1
|
Wu S, Jia W, Lu Y, Jiang H, Huang C, Tang S, Du L. Mechanism and bioinformatics analysis of the effect of berberine-enhanced fluconazole against drug-resistant Candida albicans. BMC Microbiol 2024; 24:196. [PMID: 38849761 PMCID: PMC11157861 DOI: 10.1186/s12866-024-03334-0] [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: 08/19/2023] [Accepted: 05/16/2024] [Indexed: 06/09/2024] Open
Abstract
Biofilms produced by Candida albicans present a challenge in treatment with antifungal drug. Enhancing the sensitivity to fluconazole (FLC) is a reasonable method for treating FLC-resistant species. Moreover, several lines of evidence have demonstrated that berberine (BBR) can have antimicrobial effects. The aim of this study was to clarify the underlying mechanism of these effects. We conducted a comparative study of the inhibition of FLC-resistant strain growth by FLC treatment alone, BBR treatment alone, and the synergistic effect of combined FLC and BBR treatment. Twenty-four isolated strains showed distinct biofilm formation capabilities. The antifungal effect of combined FLC and BBR treatment in terms of the growth and biofilm formation of Candida albicans species was determined via checkerboard, time-kill, and fluorescence microscopy assays. The synergistic effect of BBR and FLC downregulated the expression of the efflux pump genes CDR1 and MDR, the hyphal gene HWP1, and the adhesion gene ALS3; however, the gene expression of the transcriptional repressor TUP1 was upregulated following treatment with this drug combination. Furthermore, the addition of BBR led to a marked reduction in cell surface hydrophobicity. To identify resistance-related genes and virulence factors through genome-wide sequencing analysis, we investigated the inhibition of related resistance gene expression by the combination of BBR and FLC, as well as the associated signaling pathways and metabolic pathways. The KEGG metabolic map showed that the metabolic genes in this strain are mainly involved in amino acid and carbon metabolism. The metabolic pathway map showed that several ergosterol (ERG) genes were involved in the synthesis of cell membrane sterols, which may be related to drug resistance. In this study, BBR + FLC combination treatment upregulated the expression of the ERG1, ERG3, ERG4, ERG5, ERG24, and ERG25 genes and downregulated the expression of the ERG6 and ERG9 genes compared with fluconazole treatment alone (p < 0.05).
Collapse
Affiliation(s)
- Sitong Wu
- Department of Laboratory Medicine, Key Laboratory of Precision Medicine for Viral Diseases, Guangxi Health Commission Key Laboratory of Clinical Biotechnology, Liuzhou People's Hospital, Liu Zhou, 545006, China
| | - Wei Jia
- Ningxia Key Laboratory of Clinical and Pathogenic Microbiology, The General Hospital of Ningxia Medical University, Yinchuan, 750004, Ningxia, China
| | - Yu Lu
- Department of Laboratory Medicine, Key Laboratory of Precision Medicine for Viral Diseases, Guangxi Health Commission Key Laboratory of Clinical Biotechnology, Liuzhou People's Hospital, Liu Zhou, 545006, China
| | - Hongkun Jiang
- Department of Laboratory Medicine, Key Laboratory of Precision Medicine for Viral Diseases, Guangxi Health Commission Key Laboratory of Clinical Biotechnology, Liuzhou People's Hospital, Liu Zhou, 545006, China
| | - Chunlan Huang
- Department of Laboratory Medicine, Key Laboratory of Precision Medicine for Viral Diseases, Guangxi Health Commission Key Laboratory of Clinical Biotechnology, Liuzhou People's Hospital, Liu Zhou, 545006, China
| | - Shifu Tang
- Department of Laboratory Medicine, Key Laboratory of Precision Medicine for Viral Diseases, Guangxi Health Commission Key Laboratory of Clinical Biotechnology, Liuzhou People's Hospital, Liu Zhou, 545006, China
| | - Le Du
- Department of Laboratory Medicine, Key Laboratory of Precision Medicine for Viral Diseases, Guangxi Health Commission Key Laboratory of Clinical Biotechnology, Liuzhou People's Hospital, Liu Zhou, 545006, China.
| |
Collapse
|
2
|
Zhang W, Zhang Q, Cao Z, Zheng L, Hu W. Physiologically Based Pharmacokinetic Modeling in Neonates: Current Status and Future Perspectives. Pharmaceutics 2023; 15:2765. [PMID: 38140105 PMCID: PMC10747965 DOI: 10.3390/pharmaceutics15122765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/07/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023] Open
Abstract
Rational drug use in special populations is a clinical problem that doctors and pharma-cists must consider seriously. Neonates are the most physiologically immature and vulnerable to drug dosing. There is a pronounced difference in the anatomical and physiological profiles be-tween neonates and older people, affecting the absorption, distribution, metabolism, and excretion of drugs in vivo, ultimately leading to changes in drug concentration. Thus, dose adjustments in neonates are necessary to achieve adequate therapeutic concentrations and avoid drug toxicity. Over the past few decades, modeling and simulation techniques, especially physiologically based pharmacokinetic (PBPK) modeling, have been increasingly used in pediatric drug development and clinical therapy. This rigorously designed and verified model can effectively compensate for the deficiencies of clinical trials in neonates, provide a valuable reference for clinical research design, and even replace some clinical trials to predict drug plasma concentrations in newborns. This review introduces previous findings regarding age-dependent physiological changes and pathological factors affecting neonatal pharmacokinetics, along with their research means. The application of PBPK modeling in neonatal pharmacokinetic studies of various medications is also reviewed. Based on this, we propose future perspectives on neonatal PBPK modeling and hope for its broader application.
Collapse
Affiliation(s)
| | | | | | - Liang Zheng
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (W.Z.); (Q.Z.); (Z.C.)
| | - Wei Hu
- Department of Clinical Pharmacology, The Second Affiliated Hospital of Anhui Medical University, Hefei 230601, China; (W.Z.); (Q.Z.); (Z.C.)
| |
Collapse
|
3
|
Hu C, Xu Z, Huang Z, Wang R, Zhang Y, Mao Z. Synthesis and Antifungal Evaluation of New Azole Derivatives against Candida albicans. ACS Med Chem Lett 2023; 14:1448-1454. [PMID: 37849555 PMCID: PMC10577697 DOI: 10.1021/acsmedchemlett.3c00361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/29/2023] [Indexed: 10/19/2023] Open
Abstract
In this study, we designed and prepared a series of new azole derivatives by recombination of fluconazole (FLC) and ketoconazole units, and in vitro antifungal activities against Candida albicans were evaluated. The results indicated that most azoles showed good antifungal activity against the drug-sensitive C. albicans strain, especially compounds 6a, 6e, 6n, 6p, 6r, 6s, 6t, and 6v, which displayed better antifungal activity (MIC50 < 1.0 μg/mL) than FLC against SC5314. The further mechanism study showed that compound 6r could significantly inhibit the formation of C. albicans biofilm, increase the permeability of the cell membrane, reduce the ergosterol level of the cell membrane, damage the membrane structure, and destroy the integrity of the cell structure to exert excellent antifungal activity. Subsequently, a molecular docking study indicated that azole compounds could inhibit cytochrome P450 14α-demethylase (CYP51). Therefore, these azole derivatives can be considered as potent antifungal drugs to treat fungal infections.
Collapse
Affiliation(s)
| | | | - Zhengxiao Huang
- School of Chinese Materia
Medica, Yunnan University of Chinese Medicine, Kunming 650500, China
| | - Ruirui Wang
- School of Chinese Materia
Medica, Yunnan University of Chinese Medicine, Kunming 650500, China
| | - Yi Zhang
- School of Chinese Materia
Medica, Yunnan University of Chinese Medicine, Kunming 650500, China
| | - Zewei Mao
- School of Chinese Materia
Medica, Yunnan University of Chinese Medicine, Kunming 650500, China
| |
Collapse
|
4
|
Abstract
Extremely preterm infants are particularly vulnerable to systemic infections secondary to their immature immune defenses, prolonged hospitalizations, delays in enteral feeding, early antibiotic exposure, and need for life-sustaining invasive interventions. There have been several evidence-based practices for infection prevention in this population, such as human milk feedings, utilization of "bundle checklists" and decolonization of pathogenic organisms. Other practices, such as the use of probiotics, human milk-derived fortifiers, and antifungal prophylaxis are more controversial and require further investigation regarding the risks and benefits of such interventions. This chapter examines the susceptibility of the preterm newborn infant to invasive infections and describes several strategies for infection prevention, along with the associated limitations of such practices. It also addresses the various gaps in our understanding of preventing infections in this population, and the need for additional large multi-center randomized controlled trials. Additionally, the role of the SARs-CoV-2 global pandemic and associated strategies for infection prevention in the NICU are discussed.
Collapse
|
5
|
Koklu E, Kalay S, Koklu S, Ariguloglu EA. Fluconazole administration leading to anaphylactic shock in a preterm newborn. Neonatal Netw 2018; 33:83-5. [PMID: 24589899 DOI: 10.1891/0730-0832.33.2.83] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Preterm infants, born with immature innate immunity, are less likely to develop anaphylaxis. Fluconazole prophylaxis during the first six weeks of life decreases invasive candidiasis in very low birth weight infants. Adverse effects of fluconazole are very rare. In this study, we report a newborn (a male, 26 weeks gestation and 900 g birth weight) who developed anaphylaxis after fluconazole administration. Hypotension and erythematous rash were present. We believe this to be the first anaphylaxis case in newborns caused by fluconazole in literature. Clinicians should be aware of the possibility of this potentially fatal adverse effect occurring with intravenous fluconazole.
Collapse
|
6
|
Lee J, Kim HS, Shin SH, Choi CW, Kim EK, Choi EH, Kim BI, Choi JH. Efficacy and safety of fluconazole prophylaxis in extremely low birth weight infants: multicenter pre-post cohort study. BMC Pediatr 2016; 16:67. [PMID: 27184665 PMCID: PMC4869366 DOI: 10.1186/s12887-016-0605-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 05/11/2016] [Indexed: 12/02/2022] Open
Abstract
Background There have been many studies supporting fluconazole prophylaxis in preterm infants for prevention of invasive fungal infections (IFIs). However, the routine use of fluconazole prophylaxis in neonatal intensive care units (NICUs) raises concerns with respect to resistance development, including the selection of resistant Candida species. We aimed to evaluate the efficacy and safety of fluconazole prophylaxis in extremely low birth weight (ELBW) infants. Methods An interventional pre-post cohort study at two tertiary NICUs was conducted. Data from two 5-year periods with and without fluconazole prophylaxis (Mar 2008–Feb 2013 and Mar 2003–Feb 2008) was compared. Prophylactic fluconazole was administered starting on the 3rd day at a dose of 3 mg/kg twice a week for 4 weeks during the prophylaxis period. Results The fluconazole prophylaxis group consisted of 264 infants, and the non-prophylaxis group consisted of 159 infants. IFI occurred in a total of 19 neonates (4.7 %) during the 10-year study period. Fluconazole prophylaxis lower the fungal colonization rate significantly (59.1 % vs. 33.9 %, P <0.001). However, the incidence of IFIs in ELBW infants was not reduced after fluconazole prophylaxis (4.4 % vs. 5.5 %, P = 0.80). Rather, although the increase did not reach statistical significance, fluconazole prophylaxis tended to increase the incidence of invasive infections involving fluconazole-resistant C. parapsilosis (0 % vs. 41.7 %, P = 0.11). Conclusions Fluconazole prophylaxis was not efficacious in decreasing IFIs in ELBW infants. There is a need for targeting prophylaxis to greatest risk population and prospective studies to measure the long-term effect of fluconazole prophylaxis on the emergence of organisms with antifungal resistance. Electronic supplementary material The online version of this article (doi:10.1186/s12887-016-0605-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Juyoung Lee
- Department of Pediatrics, Inha University School of Medicine, 100 Inharo, Incheon, Nam-gu, 22212, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University Children`s Hospital, 101 Daehak-ro, Seoul, Jongno-gu, 03080, Korea. .,Department of Pediatrics, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Jongno-gu, 03080, Korea.
| | - Seung Han Shin
- Department of Pediatrics, Seoul National University Children`s Hospital, 101 Daehak-ro, Seoul, Jongno-gu, 03080, Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Jongno-gu, 03080, Korea.,Department of Pediatrics, Seoul National University Bundang Hospital, 82, Gumi-ro 173, Bundang-gu, Seongnam, Gyeonggi, 13620, Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University Children`s Hospital, 101 Daehak-ro, Seoul, Jongno-gu, 03080, Korea
| | - Eun Hwa Choi
- Department of Pediatrics, Seoul National University Children`s Hospital, 101 Daehak-ro, Seoul, Jongno-gu, 03080, Korea.,Department of Pediatrics, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Jongno-gu, 03080, Korea
| | - Beyong Il Kim
- Department of Pediatrics, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Jongno-gu, 03080, Korea.,Department of Pediatrics, Seoul National University Bundang Hospital, 82, Gumi-ro 173, Bundang-gu, Seongnam, Gyeonggi, 13620, Korea
| | - Jung-Hwan Choi
- Department of Pediatrics, Seoul National University Children`s Hospital, 101 Daehak-ro, Seoul, Jongno-gu, 03080, Korea.,Department of Pediatrics, Seoul National University College of Medicine, 103 Daehak-ro, Seoul, Jongno-gu, 03080, Korea
| |
Collapse
|
7
|
Manzoni P, Mostert M, Castagnola E. Update on the management of Candida infections in preterm neonates. Arch Dis Child Fetal Neonatal Ed 2015; 100:F454-9. [PMID: 25605617 DOI: 10.1136/archdischild-2012-303350] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/24/2014] [Indexed: 11/03/2022]
Abstract
Invasive fungal infections in preterm neonates in the neonatal intensive care unit are predominantly caused by Candida spp, and have a high burden of morbidity and mortality. Effective prophylactic strategies have recently become available, but the identification of the best possible strategies to manage high-risk infants is still a priority. Choice and use of appropriate antifungal drugs needs careful assessment of neonatal characteristics, the epidemiology and drug pharmacokinetics. Ideally, antifungal drugs for preterm neonates should target fungal bio-films, prevent or effectively treat end-organ localisations, be active against fluconazole-resistant Candida species, and have reliable safety and tolerability profiles. The paper reviews the state-of-the-art in the area of neonatal fungal infections, and addresses some open questions related to the best possible prophylactic and therapeutic strategies to be implemented in such unique patients.
Collapse
Affiliation(s)
- P Manzoni
- Department of Neonatology and NICU, S. Anna Hospital, Torino, Italy
| | - M Mostert
- Department of Pediatrics, University of Torino, Torino, Italy
| | - E Castagnola
- Infectious Disease Unit, Istituto Giannina Gaslini, Genova, Italy
| |
Collapse
|
8
|
Metsvaht T, Nellis G, Varendi H, Nunn AJ, Graham S, Rieutord A, Storme T, McElnay J, Mulla H, Turner MA, Lutsar I. High variability in the dosing of commonly used antibiotics revealed by a Europe-wide point prevalence study: implications for research and dissemination. BMC Pediatr 2015; 15:41. [PMID: 25880733 PMCID: PMC4407781 DOI: 10.1186/s12887-015-0359-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Accepted: 03/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic dosing in neonates varies between countries and centres, suggesting suboptimal exposures for some neonates. We aimed to describe variations and factors influencing the variability in the dosing of frequently used antibiotics in European NICUs to help define strategies for improvement. METHODS A sub-analysis of the European Study of Neonatal Exposure to Excipients point prevalence study was undertaken. Demographic data of neonates receiving any antibiotic on the study day within one of three two-week periods from January to June 2012, the dose, dosing interval and route of administration of each prescription were recorded. The British National Formulary for Children (BNFC) and Neofax were used as reference sources. Risk factors for deviations exceeding ±25% of the relevant BNFC dosage recommendation were identified by multivariate logistic regression analysis. RESULTS In 89 NICUs from 21 countries, 586 antibiotic prescriptions for 342 infants were reported. The twelve most frequently used antibiotics - gentamicin, penicillin G, ampicillin, vancomycin, amikacin, cefotaxime, ceftazidime, meropenem, amoxicillin, metronidazole, teicoplanin and flucloxacillin - covered 92% of systemic prescriptions. Glycopeptide class, GA <32 weeks, 5(th) minute Apgar score <5 and geographical region were associated with deviation from the BNFC dosage recommendation. While the doses of penicillins exceeded recommendations, antibiotics with safety concerns followed (gentamicin) or were dosed below (vancomycin) recommendations. CONCLUSIONS The current lack of compliance with existing dosing recommendations for neonates needs to be overcome through the conduct of well-designed clinical trials with a limited number of antibiotics to define pharmacokinetics/pharmacodynamics, efficacy and safety in this population and by efficient dissemination of the results.
Collapse
Affiliation(s)
- Tuuli Metsvaht
- Institute of Microbiology, Tartu University, Tartu, Estonia. .,Clinic of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia.
| | - Georgi Nellis
- Institute of Microbiology, Tartu University, Tartu, Estonia. .,Children's Clinic, Tartu University Hospital, Tartu, Estonia.
| | - Heili Varendi
- Children's Clinic, Tartu University Hospital, Tartu, Estonia.
| | - Anthony J Nunn
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - Susan Graham
- Research and Development, Liverpool women's NHS Foundation Trust, Liverpool, UK.
| | - Andre Rieutord
- Pharmacy Department, Hospital Antoine Beclère, Paris, France.
| | - Thomas Storme
- Pharmacy Department, APHP, Hospital Robert Debré, Paris, France.
| | - James McElnay
- Clinical and Practice Research Group, School of Pharmacy, Queen's University Belfast, Belfast, UK.
| | - Hussain Mulla
- Department of Pharmacy, University Hospitals of Leicester, Leicester, UK.
| | - Mark A Turner
- Department of Women's and Children's Health, Institute of Translational Medicine, Liverpool Women's NHS Foundation Trust, University of Liverpool, Liverpool, UK.
| | - Irja Lutsar
- Institute of Microbiology, Tartu University, Tartu, Estonia.
| |
Collapse
|
9
|
Abstract
BACKGROUND Invasive fungal infections cause excessive morbidity and mortality in premature neonates and severely ill infants. METHODS Safety and efficacy outcomes of micafungin were compared between prematurely and non-prematurely born infants <2 years of age. Data were obtained from all completed phase I-III clinical trials with micafungin that had enrolled infants (<2 years of age) that were listed in the Astellas Clinical Study Database. Demographics, adverse events, hepatic function tests and treatment success data were extracted and validated by the Astellas biostatistical group for all micafungin-treated patients, <2 years of age, using the unique patient identifier. RESULTS One-hundred and sixteen patients included in 9 clinical trials, 48% premature [birth weight (BW) <2500 g and/or gestational age <37 weeks], 52% non-premature, received ≥ 1 dose of micafungin. Among premature patients, 14.5% were low BW (1500-2499 g), 36.4% very low BW (1000-1499 g) and 49.1% extremely low BW (<1000 g). Ninety patients (78%) completed the studies; 13 [11% (4 premature)] died. Significantly more non-premature than premature patients discontinued treatment (P = 0.003). Treatment-related adverse events were recorded in 23% of patients with no difference between groups. More extremely low BW (n = 4, 15%) and very low BW (n = 8, 40%) infants experienced treatment-related adverse events than low BW (n = 0) and there was no relation to micafungin dose or duration. For a subgroup of 30 patients with invasive candidiasis, treatment success was achieved in 73% in both premature and non-premature groups. Prophylaxis was successful in 4/5 non-premature hematopoietic stem cell transplant patients. CONCLUSION Micafungin has a safe profile in premature and non-premature infants with substantial efficacy.
Collapse
|
10
|
Costa S, Barone G, Vento G, Tirone C, Perelli S, Romagnoli C. Adrenocortical insufficiency is not a problem in preterm infants treated with antifungal prophylaxis with fluconazole. Acta Paediatr 2014; 103:e234-7. [PMID: 24575768 DOI: 10.1111/apa.12613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 02/24/2014] [Indexed: 11/30/2022]
Abstract
AIM Fluconazole prophylaxis of invasive fungal infections is a cornerstone of neonatal care, but in vitro studies have shown that it inhibits corticosteroid production. This study assessed whether preterm infants demonstrated an association between fluconazole administration, and its duration, and symptoms of adrenocortical insufficiency. METHODS We compared two groups who were treated before and after we introduced the use of fluconazole to our neonatal intensive care unit. Infants with a gestational age of ≤27 weeks or with a birth weight of ≤750 g were considered for the retrospective analysis. In order to assess whether the duration of prophylaxis was related to adrenocortical insufficiency, regression models were performed in all preterm infants in the fluconazole group. RESULTS The fluconazole group (n = 37) and nonfluconazole group (n = 41) were compared. No differences were found in the percentage of infants with symptoms of adrenocortical insufficiency, such as hypotension or need of vasopressor therapy. The incidence of hypotension and the use of vasopressor therapy were not related to duration of fluconazole prophylaxis. CONCLUSION Fluconazole and it duration were not associated with the incidence of symptoms related to adrenocortical insufficiency. Further prospective trials are needed to better define the relationship between fluconazole and adrenocortical insufficiency.
Collapse
Affiliation(s)
- S Costa
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
| | - G Barone
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
| | - G Vento
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
| | - C Tirone
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
| | - S Perelli
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
| | - C Romagnoli
- Division of Neonatology; Department of Pediatrics; Catholic University of Sacred Heart; Rome Italy
| |
Collapse
|