Prevalence and correlates of QTc prolongation in Italian psychiatric care

Cross-sectional multicentre study

M. Nosè, I. Bighelli, M. Castellazzi, G. Martinotti, G. Carrà, C. Lucii, G. Ostuzzi, F. Sozzi, C. Barbui, T. Acciavatti, A. Adamo, A. Aguglia, C. Albanese, S. Baccaglini, C. Barbui, F. Bardicchia, R. Barone, Y. Barone, F. Bartoli, C. Bergamini & 84 others F. Bertolini, I. Bighelli, S. Bolognesi, A. Bordone, P. Bortolaso, M. Bugliani, C. Calandra, S. Calò, G. Cardamone, M. Caroleo, E. Carra, D. Carretta, M. Castellazzi, L. Chiocchi, M. Clerici, M. Corbo, E. Corsi, R. Costanzo, G. Costoloni, F. D'Arienzo, S. Debolini, A. De Capua, W. A. Di Napoli, M. Dinelli, E. Facchi, F. Fargnoli, F. Fiori, A. Franchi, F. Gardellin, E. Gazzoletti, L. Ghio, M. Giacomin, M. Gregis, N. Iovieno, D. Koukouna, A. Lax, C. Lintas, A. Luca, M. Luca, C. Lucii, M. Lussetti, M. Madrucci, N. Magnani, L. Magni, E. Manca, G. Martinotti, C. Martorelli, R. Mattafirri, M. Nosè, G. Ostuzzi, M. Percudani, G. Perini, P. Petrosemolo, M. Pezzullo, S. Piantanida, F. Pinna, K. Prato, D. Prestia, D. Quattrone, C. Reggianini, F. Restaino, M. Ribolsi, G. Rinosi, C. Rizzo, R. Rizzo, M. Roggi, G. Rossi, S. Rossi, S. Ruberto, M. Santi, R. Santoro, M. S. Signorelli, F. Soscia, F. Sozzi, P. Staffa, M. Stilo, S. Strizzolo, F. Suraniti, N. Tavian, L. Tortelli, F. Tosoni, M. Valdagno, V. Zanobini, C. Barbui

Research output: Contribution to journalArticle

Abstract

Aims. In recent years several warnings have been issued by regulatory authorities on the risk of electrocardiogram abnormalities in individuals exposed to psychotropic drugs. As a consequence of these warnings, monitoring of the QT interval corrected for heart rate (QTc) has become increasingly common. This study was conducted to measure the frequency of QTc prolongation in unselected psychiatric patients, and to document the associated factors using a cross-sectional approach. Method. The study was carried out in 35 Italian psychiatric services that are part of the STAR (Servizi Territoriali Associati per la Ricerca) Network, a research group established to produce scientific knowledge by collecting data under ordinary circumstances. During a three-month period, a consecutive unselected series of both in- and out-patients were enrolled if they performed an ECG during the recruitment period and were receiving psychotropic drugs on the day ECG was recorded. Results. During the recruitment period a total of 2411 patients were included in the study. The prevalence of QTc prolongation ranged from 14.7% (men) and 18.6% (women) for the cut-off of 450 ms, to 1.26% (men) and 1.01% (women) for the cut-off of 500 ms. In the multivariate model conducted in the whole sample of patients exposed to psychotropic drugs, female sex, age, heart rate, alcohol and/or substance abuse, cardiovascular diseases and cardiovascular drug treatment, and drug overdose were significantly associated with QTc prolongation. In patients exposed to antipsychotic drugs, polypharmacy was positively associated with QTc prolongation, whereas use of aripiprazole decreased the risk. In patients exposed to antidepressant drugs, use of citalopram, citalopram dose and use of haloperidol in addition to antidepressant drugs, were all positively associated with QTc prolongation. Conclusions. The confirmation of a link between antipsychotic polypharmacy and QTc prolongation supports the current guidelines that recommend avoiding the concurrent use of two or more antipsychotic drugs, and the confirmation of a link between citalopram and QTc prolongation supports the need for routine QTc monitoring. The relatively low proportion of patients with QTc prolongation not only suggests compliance with current safety warnings issued by regulatory authorities, but also casts some doubts on the clinical relevance of QTc prolongation related to some psychotropic drugs.

Original languageEnglish
Pages (from-to)532-540
Number of pages9
JournalEpidemiology and Psychiatric Sciences
Volume25
Issue number6
DOIs
Publication statusPublished - Dec 1 2016

Fingerprint

Multicenter Studies
Psychiatry
Cross-Sectional Studies
Psychotropic Drugs
Citalopram
Antipsychotic Agents
Polypharmacy
Electrocardiography
Antidepressive Agents
Heart Rate
Drug Overdose
Cardiovascular Agents
Haloperidol
Alcoholism
Substance-Related Disorders
Outpatients
Cardiovascular Diseases
Guidelines
Safety
Research

Keywords

  • Adverse effect
  • Antidepressant
  • Antipsychotic
  • Psychotropic drugs

ASJC Scopus subject areas

  • Epidemiology
  • Public Health, Environmental and Occupational Health
  • Psychiatry and Mental health

Cite this

Nosè, M., Bighelli, I., Castellazzi, M., Martinotti, G., Carrà, G., Lucii, C., ... Barbui, C. (2016). Prevalence and correlates of QTc prolongation in Italian psychiatric care: Cross-sectional multicentre study. Epidemiology and Psychiatric Sciences, 25(6), 532-540. https://doi.org/10.1017/S2045796015000906

Prevalence and correlates of QTc prolongation in Italian psychiatric care : Cross-sectional multicentre study. / Nosè, M.; Bighelli, I.; Castellazzi, M.; Martinotti, G.; Carrà, G.; Lucii, C.; Ostuzzi, G.; Sozzi, F.; Barbui, C.; Acciavatti, T.; Adamo, A.; Aguglia, A.; Albanese, C.; Baccaglini, S.; Barbui, C.; Bardicchia, F.; Barone, R.; Barone, Y.; Bartoli, F.; Bergamini, C.; Bertolini, F.; Bighelli, I.; Bolognesi, S.; Bordone, A.; Bortolaso, P.; Bugliani, M.; Calandra, C.; Calò, S.; Cardamone, G.; Caroleo, M.; Carra, E.; Carretta, D.; Castellazzi, M.; Chiocchi, L.; Clerici, M.; Corbo, M.; Corsi, E.; Costanzo, R.; Costoloni, G.; D'Arienzo, F.; Debolini, S.; De Capua, A.; Di Napoli, W. A.; Dinelli, M.; Facchi, E.; Fargnoli, F.; Fiori, F.; Franchi, A.; Gardellin, F.; Gazzoletti, E.; Ghio, L.; Giacomin, M.; Gregis, M.; Iovieno, N.; Koukouna, D.; Lax, A.; Lintas, C.; Luca, A.; Luca, M.; Lucii, C.; Lussetti, M.; Madrucci, M.; Magnani, N.; Magni, L.; Manca, E.; Martinotti, G.; Martorelli, C.; Mattafirri, R.; Nosè, M.; Ostuzzi, G.; Percudani, M.; Perini, G.; Petrosemolo, P.; Pezzullo, M.; Piantanida, S.; Pinna, F.; Prato, K.; Prestia, D.; Quattrone, D.; Reggianini, C.; Restaino, F.; Ribolsi, M.; Rinosi, G.; Rizzo, C.; Rizzo, R.; Roggi, M.; Rossi, G.; Rossi, S.; Ruberto, S.; Santi, M.; Santoro, R.; Signorelli, M. S.; Soscia, F.; Sozzi, F.; Staffa, P.; Stilo, M.; Strizzolo, S.; Suraniti, F.; Tavian, N.; Tortelli, L.; Tosoni, F.; Valdagno, M.; Zanobini, V.; Barbui, C.

In: Epidemiology and Psychiatric Sciences, Vol. 25, No. 6, 01.12.2016, p. 532-540.

Research output: Contribution to journalArticle

Nosè, M, Bighelli, I, Castellazzi, M, Martinotti, G, Carrà, G, Lucii, C, Ostuzzi, G, Sozzi, F, Barbui, C, Acciavatti, T, Adamo, A, Aguglia, A, Albanese, C, Baccaglini, S, Barbui, C, Bardicchia, F, Barone, R, Barone, Y, Bartoli, F, Bergamini, C, Bertolini, F, Bighelli, I, Bolognesi, S, Bordone, A, Bortolaso, P, Bugliani, M, Calandra, C, Calò, S, Cardamone, G, Caroleo, M, Carra, E, Carretta, D, Castellazzi, M, Chiocchi, L, Clerici, M, Corbo, M, Corsi, E, Costanzo, R, Costoloni, G, D'Arienzo, F, Debolini, S, De Capua, A, Di Napoli, WA, Dinelli, M, Facchi, E, Fargnoli, F, Fiori, F, Franchi, A, Gardellin, F, Gazzoletti, E, Ghio, L, Giacomin, M, Gregis, M, Iovieno, N, Koukouna, D, Lax, A, Lintas, C, Luca, A, Luca, M, Lucii, C, Lussetti, M, Madrucci, M, Magnani, N, Magni, L, Manca, E, Martinotti, G, Martorelli, C, Mattafirri, R, Nosè, M, Ostuzzi, G, Percudani, M, Perini, G, Petrosemolo, P, Pezzullo, M, Piantanida, S, Pinna, F, Prato, K, Prestia, D, Quattrone, D, Reggianini, C, Restaino, F, Ribolsi, M, Rinosi, G, Rizzo, C, Rizzo, R, Roggi, M, Rossi, G, Rossi, S, Ruberto, S, Santi, M, Santoro, R, Signorelli, MS, Soscia, F, Sozzi, F, Staffa, P, Stilo, M, Strizzolo, S, Suraniti, F, Tavian, N, Tortelli, L, Tosoni, F, Valdagno, M, Zanobini, V & Barbui, C 2016, 'Prevalence and correlates of QTc prolongation in Italian psychiatric care: Cross-sectional multicentre study', Epidemiology and Psychiatric Sciences, vol. 25, no. 6, pp. 532-540. https://doi.org/10.1017/S2045796015000906
Nosè, M. ; Bighelli, I. ; Castellazzi, M. ; Martinotti, G. ; Carrà, G. ; Lucii, C. ; Ostuzzi, G. ; Sozzi, F. ; Barbui, C. ; Acciavatti, T. ; Adamo, A. ; Aguglia, A. ; Albanese, C. ; Baccaglini, S. ; Barbui, C. ; Bardicchia, F. ; Barone, R. ; Barone, Y. ; Bartoli, F. ; Bergamini, C. ; Bertolini, F. ; Bighelli, I. ; Bolognesi, S. ; Bordone, A. ; Bortolaso, P. ; Bugliani, M. ; Calandra, C. ; Calò, S. ; Cardamone, G. ; Caroleo, M. ; Carra, E. ; Carretta, D. ; Castellazzi, M. ; Chiocchi, L. ; Clerici, M. ; Corbo, M. ; Corsi, E. ; Costanzo, R. ; Costoloni, G. ; D'Arienzo, F. ; Debolini, S. ; De Capua, A. ; Di Napoli, W. A. ; Dinelli, M. ; Facchi, E. ; Fargnoli, F. ; Fiori, F. ; Franchi, A. ; Gardellin, F. ; Gazzoletti, E. ; Ghio, L. ; Giacomin, M. ; Gregis, M. ; Iovieno, N. ; Koukouna, D. ; Lax, A. ; Lintas, C. ; Luca, A. ; Luca, M. ; Lucii, C. ; Lussetti, M. ; Madrucci, M. ; Magnani, N. ; Magni, L. ; Manca, E. ; Martinotti, G. ; Martorelli, C. ; Mattafirri, R. ; Nosè, M. ; Ostuzzi, G. ; Percudani, M. ; Perini, G. ; Petrosemolo, P. ; Pezzullo, M. ; Piantanida, S. ; Pinna, F. ; Prato, K. ; Prestia, D. ; Quattrone, D. ; Reggianini, C. ; Restaino, F. ; Ribolsi, M. ; Rinosi, G. ; Rizzo, C. ; Rizzo, R. ; Roggi, M. ; Rossi, G. ; Rossi, S. ; Ruberto, S. ; Santi, M. ; Santoro, R. ; Signorelli, M. S. ; Soscia, F. ; Sozzi, F. ; Staffa, P. ; Stilo, M. ; Strizzolo, S. ; Suraniti, F. ; Tavian, N. ; Tortelli, L. ; Tosoni, F. ; Valdagno, M. ; Zanobini, V. ; Barbui, C. / Prevalence and correlates of QTc prolongation in Italian psychiatric care : Cross-sectional multicentre study. In: Epidemiology and Psychiatric Sciences. 2016 ; Vol. 25, No. 6. pp. 532-540.
@article{1e1456e94415416db99e639f77eac0d2,
title = "Prevalence and correlates of QTc prolongation in Italian psychiatric care: Cross-sectional multicentre study",
abstract = "Aims. In recent years several warnings have been issued by regulatory authorities on the risk of electrocardiogram abnormalities in individuals exposed to psychotropic drugs. As a consequence of these warnings, monitoring of the QT interval corrected for heart rate (QTc) has become increasingly common. This study was conducted to measure the frequency of QTc prolongation in unselected psychiatric patients, and to document the associated factors using a cross-sectional approach. Method. The study was carried out in 35 Italian psychiatric services that are part of the STAR (Servizi Territoriali Associati per la Ricerca) Network, a research group established to produce scientific knowledge by collecting data under ordinary circumstances. During a three-month period, a consecutive unselected series of both in- and out-patients were enrolled if they performed an ECG during the recruitment period and were receiving psychotropic drugs on the day ECG was recorded. Results. During the recruitment period a total of 2411 patients were included in the study. The prevalence of QTc prolongation ranged from 14.7{\%} (men) and 18.6{\%} (women) for the cut-off of 450 ms, to 1.26{\%} (men) and 1.01{\%} (women) for the cut-off of 500 ms. In the multivariate model conducted in the whole sample of patients exposed to psychotropic drugs, female sex, age, heart rate, alcohol and/or substance abuse, cardiovascular diseases and cardiovascular drug treatment, and drug overdose were significantly associated with QTc prolongation. In patients exposed to antipsychotic drugs, polypharmacy was positively associated with QTc prolongation, whereas use of aripiprazole decreased the risk. In patients exposed to antidepressant drugs, use of citalopram, citalopram dose and use of haloperidol in addition to antidepressant drugs, were all positively associated with QTc prolongation. Conclusions. The confirmation of a link between antipsychotic polypharmacy and QTc prolongation supports the current guidelines that recommend avoiding the concurrent use of two or more antipsychotic drugs, and the confirmation of a link between citalopram and QTc prolongation supports the need for routine QTc monitoring. The relatively low proportion of patients with QTc prolongation not only suggests compliance with current safety warnings issued by regulatory authorities, but also casts some doubts on the clinical relevance of QTc prolongation related to some psychotropic drugs.",
keywords = "Adverse effect, Antidepressant, Antipsychotic, Psychotropic drugs",
author = "M. Nos{\`e} and I. Bighelli and M. Castellazzi and G. Martinotti and G. Carr{\`a} and C. Lucii and G. Ostuzzi and F. Sozzi and C. Barbui and T. Acciavatti and A. Adamo and A. Aguglia and C. Albanese and S. Baccaglini and C. Barbui and F. Bardicchia and R. Barone and Y. Barone and F. Bartoli and C. Bergamini and F. Bertolini and I. Bighelli and S. Bolognesi and A. Bordone and P. Bortolaso and M. Bugliani and C. Calandra and S. Cal{\`o} and G. Cardamone and M. Caroleo and E. Carra and D. Carretta and M. Castellazzi and L. Chiocchi and M. Clerici and M. Corbo and E. Corsi and R. Costanzo and G. Costoloni and F. D'Arienzo and S. Debolini and {De Capua}, A. and {Di Napoli}, {W. A.} and M. Dinelli and E. Facchi and F. Fargnoli and F. Fiori and A. Franchi and F. Gardellin and E. Gazzoletti and L. Ghio and M. Giacomin and M. Gregis and N. Iovieno and D. Koukouna and A. Lax and C. Lintas and A. Luca and M. Luca and C. Lucii and M. Lussetti and M. Madrucci and N. Magnani and L. Magni and E. Manca and G. Martinotti and C. Martorelli and R. Mattafirri and M. Nos{\`e} and G. Ostuzzi and M. Percudani and G. Perini and P. Petrosemolo and M. Pezzullo and S. Piantanida and F. Pinna and K. Prato and D. Prestia and D. Quattrone and C. Reggianini and F. Restaino and M. Ribolsi and G. Rinosi and C. Rizzo and R. Rizzo and M. Roggi and G. Rossi and S. Rossi and S. Ruberto and M. Santi and R. Santoro and Signorelli, {M. S.} and F. Soscia and F. Sozzi and P. Staffa and M. Stilo and S. Strizzolo and F. Suraniti and N. Tavian and L. Tortelli and F. Tosoni and M. Valdagno and V. Zanobini and C. Barbui",
year = "2016",
month = "12",
day = "1",
doi = "10.1017/S2045796015000906",
language = "English",
volume = "25",
pages = "532--540",
journal = "Epidemiology and Psychiatric Sciences",
issn = "2045-7960",
publisher = "Cambridge University Press",
number = "6",

}

TY - JOUR

T1 - Prevalence and correlates of QTc prolongation in Italian psychiatric care

T2 - Cross-sectional multicentre study

AU - Nosè, M.

AU - Bighelli, I.

AU - Castellazzi, M.

AU - Martinotti, G.

AU - Carrà, G.

AU - Lucii, C.

AU - Ostuzzi, G.

AU - Sozzi, F.

AU - Barbui, C.

AU - Acciavatti, T.

AU - Adamo, A.

AU - Aguglia, A.

AU - Albanese, C.

AU - Baccaglini, S.

AU - Barbui, C.

AU - Bardicchia, F.

AU - Barone, R.

AU - Barone, Y.

AU - Bartoli, F.

AU - Bergamini, C.

AU - Bertolini, F.

AU - Bighelli, I.

AU - Bolognesi, S.

AU - Bordone, A.

AU - Bortolaso, P.

AU - Bugliani, M.

AU - Calandra, C.

AU - Calò, S.

AU - Cardamone, G.

AU - Caroleo, M.

AU - Carra, E.

AU - Carretta, D.

AU - Castellazzi, M.

AU - Chiocchi, L.

AU - Clerici, M.

AU - Corbo, M.

AU - Corsi, E.

AU - Costanzo, R.

AU - Costoloni, G.

AU - D'Arienzo, F.

AU - Debolini, S.

AU - De Capua, A.

AU - Di Napoli, W. A.

AU - Dinelli, M.

AU - Facchi, E.

AU - Fargnoli, F.

AU - Fiori, F.

AU - Franchi, A.

AU - Gardellin, F.

AU - Gazzoletti, E.

AU - Ghio, L.

AU - Giacomin, M.

AU - Gregis, M.

AU - Iovieno, N.

AU - Koukouna, D.

AU - Lax, A.

AU - Lintas, C.

AU - Luca, A.

AU - Luca, M.

AU - Lucii, C.

AU - Lussetti, M.

AU - Madrucci, M.

AU - Magnani, N.

AU - Magni, L.

AU - Manca, E.

AU - Martinotti, G.

AU - Martorelli, C.

AU - Mattafirri, R.

AU - Nosè, M.

AU - Ostuzzi, G.

AU - Percudani, M.

AU - Perini, G.

AU - Petrosemolo, P.

AU - Pezzullo, M.

AU - Piantanida, S.

AU - Pinna, F.

AU - Prato, K.

AU - Prestia, D.

AU - Quattrone, D.

AU - Reggianini, C.

AU - Restaino, F.

AU - Ribolsi, M.

AU - Rinosi, G.

AU - Rizzo, C.

AU - Rizzo, R.

AU - Roggi, M.

AU - Rossi, G.

AU - Rossi, S.

AU - Ruberto, S.

AU - Santi, M.

AU - Santoro, R.

AU - Signorelli, M. S.

AU - Soscia, F.

AU - Sozzi, F.

AU - Staffa, P.

AU - Stilo, M.

AU - Strizzolo, S.

AU - Suraniti, F.

AU - Tavian, N.

AU - Tortelli, L.

AU - Tosoni, F.

AU - Valdagno, M.

AU - Zanobini, V.

AU - Barbui, C.

PY - 2016/12/1

Y1 - 2016/12/1

N2 - Aims. In recent years several warnings have been issued by regulatory authorities on the risk of electrocardiogram abnormalities in individuals exposed to psychotropic drugs. As a consequence of these warnings, monitoring of the QT interval corrected for heart rate (QTc) has become increasingly common. This study was conducted to measure the frequency of QTc prolongation in unselected psychiatric patients, and to document the associated factors using a cross-sectional approach. Method. The study was carried out in 35 Italian psychiatric services that are part of the STAR (Servizi Territoriali Associati per la Ricerca) Network, a research group established to produce scientific knowledge by collecting data under ordinary circumstances. During a three-month period, a consecutive unselected series of both in- and out-patients were enrolled if they performed an ECG during the recruitment period and were receiving psychotropic drugs on the day ECG was recorded. Results. During the recruitment period a total of 2411 patients were included in the study. The prevalence of QTc prolongation ranged from 14.7% (men) and 18.6% (women) for the cut-off of 450 ms, to 1.26% (men) and 1.01% (women) for the cut-off of 500 ms. In the multivariate model conducted in the whole sample of patients exposed to psychotropic drugs, female sex, age, heart rate, alcohol and/or substance abuse, cardiovascular diseases and cardiovascular drug treatment, and drug overdose were significantly associated with QTc prolongation. In patients exposed to antipsychotic drugs, polypharmacy was positively associated with QTc prolongation, whereas use of aripiprazole decreased the risk. In patients exposed to antidepressant drugs, use of citalopram, citalopram dose and use of haloperidol in addition to antidepressant drugs, were all positively associated with QTc prolongation. Conclusions. The confirmation of a link between antipsychotic polypharmacy and QTc prolongation supports the current guidelines that recommend avoiding the concurrent use of two or more antipsychotic drugs, and the confirmation of a link between citalopram and QTc prolongation supports the need for routine QTc monitoring. The relatively low proportion of patients with QTc prolongation not only suggests compliance with current safety warnings issued by regulatory authorities, but also casts some doubts on the clinical relevance of QTc prolongation related to some psychotropic drugs.

AB - Aims. In recent years several warnings have been issued by regulatory authorities on the risk of electrocardiogram abnormalities in individuals exposed to psychotropic drugs. As a consequence of these warnings, monitoring of the QT interval corrected for heart rate (QTc) has become increasingly common. This study was conducted to measure the frequency of QTc prolongation in unselected psychiatric patients, and to document the associated factors using a cross-sectional approach. Method. The study was carried out in 35 Italian psychiatric services that are part of the STAR (Servizi Territoriali Associati per la Ricerca) Network, a research group established to produce scientific knowledge by collecting data under ordinary circumstances. During a three-month period, a consecutive unselected series of both in- and out-patients were enrolled if they performed an ECG during the recruitment period and were receiving psychotropic drugs on the day ECG was recorded. Results. During the recruitment period a total of 2411 patients were included in the study. The prevalence of QTc prolongation ranged from 14.7% (men) and 18.6% (women) for the cut-off of 450 ms, to 1.26% (men) and 1.01% (women) for the cut-off of 500 ms. In the multivariate model conducted in the whole sample of patients exposed to psychotropic drugs, female sex, age, heart rate, alcohol and/or substance abuse, cardiovascular diseases and cardiovascular drug treatment, and drug overdose were significantly associated with QTc prolongation. In patients exposed to antipsychotic drugs, polypharmacy was positively associated with QTc prolongation, whereas use of aripiprazole decreased the risk. In patients exposed to antidepressant drugs, use of citalopram, citalopram dose and use of haloperidol in addition to antidepressant drugs, were all positively associated with QTc prolongation. Conclusions. The confirmation of a link between antipsychotic polypharmacy and QTc prolongation supports the current guidelines that recommend avoiding the concurrent use of two or more antipsychotic drugs, and the confirmation of a link between citalopram and QTc prolongation supports the need for routine QTc monitoring. The relatively low proportion of patients with QTc prolongation not only suggests compliance with current safety warnings issued by regulatory authorities, but also casts some doubts on the clinical relevance of QTc prolongation related to some psychotropic drugs.

KW - Adverse effect

KW - Antidepressant

KW - Antipsychotic

KW - Psychotropic drugs

UR - http://www.scopus.com/inward/record.url?scp=84944081361&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84944081361&partnerID=8YFLogxK

U2 - 10.1017/S2045796015000906

DO - 10.1017/S2045796015000906

M3 - Article

VL - 25

SP - 532

EP - 540

JO - Epidemiology and Psychiatric Sciences

JF - Epidemiology and Psychiatric Sciences

SN - 2045-7960

IS - 6

ER -