Proton Pump Inhibitor Usage and the Risk of Myocardial Infarction in the General Population
Publication Date
June 10, 2015
Journal
PLOS ONE
Authors
Nigam H. Shah, Paea Le Pendu, Anna Bauer Mehren, Yohannes T. Ghebremariam, et al
Volume
10
Issue
6
Pages
e0124653
DOI
https://dx.plos.org/10.1371/journal.pone.0124653
Publisher URL
http://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0124653
PubMed
http://www.ncbi.nlm.nih.gov/pubmed/26061035
PubMed Central
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462578
Europe PMC
http://europepmc.org/abstract/MED/26061035
Web of Science
000355979500007
Scopus
84936774522
Mendeley
http://www.mendeley.com/research/proton-pump-inhibitor-usage-risk-myocardial-infarction-general-population
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{"title"=>"Proton pump inhibitor usage and the risk of myocardial infarction in the general population", "type"=>"journal", "authors"=>[{"first_name"=>"Nigam H.", "last_name"=>"Shah", "scopus_author_id"=>"7401823709"}, {"first_name"=>"Paea", "last_name"=>"LePendu", "scopus_author_id"=>"13605247200"}, {"first_name"=>"Anna", "last_name"=>"Bauer-Mehren", "scopus_author_id"=>"35572639000"}, {"first_name"=>"Yohannes T.", "last_name"=>"Ghebremariam", "scopus_author_id"=>"10639679600"}, {"first_name"=>"Srinivasan V.", "last_name"=>"Iyer", "scopus_author_id"=>"55643743800"}, {"first_name"=>"Jake", "last_name"=>"Marcus", "scopus_author_id"=>"56715021900"}, {"first_name"=>"Kevin T.", "last_name"=>"Nead", "scopus_author_id"=>"24339007700"}, {"first_name"=>"John P.", "last_name"=>"Cooke", "scopus_author_id"=>"7202378672"}, {"first_name"=>"Nicholas J.", "last_name"=>"Leeper", "scopus_author_id"=>"55882699900"}], "year"=>2015, "source"=>"PLoS ONE", "identifiers"=>{"sgr"=>"84936774522", "pmid"=>"26061035", "pui"=>"605092304", "issn"=>"19326203", "isbn"=>"1932-6203", "scopus"=>"2-s2.0-84936774522", "doi"=>"10.1371/journal.pone.0124653"}, "id"=>"98dbc1d9-2244-3509-af8b-25837b85d700", "abstract"=>"BACKGROUND AND AIMS Proton pump inhibitors (PPIs) have been associated with adverse clinical outcomes amongst clopidogrel users after an acute coronary syndrome. Recent pre-clinical results suggest that this risk might extend to subjects without any prior history of cardiovascular disease. We explore this potential risk in the general population via data-mining approaches. METHODS Using a novel approach for mining clinical data for pharmacovigilance, we queried over 16 million clinical documents on 2.9 million individuals to examine whether PPI usage was associated with cardiovascular risk in the general population. RESULTS In multiple data sources, we found gastroesophageal reflux disease (GERD) patients exposed to PPIs to have a 1.16 fold increased association (95% CI 1.09-1.24) with myocardial infarction (MI). Survival analysis in a prospective cohort found a two-fold (HR = 2.00; 95% CI 1.07-3.78; P = 0.031) increase in association with cardiovascular mortality. We found that this association exists regardless of clopidogrel use. We also found that H2 blockers, an alternate treatment for GERD, were not associated with increased cardiovascular risk; had they been in place, such pharmacovigilance algorithms could have flagged this risk as early as the year 2000. CONCLUSIONS Consistent with our pre-clinical findings that PPIs may adversely impact vascular function, our data-mining study supports the association of PPI exposure with risk for MI in the general population. These data provide an example of how a combination of experimental studies and data-mining approaches can be applied to prioritize drug safety signals for further investigation.", "link"=>"http://www.mendeley.com/research/proton-pump-inhibitor-usage-risk-myocardial-infarction-general-population", "reader_count"=>149, "reader_count_by_academic_status"=>{"Unspecified"=>1, "Professor > Associate Professor"=>9, "Librarian"=>1, "Researcher"=>29, "Student > Doctoral Student"=>13, "Student > Ph. D. Student"=>14, "Student > Postgraduate"=>14, "Other"=>28, "Student > Master"=>12, "Student > Bachelor"=>16, "Lecturer"=>5, "Professor"=>7}, "reader_count_by_user_role"=>{"Unspecified"=>1, "Professor > Associate Professor"=>9, "Librarian"=>1, "Researcher"=>29, "Student > Doctoral Student"=>13, "Student > Ph. D. Student"=>14, "Student > Postgraduate"=>14, "Other"=>28, "Student > Master"=>12, "Student > Bachelor"=>16, "Lecturer"=>5, "Professor"=>7}, "reader_count_by_subject_area"=>{"Unspecified"=>6, "Agricultural and Biological Sciences"=>13, "Chemistry"=>1, "Computer Science"=>3, "Economics, Econometrics and Finance"=>1, "Engineering"=>1, "Biochemistry, Genetics and Molecular Biology"=>3, "Nursing and Health Professions"=>5, "Medicine and Dentistry"=>104, "Pharmacology, Toxicology and Pharmaceutical Science"=>5, "Psychology"=>2, "Social Sciences"=>4, "Immunology and Microbiology"=>1}, "reader_count_by_subdiscipline"=>{"Medicine and Dentistry"=>{"Medicine and Dentistry"=>104}, "Social Sciences"=>{"Social Sciences"=>4}, "Psychology"=>{"Psychology"=>2}, "Unspecified"=>{"Unspecified"=>6}, "Pharmacology, Toxicology and Pharmaceutical Science"=>{"Pharmacology, Toxicology and Pharmaceutical Science"=>5}, "Engineering"=>{"Engineering"=>1}, "Chemistry"=>{"Chemistry"=>1}, "Economics, Econometrics and Finance"=>{"Economics, Econometrics and Finance"=>1}, "Immunology and Microbiology"=>{"Immunology and Microbiology"=>1}, "Agricultural and Biological Sciences"=>{"Agricultural and Biological Sciences"=>13}, "Computer Science"=>{"Computer Science"=>3}, "Nursing and Health Professions"=>{"Nursing and Health Professions"=>5}, "Biochemistry, Genetics and Molecular Biology"=>{"Biochemistry, Genetics and Molecular Biology"=>3}}, "reader_count_by_country"=>{"Sweden"=>1, "United States"=>4, "Brazil"=>1, "United Kingdom"=>3, "Italy"=>1, "Israel"=>1, "Australia"=>1, "Switzerland"=>1, "Spain"=>1}, "group_count"=>8}

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Figshare

  • {"files"=>["https://ndownloader.figshare.com/files/2105205"], "description"=>"<p>There are 227,438 patients with gastroesophageal reflux disease (GERD) who are at least 18 years old in this confirmation cohort. In all study groups other than the one in which clopidogrel patients are excluded, the populations are matched based on clopidogrel use and other covariates such as age, gender, race, length of observation, and number of unique drugs mentioned in the record as well as the number of unique disease concepts (as proxies for health status). The matching process attempts to achieve a ratio of 1:5 (exposure to control), but will settle for 1:3, 1:2, or 1:1 if there are not enough controls from which to draw. The length of observation in the PF dataset makes balancing variables difficult, so confounding cannot be entirely ruled out even after matching.</p><p>† patients on clopidogrel are excluded</p><p>‡ patients are restricted by age</p><p>Study group populations for the PF dataset.</p>", "links"=>[], "tags"=>["gerd", "Myocardial infarction", "clopidogrel users", "association", "data sources", "hr", "Proton Pump Inhibitor Usage", "prioritize drug safety signals", "pharmacovigilance algorithms", "General Population Background", "PPI usage", "mi", "H 2 blockers", "ci", "gastroesophageal reflux disease", "clopidogrel use", "year 2000. ConclusionsConsistent", "novel approach", "survival analysis", "PPI exposure"], "article_id"=>1444827, "categories"=>["Biological Sciences"], "users"=>["Nigam H. Shah", "Paea LePendu", "Anna Bauer-Mehren", "Yohannes T. Ghebremariam", "Srinivasan V. Iyer", "Jake Marcus", "Kevin T. Nead", "John P. Cooke", "Nicholas J. Leeper"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0124653.t004", "stats"=>{"downloads"=>1, "page_views"=>8, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Study_group_populations_for_the_PF_dataset_/1444827", "title"=>"Study group populations for the PF dataset.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2015-06-10 03:13:51"}
  • {"files"=>["https://ndownloader.figshare.com/files/2105204"], "description"=>"<p>PPI exposure and control groups for patients with gastroesophageal reflux disease (GERD) are balanced across a number of basic covariates. Importantly, the use of clopidogrel is equally balanced across exposed and control groups. Continuous variables (no. of unique disease mentions, no. unique drug mentions, length of observation) are binned according to their distributions. Before matching, H<sub>2</sub> blocker patients tend to be sicker, have more diseases and more drugs mentioned in their record. After matching, these variables are mostly balanced.</p><p>Balance of variables in patients on H<sub>2</sub> blockers in the STRIDE dataset.</p>", "links"=>[], "tags"=>["gerd", "Myocardial infarction", "clopidogrel users", "association", "data sources", "hr", "Proton Pump Inhibitor Usage", "prioritize drug safety signals", "pharmacovigilance algorithms", "General Population Background", "PPI usage", "mi", "H 2 blockers", "ci", "gastroesophageal reflux disease", "clopidogrel use", "year 2000. ConclusionsConsistent", "novel approach", "survival analysis", "PPI exposure"], "article_id"=>1444826, "categories"=>["Biological Sciences"], "users"=>["Nigam H. Shah", "Paea LePendu", "Anna Bauer-Mehren", "Yohannes T. Ghebremariam", "Srinivasan V. Iyer", "Jake Marcus", "Kevin T. Nead", "John P. Cooke", "Nicholas J. Leeper"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0124653.t003", "stats"=>{"downloads"=>1, "page_views"=>13, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Balance_of_variables_in_patients_on_H_2_blockers_in_the_STRIDE_dataset_/1444826", "title"=>"Balance of variables in patients on H<sub>2</sub> blockers in the STRIDE dataset.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2015-06-10 03:13:51"}
  • {"files"=>["https://ndownloader.figshare.com/files/2105199"], "description"=>"<p>The Kaplan–Meier curves in the fig show the survival probability from cardiovascular mortality according to PPI usage over an 8 years follow-up period in the ongoing Genetic Determinants of Peripheral Artery Disease (GenePAD) study. PPI usage is associated with a 2.22 fold (CI 1.19–4.16) increased risk of cardiovascular mortality, relative to controls in unadjusted Cox proportional hazards models.</p>", "links"=>[], "tags"=>["gerd", "Myocardial infarction", "clopidogrel users", "association", "data sources", "hr", "Proton Pump Inhibitor Usage", "prioritize drug safety signals", "pharmacovigilance algorithms", "General Population Background", "PPI usage", "mi", "H 2 blockers", "ci", "gastroesophageal reflux disease", "clopidogrel use", "year 2000. ConclusionsConsistent", "novel approach", "survival analysis", "PPI exposure"], "article_id"=>1444821, "categories"=>["Biological Sciences"], "users"=>["Nigam H. Shah", "Paea LePendu", "Anna Bauer-Mehren", "Yohannes T. Ghebremariam", "Srinivasan V. Iyer", "Jake Marcus", "Kevin T. Nead", "John P. Cooke", "Nicholas J. Leeper"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0124653.g002", "stats"=>{"downloads"=>1, "page_views"=>30, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Survival_plot_from_the_prospectively_followed_GenePAD_study_confirms_that_PPI_use_is_associated_adverse_outcome_/1444821", "title"=>"Survival plot from the prospectively followed GenePAD study confirms that PPI use is associated adverse outcome.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2015-06-10 03:13:51"}
  • {"files"=>["https://ndownloader.figshare.com/files/2105198"], "description"=>"<p>No association is identified for H<sub>2</sub> Blocker use: In the fig, the dotted red line represents the reference point indicating no elevated risk for myocardial infarction (MI). The odds ratio and 95% confidence interval for each exposure are indicated by a blue dot and blue line, respectively, which are also represented numerically to the right of each fig. The size of the dot is proportional to the exposure size of each group (see <a href=\"http://www.plosone.org/article/info:doi/10.1371/journal.pone.0124653#pone.0124653.t001\" target=\"_blank\">Table 1</a>). Fig A, derived from STRIDE (N = 70,477), shows that PPIs have a class-level effect for MI in the general population of patients with GERD. By comparison, H<sub>2</sub> blockers, an alternate treatment, have no association. Fig B breaks down the associations for each PPI individually. Figs C and D use stratification to show that the signals are corroborated in two independent datasets (STRIDE and Practice Fusion) and are robust in important subgroups. Fig C shows that, for the STRIDE dataset, when patients on clopidogrel are excluded, the associations are unchanged. Also, in lower-risk age groups for MI, the associations are still present. Similar trends are seen in these subgroups in the Practice Fusion (PF) dataset (N = 227,438) shown in Fig D.</p>", "links"=>[], "tags"=>["gerd", "Myocardial infarction", "clopidogrel users", "association", "data sources", "hr", "Proton Pump Inhibitor Usage", "prioritize drug safety signals", "pharmacovigilance algorithms", "General Population Background", "PPI usage", "mi", "H 2 blockers", "ci", "gastroesophageal reflux disease", "clopidogrel use", "year 2000. ConclusionsConsistent", "novel approach", "survival analysis", "PPI exposure"], "article_id"=>1444820, "categories"=>["Biological Sciences"], "users"=>["Nigam H. Shah", "Paea LePendu", "Anna Bauer-Mehren", "Yohannes T. Ghebremariam", "Srinivasan V. Iyer", "Jake Marcus", "Kevin T. Nead", "John P. Cooke", "Nicholas J. Leeper"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0124653.g001", "stats"=>{"downloads"=>0, "page_views"=>7, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_PPI_use_is_associated_with_an_increased_risk_for_MI_regardless_of_age_or_clopidogrel_use_/1444820", "title"=>"PPI use is associated with an increased risk for MI, regardless of age or clopidogrel use.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2015-06-10 03:13:51"}
  • {"files"=>["https://ndownloader.figshare.com/files/2105206", "https://ndownloader.figshare.com/files/2105207", "https://ndownloader.figshare.com/files/2105208"], "description"=>"<div><p>Background and Aims</p><p>Proton pump inhibitors (PPIs) have been associated with adverse clinical outcomes amongst clopidogrel users after an acute coronary syndrome. Recent pre-clinical results suggest that this risk might extend to subjects without any prior history of cardiovascular disease. We explore this potential risk in the general population via data-mining approaches.</p><p>Methods</p><p>Using a novel approach for mining clinical data for pharmacovigilance, we queried over 16 million clinical documents on 2.9 million individuals to examine whether PPI usage was associated with cardiovascular risk in the general population.</p><p>Results</p><p>In multiple data sources, we found gastroesophageal reflux disease (GERD) patients exposed to PPIs to have a 1.16 fold increased association (95% CI 1.09–1.24) with myocardial infarction (MI). Survival analysis in a prospective cohort found a two-fold (HR = 2.00; 95% CI 1.07–3.78; P = 0.031) increase in association with cardiovascular mortality. We found that this association exists regardless of clopidogrel use. We also found that H<sub>2</sub> blockers, an alternate treatment for GERD, were not associated with increased cardiovascular risk; had they been in place, such pharmacovigilance algorithms could have flagged this risk as early as the year 2000.</p><p>Conclusions</p><p>Consistent with our pre-clinical findings that PPIs may adversely impact vascular function, our data-mining study supports the association of PPI exposure with risk for MI in the general population. These data provide an example of how a combination of experimental studies and data-mining approaches can be applied to prioritize drug safety signals for further investigation.</p></div>", "links"=>[], "tags"=>["gerd", "Myocardial infarction", "clopidogrel users", "association", "data sources", "hr", "Proton Pump Inhibitor Usage", "prioritize drug safety signals", "pharmacovigilance algorithms", "General Population Background", "PPI usage", "mi", "H 2 blockers", "ci", "gastroesophageal reflux disease", "clopidogrel use", "year 2000. ConclusionsConsistent", "novel approach", "survival analysis", "PPI exposure"], "article_id"=>1444828, "categories"=>["Biological Sciences"], "users"=>["Nigam H. Shah", "Paea LePendu", "Anna Bauer-Mehren", "Yohannes T. Ghebremariam", "Srinivasan V. Iyer", "Jake Marcus", "Kevin T. Nead", "John P. Cooke", "Nicholas J. Leeper"], "doi"=>["https://dx.doi.org/10.1371/journal.pone.0124653.s001", "https://dx.doi.org/10.1371/journal.pone.0124653.s002", "https://dx.doi.org/10.1371/journal.pone.0124653.s003"], "stats"=>{"downloads"=>14, "page_views"=>13, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Proton_Pump_Inhibitor_Usage_and_the_Risk_of_Myocardial_Infarction_in_the_General_Population_/1444828", "title"=>"Proton Pump Inhibitor Usage and the Risk of Myocardial Infarction in the General Population", "pos_in_sequence"=>0, "defined_type"=>4, "published_date"=>"2015-06-10 03:13:51"}
  • {"files"=>["https://ndownloader.figshare.com/files/2105203"], "description"=>"<p>PPI exposure and control groups for patients with gastroesophageal reflux disease (GERD) are balanced across a number of basic covariates. Importantly, the use of clopidogrel is equally balanced across exposed and control groups. Other variables (no. of unique disease mentions, no. unique drug mentions, length of observation) are binned according to their distributions. Before matching, PI patients tend to be sicker, have more diseases and more drugs mentioned in their record. After matching, these variables are balanced.</p><p>Balance of variables for patients on PPIs in the STRIDE dataset.</p>", "links"=>[], "tags"=>["gerd", "Myocardial infarction", "clopidogrel users", "association", "data sources", "hr", "Proton Pump Inhibitor Usage", "prioritize drug safety signals", "pharmacovigilance algorithms", "General Population Background", "PPI usage", "mi", "H 2 blockers", "ci", "gastroesophageal reflux disease", "clopidogrel use", "year 2000. ConclusionsConsistent", "novel approach", "survival analysis", "PPI exposure"], "article_id"=>1444825, "categories"=>["Biological Sciences"], "users"=>["Nigam H. Shah", "Paea LePendu", "Anna Bauer-Mehren", "Yohannes T. Ghebremariam", "Srinivasan V. Iyer", "Jake Marcus", "Kevin T. Nead", "John P. Cooke", "Nicholas J. Leeper"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0124653.t002", "stats"=>{"downloads"=>2, "page_views"=>14, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Balance_of_variables_for_patients_on_PPIs_in_the_STRIDE_dataset_/1444825", "title"=>"Balance of variables for patients on PPIs in the STRIDE dataset.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2015-06-10 03:13:51"}
  • {"files"=>["https://ndownloader.figshare.com/files/2105201"], "description"=>"<p>The x-axis is calendar year; the y-axis on the left is the unadjusted odds ratio; the y-axis on the right is the number of patients exposed. The solid red line is the point estimate of the odds ratio. The dotted red lines are the confidence intervals. The blue line is the number of patients exposed. Vertical lines mark the earliest detected signal—the year when the lower bound on the 95% confidence interval rises above 1.0. Signal detection algorithms on clinical notes would have flagged lansoprazole for monitoring as early as the year 2000.</p>", "links"=>[], "tags"=>["gerd", "Myocardial infarction", "clopidogrel users", "association", "data sources", "hr", "Proton Pump Inhibitor Usage", "prioritize drug safety signals", "pharmacovigilance algorithms", "General Population Background", "PPI usage", "mi", "H 2 blockers", "ci", "gastroesophageal reflux disease", "clopidogrel use", "year 2000. ConclusionsConsistent", "novel approach", "survival analysis", "PPI exposure"], "article_id"=>1444823, "categories"=>["Biological Sciences"], "users"=>["Nigam H. Shah", "Paea LePendu", "Anna Bauer-Mehren", "Yohannes T. Ghebremariam", "Srinivasan V. Iyer", "Jake Marcus", "Kevin T. Nead", "John P. Cooke", "Nicholas J. Leeper"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0124653.g003", "stats"=>{"downloads"=>0, "page_views"=>11, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Cumulative_risk_and_exposure_plots_reveal_that_pharmacovigilance_algorithms_could_have_flagged_lansoprazole_for_monitoring_as_early_as_the_year_2000_/1444823", "title"=>"Cumulative risk and exposure plots reveal that pharmacovigilance algorithms could have flagged lansoprazole for monitoring as early as the year 2000.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2015-06-10 03:13:51"}
  • {"files"=>["https://ndownloader.figshare.com/files/2105202"], "description"=>"<p>There are 93,149 patients with gastroesophageal reflux disease (GERD), of which 70,477 are at least 18 years old. In all study groups other than the one in which clopidogrel patients are excluded, the populations are matched (and balanced) based on clopidogrel use and other covariates such as age, gender, race, length of observation, number of unique drugs mentioned in the record, and validated proxies of health status (based on the number of unique disease concepts attributed to each patient). The matching process attempts to achieve a ratio of 1:5 (exposure to control), but will settle for 1:3 or 1:1 if there are not enough controls from which to draw.</p><p>* balanced for clopidogrel use</p><p>† patients on clopidogrel are excluded</p><p>‡ patients are restricted by age</p><p>Study group populations for the STRIDE dataset, including 5:1 propensity matching.</p>", "links"=>[], "tags"=>["gerd", "Myocardial infarction", "clopidogrel users", "association", "data sources", "hr", "Proton Pump Inhibitor Usage", "prioritize drug safety signals", "pharmacovigilance algorithms", "General Population Background", "PPI usage", "mi", "H 2 blockers", "ci", "gastroesophageal reflux disease", "clopidogrel use", "year 2000. ConclusionsConsistent", "novel approach", "survival analysis", "PPI exposure"], "article_id"=>1444824, "categories"=>["Biological Sciences"], "users"=>["Nigam H. Shah", "Paea LePendu", "Anna Bauer-Mehren", "Yohannes T. Ghebremariam", "Srinivasan V. Iyer", "Jake Marcus", "Kevin T. Nead", "John P. Cooke", "Nicholas J. Leeper"], "doi"=>"https://dx.doi.org/10.1371/journal.pone.0124653.t001", "stats"=>{"downloads"=>6, "page_views"=>24, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Study_group_populations_for_the_STRIDE_dataset_including_5_1_propensity_matching_/1444824", "title"=>"Study group populations for the STRIDE dataset, including 5:1 propensity matching.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2015-06-10 03:13:51"}

PMC Usage Stats | Further Information

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  • {"unique-ip"=>"137", "full-text"=>"196", "pdf"=>"13", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2018", "month"=>"8"}
  • {"unique-ip"=>"306", "full-text"=>"361", "pdf"=>"30", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"19", "supp-data"=>"6", "cited-by"=>"0", "year"=>"2018", "month"=>"10"}
  • {"unique-ip"=>"160", "full-text"=>"182", "pdf"=>"14", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"3", "supp-data"=>"2", "cited-by"=>"0", "year"=>"2019", "month"=>"2"}
  • {"unique-ip"=>"215", "full-text"=>"234", "pdf"=>"23", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"3", "supp-data"=>"2", "cited-by"=>"0", "year"=>"2019", "month"=>"3"}
  • {"unique-ip"=>"283", "full-text"=>"333", "pdf"=>"21", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"4", "supp-data"=>"3", "cited-by"=>"1", "year"=>"2019", "month"=>"4"}
  • {"unique-ip"=>"187", "full-text"=>"213", "pdf"=>"18", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"1", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"5"}
  • {"unique-ip"=>"131", "full-text"=>"122", "pdf"=>"20", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"3", "supp-data"=>"6", "cited-by"=>"0", "year"=>"2019", "month"=>"8"}
  • {"unique-ip"=>"149", "full-text"=>"160", "pdf"=>"12", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"3", "supp-data"=>"0", "cited-by"=>"0", "year"=>"2019", "month"=>"9"}
  • {"unique-ip"=>"194", "full-text"=>"210", "pdf"=>"23", "scanned-summary"=>"0", "scanned-page-browse"=>"0", "figure"=>"8", "supp-data"=>"4", "cited-by"=>"0", "year"=>"2019", "month"=>"10"}

Relative Metric

{"start_date"=>"2015-01-01T00:00:00Z", "end_date"=>"2015-12-31T00:00:00Z", "subject_areas"=>[]}
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