Commentary on: Enhanced Recovery After Surgery: The Plastic Surgery Paradigm Shift

Commentary on: Enhanced Recovery After Surgery: The Plastic Surgery Paradigm Shift There has been a tremendous culture shift in the perioperative care of surgical patients with the introduction of enhanced recovery after surgery (ERAS), championed by Henik Kehlet, MD.1 Kehlet and colleagues reported a reduction in the length of stay (LOS) and complications in patients undergoing complex colorectal surgery by implementing a multidisciplinary approach to perioperative care focused on reducing the physiologic stress of surgery. Key tenets included patient education, a multimodal pain strategy limiting opiates, early ambulation, and early feeding to hasten recovery.2 The authors reported LOS of 2 days. These results were almost unbelievable and quite provocative. However, this work has been replicated with numerous high-quality, randomized control trials and meta-analysis comparing ERAS to standard perioperative care. Results have consistently shown a decrease in LOS, reduction in complications, and no increase in 30 day readmissions.3,4 Although the original studies concentrated on colon and rectal surgery, the application of ERAS has expanded to almost every other discipline of surgery. ERAS programs incorporate the best available evidence-based care plans to maximize outcomes, minimize waste and complications, and optimize the patient experience. Some of the most important tenets in any perioperative program include patient preparation with counseling/education of the surgical experience and avoidance of opiates. Measuring the value of each individual item of an ERAS program is challenging; although, when used together, there is a significant improvement in patient outcomes. ERAS program implementation requires coordination of care that historically has been compartmentalized. The preoperative, intraoperative, and postoperative care must be coordinated using a multidisciplinary and multimodal approach. ERAS programs have not been widely implemented because of the considerable operational challenges. The ERAS society publishes evidence-based guidelines detailing components of optimal perioperative care which is used as a resource for starting an ERAS program.5 The current study demonstrates that the same ideas of evidence-based perioperative surgical care can be adopted and employed for patients undergoing cosmetic elective surgery. This prospective study compared outcomes of 22 patients undergoing a variety of elective cosmetic surgical procedures (ranging from breast surgeries to trunk and facial procedures) treated with an ERAS program vs a standard pathway.6 Ten patients were treated with an ERAS defined perioperative program and 12 were patients treated with standard perioperative practice. The aim of the study was to compare short-term (2 week) outcomes between groups. The ERAS program included preoperative, preemptive analgesia and antiemetic therapy including celecoxib, gabapentin, and ondansetron. Intraoperative elements included weight-based dosing of fentanyl and propofol, as well as use of dexamethasone and promethazine suppository. Patients were given local anesthetic blocks and received intravenous acetaminophen prior to the conclusion of the operation. Postoperatively the patients were given a multimodal pain regimen which included gabapentin, celecoxib, scopolamine patch for indicated procedures, and acetaminophen use for breakthrough pain. Patients in the control arm were given narcotics as needed. Patients in the ERAS group were given a 6-day course of postoperative steroids in the form of a methylprednisolone dose pack. The patients were then surveyed daily with a study questionnaire until the first postoperative office visit (>POD 7) inquiring about pain scores, nausea/vomiting, fatigue/drowsiness, constipation, and hindrance to ambulate. Patients in the ERAS program were more likely to be ready for discharge at 23 hours, had significantly less pain, less nausea/vomiting of postoperative 1 and 2, no fatigue/drowsiness after surgery, and improved ability to ambulate. Only one patient required narcotics postoperatively. The majority of the short-term outcome improvements were thought to be related to narcotic avoidance in the ERAS group. The multimodal pain strategy in the ERAS cohort was very effective in avoiding narcotics with only one patient taking tramadol postoperatively. As the authors pointed out, the study cohort is quite small due to limitations by the institutional review board, and this limited the ability to detect true differences between groups. The short follow up of 2 weeks is too short to capture perioperative complications. The study questionnaire used is not a validated instrument and can add bias. The study included diverse surgical procedures and techniques introducing differences between groups. Recent studies evaluating ERAS programs have had primary outcomes including LOS, complications, and readmission.7 The authors report a shorter length of stay in the ERAS group; however, in the methods section it states a one night stay is included in the “cosmetic surgery package.” As a surrogate for LOS, patients were asked about reluctance to discharge. Therefore, it is difficult to compare LOS if patients had an expectation of staying at least one night. There were no postoperative complications in the study; however, the study was not powered to detect a significant difference between complications in each group. This is the first study to evaluate the use of an evidence-based program of perioperative care and evaluate patient reported outcomes in an elective cosmetic surgery practice. Subsequent studies should be powered to detect 30-day outcome differences in homogenous patient groups including LOS, complications, and readmission. Defining discharge criteria, measuring quantitative oral morphine equivalent of opiate use between groups, and using a standardized patient survey to limit the questionnaire bias would improve the ability to compare groups. Baseline patient comorbidities, functional status, and previous opiate use should be defined, and a description of the “standard” non-ERAS postoperative care plan should be described. Future studies need to include more patients to determine if there is a true difference in LOS, 30 day complications, as well as readmission rates. There are national and international ERAS societies which champion the goal of evaluating and disseminating the best evidence-based protocols in different fields of surgical practice.8 In addition to the program outlined by the authors, several other elements could be considered for inclusion. Avoidance of intraoperative hypothermia in patients undergoing body contouring procedures may decrease anesthesia recovery.9 Further studies are needed to determine whether avoiding perioperative hypothermia can decrease surgical site infections.10,11 Carbohydrate loading in the form of hydrating sports drinks and nutritional supplements have been shown to decrease insulin resistance and prevent dehydration, and patients are encouraged to drink up until 2 hours before the procedure.12 Optimizing perioperative intravenous fluids by avoiding over hydration and under resuscitation has been shown to decrease postoperative ileus rates and hasten bowel recovery.13 The standardization of intravenous antibiotic prophylaxis as well as venous thromboembolism prophylaxis is important in decreasing postoperative complications. Perioperative steroids reduce nausea, vomiting, and pain postoperatively; however, discharging a patient with a methylprednisolone dose pack for 6 days is not typically a standard recommendation. Now more than ever, patients are becoming informed consumers, and they are holding providers and healthcare organizations accountable for high-value care which maximizes quality and reduces cost. It remains to be shown that ERAS affects direct variable cost per case between cohorts that were included in this study, and subsequent studies with greater numbers of patients receiving the same procedures are warranted; geographical variation in costs would need to be considered. Accurate determination of cost is important in understanding the true value of an ERAS program. Healthcare institutions are now evaluated based on the value of care that they provide, and this information is increasingly available to consumers. Patients will be able to transparently evaluate the quality of surgical procedures and their cost. The adoption of evidence-based best practice has been slow to be incorporated across disciplines.14 It is important that we work with our colleagues that influence perioperative care including anesthesia, surgery, nursing, social services, and physical therapy to implement evidence-based best practice to maximize the value for our patients. ERAS for different surgical procedures places the patient and family at the center of care, and enhances the patient experience and the perception of value. Lastly, ERAS offers yet another way to respond to the opiate crisis epidemic. Programs that are able to effectively use multidisciplinary and multimodal pain regimens that decreased perioperative use of narcotics will greatly benefit patients in the long run. The authors should be commended because they have shown that an enhanced recovery after surgery program can be implemented for elective cosmetic surgery in the outpatient setting. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Kehlet H . Multimodal approach to control postoperative pathophysiology and rehabilitation . Br J Anaesth . 1997 ; 78 ( 5 ): 606 - 617 . Google Scholar CrossRef Search ADS PubMed 2. Kehlet H , Mogensen T . Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme . Br J Surg . 1999 ; 86 ( 2 ): 227 - 230 . Google Scholar CrossRef Search ADS PubMed 3. Greco M , Capretti G , Beretta L , Gemma M , Pecorelli N , Braga M . Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials . World J Surg . 2014 ; 38 ( 6 ): 1531 - 1541 . Google Scholar CrossRef Search ADS PubMed 4. Nicholson A , Lowe MC , Parker J , Lewis SR , Alderson P , Smith AF . Systematic review and meta-analysis of enhanced recovery programmes in surgical patients . Br J Surg . 2014 ; 101 ( 3 ): 172 - 188 . Google Scholar CrossRef Search ADS PubMed 5. Beverly A , Kaye AD , Ljungqvist O , Urman RD . Essential elements of multimodal analgesia in enhanced recovery after surgery (ERAS) guidelines . Anesthesiol Clin . 2017 ; 35 ( 2 ): e115 - e143 . Google Scholar CrossRef Search ADS PubMed 6. Bartlett EL , Zavlin D , Friedman JD , Abdollahi A , Rappaport NH . Enhanced recovery after surgery: the plastic surgery paradigm shift . Aesthet Surg J . 2018 ; 38 ( 6 ); 676 - 685 . 7. Batdorf NJ , Lemaine V , Lovely JK et al. Enhanced recovery after surgery in microvascular breast reconstruction . J Plast Reconstr Aesthet Surg . 2015 ; 68 ( 3 ): 395 - 402 . Google Scholar CrossRef Search ADS PubMed 8. Temple-Oberle C , Shea-Budgell MA , Tan M et al. ; ERAS Society . Consensus review of optimal perioperative care in breast reconstruction: enhanced recovery after surgery (ERAS) society recommendations . Plast Reconstr Surg . 2017 ; 139 ( 5 ): 1056e - 1071e . Google Scholar CrossRef Search ADS PubMed 9. Bayter-Marin JE , Cárdenas-Camarena L , Durán H , Valedon A , Rubio J , Macias AA . Effects of thermal protection in patients undergoing body contouring procedures: a controlled clinical trial . Aesthet Surg J . 2018 ; 38 ( 4 ): 448 - 456 . Google Scholar CrossRef Search ADS PubMed 10. Kurz A , Sessler DI , Lenhardt R . Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of wound infection and temperature group . N Engl J Med . 1996 ; 334 ( 19 ): 1209 - 1215 . Google Scholar CrossRef Search ADS PubMed 11. Constantine RS , Kenkel M , Hein RE et al. The impact of perioperative hypothermia on plastic surgery outcomes: a multivariate logistic regression of 1062 cases . Aesthet Surg J . 2015 ; 35 ( 1 ): 81 - 88 . Google Scholar CrossRef Search ADS PubMed 12. Bilku DK , Dennison AR , Hall TC , Metcalfe MS , Garcea G . Role of preoperative carbohydrate loading: a systematic review . Ann R Coll Surg Engl . 2014 ; 96 ( 1 ): 15 - 22 . Google Scholar CrossRef Search ADS PubMed 13. Brandstrup B , Tønnesen H , Beier-Holgersen R et al. ; Danish Study Group on Perioperative Fluid Therapy . Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial . Ann Surg . 2003 ; 238 ( 5 ): 641 - 648 . Google Scholar CrossRef Search ADS PubMed 14. Ljungqvist O , Scott M , Fearon KC . Enhanced recovery after surgery: a review . JAMA Surg . 2017 ; 152 ( 3 ): 292 - 298 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Commentary on: Enhanced Recovery After Surgery: The Plastic Surgery Paradigm Shift

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Oxford University Press
Copyright
© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
ISSN
1090-820X
eISSN
1527-330X
D.O.I.
10.1093/asj/sjx270
Publisher site
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Abstract

There has been a tremendous culture shift in the perioperative care of surgical patients with the introduction of enhanced recovery after surgery (ERAS), championed by Henik Kehlet, MD.1 Kehlet and colleagues reported a reduction in the length of stay (LOS) and complications in patients undergoing complex colorectal surgery by implementing a multidisciplinary approach to perioperative care focused on reducing the physiologic stress of surgery. Key tenets included patient education, a multimodal pain strategy limiting opiates, early ambulation, and early feeding to hasten recovery.2 The authors reported LOS of 2 days. These results were almost unbelievable and quite provocative. However, this work has been replicated with numerous high-quality, randomized control trials and meta-analysis comparing ERAS to standard perioperative care. Results have consistently shown a decrease in LOS, reduction in complications, and no increase in 30 day readmissions.3,4 Although the original studies concentrated on colon and rectal surgery, the application of ERAS has expanded to almost every other discipline of surgery. ERAS programs incorporate the best available evidence-based care plans to maximize outcomes, minimize waste and complications, and optimize the patient experience. Some of the most important tenets in any perioperative program include patient preparation with counseling/education of the surgical experience and avoidance of opiates. Measuring the value of each individual item of an ERAS program is challenging; although, when used together, there is a significant improvement in patient outcomes. ERAS program implementation requires coordination of care that historically has been compartmentalized. The preoperative, intraoperative, and postoperative care must be coordinated using a multidisciplinary and multimodal approach. ERAS programs have not been widely implemented because of the considerable operational challenges. The ERAS society publishes evidence-based guidelines detailing components of optimal perioperative care which is used as a resource for starting an ERAS program.5 The current study demonstrates that the same ideas of evidence-based perioperative surgical care can be adopted and employed for patients undergoing cosmetic elective surgery. This prospective study compared outcomes of 22 patients undergoing a variety of elective cosmetic surgical procedures (ranging from breast surgeries to trunk and facial procedures) treated with an ERAS program vs a standard pathway.6 Ten patients were treated with an ERAS defined perioperative program and 12 were patients treated with standard perioperative practice. The aim of the study was to compare short-term (2 week) outcomes between groups. The ERAS program included preoperative, preemptive analgesia and antiemetic therapy including celecoxib, gabapentin, and ondansetron. Intraoperative elements included weight-based dosing of fentanyl and propofol, as well as use of dexamethasone and promethazine suppository. Patients were given local anesthetic blocks and received intravenous acetaminophen prior to the conclusion of the operation. Postoperatively the patients were given a multimodal pain regimen which included gabapentin, celecoxib, scopolamine patch for indicated procedures, and acetaminophen use for breakthrough pain. Patients in the control arm were given narcotics as needed. Patients in the ERAS group were given a 6-day course of postoperative steroids in the form of a methylprednisolone dose pack. The patients were then surveyed daily with a study questionnaire until the first postoperative office visit (>POD 7) inquiring about pain scores, nausea/vomiting, fatigue/drowsiness, constipation, and hindrance to ambulate. Patients in the ERAS program were more likely to be ready for discharge at 23 hours, had significantly less pain, less nausea/vomiting of postoperative 1 and 2, no fatigue/drowsiness after surgery, and improved ability to ambulate. Only one patient required narcotics postoperatively. The majority of the short-term outcome improvements were thought to be related to narcotic avoidance in the ERAS group. The multimodal pain strategy in the ERAS cohort was very effective in avoiding narcotics with only one patient taking tramadol postoperatively. As the authors pointed out, the study cohort is quite small due to limitations by the institutional review board, and this limited the ability to detect true differences between groups. The short follow up of 2 weeks is too short to capture perioperative complications. The study questionnaire used is not a validated instrument and can add bias. The study included diverse surgical procedures and techniques introducing differences between groups. Recent studies evaluating ERAS programs have had primary outcomes including LOS, complications, and readmission.7 The authors report a shorter length of stay in the ERAS group; however, in the methods section it states a one night stay is included in the “cosmetic surgery package.” As a surrogate for LOS, patients were asked about reluctance to discharge. Therefore, it is difficult to compare LOS if patients had an expectation of staying at least one night. There were no postoperative complications in the study; however, the study was not powered to detect a significant difference between complications in each group. This is the first study to evaluate the use of an evidence-based program of perioperative care and evaluate patient reported outcomes in an elective cosmetic surgery practice. Subsequent studies should be powered to detect 30-day outcome differences in homogenous patient groups including LOS, complications, and readmission. Defining discharge criteria, measuring quantitative oral morphine equivalent of opiate use between groups, and using a standardized patient survey to limit the questionnaire bias would improve the ability to compare groups. Baseline patient comorbidities, functional status, and previous opiate use should be defined, and a description of the “standard” non-ERAS postoperative care plan should be described. Future studies need to include more patients to determine if there is a true difference in LOS, 30 day complications, as well as readmission rates. There are national and international ERAS societies which champion the goal of evaluating and disseminating the best evidence-based protocols in different fields of surgical practice.8 In addition to the program outlined by the authors, several other elements could be considered for inclusion. Avoidance of intraoperative hypothermia in patients undergoing body contouring procedures may decrease anesthesia recovery.9 Further studies are needed to determine whether avoiding perioperative hypothermia can decrease surgical site infections.10,11 Carbohydrate loading in the form of hydrating sports drinks and nutritional supplements have been shown to decrease insulin resistance and prevent dehydration, and patients are encouraged to drink up until 2 hours before the procedure.12 Optimizing perioperative intravenous fluids by avoiding over hydration and under resuscitation has been shown to decrease postoperative ileus rates and hasten bowel recovery.13 The standardization of intravenous antibiotic prophylaxis as well as venous thromboembolism prophylaxis is important in decreasing postoperative complications. Perioperative steroids reduce nausea, vomiting, and pain postoperatively; however, discharging a patient with a methylprednisolone dose pack for 6 days is not typically a standard recommendation. Now more than ever, patients are becoming informed consumers, and they are holding providers and healthcare organizations accountable for high-value care which maximizes quality and reduces cost. It remains to be shown that ERAS affects direct variable cost per case between cohorts that were included in this study, and subsequent studies with greater numbers of patients receiving the same procedures are warranted; geographical variation in costs would need to be considered. Accurate determination of cost is important in understanding the true value of an ERAS program. Healthcare institutions are now evaluated based on the value of care that they provide, and this information is increasingly available to consumers. Patients will be able to transparently evaluate the quality of surgical procedures and their cost. The adoption of evidence-based best practice has been slow to be incorporated across disciplines.14 It is important that we work with our colleagues that influence perioperative care including anesthesia, surgery, nursing, social services, and physical therapy to implement evidence-based best practice to maximize the value for our patients. ERAS for different surgical procedures places the patient and family at the center of care, and enhances the patient experience and the perception of value. Lastly, ERAS offers yet another way to respond to the opiate crisis epidemic. Programs that are able to effectively use multidisciplinary and multimodal pain regimens that decreased perioperative use of narcotics will greatly benefit patients in the long run. The authors should be commended because they have shown that an enhanced recovery after surgery program can be implemented for elective cosmetic surgery in the outpatient setting. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Kehlet H . Multimodal approach to control postoperative pathophysiology and rehabilitation . Br J Anaesth . 1997 ; 78 ( 5 ): 606 - 617 . Google Scholar CrossRef Search ADS PubMed 2. Kehlet H , Mogensen T . Hospital stay of 2 days after open sigmoidectomy with a multimodal rehabilitation programme . Br J Surg . 1999 ; 86 ( 2 ): 227 - 230 . Google Scholar CrossRef Search ADS PubMed 3. Greco M , Capretti G , Beretta L , Gemma M , Pecorelli N , Braga M . Enhanced recovery program in colorectal surgery: a meta-analysis of randomized controlled trials . World J Surg . 2014 ; 38 ( 6 ): 1531 - 1541 . Google Scholar CrossRef Search ADS PubMed 4. Nicholson A , Lowe MC , Parker J , Lewis SR , Alderson P , Smith AF . Systematic review and meta-analysis of enhanced recovery programmes in surgical patients . Br J Surg . 2014 ; 101 ( 3 ): 172 - 188 . Google Scholar CrossRef Search ADS PubMed 5. Beverly A , Kaye AD , Ljungqvist O , Urman RD . Essential elements of multimodal analgesia in enhanced recovery after surgery (ERAS) guidelines . Anesthesiol Clin . 2017 ; 35 ( 2 ): e115 - e143 . Google Scholar CrossRef Search ADS PubMed 6. Bartlett EL , Zavlin D , Friedman JD , Abdollahi A , Rappaport NH . Enhanced recovery after surgery: the plastic surgery paradigm shift . Aesthet Surg J . 2018 ; 38 ( 6 ); 676 - 685 . 7. Batdorf NJ , Lemaine V , Lovely JK et al. Enhanced recovery after surgery in microvascular breast reconstruction . J Plast Reconstr Aesthet Surg . 2015 ; 68 ( 3 ): 395 - 402 . Google Scholar CrossRef Search ADS PubMed 8. Temple-Oberle C , Shea-Budgell MA , Tan M et al. ; ERAS Society . Consensus review of optimal perioperative care in breast reconstruction: enhanced recovery after surgery (ERAS) society recommendations . Plast Reconstr Surg . 2017 ; 139 ( 5 ): 1056e - 1071e . Google Scholar CrossRef Search ADS PubMed 9. Bayter-Marin JE , Cárdenas-Camarena L , Durán H , Valedon A , Rubio J , Macias AA . Effects of thermal protection in patients undergoing body contouring procedures: a controlled clinical trial . Aesthet Surg J . 2018 ; 38 ( 4 ): 448 - 456 . Google Scholar CrossRef Search ADS PubMed 10. Kurz A , Sessler DI , Lenhardt R . Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of wound infection and temperature group . N Engl J Med . 1996 ; 334 ( 19 ): 1209 - 1215 . Google Scholar CrossRef Search ADS PubMed 11. Constantine RS , Kenkel M , Hein RE et al. The impact of perioperative hypothermia on plastic surgery outcomes: a multivariate logistic regression of 1062 cases . Aesthet Surg J . 2015 ; 35 ( 1 ): 81 - 88 . Google Scholar CrossRef Search ADS PubMed 12. Bilku DK , Dennison AR , Hall TC , Metcalfe MS , Garcea G . Role of preoperative carbohydrate loading: a systematic review . Ann R Coll Surg Engl . 2014 ; 96 ( 1 ): 15 - 22 . Google Scholar CrossRef Search ADS PubMed 13. Brandstrup B , Tønnesen H , Beier-Holgersen R et al. ; Danish Study Group on Perioperative Fluid Therapy . Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial . Ann Surg . 2003 ; 238 ( 5 ): 641 - 648 . Google Scholar CrossRef Search ADS PubMed 14. Ljungqvist O , Scott M , Fearon KC . Enhanced recovery after surgery: a review . JAMA Surg . 2017 ; 152 ( 3 ): 292 - 298 . Google Scholar CrossRef Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Aesthetic Surgery JournalOxford University Press

Published: Jan 31, 2018

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