Low-Dose Adrenaline, Promethazine, and Hydrocortisone in the Prevention of Acute Adverse Reactions to Antivenom following Snakebite: A Randomised, Double-Blind, Placebo-Controlled Trial
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{"title"=>"Low-dose adrenaline, promethazine, and hydrocortisone in the prevention of acute adverse reactions to antivenom following snakebite: A randomised, double-blind, placebo-controlled trial", "type"=>"journal", "authors"=>[{"first_name"=>"H. Asita", "last_name"=>"de Silva", "scopus_author_id"=>"57198672075"}, {"first_name"=>"Arunasalam", "last_name"=>"Pathmeswaran", "scopus_author_id"=>"8245951400"}, {"first_name"=>"Channa D.", "last_name"=>"Ranasinha", "scopus_author_id"=>"6506818231"}, {"first_name"=>"Shaluka", "last_name"=>"Jayamanne", "scopus_author_id"=>"16480647500"}, {"first_name"=>"Senarath B.", "last_name"=>"Samarakoon", "scopus_author_id"=>"41461674500"}, {"first_name"=>"Ariyasena", "last_name"=>"Hittharage", "scopus_author_id"=>"39161238100"}, {"first_name"=>"Ranjith", "last_name"=>"Kalupahana", "scopus_author_id"=>"41461444500"}, {"first_name"=>"G. Asoka", "last_name"=>"Ratnatilaka", "scopus_author_id"=>"39162012500"}, {"first_name"=>"Wimalasiri", "last_name"=>"Uluwatthage", "scopus_author_id"=>"39162350900"}, {"first_name"=>"Jeffrey K.", "last_name"=>"Aronson", "scopus_author_id"=>"55683060600"}, {"first_name"=>"Jane M.", "last_name"=>"Armitage", "scopus_author_id"=>"7202699349"}, {"first_name"=>"David G.", "last_name"=>"Lalloo", "scopus_author_id"=>"7004734207"}, {"first_name"=>"H. Janaka", "last_name"=>"de Silva", "scopus_author_id"=>"57109046500"}], "year"=>2011, "source"=>"PLoS Medicine", "identifiers"=>{"isbn"=>"1549-1676 (Electronic)\\r1549-1277 (Linking)", "scopus"=>"2-s2.0-79957979890", "pui"=>"361887772", "doi"=>"10.1371/journal.pmed.1000435", "issn"=>"15491277", "pmid"=>"21572992", "sgr"=>"79957979890"}, "id"=>"d4f2845c-8e10-3354-9ce0-25079065ddcb", "abstract"=>"BACKGROUND: Envenoming from snakebites is most effectively treated by antivenom. However, the antivenom available in South Asian countries commonly causes acute allergic reactions, anaphylactic reactions being particularly serious. We investigated whether adrenaline, promethazine, and hydrocortisone prevent such reactions in secondary referral hospitals in Sri Lanka by conducting a randomised, double-blind placebo-controlled trial.\\n\\nMETHODS AND FINDINGS: In total, 1,007 patients were randomized, using a 2 × 2 × 2 factorial design, in a double-blind, placebo-controlled trial of adrenaline (0.25 ml of a 1∶1,000 solution subcutaneously), promethazine (25 mg intravenously), and hydrocortisone (200 mg intravenously), each alone and in all possible combinations. The interventions, or matching placebo, were given immediately before infusion of antivenom. Patients were monitored for mild, moderate, or severe adverse reactions for at least 96 h. The prespecified primary end point was the effect of the interventions on the incidence of severe reactions up to and including 48 h after antivenom administration. In total, 752 (75%) patients had acute reactions to antivenom: 9% mild, 48% moderate, and 43% severe; 89% of the reactions occurred within 1 h; and 40% of all patients were given rescue medication (adrenaline, promethazine, and hydrocortisone) during the first hour. Compared with placebo, adrenaline significantly reduced severe reactions to antivenom by 43% (95% CI 25-67) at 1 h and by 38% (95% CI 26-49) up to and including 48 h after antivenom administration; hydrocortisone and promethazine did not. Adding hydrocortisone negated the benefit of adrenaline.\\n\\nCONCLUSIONS: Pretreatment with low-dose adrenaline was safe and reduced the risk of acute severe reactions to snake antivenom. This may be of particular importance in countries where adverse reactions to antivenom are common, although the need to improve the quality of available antivenom cannot be overemphasized.", "link"=>"http://www.mendeley.com/research/lowdose-adrenaline-promethazine-hydrocortisone-prevention-acute-adverse-reactions-antivenom-followin", "reader_count"=>80, "reader_count_by_academic_status"=>{"Unspecified"=>3, "Professor > Associate Professor"=>3, "Librarian"=>1, "Researcher"=>8, "Student > Doctoral Student"=>3, "Student > Ph. D. Student"=>8, "Student > Postgraduate"=>5, "Other"=>16, "Student > Master"=>11, "Student > Bachelor"=>9, "Lecturer"=>4, "Lecturer > Senior Lecturer"=>2, "Professor"=>7}, "reader_count_by_user_role"=>{"Unspecified"=>3, "Professor > Associate Professor"=>3, "Librarian"=>1, "Researcher"=>8, "Student > Doctoral Student"=>3, "Student > Ph. D. Student"=>8, "Student > Postgraduate"=>5, "Other"=>16, "Student > Master"=>11, "Student > Bachelor"=>9, "Lecturer"=>4, "Lecturer > Senior Lecturer"=>2, "Professor"=>7}, "reader_count_by_subject_area"=>{"Unspecified"=>5, "Environmental Science"=>3, "Biochemistry, Genetics and Molecular Biology"=>3, "Nursing and Health Professions"=>2, "Medicine and Dentistry"=>47, "Agricultural and Biological Sciences"=>13, "Business, Management and Accounting"=>1, "Pharmacology, Toxicology and Pharmaceutical Science"=>3, "Chemistry"=>1, "Social Sciences"=>2}, "reader_count_by_subdiscipline"=>{"Medicine and Dentistry"=>{"Medicine and Dentistry"=>47}, "Chemistry"=>{"Chemistry"=>1}, "Social Sciences"=>{"Social Sciences"=>2}, "Agricultural and Biological Sciences"=>{"Agricultural and Biological Sciences"=>13}, "Nursing and Health Professions"=>{"Nursing and Health Professions"=>2}, "Business, Management and Accounting"=>{"Business, Management and Accounting"=>1}, "Biochemistry, Genetics and Molecular Biology"=>{"Biochemistry, Genetics and Molecular Biology"=>3}, "Unspecified"=>{"Unspecified"=>5}, "Environmental Science"=>{"Environmental Science"=>3}, "Pharmacology, Toxicology and Pharmaceutical Science"=>{"Pharmacology, Toxicology and Pharmaceutical Science"=>3}}, "reader_count_by_country"=>{"Netherlands"=>2, "Sri Lanka"=>1, "Denmark"=>1, "Brazil"=>1, "South Africa"=>1}, "group_count"=>2}

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  • {"files"=>["https://ndownloader.figshare.com/files/389411", "https://ndownloader.figshare.com/files/389434", "https://ndownloader.figshare.com/files/389457", "https://ndownloader.figshare.com/files/389517"], "description"=>"<div><h3>Background</h3><p> Envenoming from snakebites is most effectively treated by antivenom. However, the antivenom available in South Asian countries commonly causes acute allergic reactions, anaphylactic reactions being particularly serious. We investigated whether adrenaline, promethazine, and hydrocortisone prevent such reactions in secondary referral hospitals in Sri Lanka by conducting a randomised, double-blind placebo-controlled trial.</p><h3>Methods and Findings</h3><p>In total, 1,007 patients were randomized, using a 2×2×2 factorial design, in a double-blind, placebo-controlled trial of adrenaline (0.25 ml of a 1∶1,000 solution subcutaneously), promethazine (25 mg intravenously), and hydrocortisone (200 mg intravenously), each alone and in all possible combinations. The interventions, or matching placebo, were given immediately before infusion of antivenom. Patients were monitored for mild, moderate, or severe adverse reactions for at least 96 h. The prespecified primary end point was the effect of the interventions on the incidence of severe reactions up to and including 48 h after antivenom administration. In total, 752 (75%) patients had acute reactions to antivenom: 9% mild, 48% moderate, and 43% severe; 89% of the reactions occurred within 1 h; and 40% of all patients were given rescue medication (adrenaline, promethazine, and hydrocortisone) during the first hour. Compared with placebo, adrenaline significantly reduced severe reactions to antivenom by 43% (95% CI 25–67) at 1 h and by 38% (95% CI 26–49) up to and including 48 h after antivenom administration; hydrocortisone and promethazine did not. Adding hydrocortisone negated the benefit of adrenaline.</p><h3>Conclusions</h3><p>Pretreatment with low-dose adrenaline was safe and reduced the risk of acute severe reactions to snake antivenom. This may be of particular importance in countries where adverse reactions to antivenom are common, although the need to improve the quality of available antivenom cannot be overemphasized.</p><h3>Trial registration</h3><p><a href=\"http://www.ClinicalTrials.gov\">www.ClinicalTrials.gov</a><a href=\"http://www.clinicaltrials.gov/ct2/show/NCT00270777\">NCT00270777</a></p><h3></h3><p><em>Please see later in the article for the Editors' Summary</em></p></div>", "links"=>[], "tags"=>["low-dose", "hydrocortisone", "acute", "adverse", "reactions", "antivenom", "placebo-controlled"], "article_id"=>136891, "categories"=>["Medicine"], "users"=>["H. Asita de Silva", "Arunasalam Pathmeswaran", "Channa D. Ranasinha", "Shaluka Jayamanne", "Senarath B. Samarakoon", "Ariyasena Hittharage", "Ranjith Kalupahana", "G. Asoka Ratnatilaka", "Wimalasiri Uluwatthage", "Jeffrey K. Aronson", "Jane M. Armitage", "David G. Lalloo", "H. Janaka de Silva"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000435.s001", "https://dx.doi.org/10.1371/journal.pmed.1000435.s002", "https://dx.doi.org/10.1371/journal.pmed.1000435.s003", "https://dx.doi.org/10.1371/journal.pmed.1000435.s004"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/Low_Dose_Adrenaline_Promethazine_and_Hydrocortisone_in_the_Prevention_of_Acute_Adverse_Reactions_to_Antivenom_following_Snakebite_A_Randomised_Double_Blind_Placebo_Controlled_Trial/136891", "title"=>"Low-Dose Adrenaline, Promethazine, and Hydrocortisone in the Prevention of Acute Adverse Reactions to Antivenom following Snakebite: A Randomised, Double-Blind, Placebo-Controlled Trial", "pos_in_sequence"=>0, "defined_type"=>4, "published_date"=>"2011-05-10 01:54:51"}
  • {"files"=>["https://ndownloader.figshare.com/files/776167"], "description"=>"<p>Trial profile.</p>", "links"=>[], "tags"=>["Critical care and emergency medicine", "evidence-based healthcare/bedside evidence-based medicine", "infectious diseases/neglected tropical diseases"], "article_id"=>446521, "categories"=>["Medicine"], "users"=>["H. Asita de Silva", "Arunasalam Pathmeswaran", "Channa D. Ranasinha", "Shaluka Jayamanne", "Senarath B. Samarakoon", "Ariyasena Hittharage", "Ranjith Kalupahana", "G. Asoka Ratnatilaka", "Wimalasiri Uluwatthage", "Jeffrey K. Aronson", "Jane M. Armitage", "David G. Lalloo", "H. Janaka de Silva"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000435.g001"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Trial_profile_/446521", "title"=>"Trial profile.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2011-05-10 01:48:41"}
  • {"files"=>["https://ndownloader.figshare.com/files/776313"], "description"=>"<p>Numbers within boxes indicate the number of patients according to the highest category of reaction they had experienced by that time. Numbers above the boxes indicate the number of patients who experienced a higher category of reaction during the preceding interval. Those who changed from no reaction to a reaction category are indicated by numbers highlighted in yellow. Those who changed from mild reaction to a higher category are indicated by numbers highlighted in green. Those who changed from moderate to severe reaction are indicated by numbers highlighted in turquoise. For example the above numbers can be interpreted as follows. At 1 h, there were 315 patients with moderate reaction, and by 6 h, 336 patients were classified as moderate reactions; 33 patients who had had no reaction in 1 h had a moderate reaction during this interval, six patients who had had mild reaction in 1 h had a moderate reaction during this interval, and 18 patients who had had moderate reaction in 1 h had a severe reaction during this interval: 336 = (315+33+6)−18.</p>", "links"=>[], "tags"=>["48"], "article_id"=>446672, "categories"=>["Medicine"], "users"=>["H. Asita de Silva", "Arunasalam Pathmeswaran", "Channa D. Ranasinha", "Shaluka Jayamanne", "Senarath B. Samarakoon", "Ariyasena Hittharage", "Ranjith Kalupahana", "G. Asoka Ratnatilaka", "Wimalasiri Uluwatthage", "Jeffrey K. Aronson", "Jane M. Armitage", "David G. Lalloo", "H. Janaka de Silva"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000435.g002"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Progression_of_type_of_reaction_over_48_h_/446672", "title"=>"Progression of type of reaction over 48 h.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2011-05-10 01:51:12"}
  • {"files"=>["https://ndownloader.figshare.com/files/776420"], "description"=>"<p>Inclusion and exclusion criteria.</p>", "links"=>[], "tags"=>["exclusion"], "article_id"=>446780, "categories"=>["Medicine"], "users"=>["H. Asita de Silva", "Arunasalam Pathmeswaran", "Channa D. Ranasinha", "Shaluka Jayamanne", "Senarath B. Samarakoon", "Ariyasena Hittharage", "Ranjith Kalupahana", "G. Asoka Ratnatilaka", "Wimalasiri Uluwatthage", "Jeffrey K. Aronson", "Jane M. Armitage", "David G. Lalloo", "H. Janaka de Silva"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000435.t001"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Inclusion_and_exclusion_criteria_/446780", "title"=>"Inclusion and exclusion criteria.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-05-10 01:53:00"}
  • {"files"=>["https://ndownloader.figshare.com/files/776465"], "description"=>"<p>Patient baseline characteristics by treatment allocation.</p>", "links"=>[], "tags"=>["baseline", "characteristics"], "article_id"=>446821, "categories"=>["Medicine"], "users"=>["H. Asita de Silva", "Arunasalam Pathmeswaran", "Channa D. Ranasinha", "Shaluka Jayamanne", "Senarath B. Samarakoon", "Ariyasena Hittharage", "Ranjith Kalupahana", "G. Asoka Ratnatilaka", "Wimalasiri Uluwatthage", "Jeffrey K. Aronson", "Jane M. Armitage", "David G. Lalloo", "H. Janaka de Silva"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000435.t003"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Patient_baseline_characteristics_by_treatment_allocation_/446821", "title"=>"Patient baseline characteristics by treatment allocation.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-05-10 01:53:41"}
  • {"files"=>["https://ndownloader.figshare.com/files/776523"], "description"=>"a<p>Not in original classification <a href=\"http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000435#pmed.1000435-Brown1\" target=\"_blank\">[17]</a> but added to capture all of the systemic reactions.</p>", "links"=>[], "tags"=>["acute", "adverse", "reactions"], "article_id"=>446877, "categories"=>["Medicine"], "users"=>["H. Asita de Silva", "Arunasalam Pathmeswaran", "Channa D. Ranasinha", "Shaluka Jayamanne", "Senarath B. Samarakoon", "Ariyasena Hittharage", "Ranjith Kalupahana", "G. Asoka Ratnatilaka", "Wimalasiri Uluwatthage", "Jeffrey K. Aronson", "Jane M. Armitage", "David G. Lalloo", "H. Janaka de Silva"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000435.t002"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Classification_of_acute_adverse_reactions_to_antivenom_/446877", "title"=>"Classification of acute adverse reactions to antivenom.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-05-10 01:54:37"}
  • {"files"=>["https://ndownloader.figshare.com/files/776574"], "description"=>"<p>There were no three-way interactions. Data are from five hospitals. All time points relate to time after starting the antivenom infusion.</p>", "links"=>[], "tags"=>["two-way", "interactions", "adjusted", "clustering"], "article_id"=>446926, "categories"=>["Medicine"], "users"=>["H. Asita de Silva", "Arunasalam Pathmeswaran", "Channa D. Ranasinha", "Shaluka Jayamanne", "Senarath B. Samarakoon", "Ariyasena Hittharage", "Ranjith Kalupahana", "G. Asoka Ratnatilaka", "Wimalasiri Uluwatthage", "Jeffrey K. Aronson", "Jane M. Armitage", "David G. Lalloo", "H. Janaka de Silva"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000435.t005"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Risk_of_severe_reaction_during_the_first_hour_by_treatment_main_effects_and_two_way_interactions_adjusted_for_clustering_by_trial_site_/446926", "title"=>"Risk of severe reaction during the first hour by treatment: main effects and two-way interactions adjusted for clustering by trial site.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-05-10 01:55:26"}
  • {"files"=>["https://ndownloader.figshare.com/files/776617"], "description"=>"<p>All time points relate to time after starting the antivenom infusion.</p>a<p>For predictors of severe reaction, ORs were calculated using the main effects and all two-way interactions of the trial medications; for predictors of any reaction, ORs were calculated using only the main effects of the trial medications because there were no significant interactions.</p>", "links"=>[], "tags"=>["48"], "article_id"=>446977, "categories"=>["Medicine"], "users"=>["H. Asita de Silva", "Arunasalam Pathmeswaran", "Channa D. Ranasinha", "Shaluka Jayamanne", "Senarath B. Samarakoon", "Ariyasena Hittharage", "Ranjith Kalupahana", "G. Asoka Ratnatilaka", "Wimalasiri Uluwatthage", "Jeffrey K. Aronson", "Jane M. Armitage", "David G. Lalloo", "H. Janaka de Silva"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000435.t004"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Outcomes_during_first_hour_and_48_h_by_treatment_allocation_/446977", "title"=>"Outcomes during first hour and 48 h by treatment allocation.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-05-10 01:56:17"}
  • {"files"=>["https://ndownloader.figshare.com/files/776674"], "description"=>"<p>All values are mean (standard error).</p>a<p>An increase in systolic BP of >30 mm Hg and/or diastolic BP of >20 mm Hg higher than baseline.</p>", "links"=>[], "tags"=>["patients", "30", "min", "60", "pretreatment"], "article_id"=>447026, "categories"=>["Medicine"], "users"=>["H. Asita de Silva", "Arunasalam Pathmeswaran", "Channa D. Ranasinha", "Shaluka Jayamanne", "Senarath B. Samarakoon", "Ariyasena Hittharage", "Ranjith Kalupahana", "G. Asoka Ratnatilaka", "Wimalasiri Uluwatthage", "Jeffrey K. Aronson", "Jane M. Armitage", "David G. Lalloo", "H. Janaka de Silva"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000435.t007"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Heart_rate_blood_pressure_and_number_of_patients_with_rise_in_blood_pressure_at_30_min_and_60_min_after_pretreatment_administered_/447026", "title"=>"Heart rate, blood pressure, and number of patients with rise in blood pressure at 30 min and 60 min after pretreatment administered.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-05-10 01:57:06"}
  • {"files"=>["https://ndownloader.figshare.com/files/776727"], "description"=>"<p>There were no three-way interactions. Data are from five hospitals. All time points relate to time after starting the antivenom infusion.</p>", "links"=>[], "tags"=>["48", "two-way", "interactions", "adjusted", "clustering"], "article_id"=>447071, "categories"=>["Medicine"], "users"=>["H. Asita de Silva", "Arunasalam Pathmeswaran", "Channa D. Ranasinha", "Shaluka Jayamanne", "Senarath B. Samarakoon", "Ariyasena Hittharage", "Ranjith Kalupahana", "G. Asoka Ratnatilaka", "Wimalasiri Uluwatthage", "Jeffrey K. Aronson", "Jane M. Armitage", "David G. Lalloo", "H. Janaka de Silva"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000435.t006"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Risk_of_severe_reaction_up_to_and_including_48_h_by_treatment_main_effects_and_two_way_interactions_adjusted_for_clustering_by_trial_site_/447071", "title"=>"Risk of severe reaction up to and including 48 h by treatment: main effects and two-way interactions adjusted for clustering by trial site.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-05-10 01:57:51"}
  • {"files"=>["https://ndownloader.figshare.com/files/776777"], "description"=>"<p>Data from five hospitals.</p>", "links"=>[], "tags"=>["adjusted", "clustering"], "article_id"=>447132, "categories"=>["Medicine"], "users"=>["H. Asita de Silva", "Arunasalam Pathmeswaran", "Channa D. Ranasinha", "Shaluka Jayamanne", "Senarath B. Samarakoon", "Ariyasena Hittharage", "Ranjith Kalupahana", "G. Asoka Ratnatilaka", "Wimalasiri Uluwatthage", "Jeffrey K. Aronson", "Jane M. Armitage", "David G. Lalloo", "H. Janaka de Silva"], "doi"=>["https://dx.doi.org/10.1371/journal.pmed.1000435.t008"], "stats"=>{"downloads"=>0, "page_views"=>0, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Risk_of_death_by_treatment_main_effects_adjusted_for_clustering_by_trial_site_/447132", "title"=>"Risk of death by treatment: main effects adjusted for clustering by trial site.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2011-05-10 01:58:52"}

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  • {"unique-ip"=>"21", "full-text"=>"23", "pdf"=>"5", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2016", "month"=>"11"}
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  • {"unique-ip"=>"36", "full-text"=>"41", "pdf"=>"6", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"11"}
  • {"unique-ip"=>"24", "full-text"=>"28", "pdf"=>"2", "abstract"=>"0", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2017", "month"=>"12"}
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  • {"unique-ip"=>"36", "full-text"=>"42", "pdf"=>"1", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"1", "cited-by"=>"0", "year"=>"2018", "month"=>"7"}
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  • {"unique-ip"=>"73", "full-text"=>"84", "pdf"=>"10", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"2", "supp-data"=>"4", "cited-by"=>"1", "year"=>"2018", "month"=>"11"}
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  • {"unique-ip"=>"47", "full-text"=>"49", "pdf"=>"7", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"12"}
  • {"unique-ip"=>"57", "full-text"=>"60", "pdf"=>"4", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"2"}
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  • {"unique-ip"=>"53", "full-text"=>"59", "pdf"=>"5", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"4"}
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  • {"unique-ip"=>"75", "full-text"=>"82", "pdf"=>"6", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"6"}
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  • {"unique-ip"=>"56", "full-text"=>"60", "pdf"=>"10", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2020", "month"=>"8"}
  • {"unique-ip"=>"54", "full-text"=>"62", "pdf"=>"5", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"0", "supp-data"=>"0", "cited-by"=>"1", "year"=>"2020", "month"=>"9"}
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Relative Metric

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