1
|
Biedrzycki G, Wolszczak-Biedrzycka B, Dorf J, Michalak D, Żendzian-Piotrowska M, Zalewska A, Maciejczyk M. The antiglycation potential of H1 receptor antagonists - in vitro studies in bovine serum albumin model and in silico molecular docking analyses. Biomed Pharmacother 2024; 175:116632. [PMID: 38663107 DOI: 10.1016/j.biopha.2024.116632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/17/2024] [Indexed: 06/03/2024] Open
Abstract
The H1 receptor belongs to the family of rhodopsin-like G-protein-coupled receptors activated by the biogenic amine histamine. H1 receptor antagonists are widely used in the treatment of allergies. However, these drugs could have a much broader spectrum of activity, including hypoglycemic effects, which can broaden the spectrum of their use. The aim of the study was to evaluate the antiglycation potential of twelve H1 receptor antagonists (diphenhydramine, antazoline, promethazine, ketotifen, clemastine, pheniramine, cetirizine, levocetirizine, bilastine, fexofenadine, desloratadine, and loratadine). Bovine serum albumin (BSA) was glycated with sugars (glucose, fructose, galactose, and ribose) and aldehydes (glyoxal and methylglyoxal) in the presence of H1 blockers. The tested substances did not induce a significant decrease in the content of albumin glycation end-products, and the inhibition rate of glycoxidation was not influenced by the chemical structure or generation of H1 blockers. None of the tested H1 receptor antagonists exhibited strong antiglycation activity. Antiglycemic potential of H1 blockers could be attributed to their antioxidant and anti-inflammatory activity, as well as their effects on carbohydrate metabolism/metabolic balance at the systemic level.
Collapse
Affiliation(s)
| | - Blanka Wolszczak-Biedrzycka
- Department of Psychology and Sociology of Health and Public Health, University of Warmia and Mazury in Olsztyn, Poland
| | - Justyna Dorf
- Department of Clinical Laboratory Diagnostics, Medical University of Bialystok, Poland
| | - Daniel Michalak
- "Biochemistry of Civilization Diseases" Student Scientific Club at the Department of Hygiene, Epidemiology and Ergonomics, Medical University of Bialystok, Poland
| | | | - Anna Zalewska
- Experimental Dentistry Laboratory, Medical University of Bialystok, ul. M. Sklodowskiej-Curie 24a, Bialystok 15-274, Poland
| | - Mateusz Maciejczyk
- Department of Hygiene, Epidemiology and Ergonomics, Medical University of Bialystok, Poland.
| |
Collapse
|
2
|
Leconte S, Valentin S, Dromelet E, De Jonghe M. Prolonged Cough in Pediatric Population First Line Care, Belgian Guidelines. Open Respir Med J 2017; 11:54-66. [PMID: 29081858 PMCID: PMC5633727 DOI: 10.2174/1874306401711010054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 07/31/2017] [Accepted: 07/31/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The clinical approach to a prolonged cough, i.e. a cough lasting more than three weeks, is challenging for general practitioners as well for primary care pediatricians. What the recommended clinical approach in primary care is, how cough duration or cough characteristics impact the diagnosis, and what the efficiency and safety of antibiotics or symptomatic treatments are remain in question for primary care physicians. OBJECTIVE The last Belgian guidelines were published in 2006 and needed to be reviewed. Those background questions were used to conduct our guideline updating procedure. METHODS We systematically performed a pyramidal literature search between the periods 2006-2014 in order to write evidence based guidelines. The data of the literature was summarized, discussed by the authors, experts and the Belgian primary care guidelines committee. Recommendations were formulated and scored following the GRADE classification. RESULTS The consultation history as well as the physical examination should be directed towards searching for warning signs (GRADE 1B) and towards the common etiologies depending on cough duration (GRADE 2C). If the cough lasts for more than eight weeks, chest radiography and spirometry should be considered (GRADE 2C). An antibiotic is recommended for a prolonged wet cough (over eight weeks) if prolonged bacterial bronchitis is suspected (GRADE 1B). In the absence of clinical signs of a specific etiology of a cough, no drug can be recommended (GRADE 1B). For all cases, it is initially suggested to avoid irritants (GRADE 1C) as well as to take into account the concerns of parents and inform them about the natural development of a cough. CONCLUSIONS More research is needed to provide evidence on the clinical pathway on prolonged cough for primary care. Cough duration of more than eight weeks and prolonged wet cough are the most useful cough characteristics. Regarding a specific cough treatment, no medication has proved any effect greater than placebo. Attention to environmental triggers and patient-centered care remain the keystones of interventions.
Collapse
Affiliation(s)
- Sophie Leconte
- Centre académique de médecine générale, Université catholique de Louvain, Bruxelles, Belgium
- Institut de Recherche santé et société, Université catholique de Louvain, Bruxelles, Belgium
| | - Stéphanie Valentin
- Centre académique de médecine générale, Université catholique de Louvain, Bruxelles, Belgium
| | - Estelle Dromelet
- Centre académique de médecine générale, Université catholique de Louvain, Bruxelles, Belgium
| | - Michel De Jonghe
- Centre académique de médecine générale, Université catholique de Louvain, Bruxelles, Belgium
| |
Collapse
|
3
|
Motola D, Donati M, Biagi C, Calamelli E, Cipriani F, Melis M, Monaco L, Vaccheri A, Ricci G. Safety profile of H1-antihistamines in pediatrics: an analysis based on data from VigiBase. Pharmacoepidemiol Drug Saf 2017; 26:1164-1171. [DOI: 10.1002/pds.4246] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 03/15/2017] [Accepted: 05/23/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Domenico Motola
- Unit of Pharmacology, Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| | - Monia Donati
- Unit of Pharmacology, Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| | - Chiara Biagi
- Unit of Pharmacology, Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| | - Elisabetta Calamelli
- Units of Pediatrics, Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| | - Francesca Cipriani
- Units of Pediatrics, Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| | - Mauro Melis
- Unit of Pharmacology, Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| | - Luca Monaco
- Unit of Pharmacology, Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| | - Alberto Vaccheri
- Unit of Pharmacology, Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| | - Giampaolo Ricci
- Units of Pediatrics, Department of Medical and Surgical Sciences; University of Bologna; Bologna Italy
| |
Collapse
|
4
|
Bergamini M, Kantar A, Cutrera R, Interest Group IPC. Analysis of the Literature on Chronic Cough in Children. Open Respir Med J 2017; 11:1-9. [PMID: 28553418 PMCID: PMC5427690 DOI: 10.2174/1874306401711010001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 12/25/2022] Open
Abstract
Throughout childhood, various developmental phenomena influence the cough reflex. Among these are the modifications in the anatomy and functions of the respiratory tract and the central and peripheral nervous systems. Moreover, after birth, the immunological response undergoes progressive transformations with the acquisition of immune memory processes. These conditions make infections and airway abnormalities the overwhelming cause of chronic cough in children and infants. In children, chronic cough should be treated on the basis of etiology. The aim of this article is to provide thorough research and analysis of the medical literature published up to 2014 on chronic cough in children as a disease entity, including the epidemiologic, etiologic, diagnostic, prognostic, and therapeutic aspects. Our results demonstrate differences in the definition of chronic cough, the characteristics of diagnostic procedures, study settings, and prevalence of the main causes. However, few studies regarding epidemiology and the quality of life have been reported. Many therapeutic approaches that are considered effective in adults with chronic cough seem to be less efficient in children. Regardless of the setting, whether pediatric or non-pediatric, children with chronic cough should be carefully evaluated using child-specific protocols and algorithms. Awareness of the various pathophysiological conditions associated with chronic cough is vital for making a correct diagnosis and providing appropriate treatment. The prevalence of the different causes of chronic cough depends on various issues. Among these are the population under consideration and its age range, infectious disease control and prevention, the diagnostic procedures employed, disease definition criteria, and the local health system. Clinical guidelines for the management of children with chronic cough should take these components into consideration. Further clinical and basic research studies are still needed for better diagnosis, treatment, and prevention of chronic cough in children.
Collapse
Affiliation(s)
| | - Ahmad Kantar
- Pediatric Cough and Asthma Centre, University and Research Hospitals, Istituti Ospedalieri Bergamaschi, Bergamo, Italy
| | - Renato Cutrera
- Respiratory Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Italian Pediatric Cough Interest Group
- Italian Pediatric Cough Interest Group: F. Antonelli (Department of Pediatric Pneumology, Santobono-Pausilipon Hospital, Naples, Italy), A. Barbato (Pediatrics Department, University of Padua, Padua, Italy), R. Bernardini (Pediatric Unit, San Giuseppe Hospital, Empoli, Italy), E. Bignamini (Pneumology Unit, AOU Città della Salute e della Scienza, Turin, Italy), F. Cardinale (Pediatric Unit, Division of Pulmonology, Allergy and Immunology, AOU “Policlinico-Giovanni XXIII”, Bari, Italy), S. Cazzato (Department of Pediatrics, University of Bologna, St. Orsola-Malpighi Hospital, Bologna, Italy), M. Ghezzi (Pediatric Pulmonary and Allergy Unit, Istituto Giannina Gaslini, Genoa, Italy), F. Midulla (Department of Pediatric Emergency, “Sapienza” University, Rome, Italy), M. Miraglia del Giudice (Department of Pediatrics, Second University of Naples, Naples, Italy), A. Novelli (Clinical Pharmacology and Oncology Section, University of Florence, Florence, Italy), V. Ragazzo (Pediatric Unit, San Giuseppe Hospital, Empoli, Italy), G.A. Rossi (Pediatric Pulmonary and Allergy Unit, Istituto Giannina Gaslini, Genoa, Italy), O. Sacco (Pediatric Pulmonary and Allergy Unit, Istituto Giannina Gaslini, Genoa, Italy), A. Saggin (School of Management, Bocconi University, Milan, Italy), B. Tagliaferri (Department of Radiology, Melloni University Hospital, Milan, Italy), G. Tancredi (Department of Pediatrics, “Sapienza” University, Rome, Italy), L. Terracciano (Department of Pediatrics, Melloni University Hospital, Milan, Italy), N. Ullmann (Respiratory Unit, Bambino Gesù Children's Hospital, Rome, Italy), A. Zanasi (Pneumology Unit, University of Bologna, S. Orsola Malpighi Hospital, Bologna, Italy)
| |
Collapse
|
5
|
Balbani APS. Cough: neurophysiology, methods of research, pharmacological therapy and phonoaudiology. Int Arch Otorhinolaryngol 2015; 16:259-68. [PMID: 25991944 PMCID: PMC4435438 DOI: 10.7162/s1809-97772012000200016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Accepted: 06/25/2011] [Indexed: 12/13/2022] Open
Abstract
Introduction: The cough is the more common respiratory symptom in children and adults. Objective: To present a revision on the neurophysiology and the methods for study of the consequence of the cough, as well as the pharmacotherapy and phonoaudiology therapy of the cough, based on the works published between 2005 and 2010 and indexed in the bases Medline, Lilacs and Library Cochrane under them to keywords “cough” or “anti-cough”. Synthesis of the data: The consequence of the cough involves activation of receiving multiples becomes vacant in the aerial ways and of neural projections of the nucleus of the solitary treatment for other structures of the central nervous system. Experimental techniques allow studying the consequence of the cough to the cellular and molecular level to develop new anti-cough agents. It does not have evidences of that anti-cough exempt of medical lapsing they have superior effectiveness to the one of placebo for the relief of the cough. The phonoaudiology therapy can benefit patients with refractory chronic cough to the pharmacological treatment, over all when paradoxical movement of the vocal folds coexists. Final Comments: The boarding to multidiscipline has basic paper in the etiological diagnosis and treatment of the cough. The otolaryngologist must inform the patients on the risks of the anti-cough of free sales in order to prevent adverse poisonings and effect, especially in children.
Collapse
|
6
|
Ates F, Vaezi MF. Approach to the patient with presumed extraoesophageal GERD. Best Pract Res Clin Gastroenterol 2013; 27:415-31. [PMID: 23998979 DOI: 10.1016/j.bpg.2013.06.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Revised: 06/27/2013] [Accepted: 06/28/2013] [Indexed: 01/31/2023]
Abstract
Reflux related cough, asthma and laryngitis are frequently encountered and are considered part of extraoesophageal syndromes. The diagnosis of extraoesophageal reflux is difficult due to the lack of gold standard diagnostic criteria. Esophagogastroduodenoscopy and esophageal pH monitoring are inadequate diagnostic tools for due to poor sensitivity and specificity. For this reason, empirical PPI therapy is recommended as an initial approach to diagnose and treat the potential underlying cause of these symptoms in patients without alarm symptoms. Diagnostic testing with esophageal pH and/or impedance monitoring and esophageal motility testing is usually reserved for those who continue to be symptomatic despite a trial of therapy with PPIs. Recent developments have increased our understanding of this difficult to treat group of patients but more research into reflux related extraoesophageal symptoms are needed to better diagnose and treat this group.
Collapse
Affiliation(s)
- Fehmi Ates
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Vanderbilt University Medical Center, C2104-MCN Nashville, TN, USA
| | | |
Collapse
|
7
|
Gyimesi E, Gönczi F, Szilasi M, Pál G, Baráth S, Sipka S. The effects of various doses of bacterial lipopolysaccharide on the expression of CD63 and the release of histamine by basophils of atopic and non-atopic patients. Inflamm Res 2012; 62:213-8. [PMID: 23109053 DOI: 10.1007/s00011-012-0569-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 09/15/2012] [Accepted: 10/18/2012] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE We tested the effect of various doses of bacterial lipopolysaccharide (LPS, endotoxin) on the expression of CD63 and the in vitro release of histamine by basophils stimulated with ragweed allergen in patients with or without ragweed and mite allergies. METHODS The peripheral blood of 11 patients with ragweed allergy, 10 patients with mite allergy and 14 control patients was incubated with ragweed allergen extract following pretreatment with varying doses of LPS. The expression of CD63 in basophils was measured by flow cytometry, and the release of histamine was determined by ELISA. RESULTS In the samples of patients with ragweed allergy that were exposed to specific allergen, only high doses of LPS significantly elevated the expression of CD63 (200 ng/ml; 1,000 EU/ml) and the release of histamine (2,000 ng/ml; 10,000 EU/ml). There was no effect of LPS in any other cases. CONCLUSIONS Bacterial LPS (endotoxin) concentrations higher than 200 ng/ml (1,000 EU/ml), which rarely occurs in nature, could only activate the basophils from atopic patients whilst in the presence of the specific allergen. Thus, the restoration of the urban, "microbe-poor" milieu with endotoxin (as LPS) can be a promising and harmless approach for allergy prevention.
Collapse
Affiliation(s)
- E Gyimesi
- Division of Clinical Immunology, Department of Medicine, Medical and Health Science Centre, University of Debrecen, Móricz Zs U. 22, Debrecen 4032, Hungary
| | | | | | | | | | | |
Collapse
|
8
|
Cough management: a practical approach. COUGH 2011; 7:7. [PMID: 21985340 PMCID: PMC3205006 DOI: 10.1186/1745-9974-7-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 10/10/2011] [Indexed: 12/13/2022]
Abstract
Cough is one of the most common symptoms for which patients seek medical attention from primary care physicians and pulmonologists. Cough is an important defensive reflex that enhances the clearance of secretions and particles from the airways and protects the lower airways from the aspiration of foreign materials. Therapeutic suppression of cough may be either disease-specific or symptom related. The potential benefits of an early treatment of cough could include the prevention of the vicious cycle of cough. There has been a long tradition in acute cough, which is frequently due to upper respiratory tract infections, to use symptom-related anti-tussives. Suppression of cough (during chronic cough) may be achieved by disease-specific therapies, but in many patients it is often necessary to use symptomatic anti-tussives, too. According to the current guidelines of the American College of Chest Physician on "Cough Suppressants and Pharmacologic Protussive Therapy" and additional clinical trials on the most frequent anti-tussive drugs, it should be possible to diagnose and treat cough successfully in a majority of cases. Among drugs used for the symptomatic treatment of cough, peripherally acting anti-tussives such as levodropropizine and moguisteine show the highest level of benefit and should be recommended especially in children. By improving our understanding of the specific effects of these anti-tussive agents, the therapeutic use of these drugs may be refined. The present review provides a summary of the most clinically relevant anti-tussive drugs in addition to their potential mechanism of action.
Collapse
|
9
|
Chang AB, Gibson PG, Willis C, Petsky HL, Widdicombe JG, Masters IB, Robertson CF. Do sex and atopy influence cough outcome measurements in children? Chest 2011; 140:324-330. [PMID: 21393395 DOI: 10.1378/chest.10-2507] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Despite the commonality of cough and its burden, there are no published data on the relationship between atopy or sex on objectively measured cough frequency or subjective cough scores in children. In 202 children with and without cough, we determined the effect of sex and atopy on validated cough outcome measurements (cough receptor sensitivity [CRS], objective cough counts, and cough scores). We hypothesized that in contrast to adult data, sex does not influence cough outcome measures, and atopy is not a determinant of these cough measurements. METHODS We combined data from four previous studies. Atopy (skin prick test), the concentration of capsaicin causing two and five or more coughs (C2 and C5, respectively), objectively measured cough frequency, and cough scores were determined and their relationship explored. The children's (93 girls, 109 boys) mean age was 10.6 years (SD 2.9), and 56% had atopy. RESULTS In multivariate analysis, CRS was influenced by age (C2 coefficient, 5.9; P = .034; C5 coefficient, 29.1; P = .0001). Atopy and sex did not significantly influence any of the cough outcomes (cough counts, C2, C5, cough score) in control subjects and children with cough. CONCLUSIONS Atopy does not influence important cough outcome measures in children with and without chronic cough. However, age, but not sex, influences CRS in children. Unlike adult data, sex does not affect objective counts or cough score in children with and without chronic cough. Studies on cough in children should be age matched, but matching for atopic status and sex is less important.
Collapse
Affiliation(s)
- Anne B Chang
- Queensland Children's Respiratory Centre and Children's Medical Research Institute, Royal Children's Hospital, Brisbane, QLD, Australia; Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
| | - Peter G Gibson
- Department of Respiratory Medicine, John Hunter Hospital, University of Newcastle, NSW, Australia
| | - Carol Willis
- Queensland Children's Respiratory Centre and Children's Medical Research Institute, Royal Children's Hospital, Brisbane, QLD, Australia
| | - Helen L Petsky
- Queensland Children's Respiratory Centre and Children's Medical Research Institute, Royal Children's Hospital, Brisbane, QLD, Australia
| | | | - I Brent Masters
- Queensland Children's Respiratory Centre and Children's Medical Research Institute, Royal Children's Hospital, Brisbane, QLD, Australia
| | - Colin F Robertson
- Department of Respiratory Medicine, Royal Children's Hospital, Melbourne, Murdoch Children's Research Institute, University of Melbourne, VIC, Australia
| |
Collapse
|
10
|
Russell K, Chang AB, Foisy M, Thomson D, Williams K. The Cochrane Library and the Treatment of Chronic Cough in Children: An Overview of Reviews. ACTA ACUST UNITED AC 2010. [DOI: 10.1002/ebch.585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
11
|
Huston SA, Porter KB, Clements T, Shepherd G. Pharmacists' attitudes towards pediatric cough and cold products and behind the counter status. J Pediatr Pharmacol Ther 2010; 15:126-37. [PMID: 22477803 PMCID: PMC3018184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Safety and efficacy issues regarding over-the-counter cough and cold (CAC) products for use in children have surfaced. Late in 2007 the FDA began reviewing CAC product status for use in children under 6 years old. OBJECTIVE In regards to CAC products for children < 6 years old, to determine pharmacists: 1) comfort level in recommending; 2) attitudes towards behind-the-counter (BTC) status; and 3) level of support for BTC status. An additional objective was to determine how frequently pharmacists were asked for CAC product recommendations for children METHODS Georgia Pharmacy Association members (2,045) were invited to anonymously participate in a self-administered online survey from January 3 - Feb 6, 2008. Topic areas included demographics, comfort in recommending CAC, and BTC status. RESULTS Most responding pharmacists (99.1%) feel pediatric CAC medicine safety problems are due to inappropriate use. More than 50% of chain and independent pharmacists were asked to recommend CAC medicines for children during cold/flu season once a day or less, and 79% reported counseling on less than 50% of total CAC sales. The majority of pharmacists felt comfortable recommending CAC medications when thinking of both safety and efficacy. Most pharmacists supported a BTC condition of sale for children under two for decongestants, antihistamines, and antitussives, and for decongestants and antitussives for children between 2 and 5 years old. CONCLUSIONS Most pharmacists indicate comfort in recommending CAC despite lack of evidence for safety or efficacy and support BTC status. Pharmacist education on this topic would be useful.
Collapse
Affiliation(s)
- Sally A. Huston
- University of Georgia, College of Pharmacy, Department of Clinical and Administrative Pharmacy
| | - Kalen B. Porter
- University of Georgia, College of Pharmacy, Department of Clinical and Administrative Pharmacy
| | - Tom Clements
- Northstar Healthcare Consulting, Atlanta, Georgia
| | - Greene Shepherd
- Clinical Pharmacy Program, Athens, Georgia
- Medical College of Georgia, Augusta, Georgia
| |
Collapse
|
12
|
|