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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 3  |  Page : 111-118

Assessment of quality of life and drug prescription pattern in acute coronary syndrome


Department of Clinical Pharmacy Practice, Samskruti College of Pharmacy, JNTU, Hyderabad, Telangana, India

Date of Submission14-Aug-2021
Date of Decision15-Sep-2021
Date of Acceptance02-May-2022
Date of Web Publication14-Sep-2022

Correspondence Address:
Dr. Nikhilesh Andhi
Assistant Professor, Department of Clinical Pharmacy Practice, Samskruti College of Pharmacy, Kondapur, Ghatkesar Medchal District, Telangana - 501 301
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicc.jicc_50_21

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  Abstract 


Objectives: To assess the health-related quality of life (QOL) in patients with acute coronary syndrome (ACS) and predict those patients who may have worsened QOL 6 months later and also observe the prescribing patterns of drugs given in their treatment. Materials and Methods: A prospective observational study was conducted at the cardiology department in a tertiary care hospital. The data were collected in both inpatient and outpatient cardiology departments based on our inclusion and exclusion criteria for a period of 6 months. A total of 240 patients were analyzed with a data collection form by interviewing the patients about their sociodemographic details, laboratory parameters, and diagnostic reports. The MacNew Heart Disease Questionnaire, Medical Research Council Breathlessness Scale, and New York Heart Association (NYHA) Functional Scale were used for assessing the QOL in patients with ACS. We calculated Global Registry of Acute Coronary Events Score and Thrombolysis in Myocardial Infarction Score for ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) patients for identifying the mortality risk. Results: Urban people were more prone to ACS than rural people, according to our data. According to the NYHA Functional Classification, ability to do physical activity was more considerably affected in NSTEMI patients than STEMI and angina. Most of the patients had Grade 2 shortness of breath. 35% of the patients had a high mortality risk. Based on the MacNew Questionnaire data, 23% of the patients with ACS were doing emotionally poor, 45% of the patients had shown physically impaired symptoms, 28% of the patients were socially dependent, 8% of the patients showed poor gastric condition. 49% of the patients were given reperfusion therapy with either percutaneous coronary intervention (PCI) or coronary artery bypass graft, 25% of the patients were managed with dual-anticoagulant therapy, and 6% of the patients were treated with single-anticoagulant therapy. Commonly prescribed drug classes were statins (90%), antiplatelets (86%), anticoagulants (75%), antianginal (55%), beta-blockers (50%), diuretics (35%), angiotensin-converting enzyme inhibitors (18%), and angiotensin receptor blockers (16%). Conclusion: QOL was significantly affected in ACS patients. Most of the patients had risk factors for ACS. Patients explained impairments in all the four domains used in the questionnaire such as emotional, physical, social, and gastric impairments. QOL was more affected in STEMI patients and they had a high mortality risk. Most of the patients had NSTEMI. Low-risk patients were given single-anticoagulant therapy and medium-risk patients were treated with dual-anticoagulant therapy. PCI was preferred in almost all the patients.

Keywords: Acute coronary syndrome, coronary artery disease, Global Risk of Acute Coronary Events Score, MacNew Heart Disease Questionnaire, Medical Research Council Breathlessness Scale, New York Heart Association Functional Classification, non-ST-segment elevated myocardial infarction, quality of life, shortness of breath, ST-segment elevation myocardial infarction


How to cite this article:
Andhi N, Desham P, Madavi C, Bhavana S, Naresh D. Assessment of quality of life and drug prescription pattern in acute coronary syndrome. J Indian coll cardiol 2022;12:111-8

How to cite this URL:
Andhi N, Desham P, Madavi C, Bhavana S, Naresh D. Assessment of quality of life and drug prescription pattern in acute coronary syndrome. J Indian coll cardiol [serial online] 2022 [cited 2022 Oct 1];12:111-8. Available from: https://www.joicc.org/text.asp?2022/12/3/111/356068




  Introduction Top


Acute coronary syndrome (ACS) refers to a set of clinical presentations related to ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina.[1] The term ACS is applied to those patients who are suspected of acute myocardial ischemia or infarction.[2] Nearly 8 million patients are seen for chest pain in emergency departments each year in the US. More than 1.5 million patients are admitted with an ACS (330,000 with STEMI and 1.24 million with UA and NSTEMI).[3] Myocardial infarction (MI) (i.e., heart attack) is the irreversible death of heart muscle secondary to prolonged lack of oxygen supply. Unstable angina is considered an ACS, in which there is myocardial ischemia without detectable myocardial necrosis (i.e., cardiac biomarkers of myocardial necrosis such as creatine kinase MB isozyme, troponin, and myoglobin are not released into the circulation).

ACS is associated with a rupture of an atherosclerotic plaque and thrombosis of the infarct-related artery.[4] In some, stable coronary artery disease (CAD) may result in ACS in the absence of plaque rupture and thrombosis, when physiologic stress (e.g., trauma, blood loss, anemia, infection, and tachyarrhythmia) increases demands on the heart. The main characteristic of ACS is persistent chest pain; may present as pressure, squeezing, or burning type; and may radiate to the neck, shoulder, jaw, back, upper abdomen, or either arm. Other complaints include sweating, nausea, vomiting, shortness of breath (SOB), palpitations, fainting, anxiety, restlessness, sudden drop in blood pressure, and death.[5]

Diagnosis is presumed and treatment is given based on the patient's complaints and electrocardiogram (ECG). ECG intimates ST-elevation in the leads indicating STEMI, peaked upright or inverted T-waves referring to acute myocardial injury and the early stages of transmural Q-wave MI. Persistent ST-depression may also indicate non-Q-wave MI.[6] Cardiac markers (troponin T or I and creatine kinase MB subforms) are the sensitive determinants of ACS. Myoglobin and CK-MB subforms are the early markers of acute ischemia. Cardiac troponin levels increase 3–12 h after the onset of pain, peak at 24–48 h, and return to baseline over 5–14 days. CK-MB is first elevated 3–12 h after the onset of pain, peaks in 24 h, and returns to baseline in 48–72 h.[7]

Prehospital care and initial treatment include oxygen, aspirin, and nitrates and transfer to an appropriate hospital. Drug treatment includes antiplatelet drugs, antianginal drugs, and anticoagulants.[8] Angiography may be performed to assess anatomy of coronary artery in serious cases. Reperfusion therapy includes fibrinolytics, percutaneous coronary intervention (PCI), or coronary artery bypass graft (CABG). STEMI patients mostly require immediate reperfusion therapy with PCI, CABG, or fibrinolytics. NSTEMI patients may require early invasive therapy with dual-anticoagulant therapy. Conservative therapy with single-anticoagulant therapy may be used in unstable angina.[9]

In the clinical course of coronary heart disease, there are many aspects where the patient's quality of life (QOL) may be affected, which include symptoms of angina and heart failure, limited exercise capacity, the physiological debility, and chronic psychological stress.

Health-related quality of life (HRQOL) assessment is an important patient-centered health outcomes that is useful for assessing both the impact of disease burden and effectiveness of treatment interventions.[10],[11]

An accurate assessment of the severity of patient's angina/ MI/CAD has its impact on their functional status, risk of cardiovascular complications , thus is the key to the successful treatment of the condition.[12],[13]

HRQOL instruments provide an assessment of patient's experience of his/her health problems in areas such as physical, emotional, social functioning, role of performance, pain, and fatigue.

The MacNew Heart Disease HRQOL Questionnaire is a self-administered questionnaire that evaluates angina symptoms experienced in the past 2 weeks and the effect of CAD treatment on daily activities and physical, emotional, and social functioning.[14],[15]

The Global Registry of Acute Coronary Events (GRACE) Score estimates the risk of death or death/MI in patients following an initial ACS. The Thrombolysis in Myocardial Infarction (TIMI) Risk Score for STEMI is a convenient, bedside, and clinical score for risk assessment at presentation. The TIMI score for NSTEMI and unstable angina is used to determine the likelihood of ischemic events or mortality in patients.[16],[17],[18],[19],[20],[21],[22],[23],[24]

The Medical Research Council Dyspnea Scale (Breathlessness Scale) measures perceived respiratory disability into Grade 0, 1, 2, 3, and 4. The New York Heart Association (NYHA) Functional Scale is used for classifying patients according to their physical ability into NYHA Stage 1, 2, 3, and 4.[25]


  Materials and Methods Top


A prospective observational study was conducted at a tertiary care hospital in the outpatient and inpatient departments for a period of 6 months. The data were collected by interviewing the patients, and their consent was taken. Data collection format was verified and authenticated by hospital preceptors for the study. The study involved 240 patients who were diagnosed with ACS, heart failure, and angina. Both male and female patients and patients aged 18 years and above were included in the study. Pregnant patients and substance abuse patients were excluded from the study. Written informed consent was taken from patients to collect the data. Data collection form included sociodemographic information such as age, sex, dietary habits, medical history, social history, family history, diagnosis, personal history, and relevant laboratory data.

Statistical analysis

Descriptive analysis was done using SPSS software (Sri software solutions, Hyderabad, Telangana, India) to determine the mean and standard deviation of the collected data. Chi-square test was performed to determine the P value between the different collected data such as diagnosis versus treatment type, NYHA versus diagnosis, MRCB versus diagnosis, past history versus diagnosis, social history versus diagnosis, age versus emotional symptoms, age versus gastric symptoms, age versus social symptoms, and age versus physical symptoms. The P value is used to determine the statistical significance within statistical hypothesis significance for the assessment of QOL in ACS patients to the baseline visit. The P value was set at < 0.05 and confidence interval was 95%.


  Results Top


In the present study, around 240 cases were included as per our criteria. [Table 1] indicates sociodemographic background of heart disease patients. Age group of >50 years were more significantly affected with ACS. Males were more commonly prone to ACS. Urban people were developing ACS more commonly than rural people as shown in [Figure 1]. Most of the patients had risk factors of ACS. Sixteen percent of the patients were smokers and 26% of the patients were alcoholics. Fifteen percent of the patients had a family history of CAD. Fifty-six percent of the patients were hypertensive, 43% were diabetic, 8% had nervous disorders, 6% had kidney disorders, and 5% had pulmonary disorders. The most common complaints were chest pain (88%), SOB (43%), and sweating (30%). Other complaints include palpitations and vomiting (11%), fever (6%), and edema and cough (5%). NSTEMI (51%) was more prevalent than STEMI (40%) and unstable angina (18%). Most of the patients came under NYHA Stage 2 functional class (49%) than Stage 1 (32%) and Stage 3 (4%). Most of the patients had developed Grade 1 SOB (34%) and Grade 2 SOB (32%). [Table 2] indicates mortality risk of patients in the hospital based on the GRACE score. It shows that high-risk patients were 15%, intermediate risk patients were 26.6% and low risk patients were 58%. We also calculated mortality risk rate of patients at 6 months and found that high-risk patients were 58%, intermediate-risk patients were 26%, and low-risk patients were 15%. In our data, according to the GRACE risk score at 6 months, most of the patients had a high mortality risk (41%). [Table 3] indicates mortality risk percentage calculated using TIMI score. According to the TIMI score in 144 patients diagnosed with NSTEMI, 30% of patients had a significant mortality risk, and among 96 STEMI patients, 12% patients had a high mortality risk. We administered the MacNew questionnaire to all the patients in our study. [Figure 2] explains about emotional status. 46% of the patients were emotionally strong and 53% of the patients experienced impaired emotional symptoms. [Figure 3] describes the physical functioning of the patients. 56% of the patients had mild physical symptoms, 31% of them had moderate physical symptoms, and 11% of the patients developed severe physical symptoms. [Figure 4] shows social dependence of the patients. 28% of the patients were socially dependent. [Figure 5] interprets gastric condition of the patients. Gastric condition was poor in 8.3% of the patients. [Figure 6] indicates diagnosis versus NYHA functional class. Based on the NYHA functional scale, among STEMI patients, 3% of the patients came under NYHA Stage 1, 23% came under NYHA Stage 2, and 13% came under NYHA Stage 3. Among NSTEMI patients, 6% came under NYHA Stage 1, 26% came under Stage 2, and 18% under Stage 3. Among angina patients, 1% came under NYHA Stage 1 and 6% came under Stage 3. Most of the patients with ACS were seen in NYHA Stage 2 (49%) and Stage 3 (36%). When compared and equated with STEMI and angina patients, ability to do physical activity was considerably affected in NSTEMI patients in our data. As shown in [Figure 7], patients were categorized based on MRCB scale and their diagnosis. 1% of the STEMI patients and 6% of the NSTEMI patients had Grade 0 SOB (9%). Thirteen percent of the STEMI, 18% of the NSTEMI, and 3% of the angina patients had Grade 1 SOB (34%). Fifteen percent of the STEMI, 16% of the NSTEMI, and 1% of the angina patients had Grade 2 SOB (34%). Five percent of the STEMI patients, 6% of the NSTEMI, and 3% of the angina patients had Grade 3 SOB (15%). Five percent of the STEMI and 3% of the NSTEMI patients had Grade 4 SOB (8%). Most of the patients had Grade 1 and Grade 2 SOB. [Figure 8] indicates commonly prescribed drug classes. Commonly prescribed drug classes included statins 90%), antiplatelets (86%), anticoagulants (75%), antianginal (55%), beta-blockers (50%), diuretics (35%), angiotensin-converting enzyme (ACE) inhibitors (18%), and angiotensin receptor blockers (ARBs) (26%). As shown in [Figure 9], reperfusion therapy with PCI (58%) was considered in most of the patients than CABG (17%). [Figure 10] indicates commonly prescribed anticoagulants. Commonly prescribed anticoagulants were heparin (68%) and enoxaparin (15%). Dual-anticoagulant therapy was given in 8% of patients. [Figure 11] indicates commonly prescribed antiplatelets. Commonly prescribed antiplatelets were aspirin, clopidogrel, ticagrelor, and tirofiban. Commonly prescribed antianginal drugs were nicorandil (43%), ivabradine (15%), nitrates (7%), and trimetazidine (3%). Dual therapy was given in 24% of the patients, which can be observed in [Figure 12]. In [Figure 13], commonly prescribed antihypertensive drug classes are shown, as per which beta-blockers (48%) were more. [Figure 14] states that the combination therapy of beta-blockers and ACE inhibitors was considered in 16% of the patients, and the combination therapy of beta-blockers and ARBs was given in 10% of the patients. Beta-blockers and calcium channel blockers were given in 5% of the patients. Telmisartan was the most commonly given angiotensin receptor blocker. Metoprolol was the most commonly prescribed beta-blocker. Amlodipine was the most commonly prescribed calcium channel blocker. From [Figure 15], furosemide, spironolactone, torsemide, and metolazone are the most commonly given diuretics, among which furosemide tops the chart. By means of [Figure 16] in our study, dobutamine usage was extensive compared to noradrenaline in case of heart failure.
Figure 1: Ethnicity graph

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Figure 2: Emotional functioning

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Figure 3: Physical functioning

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Figure 4: Social functioning

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Figure 5: Gastric functioning

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Figure 6: Diagnosis versus NYHA functional class. NYHA: New York Heart Association, STEMI: ST-elevation myocardial infarction, NSTEMI: Non-ST-elevation myocardial infarction, ANGINA: Unstable

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Figure 7: MRC dyspnea scale versus diagnosis. MRC: Medical Research Council, STEMI: ST-elevation myocardial infarction, NSTEMI: Non-ST-elevation myocardial infarction, ANGINA: Unstable

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Figure 8: Commonly prescribed drug classes

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Figure 9: Surgical intervention

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Figure 10: Commonly prescribed anticoagulants

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Figure 11: Commonly prescribed antiplatelets

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Figure 12: Commonly prescribed antianginal drugs

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Figure 13: Commonly prescribed antihypertensives with dual therapy

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Figure 14: Antihypertensive drug combination. BB: Beta Blocker, ACEI: Angiotensin-converting enzyme inhibitors, ARBS: Angiotensin receptor blockers, CCB: Calcium Channel Blocker

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Figure 15: Commonly prescribed diuretics

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Figure 16: Commonly prescribed heart failure drugs

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Table 1: Demographics of subjects

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Table 2: Mortality risk in hospital and at 6 months calculated using Global Registry of Acute Coronary Events Score

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Table 3: Mortality risk in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction patients calculated using Thrombolysis in Myocardial Infarction Score

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  Discussion Top


A prospective observational study on the “assessment of QOL and prescribing pattern of drugs in patients with ACS” was conducted at a tertiary care hospital in both inpatient and outpatient cardiology departments. The data were collected for 240 patients using data collection forms. Among them, 66% were male and 33% were female. The 2016 Heart Disease and Stroke Statistics Update of the American Heart Association (AHA) has reported that MI incidence was higher in men than women. In our study, the percentage of urban people (68%) known with ACS appear to be more in number than rural people (31%). As per AHA journals Global burden of cardiovascular diseases in urban population has increased with respect to incidence of heart diseases due to consumption of high levels of animal protein, fats and less physical activity. Similarly our study has relatively high number of patients (31%) of age group above 50 and 21% in age groups above 40.

In our study, among 240 patients, 26% were alcoholics, 16% were smokers, and 15% had a family history of CAD.

Out of 240 patients, 71% had comorbid conditions. Comorbid conditions were hypertension 56%, diabetes 43%, nervous disorder 8%, kidney disorder 6%, and pulmonary disorder 5%. The 2016 Heart Disease and Stroke Statistics Update of the AHA reported similar results.[26]

In our study, the major complaints of patients were chest pain 88%, SOB 43%, and sweating 30%. Minor complaints included palpitations and vomiting 11% each, fever 6%, and edema and cough 5% each. Among 240 patients, 124 (51%) were diagnosed with non-ST-elevated MI, 96 (40%) were with ST-elevated MI, and 20 (18%) had angina.

We calculated the mortality risk rate of patients at 6 months using GRACE score and found that high-risk patients were 35%, intermediate-risk patients were 41%, and low-risk patients were 23%.[27] We also used TIMI score for calculating mortality risk percentage. According to TIMI score in 144 patients diagnosed with NSTEMI, 30% had a significant mortality risk, and among 96 STEMI patients, 12% had a high mortality risk. Pedro de Arauxjo Gonc¸alves and Ricardo Seabra-Gomes ESC journal, January 24, 2005, exhibit alike results as of our study were high-risk in patients using GRACE score and TIMI score were 36% and 57% respectively.[28]

Based on the NYHA functional scale, among STEMI patients, 3% came under NYHA Stage 1, 23% came under NYHA Stage 2, and 13% came under NYHA Stage 3. Among NSTEMI patients, 6% came under NYHA Stage 1, 26% came under Stage 2, and 18% under Stage 3. Among angina patients, 1% came under NYHA Stage 1 and 6% came under Stage 3. Most of the patients with ACS were seen in NYHA Stage 2 (49%) and Stage 3 (36%). Ability to do physical activity was considerably affected in NSTEMI patients in our data. Ulla Fredriksson-Larsson, Cardiac Self-Efficacy and fatigue 1 year post-MI, open journal of nursing, April 17, 2019 found that 40% persons do not meet the physical activity recommendations which was identical to this study.[29]

Among 240 patients, conservative therapy (with single anticoagulant) was given in 45%, invasive (with dual anticoagulants) therapy was considered in 6%, and 49% were subjected to PCI or CABG (reperfusion therapy). Commonly prescribed drug classes were statins (90%), antiplatelets (86%), anticoagulants (75%), antianginal (55%), beta-blockers (50%), diuretics (35%), ACE inhibitors (18%), and ARBs (26%).

Commonly prescribed drugs in each class

Commonly prescribed antiplatelets were aspirin, clopidogrel, ticagrelor, and tirofiban. Commonly prescribed anticoagulants were heparin (68%) and enoxaparin (15%). Dual-anticoagulant therapy was given in 8% of the patients. Commonly prescribed antianginal drugs were nicorandil (43%), ivabradine (15%), nitrates (7%), and trimetazidine (3%). Dual therapy was given in 24% of the patients. In our study the most commonly prescribed anti hypertensive drugs were Beta-blocker ,similar study was observed by Dona saju's article on Prescription Pattern and Drug Utilization Analysis in Patients with ACS, Indian Journal of Pharmacy Practice, January–March, 2020. The combination therapy of beta-blockers and ACE inhibitors was considered in 16% of the patients, and the combination therapy of beta-blockers and ARBs was given in 10% of the patients. Beta-blockers and calcium channel blockers were given in 5% of the patients.

Telmisartan was the most commonly given angiotensin receptor blocker. Metoprolol was the most commonly prescribed beta-blocker. Furosemide, spironolactone, torsemide, and metolazone are the most commonly given diuretics. Amlodipine was the most commonly prescribed calcium channel blocker.[30]


  Conclusion Top


ACS refers to a spectrum of clinical presentations ranging from those for ST-elevation MI , non-ST-elevation MI and unstable angina.

Males are commonly prone to ACSs. Females were experiencing poorer QOL than males. With increasing age, risk of acquiring ACS and mortality risk due to it was increased. With increasing age, QOL was also getting affected. Mostly, urban people are developing ACSs than rural people. People with comorbid conditions, usually hypertension and diabetes, have significantly increased risk for developing ACSs. People with both hypertension and diabetes have doubled risk of getting ACSs than other single comorbid conditions. People with nervous, kidney, and pulmonary disorders experienced worsened QOL than other comorbidities. In addition, people with habits of smoking and drinking alcohol have experienced poorer QOL and have increased mortality risk.

QOL was more significantly affected in patients with comorbidities. Patients who have comorbid conditions such as pulmonary and kidney disorders experienced significantly poorer QOL than other comorbid conditions. People with ACS explained impairments in all the four domains included in our questionnaire, namely, emotional, physical, social, and gastric domains. Most of the patients with ACS had poor gastric condition.

QOL was significantly affected in ACSs. Where as in case of early reperfusion therapy increases survival rate and improved the QOL in patients. Patients who underwent PCI have improved QOL than patients who were treated with CABG. The most commonly prescribed drug classes were statins, antiplatelets, anticoagulants, antianginal drugs, antihypertensive drugs, and diuretics. Reperfusion therapy with PCI and CABG was considered in most of the patients. High-risk patients were treated with PCI mostly. Dual-anticoagulant therapy was considered in patients with intermediate and high mortality risks. Patients with low mortality were managed with single-anticoagulant therapy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Abstract
Introduction
Materials and Me...
Results
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