Journal of Emergencies, Trauma, and Shock
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
Users online:142   Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size   

ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Treatment outcomes of epinephrine for traumatic out-of-hospital cardiac arrest: A systematic review and meta-analysis


 Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Click here for correspondence address and email

Date of Submission07-Mar-2021
Date of Acceptance10-May-2021
 

   Abstract 


Introduction: Despite the standard guidelines stating that giving epinephrine for patients with cardiac arrest is recommended, the clinical benefits of epinephrine for patients with traumatic out-of-hospital cardiac arrest (OHCA) are still limited. This study aims to evaluate the benefits of epinephrine administration in traumatic OHCA patients. Methods: We searched four electronic databases up to June 30, 2020, without any language restriction in research sources. Studies comparing epinephrine administration for traumatic OHCA patients were included. Two independent authors performed the selection of relevant studies, data extraction, and assessment of the risk of bias. The primary outcome was inhospital survival rate. Secondary outcomes included prehospital return of spontaneous circulation (ROSC), short-term survival, and favorable neurological outcome. We calculated the odds ratios (ORs) of those outcomes using the Mantel–Haenszel model and assessed the heterogeneity using the I2 statistic. Results: Four studies were included. The risk of bias of the included studies was low, except for one study in which the risk of bias was fair. All included studies reported the inhospital survival rate. Epinephrine administration during traumatic OHCA might not demonstrate a benefit for inhospital survival (OR: 0.61, 95% confidence interval [CI]: 0.11–3.37). Epinephrine showed no significant improvement in prehospital ROSC (OR: 4.67, 95% CI: 0.66–32.81). In addition, epinephrine might not increase the chance of short-term survival (OR: 1.41, 95% CI: 0.53–3.79). Conclusion: The use of epinephrine for traumatic OHCA may not improve either inhospital survival or prehospital ROSC and short-term survival. Epinephrine administration as indicated in standard advanced life support algorithms might not be routinely used in traumatic OHCA.

Keywords: Epinephrine, out-of-hospital cardiac arrest, survival, trauma


How to cite this URL:
Wongtanasarasin W, Thepchinda T, Kasirawat C, Saetiao S, Leungvorawat J, Kittivorakanchai N. Treatment outcomes of epinephrine for traumatic out-of-hospital cardiac arrest: A systematic review and meta-analysis. J Emerg Trauma Shock [Epub ahead of print] [cited 2021 Nov 27]. Available from: https://www.onlinejets.org/preprintarticle.asp?id=330942





   Introduction Top


Trauma remains a leading cause of death and disability worldwide. According to the World Health Organization status report on road safety in 2018, over 1.35 million people die each year due to road traffic injury (RTI).[1] RTI is also the leading killer of children and young adults (5–29 years of age).[1] Traumatic cardiac arrest (TCA) is known to have the worse outcome.[2] Still, the overall survival from TCA (5.6%) is equivalent to that of non-TCA events.[2],[3],[4] The causes of TCA differed from non-TCAs; therefore, a different approach to managing the situation is needed.[5],[6],[7] The most common causes of TCA included severe traumatic brain injury and hypovolemia from hemorrhage.[3],[4] Most deaths from TCA occurred in the first 5 min following the traumatic event and most of these deaths cannot be prevented.[8] Priorities in TCA mainly focused on (1) hemorrhagic control, (2) restoration of circulatory blood volume, (3) airway management, and (4) relieving of tension pneumothoraxes, over conventional cardiopulmonary resuscitation (CPR).[2]

Currently, according to the latest CPR guidelines,[9] epinephrine is recommended for use in adults with cardiac arrest. In spite of the recommendation, the therapeutic effects of epinephrine on TCA are still controversial.[2] A large randomized-controlled trial (RCT) demonstrated that the use of epinephrine resulted in a significantly higher rate of 30-day survival in adults with out-of-hospital cardiac arrest (OHCA). However, in this study, the percentage of TCA patients was only 1.5%.[10] Epinephrine, also known as adrenaline, has direct actions on adrenergic receptors which results in an increased cardiac force of contraction, increased cardiac output, and enhanced peripheral vasoconstriction.[11] Nevertheless, cardiac arrest from TCA patients due to hypovolemia did not occur immediately after traumatic events. TCA patients will experience maximal catecholamine release and vasoconstriction for a short period after the onset of cardiac arrest.[2] Thus, epinephrine administration may worsen tissue perfusion.[2] However, in 2015, a study conducted by Chiang et al. demonstrated that epinephrine administration increased short-term survival, especially for those with a longer prehospital time.[12] Together with the study conducted by Aoki et al., in 2019, prehospital epinephrine administration was associated with prehospital return of spontaneous circulation (ROSC) but not associated with 1-month survival.[13] As a result of these issues, the treatment outcomes for the use of epinephrine in traumatic OHCA patients are still limited. Hence, we performed an up-to-date systematic review and meta-analysis to evaluate the benefits of epinephrine administration in traumatic OHCA patients.


   Methods Top


We prepared this manuscript based on the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines for systematic reviews.[14] Our review was prospectively registered with PROSPERO international prospective register of systematic reviews in health and social care (id: CRD42020199195).

Search strategy and criteria

Two authors (W. W./T. T.) independently searched on multiple standard databases, including PubMed, Scopus, Web of Science, and Cochrane CENTRAL. Each database was searched from its beginning to June 30, 2020, without language restriction. We used Medical Subject Headings terms included the combination of search terms with various spellings and endings: “trauma,” “traumatic,” “out-of-hospital,” “adrenaline,” “epinephrine,” “cardiac arrest,” “TCA,” “CPR,” “heart arrest,” “cardiopulmonary arrest,” and “sudden cardiac death.” We also searched all of the relevant meta-analyses and their references to identify additional studies. Moreover, we searched and identified any unpublished trial registered on the website “clinicaltrial.gov.”

Included studies were selected based on the following criteria: (a) a study involved a traumatic OHCA; (b) at least one arm of participants received epinephrine during OHCA; and (c) reported at least one of the following outcomes: prehospital ROSC or ROSC on arrival at the hospital, survival to hospital admission, 7- or 30-day inhospital survival, survival to hospital discharge, and neurological outcome at discharge. We limited included studies to original articles on humans. No restriction was made concerning study design. We excluded the studies lacking either a control group (i.e., case report, case series) or a review article. Three authors (T. T./C. K./S. S.) independently screened the search results to identify potentially eligible studies, and unrelated articles were excluded. Full manuscripts of the potential studies were retrieved with eligibility independently assessed by two reviewers against prespecified criteria and evaluated for inclusion [Figure 1]. At each step of selection, any disagreements were discussed and resolved by the third-party consensus.
Figure 1: Preferred reporting items for systematic reviews and meta-analyses flowchart of the studies included in the study

Click here to view


Outcomes of interest

The primary outcome was inhospital survival rate which was defined as 7-day survival rate, 30-day survival rate, or survival to hospital discharge. We chose these as a primary outcome since they are the actual patient-oriented outcomes that can provide the most important reasons why we give this medication to the patients. The secondary outcomes included the prehospital ROSC, short-term survival, and neurological outcome at discharge. Short-term survival was defined as the rate of ROSC which sustained ≥2 h at the emergency department (ED). Favorable neurological outcome was defined by the cerebral performance category score of 1–2 or a modified Rankin Score of 0–3.

Data extraction and assessment of the trial risk of bias

Two authors (W. W./T. T.) independently extracted data from the original articles using a standard data collection form. The data extracted included (i) first author, (ii) publication year, (iii) type of study, (iv) study location and setting, (v) number and age of participants, (vi) initial cardiac rhythms, (vii) witnessed and bystander cardiac arrest, (viii) intervention and comparator, and (ix) outcomes of interest. In cases of missing or incomplete data in an original publication or for required clarification, we attempted to contact by e-mail the corresponding author. Two assessors (W. W./T. T.) independently evaluated the risk of bias of each trial using the standardized Good Research for Comparative Effectiveness (GRACE) checklist for observational studies and the modified version of the Cochrane collaboration's tool for assessing the trial risk of bias for RCTs.[15],[16] Any discrepancies that arose were resolved by discussion or referred to a third reviewer for a final decision.

Data synthesis and statistical analysis

Obtained relevant data were filled in a 2 × 2 contingency table. We used odds ratios (ORs) as a summary measure for the analysis of dichotomous outcomes. We calculated the pooled effect estimates of each outcome of interest using the Mantel–Haenszel fixed-effects meta-analysis. We assessed the statistical heterogeneity among included studies using the percentage of total variability across the studies due to heterogeneity (I2 statistics). The values of less than 40%, 40%–60%, and more than 60% were categorized as low, moderate, and high heterogeneity, respectively. A fixed-effect model was used to pool estimates. If evidence of high heterogeneity (I2>60%) was observed, a random-effects model was used, instead. Publication bias which might arise from small-study effects was evaluated through visual examination of funnel plots and Egger's test. We used the Review Manager Version 5.3 (Nordic Cochrane Center, Cochrane Collaboration, 2014, Copenhagen, Denmark) to perform the quantitative statistical analysis.[17] All tests were two tailed and any P < 0.05 was considered statistically significant.


   Results Top


From the PRISMA flow diagram [Figure 1], we identified 941 potentially relevant records through a systematic search. After removing duplicates, nine full-text articles were retrieved and examined for eligibility. A total of 4 articles, published between 2015 and 2019, were included for data extraction and finally included in the meta-analysis. All were observational cohort and multicenter studies. All of the included studies were conducted in Asia: two from Japan, one from Taiwan, and the other from Qatar. The meta-analysis involved a total of 7158 traumatic OHCAs with 1909 exposed to epinephrine and 5249 nonexposed individuals. Participants' median age ranged from 33 to 61 years old. About one-third of the cardiac arrests were witnessed, but the bystander CPR varied among the trials. All studies reported the predefined primary outcome: inhospital survival. Two studies reported prehospital ROSC. Three studies reported short-term survival, and only one study reported neurological outcome at discharge. Exposure to epinephrine was defined as the administration of intravenous epinephrine in the prehospital setting, whether that be a scene or during ambulance transport in all included studies, except for one study which defined the exposure as epinephrine administration during cardiac arrest at the EDs. [Table 1] summarizes the characteristics and details of each included study. Since all of the included trials were observational studies, we assessed the trial risk of bias using the GRACE checklist. Three studies were classified as “sufficient quality” or “low risk of bias” studies, whereas one study was classified as “fair risk of bias” study [Table 2].
Table 1: Characteristics of included trials

Click here to view
Table 2: Risk of bias assessment by good research for comparative effectiveness checklist

Click here to view


Inhospital survival

Four studies (n = 7,158) reported inhospital survival.[3],[12],[13],[18] Based on the heterogeneous data (I2 = 91%), patients who received epinephrine during traumatic OHCA might not demonstrate a benefit for inhospital survival [OR: 0.61, 95% confidence interval [CI]: 0.11–3.37, [Figure 2]]. Moreover, due to a limited number of included trials, the Egger's test could not be analyzed.
Figure 2: Forest plot comparing inhospital survival between exposure to epinephrine and control groups

Click here to view


Prehospital return of spontaneous circulation

Two studies (n = 5,718) reported prehospital ROSC.[12],[13] The heterogeneous data (I2 = 93%) showed no significant improvement of prehospital ROSC [OR: 4.67, 95% CI: 0.66–32.81, [Figure 3]].
Figure 3: Forest plot comparing prehospital return of spontaneous circulation between exposure to epinephrine and control groups

Click here to view


Short-term survival

Three studies (n = 1,954) reported short-term survivals.[3],[12],[18] Epinephrine might not increase the chance of short-term survival based on the combined data of the included studies [OR: 1.41, 95% CI: 0.53–3.79, I2 = 90%, [Figure 4]].
Figure 4: Forest plot comparing short-term survival between exposure to epinephrine and control groups

Click here to view



   Discussion Top


This review summarizes the latest evidence on the use of epinephrine in traumatic OHCA after the recently updated guideline for cardiac arrest.[19] Unfortunately, we did not find any RCTs in our searches. This meta-analysis demonstrates that epinephrine administration might not show benefits, including inhospital survival, prehospital ROSC, and short-term survival, in traumatic OHCA. Although epinephrine showed a positive trend for prehospital ROSC, the result was not statistically significant. The overall trial risk of bias of included studies ranged from low to fair, mainly due to no enough information about new initiators of treatment and sensitivity analysis.

Epinephrine has been recognized as the mainstay for the treatment of cardiac arrest for decades[19] since it has potentially positive effects in CPR via the constrictions of arteries and arterioles mediated by α-adrenergic receptors.[10] Vasoconstriction increases aortic diastolic pressure, resulted in increasing coronary perfusion pressure (CPP) and myocardial blood flow, which is indicated as the potential factor of ROSC.[20] However, nonspecific vasoconstriction may worsen postresuscitation outcomes. A preclinical study demonstrated that epinephrine plus endothelin-1, an intense vasoconstrictor, improved CPP during CPR but had negative results in the postresuscitation period.[21] This study demonstrated that TCA patients who received epinephrine might not have a significantly higher chance of favorable outcomes, especially inhospital survival. These findings are correlated with a narrative review by Smith et al., finding that there is no sufficient evidence to support the use of intravenous epinephrine in patients with TCA.[2] Most TCA patients died from hypovolemia resulted from acute blood loss and head injury. Such a state of shock does not generally occur suddenly after cardiac arrest. Acute blood loss causes catecholamine surge leading to an increased heart rate, increased cardiac contraction, and peripheral vasoconstriction. As the patient's volume state continues to drop, the blood flow is diverted from an internal organ to the brain and heart. Lactic acid continuously accumulates within cells due to organ ischemia, eventually, leading to death. Previous studies have stated that the patient might experience maximal catecholamine surge and vasoconstriction during the period of deterioration until the cardiac output is lost.[2] Injection of vasopressors during this time may worsen tissue perfusion except for patients with neurologic shock where their sympathetic vascular tone was lost.[22],[23]

However, this review highlights some important points. First, Aoki et al. revealed a positive association between prehospital administration of epinephrine and prehospital ROSC in TCA patients caused by traffic collisions, whereas Chiang et al. did not find that benefit. The major difference between these two studies is the total prehospital time. The median prehospital time of patients receiving epinephrine in Aoki et al.'s study was 38 min (interquartile range [IQR]: 30–48), while the median prehospital time of the other study was 23 min (IQR 20–29). There are two phases of pathophysiological response to acute blood loss.[24] The initial phase is defined by the activation of the sympathetic system resulting in vasoconstrictions of arteries and arterioles to normalize blood pressure. In the late phase, as hemorrhaging continues and a massive amount of preload declines, the systemic sympathetic tone becomes inadequate, therefore, leading to a decrease in vascular resistance and bradycardia which could abruptly advance to cardiac arrest. This means that a longer prehospital time provides a better chance that prehospital epinephrine administration is beneficial. Second, bystander CPR varied among the included trials. Irfan et al. found that prehospital epinephrine administration lowered survival in TCA patients.[3] Notably, bystander CPR in that study was only 5% which markedly lower than the other studies (15.3–21.4%). This emphasizes the importance of public bystander CPR which has already been mentioned in the previous literatures.[25],[26] Furthermore, of all included studies, only a study by Yamamoto et al. assessed the epinephrine used in inhospital resuscitation.[18] The results for prehospital resuscitation may bias the generalizability and must be interpreted within the context of each study design. For this reason, we additionally performed analyses by excluding this study and we found that the results have not differed from the initial analyses [Supplementary data].

Limitations

This review has some limitations. To minimize the risk of bias for assessing the outcomes of interventions, RCTs are the most appropriate study design. Unfortunately, we have found only observational studies in our search. Furthermore, all of the meta-analyses in this study were highly heterogeneous which might arise from the differences of concomitant drugs and other interventions (total IV fluid administered, the use of blood components, airway management techniques, etc.,). Therefore, the results might be inconcludable. Besides, according to the included studies of this review, heterogeneity can never be completely prevented due to variation between clinical studies. There are differences between the included studies that might contribute to inevitably high heterogeneity including administration of epinephrine, definitions of the outcome, bystander CPR, and patient characteristics. Finally, the included trials were conducted in different places and applied different protocols of intervention. This led to a variance in prehospital treatments that might be occurring for ROSC as well as inhospital treatments for inhospital survivals. Basis of trauma care includes airway management, c-spine protection, breathing and ventilation, hemodynamic control, and neurological assessment. We believe that the basic trauma care and procedures for each country must be consistent with the standard guideline (advanced trauma life support), but the details might be different due to the national committee's consensus for each country. Several factors may give rise to differences in treatment outcome including available drugs, competency of the first aider, and time on the scene of the accident. However, we and the authors of the included studies used proper strategies to eliminate possible confounding factors. Yet, to confirm the true effects of intervention, an RCT is warranted.


   Conclusions Top


The use of epinephrine for traumatic OHCA might not demonstrate the benefit to improve either inhospital survival or prehospital ROSC and short-term survival. The mainstay for the management of patients in traumatic OHCA is to correct all reversible causes such as hypoxia, tension pneumothorax, cardiac tamponade, and hypovolemia as appropriate.

Research quality and ethics statement

This systematic review was registered with PROSPERO international prospective register of systematic reviews in health and social care (ID: CRD42020199195). The authors followed applicable EQUATOR Network (http:// www.equator-network.org/) guidelines during the conduct of this research project.

Acknowledgments

The authors gratefully acknowledge Mr. Jonathan Bostwick for an elaborative language editing on our manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


   Supplementary Material Top








 
   References Top

1.
World Health Organization. Global Status Report on Road Safety. Geneva, Switzerland: World Health Organization; 2018.  Back to cited text no. 1
    
2.
Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. J R Soc Med 2015;108:11-6.  Back to cited text no. 2
    
3.
Irfan FB, Consunji R, El-Menyar A, George P, Peralta R, Al-Thani H, et al. Cardiopulmonary resuscitation of out-of-hospital traumatic cardiac arrest in Qatar: A nationwide population-based study. Int J Cardiol 2017;240:438-43.  Back to cited text no. 3
    
4.
Harris T, Masud S, Lamond A, Abu-Habsa M. Traumatic cardiac arrest: A unique approach. Eur J Emerg Med 2015;22:72-8.  Back to cited text no. 4
    
5.
Smith JE, Le Clerc S, Hunt PA. Challenging the dogma of traumatic cardiac arrest management: A military perspective. Emerg Med J 2015;32:955-60.  Back to cited text no. 5
    
6.
Barnard E, Yates D, Edwards A, Fragoso-Iñiguez M, Jenks T, Smith JE. Epidemiology and aetiology of traumatic cardiac arrest in England and Wales – A retrospective database analysis. Resuscitation 2017;110:90-4.  Back to cited text no. 6
    
7.
Barnard EB, Hunt PA, Lewis PE, Smith JE. The outcome of patients in traumatic cardiac arrest presenting to deployed military medical treatment facilities: Data from the UK Joint Theatre Trauma Registry. J R Army Med Corps 2018; 164(3):150-4. [doi: 10.1136/jramc-2017-000818].  Back to cited text no. 7
    
8.
Australian and New Zealand Committee on Resuscitation (ANZCOR). Management of Cardiac Arrest due to Trauma; ANZCOR Guideline 11.10.1. Wellington: Australian and New Zealand Council of Resusitaiton; 2016.  Back to cited text no. 8
    
9.
Neumar RW, Shuster M, Callaway CW, Gent LM, Atkins DL, Bhanji F, et al. Part 1: Executive summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132 18 Suppl 2:S315-67.  Back to cited text no. 9
    
10.
Perkins GD, Ji C, Deakin CD, Quinn T, Nolan JP, Scomparin C, et al. A randomized trial of epinephrine in out-of-hospital cardiac arrest. N Engl J Med 2018;379:711-21.  Back to cited text no. 10
    
11.
Dalal R, Grujic D. Epinephrine. Treasure Island (FL): StatPearls Publishing; 2019. Available from: http://europepmc.org/books/NBK482160. [Last accessed is 2020 June 30].  Back to cited text no. 11
    
12.
Chiang WC, Chen SY, Ko PC, Hsieh MJ, Wang HC, Huang EP, et al. Prehospital intravenous epinephrine may boost survival of patients with traumatic cardiac arrest: A retrospective cohort study. Scand J Trauma Resusc Emerg Med 2015;23:102.  Back to cited text no. 12
    
13.
Aoki M, Abe T, Oshima K. Association of prehospital epinephrine administration with survival among patients with traumatic cardiac arrest caused by traffic collisions. Sci Rep 2019;9:9922.  Back to cited text no. 13
    
14.
Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009;6:e1000097.  Back to cited text no. 14
    
15.
Dreyer NA, Velentgas P, Westrich K, Dubois R. The GRACE checklist for rating the quality of observational studies of comparative effectiveness: A tale of hope and caution. J Manag Care Pharm 2014;20:301-8.  Back to cited text no. 15
    
16.
Higgins JP, Thomas JA, Chandler J, Cumpston M, Li T, Page M, editors. Cochrane Handbook for Systematic Reviews of Interventions. Ver. 6.0. Glasgow, UK: Cochrane; 2019. Available from: https://www.training.cochrane.org/handbook. [Last accessed on 2019 Jul 30].  Back to cited text no. 16
    
17.
The Cochrane Collaboration, Review Manager (RevMan). 5.3, The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark, 2011.  Back to cited text no. 17
    
18.
Yamamoto R, Suzuki M, Hayashida K, Yoshizawa J, Sakurai A, Kitamura N, et al. Epinephrine during resuscitation of traumatic cardiac arrest and increased mortality: A post hoc analysis of prospective observational study. Scand J Trauma Resusc Emerg Med 2019;27:74.  Back to cited text no. 18
    
19.
Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, et al. Part 3: Adult basic and advanced life support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020;142 16 Suppl 2:S366-468.  Back to cited text no. 19
    
20.
Paradis NA, Martin GB, Rivers EP, Goetting MG, Appleton TJ, Feingold M, et al. Coronary perfusion pressure and the return of spontaneous circulation in human cardiopulmonary resuscitation. JAMA 1990;263:1106-13.  Back to cited text no. 20
    
21.
Hilwig RW, Berg RA, Kern KB, Ewy GA. Endothelin-1 vasoconstriction during swine cardiopulmonary resuscitation improves coronary perfusion pressures but worsens postresuscitation outcome. Circulation 2000;101:2097-102.  Back to cited text no. 21
    
22.
Sperry JL, Minei JP, Frankel HL, West MA, Harbrecht BG, Moore EE, et al. Early use of vasopressors after injury: Caution before constriction. J Trauma Inj Infect Crit Care 2008;64:9-14.  Back to cited text no. 22
    
23.
Ristagno G, Tang W, Huang L, Fymat A, Chang YT, Sun S, et al. Epinephrine reduces cerebral perfusion during cardiopulmonary resuscitation. Crit Care Med 2009;37:1408-15.  Back to cited text no. 23
    
24.
Schadt JC, Ludbrook J. Hemodynamic and neurohumoral responses to acute hypovolemia in conscious mammals. Am J Physiol 1991;260:H305-18.  Back to cited text no. 24
    
25.
Blewer AL, Ho AF, Shahidah N, White AE, Pek PP, Ng YY, et al. Impact of bystander-focused public health interventions on cardiopulmonary resuscitation and survival: A cohort study. Lancet Public Heal 2020;5:e428-36.  Back to cited text no. 25
    
26.
Holmberg M, Holmberg S, Herlitz J. Effect of bystander cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients in Sweden. Resuscitation 2000;47:59-70.  Back to cited text no. 26
    

Top
Correspondence Address:
Wachira Wongtanasarasin,
110 Intavarorot Street, Sriphum, Chiang Mai 50200
Thailand
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JETS.JETS_35_21



    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
  Search
 
   Ahead Of print
  
 Article in PDF
     Search Pubmed for
 
    -  Wongtanasarasin W
    -  Thepchinda T
    -  Kasirawat C
    -  Saetiao S
    -  Leungvorawat J
    -  Kittivorakanchai N


    Abstract
   Introduction
   Methods
   Results
   Discussion
   Conclusions
    Supplementary Ma...
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed81    
    PDF Downloaded2    

Recommend this journal