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Abstract

Y. Chihara, H. Ono, T. Ishimitsu, Y. Ono, K. Ishikawa, H. Rakugi, T. Ogihara and H. Matsuoka

¹Department of Geriatric Medicine, Osaka University Graduate School of Medicine, Osaka, ²Department of Hypertension and Cardiorenal Medicine, ³Department of Pathology, Dokkyo University School of Medicine, Tochigi, Japan
Apoptotic glomerular cells have been detected in the severely damaged glomeruli that are a consequence of human IgA nephropathy. Transforming growth factor- (TGF) b1 is known to induce apoptosis in cultured mesangial cells. To clarify whether TGF-b1 contributes to the progression of IgA nephropathy by activating apoptosis in glomerular cells, we examined the expression of TGF-b1 gene and apoptotic changes in kidney biopsy samples, and assessed those relations to the severity of nephropathy. 32 patients with IgA nephropathy, showing proteinuria (> 1 g/day) and serum creatinine less than 1.5 mg/dl were classified according to glomerular sclerosis index (GSI) into 3 groups (Group I: GSI < 0.3, Group II: 0.3 £ GSI < 1.0, Group: III GSI ³ 1.0). Computer-aided morphometry of glomeruli and arteries, and terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling of fragmented DNA (TUNEL) staining were performed. Expression of TGF-b1 and caspase-3 mRNAs in renal biopsy samples was analyzed by real-time PCR (Taq Man method). Increased glomerular area, interstitial fibrosis, lymphocytic infiltration, and tubulointerstitial changes were observed to accompany increased severity of GSI. TUNEL index was higher in Group III. The levels of TGF-b1 and caspase-3 mRNAs were significantly increased in Group III (183 and 190%, respectively). Furthermore, caspase-3 mRNA levels were tightly associated with TGF-b1 mRNA expression (r = 0.677, p < 0.0001). The present study suggests that the activation of TGF-b1 plays a role in the progression of IgA nephropathy even in the moderate degree of glomerular injury, in part via activation of apoptosis of glomerular cells.Correspondence to:
H. Ono, MD, FAHA
Department of Hypertension and Cardiorenal Medicine
Dokkyo University School of Medicine
880 Kitakobayashi, Mibu, Tochigi, Japan 321-0293
Email: yukanachihara@geriat.med.osaka-u.ac.jp

Abstract

T.H. Westhoff, S. Schmidt, W. Zidek, J. Beige and M. van der Giet

¹Medical Clinic IV, Nephrology, Charité – Campus Benjamin Franklin, Berlin, ²Department of Nephrology, University-affiliated Hospital St. Georg, Leipzig, Germany
Background: Steroid resistance and steroid dependence constitute a major problem in the treatment of minimal-change disease and focal segmental glomerulosclerosis (FSGS). Cyclophosphamide and cyclosporine are well-established alternative immunomodulating agents, whereas data on FK 506 (tacrolimus) are rare. Methods: The present work provides data from 10 patients of an open, monocentric, non-randomized, prospective trial. Five patients with steroid-dependent minimal-change nephrotic syndrome, 1 patient with steroid-refractory minimal-change disease and 4 patients with steroid-refractory FSGS were started on tacrolimus at trough levels of 5 – 10 mg/l. In case of steroid-dependence, prednisolone was tapered off in presence of tacrolimus within one month. Results: Within 6 months, complete remission was achieved in 5 patients (50%) and partial remission in 4 patients (40%), yielding a final response rate of 90%. One patient was primarily resistent to tacrolimus (steroid-refractory minimal-change), another patient became secondarily resistant to tacrolimus after an initial remission (steroid-refractory FSGS). Average proteinuria significantly decreased by 77% from 9.5 ± 1.4 – 2.2 ± 1.1 g/day (p < 0.01). Serum protein significantly raised from 55.0 ± 1.9 – 64.6 ± 1.9 g/l (p < 0.01). Tacrolimus induced non-significant increases of blood glucose (4.9 ± 0.1 – 5.1 ± 0.2 mmol/l), systolic blood pressure (131.4 ± 7.1 – 139.0 ± 7.6 mmHg) and creatinine (93.2 ± 13.9 – 103.2 ± 15.3 mmol/l). Five patients have been tapered off tacrolimus so far, nephrotic syndrome relapsed in 4 of them (80%). Relapse occurred at tacrolimus levels between 2.6 and 6.9 ng/ml. Conclusions: Our data suggest that tacrolimus may be a promising alternative to cyclosporine both in steroid-resistant and steroid-dependent nephrotic syndrome.Correspondence to:
Dr. med. T.H. Westhoff
Charité – Campus Benjamin Franklin
Medizinische Klinik IV – Nephrologie
Hindenburgamm 30
12200 Berlin, Germany
Email: timm.westhoff@charite.de

Abstract

A.F. Yango, R.Y. Gohh, A.P. Monaco, S.E. Reinert, A. Gautam, L.D. Dworkin and P.E. Morrissey

¹Division of Hypertension and Renal Diseases, ²Department of Surgery, Brown University School of Medicine, Rhode Island Hospital, Providence and ³Lifespan Information Services, Rhode Island Hospital, Providence, RI, USA
Background: Successful renal transplantation in the elderly offers substantial benefits in quality and life expectancy. However, in this group of patients there is an early increased risk of death compared with those remaining on dialysis. Materials and methods: Graft and patient outcomes in 64 older transplant recipients were compared with 338 patients aged 18 – 59 years. We identified potential risk factors that may predict clinical outcomes in older transplant recipients. A log-rank test and Cox regression analyses were performed to assess the impact of various patient characteristics on graft and patient survival. Results: Among older patients, graft survival was 76.6% and 67% at 1 and 3 years, respectively. When graft survival was censored for death with functioning graft, the 1- and 3-year graft survival was 83% and 82%, respectively. Patient survival was 78% and 71% at 1 and 3 years, respectively. These survival rates were significantly lower than those of younger recipients. Pretransplant inactivity, delayed graft function, smoking history and longer waiting time predicted poor graft and patient survival. A history of chronic obstructive pulmonary disease, and peripheral vascular disease also predicted a higher mortality among older recipients. Conclusion: Older kidney transplant recipients are at high risk for allograft failure and early death. Poor functional capacity predicts a poor outcome for older patients undergoing renal transplantation. Therefore, careful patient selection is paramount, and every effort should be made to initiate timely interventions aimed at increasing physical activity in those with low fitness level. Correspondence to:
A.F. Yango, MD
Brown University School of Medicine
Rhode Island and The Miriam Hospitals
APC Building 9th Floor
593 Eddy Street
Providence, RI 02903, USA
Email: ayango@lifespan.org

Abstract

B. Thoma, V.K. Grover and A. Shoker

¹Division of Nephrology, ²Department of Community Health and Epidemiology, Royal University Hospital, ³Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
Aims: This study investigates the association between renal function and change in weight after kidney transplantation. Methods: Retrospective analyses of 165 transplant patients on maintenance steroids who were followed-up for 6.2 ± 2.4 years. Results: 101 males and 64 females participated in the study. Results are expressed as mean ± SD. At the first post-transplant outpatient visit (time 0), BMI was 25.3 ± 4.8 kg/m2. It increased significantly by 7.7 ± 10.8% and 10.9 ± 12.6% at 1 and 5 years. 18 and 29% of patients had a BMI > 30 kg/m2 at times 0 and 5 years, respectively. Thereafter, diminishing glomerular filtration rate (GFR) was associated with the loss of the excess weight. Multivariate analysis showed that GFR, but not age, race, sex, source of graft, number of HLA mismatches or length of dialysis was significant to post-transplant weight gain. 38 patients gained weight > 1 SD above the mean of the population and were designated the high weight gain (HWG) group. 41 patients gained weight < the mean – 1 SD of the population and were designated the low weight gain (LWG) group. GFR in the high and low weight gain groups at time 0 was 71.8 ± 20.3 ml/min/1.73 m2 and 66.4 ± 23.1 ml/min/1.73 m2, respectively (p = NS), as compared to 77.4 ± 23.3 ml/min/1.73 m2 and 61.5 ± 24.5 ml/min/1.73 m2 at 6 months, respectively (p < 0.01) and continued to be significant thereafter (72.7 ± 17.2 ml/min/1.73 m2 and 58.9 ± 19.8 ml/min/1.73 m2, p < 0.05 at 6 years). Conclusions: Patients with relatively better renal transplant function gained more weight, suggesting a pivotal role of improved appetite on weight gain post transplantation. Most of the weight gain occurred during the first year.Correspondence to:
A. Shoker, MD
Division of Nephrology
University of Saskatchewan
Royal University Hospital
103 Hospital Drive
Saskatoon, SK, S7N 0W8, Canada
Email: shoker@sask.usask.ca

Abstract

F. Tarrass, A. Yazidi, H. Sif, M. Zamd, M.G. Benghanem and B. Ramdani

Department of Nephrology and Dialysis, Ibn Rochd University Hospital Center, Casablanca, Morocco
Background: Secondary hyperparathyroidism, a major clinical problem in patients with chronic renal failure, develops in response to phosphate retention and impaired calcitriol [1,25-dihydroxyvitamin D3] synthesis. Vitamin D therapy, particularly alfacalcidol [1alpha-hydroxyvitamin D3], has been shown to be effective in the treatment of secondary hyperparathyroidism. The aim of this study was to compare the effect of a 12-week course of continuous versus intermittent oral alfacalcidol therapy on parathyroid hormone suppression. Patients and methods: 34 patients were selected and randomly divided into 2 groups to receive either intermittent or continuous oral alfacalcidol. Baseline data were obtained on serum calcium, phosphorus, alkaline phosphatase and PTH. All but the PTH were monitored monthly. PTH levels were measured again until the end of the protocol. The intervention was 2 µg of alfacalcidol given after each dialysis session (intermittent group) or 1 µg given 6 days/week (continuous group). Results: Serum calcium and phosphorus showed a tendency to increase from baseline levels in both groups. Mean PTH levels for both groups showed a progressive reduction over time during the study period. This decrement showed no significant difference with regard to the schedule of alfacalcidol administration when comparing the 2 groups. There also was no difference in the incidence of side effects – hypercalcemia and hyperphosphatemia – between the intermittent and continuous intervention. Conclusion: Feedback regulation of PTH with oral alfacalcidol therapy is efficient in the treatment of hyperparathyroidism. However, intermittent and continuous oral administration are equally effective in suppressing an elevated PTH level in hemodialysis patients, with similar safety margins.Correspondence to:
Dr. F. Tarrass
Salama 3, Gr 6, “B”, N° 21
20450 Casablanca, Morocco
Email: faissal76@hotmail.com

Abstract

P.-F. Chiou, C.-C. Chang, Y.-K. Wen and Y. Yang

Division of Nephrology, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan, R.O.C.
Background: In the hemodialytic population, infections are the second leading cause of death; access infections account for a large proportion of this mortality. The antibiotic lock technique has been applied to infected tunneled catheters as rescue or prophylaxis medication to reduce infection rates. In addition, application of topical antibiotic ointments to tunneled and non-tunneled catheters also prevents exit site infections. Methods: 17 patients with 25 catheters participated in our study from March 2004 – February 2005. The catheter lock comprised of mixed cefazolin (5 mg/dl) with heparin (2,500 IU/ml) and mupirocin was topically applied to the area (2 × 2 cm) surrounding the catheter exit site. Results: The catheter infection rate was reduced from 12.7 times/1,000 catheter days to 5.02 times/1,000 catheter days in patients with jugular vein catheters. The total catheter-related infection rate was 14.9 times/1,000 catheter days in the control group and 4.1 times/1,000 catheter days in the study group. The reduction in catheter infections was more evident in a subgroup of non-diabetic patients, and in those with femoral catheters. Conclusion: The use of antibiotic lock and topical antibiotics significantly reduces the incidence of temporary catheter-related infections, especially in non-diabetic patients and in those with femoral catheters. Correspondence to:
Dr. C.-C. Chang
Division of Nephrology
Department of Internal Medicine
Changhua Christian Hospital
135, Nan-Shiao Street
Changhua, Taiwan, R.O.C.
Email: 27509@cch.org.tw

Abstract

T. Kobayashi, Y. Ando, T. Umino, Y. Miyata, S. Muto, M. Hironaka, Y. Asano and E. Kusano

Department of Nephrology and Pathology, Jichi Medical School, Minamikawachi, Kawachi, Tochigi, Japan
We report a case of a 17-year-old male with relapse of minimal-change nephrotic syndrome (MCNS), in whom apheresis monotherapy without steroids or immunosuppressants resulted in complete remission. The patient initially developed nephrotic syndrome in February 1998. The first renal biopsy confirmed the diagnosis of MCNS. The patient was also found to be a carrier of hepatitis B virus. Steroid therapy was started with oral prednisolone 60 mg/day. Complete remission was achieved in 3 months, and the steroid treatment was tapered off in May 2001. During the steroid tapering, temporal exacerbation of liver function was noted. In July 2002, the patient was admitted to our hospital again due to relapse of nephrotic syndrome. Second biopsy reconfirmed the diagnosis of MCNS. Since the serum titer of HBV was elevated, apheresis monotherapy was selected to avoid the risk of steroid-induced fulminant hepatitis. Four sessions of low-density lipoprotein apheresis (LDL-A) and 5 sessions of double-filtration plasmapheresis (DFPP) reduced the proteinuria from 9.2 g/day to 0.2 g/day over 38 days without any additional medication. Proteinuria remained suppressed below 0.2 g/day for more than 12 months and no exacerbation of liver function was observed up to the final follow-up in September 2003. The present case suggested the potential of apheresis monotherapy to induce and maintain complete remission of MCNS and an important role of circulating factors in the pathogenesis of MCNS.Correspondence to:
Y. Ando, MD, PhD Department of Nephrology Jichi Medical School Minamikawachi Tochigi 329-0498, Japan
Email: nephando@jichi.ac.jp

Abstract

T. Kobayashi, S. Muto, J. Nemoto, Y. Miyata, S. Ishiharajima, M. Hironaka, Y. Asano and E. Kusano

Departments of ¹Nephrology and ²Pathology, Jichi Medical School, Shimotsuke, Tochigi, Japan
Tubulointerstitial nephritis is a well-recognized complication in primary Sjögrens syndrome. Fanconi’s syndrome is a far less frequent complication compared with distal tubular dysfunction. We here describe a 49-year-old woman with primary Sjögren’s syndrome. In 1997, she was diagnosed with primary Sjögren’s syndrome with tubulointerstitial nephritis, and was then treated with oral prednisolone for the tubulointerstitial nephritis. In 2002, she was referred to our hospital because of progressive fatigue. At that time, biclonal spike on serum protein (IgG-k and IgA-k) and Bence-Jones protein in urine were found. Bone marrow aspiration showed 1.0% plasma cell infiltration. Thus, a diagnosis of monoclonal gammopathy of undetermined significance (MGUS) was made. In 2004, she was again admitted to our hospital because of mild renal dysfunction and hypokalemia. Laboratory evaluation showed inappropriate, alkaline urine in hyperchloremic metabolic acidosis and a positive urine anion gap, indicating the presence of distal (Type 1) renal tubular acidosis (RTA). The urine concentration defect was also found. Further studies revealed proximal tubular dysfunction, including renal glycosuria, generalized aminoaciduria, phosphaturia, uricosuria and proximal RTA. The kidney biopsy represented diffuse and severe tubulointerstitial nephritis with dense infiltrates of lymphocytes and IgA and k light chain-positive plasma cells. No findings of multiple myeloma or malignant lymphoma were observed. In conclusion, our patient had Sjögren’s syndrome with MGUS and exhibited dysfunction of both proximal tubule (Fanconi’s syndrome) and distal tubule, which may be attributed to diffuse tubulointerstitial nephritis.Correspondence to:
S. Muto, MD, PhD
Department of Nephrology
Jichi Medical School
Shimotsuke, Tochigi 329-0498, Japan
Email: smuto@jichi.ac.jp

Abstract

C.-H. Wu, S.-F. Ko, C.-H. Lee, B.-C. Cheng, K.-T. Hsu, J.-B. Chen, Y.-S. Chien, C.-C. Yang, M.-C. Huang and F.-R. Chuang

¹Department of Internal Medicine, Division of Nephrology, ²Department of Radiology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
Renal vein thrombosis (RV Thromb) is a serious complication of nephrotic syndrome. Anticoagulation is usually recommended as the treatment of choice. This study reports 3 nephrotic patients diagnosed to have RVThromb combined with thromboembolic events. Low-molecular weight heparin (LMWHep) was given subcutaneously every 12 hours following the diagnosis of RVTromb, which continued at the outpatient clinic after an average of 11 in-hospital days. The patients visited the nephrology outpatient clinic every other week and underwent magnetic resonance image (MRI) studies at 6-week intervals for follow-up of patency of the involved renal vein. LMWHep was discontinued when MRI showed this patency. The average outpatient treatment period was 74 days. There was no recurrent RVThromb in the follow-up course of 6 months after discontinuation of LMWHep. Kidney function was preserved, as indicated by image studies and serial renal function tests. LMWHep produced a more predictable anti-coagulant effect, a superior bioavailability, a longer half-life and a dose-independent effect than unfractionated heparin and coumadin. These benefits made the outpatient treatment of RVThromb possible. Our report recommends outpatient treatment of RVThromb by LMWHep because it is feasible, effective and safe.Correspondence to:
F.-R. Chuang, MD Department of Internal Medicine Division of Nephrology Chang Gung Memorial Hospital 123 Ta Pei Road Niao Sung Hsiang, Kaohsiung Hsien, Taiwan
Email: vjf3@adm.cgmh.org.tw

Abstract

U. Janssen, K. Amann, J. Reumel, J. Boehm and W. Verbeek

¹Department of Cardiology, Nephrology and Intensive Care Medicine, ²Department of Hematology-Oncology and Gastroenterology, Krankenhaus St. Franziskus, Kliniken Maria Hilf, Mönchengladbach, ³Institute of Pathology, University of Freiburg, ⁴Institute of Pathology, University Erlangen-Nürnberg, Germany
Renal failure is rarely the presenting manifestation of non-Hodgkin’s lymphoma. We describe the unusual case of a patient who presented with uremia due to lymphomatous infiltration of the kidney by a low-grade T-cell lymphoma. The diagnosis of lymphoma was made by renal biopsy. Extrarenal nodular or extra-nodular involvement could not be detected. However, simultaneously, a lymphoplasmacytic lymphoma was found on bone marrow biopsy associated with IgM paraproteinemia. To our knowledge, this is the first report of a renal T-cell lymphoma associated with Waldenström’s macroglobulinemia.Correspondence to:
U. Janssen, MD
Innere Medizin II
Department of Cardiology, Nephrology and Intensive Care Medicine
Krankenhaus St. Franziskus
Kliniken Maria Hilf
Viersener Straße 450
41063 Mönchengladbach, Germany
Email: JanssenU@mariahilf.de

Abstract

K.P. Katopodis, C.G. Katsios, E.L. Koliousi, D.S. Nastos and K.C. Siamopoulos

Departments of ¹Nephrology and ²Surgery, University Hospital of Ioannina, Ioannina, Greece
We report on a case of life-threatening abdominal aorta hemorrhage following percutaneous renal biopsy. A 42-year-old woman with chronic kidney disease stage 2 and microscopic hematuria underwent a percutaneous renal biopsy to evaluate renal insufficiency. One hour following the biopsy procedure, she complained of an abdominal pain and developed signs of oligemic shock. In despite of 4 blood units transfusion, the patient continued to be in shock. She was transmitted urgently to the operating room without any other examinations (such as abdominal computer tomography) and underwent an emergency laparotomy. A transverse tear in the abdominal aorta was identified as the bleeding site, and after occlusion, the hemorrhage was stopped. The patient gradually recovered and she was discharged in good clinical condition after a few days.Correspondence to:
K.C. Siamopoulos, MD, MSc, FRSH Professor of Medicine/Nephrology Department of Internal Medicine Medical School, University of Ioannina 451 10 Ioannina, Greece
Email: ksiamop@cc.uoi.gr

Abstract

A. Huart, N. Kamar, J.M. Lanau, A. Dahmani, D. Durand and L. Rostaing

¹Nephrology, Hemodialysis and Multi-Organ Transplantation Department, CHU Rangueil, ²AIR, CHU Purpan, TSA Toulouse Cédex, France
Hypercalcemia is a frequent complication in chronic hemodialysis (CHD) patients. A rare cause of this condition is sarcoidosis, and has only been reported 6 times in CHD. Herein, we report on 3 cases of sarcoidosis-related hypercalcemia in CHD patients: an overt case, a probable case, and a recurrence of pre-dialysis sarcoidosis. Hypercalcemia is a frequent complication in chronic hemodialysis patients: it is often related to uncontrollable secondary hyperparathyroidism or to the inappropriate use of calcium phosphate binders, 1a-hydroxylated vitamin D metabolites, high dialysate calcium concentrations, or to aluminium-related bone disease [Uach and Bover 1996]. However, other rare causes should also be considered, such as multiple myeloma, non-Hodgkin lymphoma [Uach and Bover 1996], vitamin A intoxication [Fishbane et al. 1995], or granulomatous diseases such as sarcoidosis. The latter has only been described in a total of 6 hemodialysis patient reports [Barbour et al. 1981, Barnard et al. 2002, Herrero et al. 1998, Kalantar-Zadeh et al. 1994, Kuwae et al. 2003, Naito et al. 1999]. In the present paper, we report on 3 cases of sarcoidosis-related hypercalcemia in chronic hemodialysis patients with 3 different patterns, i.e. overt sarcoidosis, probable sarcoidosis, and recurrence of pre-dialysis sarcoidosis.
Correspondence to:
L. Rostaing, MD, PhD
Nephrology, Hemodialysis and Multi-Organ Transplantation Department
CHU Rangueil, TSA 50032
31059-Toulouse Cédex 9, France
Email: rostaing.l@chu-toulouse.fr

Abstract

J.A. Stevenson, J.L. Jurado, D.D. Belli and S.J. Horton

¹Brownwood Renal Care Center, Brownwood, TX, ²Angelo Dialysis Centers, San Angelo, TX, ³Division of Pathology and ⁴Division of Gastroenterology, Brownwood Regional Medical Center, Brownwood, TX, USA
Peritonitis of enteric origin may occur during treatment with peritoneal dialysis due to visceral perforation or injury or, in the absence of perforation, due to transmural migration of enteric bacteria across the bowel wall into the peritoneal cavity. To the best of our knowledge, peritonitis has not previously been reported associated with carcinomatous colon polyp in the absence of bowel wall perforation. We describe the case of a 31-year-old female who experienced recurring episodes of enteric peritonitis associated with a clinically occult adenocarcinoma of the colon, without having any other known risk factors for peritonitis. A 15 mm carcinomatous polyp was not visible on CT scan but was found at colonoscopy with polypectomy. She proceeded to transverse colectomy; the resected colon showed no evidence of bowel wall perforation. This case demonstrates that a non-perforating carcinomatous polyp of the colon may predispose to enteric peritonitis in the setting of peritoneal dialysis, and it emphasizes the importance of making an aggressive search for underlying pathology, in patients who present with recurring enteric peritonitis or unusual presentations of enteric peritonitis.Correspondence to:
J.A. Stevenson, MD Brownwood Renal Care Center 118A South Park Drive Brownwood, TX 76801, USA
Email: jstevenson@wtkidney.com

Abstract

V. Suresh, R.J. McGonigle, P.A. Rowe and W.Y. Tse

Department of Renal Medicine, Level ⁰³, Derriford Hospital, Plymouth, United Kingdom
Various infective complications associated with dialysis catheter infection have been reported in the literature previously. We report a case of a hemodialysis patient presented with confusion and dysarthria secondary to Staphylococcus aureus septicemia and meningitis originating from a tunneled catheter used for providing dialysis. Blood cultures from the periphery, central venous catheter and culture of the line tip grew methicillin-sensitive Staphylococcus aureus. Lumbar puncture after CT brain confirmed Staphylococcus aureus. He was treated with high dose of an appropriate parenteral antibiotic and also removal of the infected line. In spite of optimal treatment, he died 15 days following his admission. The ideal option will be to use a definitive access like a fistula or AV graft, but in practice a significant proportion of hemodialysis patients is dialyzed with temporary or tunneled catheters all over the world, and infection poses a serious threat to dialysis patients resulting in significant mortality and morbidity. In patients with dialysis catheter-related sepsis, removal of the infected catheters and appropriate antibiotic treatment will prevent serious metastatic complications. Planning definitive access well ahead in chronic kidney disease patients and minimizing the use of temporary access is the only way forward.Correspondence to:
Dr. V. Suresh
Department of Renal Medicine
Level 03, Derriford Hospital
Plymouth, PL6 8DH, United Kingdom
Email: vijayansuresh@hotmail.com

Abstract

F.-X. Huber, L. Herzog and P.J. Meeder

Abstract

L. Grcevska, S. Dzikova, G. Petrusevska and M. Polenakovic

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Volume 65, No. 6/2006(June)