysfunction, renal insufficiency, diabetes, and eye conditions. Secondary outcomes included myocardial infarction, stroke, and death from cardiovascular disease as measures of efficacy. Data synthesis A pairwise meta-analysis was conducted to calculate odds ratios and 95% confidence intervals for each outcome between statins and non-statin controls, and the absolute risk difference in the number of events per 10 000 patients treated for a year was estimated. A network meta-analysis was performed to compare the adverse effects of different types of statins. An E max model based meta-analysis was used to examine the dose-response relationships of the adverse effects of each statin. Results 62 trials were included, with 120 456 participants followed up for an average of 3.9 years. Statins were associated with an increased risk of self-reported muscle symptoms (21 trials, odds ratio 1.06 (95% confidence interval 1.01 to 1.13); absolute risk difference 15 (95% confidence interval 1 to 29)), liver dysfunction (21 trials, odds ratio 1.33 (1.12 to 1.58); absolute risk difference 8 (3 to 14)), renal insufficiency (eight trials, odds ratio 1.14 (1.01 to 1.28); absolute risk difference 12 (1 to 24)), and eye conditions (six trials, odds ratio 1.23 (1.04 to 1.47); absolute risk difference 14 (2 to 29)) but were not associated with clinically confirmed muscle disorders or diabetes. The increased risks did not outweigh the reduction in the risk of major cardiovascular events. Atorvastatin, lovastatin, and rosuvastatin were individually associated with some adverse events, but few significant differences were found between types of statins. An E max dose-response relationship was identified for the effect of atorvastatin on liver dysfunction, but the dose-response relationships for the other statins and adverse effects were inconclusive. Conclusions For primary prevention of cardiovascular disease, the risk of adverse events attributable to statins was low and did not outweigh their efficacy in preventing cardiovascular disease, suggesting that the benefit-to-harm balance of statins is generally favourable. Evidence to support tailoring the type or dosage of statins to account for safety concerns before starting treatment was limited. Systematic review registration PROSPERO CRD42020169955.
    Type of Medium: Online Resource
    ISSN: 1756-1833
    URL: Article
    DOI: 10.1136/bmj.n1537
    Language: English
    Publisher: BMJ
    Publication Date: 2021
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  • 4
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    Using out-of-office blood pressure measurements in established cardiovascular risk scores: a secondary analysis of data from two blood pressure monitoring studies
    Royal College of General Practitioners ; 2019
    In:  British Journal of General Practice Vol. 69, No. 683 ( 2019-06), p. e381-e388
    Details
    In: British Journal of General Practice, Royal College of General Practitioners, Vol. 69, No. 683 ( 2019-06), p. e381-e388
    Abstract: Blood pressure (BP) measurement is increasingly carried out through home or ambulatory monitoring, yet existing cardiovascular risk scores were developed for use with measurements obtained in clinics. Aim To describe differences in cardiovascular risk estimates obtained using ambulatory or home BP measurements instead of clinic readings. Design and setting Secondary analysis of data from adults aged 25–84 years in the UK and the Netherlands without prior history of cardiovascular disease (CVD) in two BP monitoring studies: the Blood Pressure in different Ethnic groups (BP-Eth) study and the Home versus Office blood pressure MEasurements: Reduction of Unnecessary treatment Study (HOMERUS). Method The primary comparison was Framingham risk calculated using BP measured as in the Framingham study or daytime ambulatory BP measurements. Statistical significance was determined using non-parametric tests. Results In 442 BP-Eth patients (mean age = 58 years, 50% female [ n = 222]) the median absolute difference in 10-year Framingham cardiovascular risk calculated using BP measured as in the Framingham study or daytime ambulatory BP measurements was 1.84% (interquartile range [IQR] 0.65–3.63, P = 0.67). In 165 HOMERUS patients (mean age = 56 years, 46% female) the median absolute difference in 10-year risk for daytime ambulatory BP was 2.76% (IQR 1.19–6.39, P 〈 0.001) and only 8 out of 165 (4.8%) of patients were reclassified. Conclusion Estimates of cardiovascular risk are similar when calculated using BP measurements obtained as in the risk score derivation study or through ambulatory monitoring. Further research is required to determine if differences in estimated risk would meaningfully influence risk score accuracy.
    Type of Medium: Online Resource
    ISSN: 0960-1643 , 1478-5242
    URL: Article
    DOI: 10.3399/bjgp19X702737
    RVK:
    XA 34050
    Language: English
    Publisher: Royal College of General Practitioners
    Publication Date: 2019
    detail.hit.zdb_id: 2097982-4
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  • 5
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    Impact of changes to national guidelines on hypertension-related workload: an interrupted time series analysis in English primary care
    Royal College of General Practitioners ; 2021
    In:  British Journal of General Practice Vol. 71, No. 705 ( 2021-04), p. e296-e302
    Details
    In: British Journal of General Practice, Royal College of General Practitioners, Vol. 71, No. 705 ( 2021-04), p. e296-e302
    Abstract: In 2011, National Institute for Health and Care Excellence (NICE) guidelines recommended the routine use of out-of-office blood pressure (BP) monitoring for the diagnosis of hypertension. These changes were predicted to reduce unnecessary treatment costs and workload associated with misdiagnosis. Aim To assess the impact of guideline change on rates of hypertension-related consultation in general practice. Design and setting A retrospective open cohort study in adults registered with English general practices contributing to the Clinical Practice Research Datalink between 1 April 2006 and 31 March 2017. Method The primary outcome was the rate of face-to-face, telephone, and home visit consultations related to hypertension with a GP or nurse. Age- and sex-standardised rates were analysed using interrupted time-series analysis. Results In 3 937 191 adults (median follow-up 4.2 years) there were 12 253 836 hypertension-related consultations. The rate of hypertension-related consultation was 71.0 per 100 person–years (95% confidence interval [CI] = 67.8 to 74.2) in April 2006, which remained flat before 2011. The introduction of the NICE hypertension guideline in 2011 was associated with a change in yearly trend (change in trend −3.60 per 100 person–years, 95% CI = −5.12 to −2.09). The rate of consultation subsequently decreased to 59.2 per 100 person–years (95% CI = 56.5 to 61.8) in March 2017. These changes occurred around the time of diagnosis, and persisted when accounting for wider trends in all consultations. Conclusion Hypertension-related workload has declined in the last decade, in association with guideline changes. This is due to changes in workload at the time of diagnosis, rather than reductions in misdiagnosis.
    Type of Medium: Online Resource
    ISSN: 0960-1643 , 1478-5242
    URL: Article
    DOI: 10.3399/bjgp21X714281
    RVK:
    XA 34050
    Language: English
    Publisher: Royal College of General Practitioners
    Publication Date: 2021
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  • 6
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    Measuring the complexity of general practice consultations: a Delphi and cross-sectional study in English primary care
    Royal College of General Practitioners ; 2021
    In:  British Journal of General Practice Vol. 71, No. 707 ( 2021-06), p. e423-e431
    Details
    In: British Journal of General Practice, Royal College of General Practitioners, Vol. 71, No. 707 ( 2021-06), p. e423-e431
    Abstract: The complexity of general practice consultations may be increasing and varies in different settings. A measure of complexity is required to test these hypotheses. Aim To develop a valid measure of general practice consultation complexity applicable to routine medical records. Design and setting Delphi study to select potential indicators of complexity followed by a cross-sectional study in English general practices to develop and validate a complexity measure. Method The online Delphi study over two rounds identified potential indicators of consultation complexity. The cross-sectional study used an age–sex stratified random sample of patients and general practice face-to-face consultations from 2013/2014 in the Clinical Practice Research Datalink. The authors explored independent relationships between each indicator and consultation duration using mixed-effects regression models, and revalidated findings using data from 2017/2018. The proportion of complex consultations in different age–sex groups was assessed. Results A total of 32 GPs participated in the Delphi study. The Delphi panel endorsed 34 of 45 possible complexity indicators after two rounds. After excluding factors because of low prevalence or confounding, 17 indicators were retained in the cross-sectional study. The study used data from 173 130 patients and 725 616 face-to-face GP consultations. On defining complexity as the presence of any of these 17 factors, 308 370 consultations (42.5%) were found to be complex. Mean duration of complex consultations was 10.49 minutes, compared to 9.64 minutes for non-complex consultations. The proportion of complex consultations was similar in males and females but increased with age. Conclusion The present consultation complexity measure has face and construct validity. It may be useful for research, management and policy, and for informing decisions about the range of resources needed in different practices.
    Type of Medium: Online Resource
    ISSN: 0960-1643 , 1478-5242
    URL: Article
    DOI: 10.3399/BJGP.2020.0486
    RVK:
    XA 34050
    Language: English
    Publisher: Royal College of General Practitioners
    Publication Date: 2021
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  • 7
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    Predicting the risk of acute kidney injury in primary care: derivation and validation of STRATIFY-AKI
    Royal College of General Practitioners ; 2023
    In:  British Journal of General Practice Vol. 73, No. 733 ( 2023-08), p. e605-e614
    Details
    In: British Journal of General Practice, Royal College of General Practitioners, Vol. 73, No. 733 ( 2023-08), p. e605-e614
    Abstract: Antihypertensives reduce the risk of cardiovascular disease but are also associated with harms including acute kidney injury (AKI). Few data exist to guide clinical decision making regarding these risks. Aim To develop a prediction model estimating the risk of AKI in people potentially indicated for antihypertensive treatment. Design and setting Observational cohort study using routine primary care data from the Clinical Practice Research Datalink (CPRD) in England. Method People aged ≥40 years, with at least one blood pressure measurement between 130 mmHg and 179 mmHg were included. Outcomes were admission to hospital or death with AKI within 1, 5, and 10 years. The model was derived with data from CPRD GOLD ( n = 1 772 618), using a Fine–Gray competing risks approach, with subsequent recalibration using pseudo-values. External validation used data from CPRD Aurum ( n = 3 805 322). Results The mean age of participants was 59.4 years and 52% were female. The final model consisted of 27 predictors and showed good discrimination at 1, 5, and 10 years (C-statistic for 10-year risk 0.821, 95% confidence interval [CI] = 0.818 to 0.823). There was some overprediction at the highest predicted probabilities (ratio of observed to expected event probability for 10-year risk 0.633, 95% CI = 0.621 to 0.645), affecting patients with the highest risk. Most patients ( 〉 95%) had a low 1- to 5-year risk of AKI, and at 10 years only 0.1% of the population had a high AKI and low CVD risk. Conclusion This clinical prediction model enables GPs to accurately identify patients at high risk of AKI, which will aid treatment decisions. As the vast majority of patients were at low risk, such a model may provide useful reassurance that most antihypertensive treatment is safe and appropriate while flagging the few for whom this is not the case.
    Type of Medium: Online Resource
    ISSN: 0960-1643 , 1478-5242
    URL: Article
    DOI: 10.3399/BJGP.2022.0389
    RVK:
    XA 34050
    Language: English
    Publisher: Royal College of General Practitioners
    Publication Date: 2023
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    The association between antihypertensive treatment and serious adverse events by age and frailty: A cohort study
    Public Library of Science (PLoS) ; 2023
    In:  PLOS Medicine Vol. 20, No. 4 ( 2023-4-19), p. e1004223-
    Details
    In: PLOS Medicine, Public Library of Science (PLoS), Vol. 20, No. 4 ( 2023-4-19), p. e1004223-
    Abstract: Antihypertensives are effective at reducing the risk of cardiovascular disease, but limited data exist quantifying their association with serious adverse events, particularly in older people with frailty. This study aimed to examine this association using nationally representative electronic health record data. Methods and findings This was a retrospective cohort study utilising linked data from 1,256 general practices across England held within the Clinical Practice Research Datalink between 1998 and 2018. Included patients were aged 40+ years, with a systolic blood pressure reading between 130 and 179 mm Hg, and not previously prescribed antihypertensive treatment. The main exposure was defined as a first prescription of antihypertensive treatment. The primary outcome was hospitalisation or death within 10 years from falls. Secondary outcomes were hypotension, syncope, fractures, acute kidney injury, electrolyte abnormalities, and primary care attendance with gout. The association between treatment and these serious adverse events was examined by Cox regression adjusted for propensity score. This propensity score was generated from a multivariable logistic regression model with patient characteristics, medical history and medication prescriptions as covariates, and new antihypertensive treatment as the outcome. Subgroup analyses were undertaken by age and frailty. Of 3,834,056 patients followed for a median of 7.1 years, 484,187 (12.6%) were prescribed new antihypertensive treatment in the 12 months before the index date (baseline). Antihypertensives were associated with an increased risk of hospitalisation or death from falls (adjusted hazard ratio [aHR] 1.23, 95% confidence interval (CI) 1.21 to 1.26), hypotension (aHR 1.32, 95% CI 1.29 to 1.35), syncope (aHR 1.20, 95% CI 1.17 to 1.22), acute kidney injury (aHR 1.44, 95% CI 1.41 to 1.47), electrolyte abnormalities (aHR 1.45, 95% CI 1.43 to 1.48), and primary care attendance with gout (aHR 1.35, 95% CI 1.32 to 1.37). The absolute risk of serious adverse events with treatment was very low, with 6 fall events per 10,000 patients treated per year. In older patients (80 to 89 years) and those with severe frailty, this absolute risk was increased, with 61 and 84 fall events per 10,000 patients treated per year (respectively). Findings were consistent in sensitivity analyses using different approaches to address confounding and taking into account the competing risk of death. A strength of this analysis is that it provides evidence regarding the association between antihypertensive treatment and serious adverse events, in a population of patients more representative than those enrolled in previous randomised controlled trials. Although treatment effect estimates fell within the 95% CIs of those from such trials, these analyses were observational in nature and so bias from unmeasured confounding cannot be ruled out. Conclusions Antihypertensive treatment was associated with serious adverse events. Overall, the absolute risk of this harm was low, with the exception of older patients and those with moderate to severe frailty, where the risks were similar to the likelihood of benefit from treatment. In these populations, physicians may want to consider alternative approaches to management of blood pressure and refrain from prescribing new treatment.
    Type of Medium: Online Resource
    ISSN: 1549-1676
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    DOI: 10.1371/journal.pmed.1004223
    DOI: 10.1371/journal.pmed.1004223.g001
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    Language: English
    Publisher: Public Library of Science (PLoS)
    Publication Date: 2023
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    The Long-Term Impact of Vaginal Surgical Mesh Devices in UK Primary Care: A Cohort Study in the Clinical Practice Research Datalink
    Informa UK Limited ; 2021
    In:  Clinical Epidemiology Vol. Volume 13 ( 2021-12), p. 1167-1180
    Details
    In: Clinical Epidemiology, Informa UK Limited, Vol. Volume 13 ( 2021-12), p. 1167-1180
    Type of Medium: Online Resource
    ISSN: 1179-1349
    URL: Article
    DOI: 10.2147/CLEP.S333775
    Language: English
    Publisher: Informa UK Limited
    Publication Date: 2021
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  • 10
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    Are blood pressure level and variability related to pregnancy outcome? Analysis of control of hypertension in pregnancy study data
    Elsevier BV ; 2020
    In:  Pregnancy Hypertension Vol. 19 ( 2020-01), p. 87-93
    Details
    In: Pregnancy Hypertension, Elsevier BV, Vol. 19 ( 2020-01), p. 87-93
    Type of Medium: Online Resource
    ISSN: 2210-7789
    URL: Article
    DOI: 10.1016/j.preghy.2019.12.002
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2020
    detail.hit.zdb_id: 2584464-7
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