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Heneghan LJ, Tsang A, Dimino C, Khandji AG, Panigrahi SK, Page-Wilson G. Ropinirole for the Treatment of Hyperprolactinemia: A Dose-Escalation Study of Efficacy and Tolerability. J Clin Endocrinol Metab 2024; 109:e667-e674. [PMID: 37715962 PMCID: PMC10795899 DOI: 10.1210/clinem/dgad545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/03/2023] [Accepted: 09/14/2023] [Indexed: 09/18/2023]
Abstract
CONTEXT Treatment of hyperprolactinemia with ergoline dopamine agonists (DAs) can be complicated by intolerance and resistance. OBJECTIVE This study examines the efficacy and tolerability of the nonergot DA ropinirole for the long-term treatment of hyperprolactinemia. METHODS Twelve hyperprolactinemic women were treated with ropinirole in a 6-month, open-label, dose-escalation trial; 7 of the 12 continued treatment in an extension study for up to 17 months. Ropinirole doses were uptitrated to achieve normal prolactin (PRL) levels, restore menses, and eliminate galactorrhea. RESULTS Two of the 12 participants were DA naive; 6 of 12 were ergot DA intolerant; and 1 of 12 had known ergot DA resistance. Baseline PRL levels were 126.2 ± 41.4 ng/mL (SEM). Ropinirole was uptitrated from 0.125 to 0.25 mg/h to a median total daily dose (TDD) of 2 mg/d (1-4 mg/d [interquartile range]). PRL normalization was achieved in 50% of the participants (5 with microadenomas and 1 with idiopathic hyperprolactinemia) at a median effective TDD of 1 mg/d. Of the patients achieving PRL normalization, 83% were ergot DA intolerant. A persistent partial biochemical response (PRL reduction >50% from baseline) was achieved in 17% of the participants. During treatment, menses resumed in 67% of amenorrheic patients; galactorrhea resolved in 67%. Mild adverse effects were reported in 92% of participants; however, ropinirole was not discontinued because of intolerance even among the 50% of individuals with a prior history of ergot DA intolerance and resultant medication discontinuation. CONCLUSION These data demonstrate the efficacy and tolerability of ropinirole for the treatment of hyperprolactinemia in patients with microprolactinomas and idiopathic hyperprolactinemia and suggest ropinirole may represent a novel therapeutic alternative for treating hyperprolactinemic disorders in patients with ergot DA intolerance.
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Affiliation(s)
- Liam J Heneghan
- Department of Medicine, Columbia University, Vagelos College of P&S, New York, NY 10032, USA
| | - Amanda Tsang
- Department of Medicine, Columbia University, Vagelos College of P&S, New York, NY 10032, USA
| | - Cara Dimino
- Department of Medicine, Columbia University, Vagelos College of P&S, New York, NY 10032, USA
| | - Alexander G Khandji
- Department of Radiology, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Sunil K Panigrahi
- Department of Medicine, Columbia University, Vagelos College of P&S, New York, NY 10032, USA
| | - Gabrielle Page-Wilson
- Department of Medicine, Columbia University, Vagelos College of P&S, New York, NY 10032, USA
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Jahani Kondori M, Kolla BP, Moore KM, Mansukhani MP. Management of Restless Legs Syndrome in Pregnancy and Lactation. J Prim Care Community Health 2021; 11:2150132720905950. [PMID: 32054396 PMCID: PMC7025421 DOI: 10.1177/2150132720905950] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Restless legs syndrome (RLS) affects about 20% of all pregnant women. RLS symptoms are usually moderate to severe in intensity during pregnancy and can result in insomnia, depression, and other adverse outcomes. Although iron deficiency has been implicated as a potential etiological factor, other mechanisms can also play a role. Nonpharmacologic methods are the primary recommended form of treatment for RLS in pregnancy and lactation. Iron supplementation may be considered when the serum ferritin is low; however, several patients are unable to tolerate iron or have severe symptoms despite oral iron replacement. Here, we describe a case of severe RLS in pregnancy and illustrate the dilemmas in diagnosis and management. We review the literature on the prevalence, diagnosis, course, possible underlying pathophysiologic mechanisms and complications of RLS in pregnancy. We describe current best evidence on the efficacy, and safety of nonpharmacologic therapies, oral and intravenous iron supplementation, as well as other medication treatments for RLS in pregnancy and lactation. We highlight gaps in the literature and provide a practical guide for the clinical management of RLS in pregnancy and during breastfeeding.
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Garbazza C, Manconi M. Management Strategies for Restless Legs Syndrome/Willis-Ekbom Disease During Pregnancy. Sleep Med Clin 2018; 13:335-348. [PMID: 30098751 DOI: 10.1016/j.jsmc.2018.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Restless legs syndrome/Willis-Ekbom disease is a common disorder during pregnancy that may significantly impact on the health of affected women, leading to negative consequences in the short and long term. An accurate diagnosis helps to recognize the syndrome and choose the optimal therapeutic strategy, based on the characteristics and needs of the patient. This article summarizes the main treatment options recommended by the consensus clinical guidelines of the International Restless Legs Syndrome Study Group and provides a short guide to the management of restless leg syndrome during pregnancy in clinical practice.
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Affiliation(s)
- Corrado Garbazza
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano (EOC), Via Tesserete 46, Lugano CH-6903, Switzerland.
| | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano (EOC), Via Tesserete 46, Lugano CH-6903, Switzerland
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Gupta R, Dhyani M, Kendzerska T, Pandi-Perumal SR, BaHammam AS, Srivanitchapoom P, Pandey S, Hallett M. Restless legs syndrome and pregnancy: prevalence, possible pathophysiological mechanisms and treatment. Acta Neurol Scand 2016; 133:320-9. [PMID: 26482928 DOI: 10.1111/ane.12520] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2015] [Indexed: 02/01/2023]
Abstract
Restless legs syndrome (RLS) is a common sleep disorder that may be associated with pregnancy. Studies have found that the prevalence of RLS among pregnant women ranged from 10 to 34%. Typically, there is complete remission of symptoms soon after parturition; however, in some patients, they may continue postpartum. RLS has been shown to be associated with a number of complications in pregnancy including preeclampsia and increased incidence of Cesarean sections. Although multiple hypotheses have been proposed to explain this association, each individual hypothesis cannot completely explain the whole pathogenesis. Present understanding suggests that a strong family history, low serum iron and ferritin level, and high estrogen level during pregnancy might play important roles. Vitamin D deficiency and calcium metabolism may also play a role. Medical treatment of RLS during pregnancy is difficult and challenging considering the risks to mother and fetus. However, in some cases, the disease may be severe enough to require treatment.
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Affiliation(s)
- R. Gupta
- Department of Psychiatry and Sleep Clinic; Himalayan Institute of Medical Sciences; Dehradun India
| | - M. Dhyani
- Department of Psychiatry and Sleep Clinic; Himalayan Institute of Medical Sciences; Dehradun India
| | - T. Kendzerska
- Institute for Clinical Evaluative Sciences; Sunnybrook Health Sciences Center; Toronto ON Canada
| | | | - A. S. BaHammam
- Department of Medicine; The University Sleep Disorders Center; College of Medicine; King Saud University; Riyadh Saudi Arabia
- Strategic Technologies Program of the National Plan for Sciences, Technology and Innovation Riyadh; Riyadh Saudi Arabia
| | - P. Srivanitchapoom
- Human Motor Control Section; National Institute of Neurological Disorders and Stroke; National Institutes of Health; Bethesda MD USA
- Department of Medicine; Faculty of Medicine; Siriraj Hospital Mahidol University; Bangkok Thailand
| | - S. Pandey
- Govind Ballabh Pant Institute of Postgraduate Medical Education & Research; New Delhi India
| | - M. Hallett
- Human Motor Control Section; National Institute of Neurological Disorders and Stroke; National Institutes of Health; Bethesda MD USA
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Meharaban Z, Yahya S, Sadegniiat K. Restless Legs Syndrome During Pregnancy and Preterm Birth in Women Referred to Health Centers of Ardabil. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e24438. [PMID: 26756014 PMCID: PMC4706982 DOI: 10.5812/ircmj.24438] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 08/15/2015] [Accepted: 09/08/2015] [Indexed: 02/07/2023]
Abstract
Background: The physiological changes of pregnancy may predispose females to develop restless legs syndrome (RLS). Studies evaluating outcomes of RLS symptoms in pregnancy are scarce. Objectives: We examined the risk of preterm birth in pregnant women with and without restless legs syndrome (RLS). Materials and Methods: A cohort study included 231 pregnant women attending Ardabil health care centers for prenatal care and delivery in the period of 2010, without any risk factors for preterm delivery and low birth weight. The instruments used were questionnaires about RLS, the Epworth sleepiness scale (ESS), demographic data, and hemoglobin values. Data were analyzed via SPSS software using descriptive statistics, the t-test, χ2, Fisher’s exact test, Pearson’s correlation, and the Mann-Whitney U test. Results: RLS complicated 43.7 percent of pregnancies. Sleepiness (ESS score > 8) was reported in 36.4% of the subjects with preterm birth and 35.9% of the term group. No significant correlation was found between the ESS score and the term and preterm groups (P = 0.843). The prevalence of preterm birth in the subjects with and without RLS was 69.7% and 30.3%, respectively: As a result, it significantly increased in the RLS group (P = 0.001). Conclusions: Pregnancies complicated by RLS are at increased risk for preterm birth. The improved sleep health of pregnant women could decrease pregnancy complications.
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Affiliation(s)
- Zahra Meharaban
- Department of Midwifery , Ardabil Branch, Islamic Azad University, Ardabil, IR Iran
- Corresponding Author: Zahra Meharaban, Department of Midwifery, Ardabil Branch, Islamic Azad University, Ardabil, IR Iran. Tel: +98-4517728024, Fax: +98-4517715514, E-mail:
| | - Somayeh Yahya
- Department of Midwifery, Rasht Branch, Islamic Azad University, Rasht, IR Iran
| | - Khosro Sadegniiat
- Occupational Sleep Research Center, Baharloo Hospital, Tehran University of Medical Sciences, Tehran, IR Iran
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Picchietti DL, Hensley JG, Bainbridge JL, Lee KA, Manconi M, McGregor JA, Silver RM, Trenkwalder C, Walters AS. Consensus clinical practice guidelines for the diagnosis and treatment of restless legs syndrome/Willis-Ekbom disease during pregnancy and lactation. Sleep Med Rev 2014; 22:64-77. [PMID: 25553600 DOI: 10.1016/j.smrv.2014.10.009] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 10/27/2014] [Accepted: 10/28/2014] [Indexed: 11/30/2022]
Abstract
Restless legs syndrome (RLS)/Willis-Ekbom disease (WED) is common during pregnancy, affecting approximately one in five pregnant women in Western countries. Many report moderate or severe symptoms and negative impact on sleep. There is very little information in the medical literature for practitioners on the management of this condition during pregnancy. Accordingly, a task force was chosen by the International RLS Study Group (IRLSSG) to develop guidelines for the diagnosis and treatment of RLS/WED during pregnancy and lactation. A committee of nine experts in RLS/WED and/or obstetrics developed a set of 12 consensus questions, conducted a literature search, and extensively discussed potential guidelines. Recommendations were approved by the IRLSSG executive committee, reviewed by IRLSSG membership, and approved by the WED Foundation Medical Advisory Board. These guidelines address diagnosis, differential diagnosis, clinical course, and severity assessment of RLS/WED during pregnancy and lactation. Nonpharmacologic approaches, including reassurance, exercise and avoidance of exacerbating factors, are outlined. A rationale for iron supplementation is presented. Medications for RLS/WED are risk/benefit rated for use during pregnancy and lactation. A few are rated "may be considered" when RLS/WED is refractory to more conservative approaches. An algorithm summarizes the recommendations. These guidelines are intended to improve clinical practice and promote further research.
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Affiliation(s)
- Daniel L Picchietti
- University of Illinois College of Medicine at Urbana-Champaign and Carle Foundation Hospital, Urbana, IL, USA.
| | | | - Jacquelyn L Bainbridge
- Department of Clinical Pharmacy and Department of Neurology, University of Colorado Denver, Aurora, CO, USA
| | - Kathryn A Lee
- Department of Family Health Care Nursing, School of Nursing, University of California San Francisco, San Francisco, CA, USA
| | - Mauro Manconi
- Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital of Lugano, Lugano, Switzerland
| | - James A McGregor
- Department of Obstetrics and Gynecology, Women's and Children's Hospital, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Claudia Trenkwalder
- Paracelsus-Elena Hospital, Center of Parkinsonism and Movement Disorders, Kassel, Germany; Department of Neurosurgery, University Medical Center, Goettingen, Germany
| | - Arthur S Walters
- Department of Neurology Vanderbilt University School of Medicine, Nashville, TN, USA
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Abstract
OBJECTIVE This narrative review describes the differential diagnosis of restless legs syndrome, and provides an overview of the evidence for the associations between RLS and potential comorbidities. Secondary causes of RLS and the characteristics of pediatric RLS are also discussed. Finally, management strategies for RLS are summarized. METHODS The review began with a comprehensive PubMed search for 'restless legs syndrome/Willis-Ekbom disease' in combination with the following: anxiety, arthritis, attention-deficit hyperactivity disorder, cardiac, cardiovascular disease, comorbidities, depression, end-stage renal disease, erectile dysfunction, fibromyalgia, insomnia, kidney disease, liver disease, migraine, mood disorder, multiple sclerosis, narcolepsy, neuropathy, obesity, pain, Parkinson's disease, polyneuropathy, pregnancy, psychiatric disorder, sleep disorder, somatoform pain disorder, and uremia. Additional papers were identified by reviewing the reference lists of retrieved publications. RESULTS AND CONCLUSIONS Although clinical diagnosis of RLS can be straightforward, diagnostic challenges may arise when patients present with comorbid conditions. Comorbidities of RLS include insomnia, depressive and anxiety disorders, and pain disorders. Differential diagnosis is particularly important, as some of the medications used to treat insomnia and depression may exacerbate RLS symptoms. Appropriate diagnosis and management of RLS symptoms may benefit patient well-being and, in some cases, may lessen comorbid disease burden. Therefore, it is important that physicians are aware of the presence of RLS when treating patients with conditions that commonly co-occur with the disorder.
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Abstract
The significance for maternal and fetal health of gestational obstructive sleep apnea, primary insomnia, restless legs syndrome, and narcolepsy are summarized. The pathophysiology, signs, symptoms, and basic Sleep Medicine concepts that assist the obstetrician in suspecting these 4 conditions are described. Where appropriate, initial management options are also outlined. Referral guidelines to a Sleep Medicine specialist are included when further diagnostic, severity assessment, and management suggestions are needed.
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Nodine PM, Matthews EE. Common sleep disorders: management strategies and pregnancy outcomes. J Midwifery Womens Health 2013; 58:368-77. [PMID: 23855316 DOI: 10.1111/jmwh.12004] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Sleep disorders, prevalent in industrialized countries, are associated with adverse health outcomes such as hypertension, diabetes, and obesity. Disturbed sleep during pregnancy is frequently overlooked by health care providers, yet recent studies suggest there is an association between sleep disorders and adverse pregnancy outcomes, including preeclampsia, elevated serum glucose, depression, prolonged labor, and cesarean birth. Growing evidence indicates that the recognition and management of prenatal sleep disorders may minimize adverse pregnancy outcomes and improve maternal and fetal well-being. This focused review of prenatal sleep disturbance literature suggests there are 3 main sleep disorders of interest: breathing-related sleep disorders (ie, habitual snoring and obstructive sleep apnea), restless legs syndrome, and insomnia. These sleep disorders are common in pregnancy and have maternal and fetal consequences if left untreated. This article describes sleep disorders of pregnancy, elucidates their relationship with maternal and neonatal outcomes, and presents current evidence regarding diagnostic and management strategies.
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Affiliation(s)
- Priscilla M Nodine
- University of Colorado Denver, Campus, Anchutz Outpatient Pavilion, 1635 North Aurora Court, Aurora, CO 80045, USA.
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Zagouri F, Psaltopoulou T, Dimitrakakis C, Bartsch R, Dimopoulos MA. Challenges in managing breast cancer during pregnancy. J Thorac Dis 2013; 5 Suppl 1:S62-7. [PMID: 23819029 DOI: 10.3978/j.issn.2072-1439.2013.05.21] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 05/28/2013] [Indexed: 12/13/2022]
Abstract
Pregnancy-associated breast cancer (PABC) is defined as breast cancer occurring anytime during gestation, lactation or within one year after delivery. The optimal management of pregnant women with breast cancer is challenging and not well established; the main concern is the effect of the drugs on the developing fetus and long-term complications after in utero exposure to anti-cancer drugs. Surgical resection is the mainstay of treatment for early breast cancer diagnosed during pregnancy. Modified radical mastectomy is standard of care in first trimester, whereas breast-conserving surgery (lumpectomy with lymph node dissection) can be performed preferably in the second and third trimester. Of note, breast-conserving surgery is not contraindicated per se during the first trimester, but owing to the potential impact of delaying radiotherapy. Radiation therapy is not favored during pregnancy. Moreover, tamoxifen is contraindicated during pregnancy; the agent has been associated with birth defects in up to 20% of exposures. Chemotherapy is generally contraindicated during the first trimester because of the possible damage to organogenesis. Anthracyclines-based regimens are the most widely used is breast cancer treatment and were been shown to be associated with favourable safety profile when administered during pregnancy. As for taxanes, more limited data is available. The use of trastuzumab is contraindicated during pregnancy, given the apparent risk of oligo- and/or anhydramnios as well as the unknown long-term sequelae on the fetus. It is obvious that, diagnosis of breast cancer during pregnancy adds complexity to cancer treatment recommendations. In all cases, a multidisciplinary therapeutic approach among obstetricians, gynaecologists, surgical oncologists, radiation oncologists, medical oncologists, pediatricians and hematologists is clearly warranted.
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Affiliation(s)
- Flora Zagouri
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, University of Athens, Athens, Greece; ; Comprehensive Cancer Center Vienna, Department of Medicine I/Division of Oncology, Medical University of Vienna, Austria
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Fujii H, Goel A, Bernard N, Pistelli A, Yates LM, Stephens S, Han JY, Matsui D, Etwell F, Einarson TR, Koren G, Einarson A. Pregnancy outcomes following gabapentin use: results of a prospective comparative cohort study. Neurology 2013; 80:1565-70. [PMID: 23553472 DOI: 10.1212/wnl.0b013e31828f18c1] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Our objectives were to 1) determine whether first-trimester use of gabapentin is associated with an increased risk for major malformations; 2) examine rates of spontaneous abortions, therapeutic abortions, stillbirths, mean birth weight and gestational age at delivery; and 3) examine rates of poor neonatal adaptation syndrome following late pregnancy exposure. METHODS The study design was prospective. Women were included who initially contacted the services between 5 and 8 weeks with a comparison group of women exposed to nonteratogens, collected in a similar manner. RESULTS We have data on 223 pregnancy outcomes exposed to gabapentin and 223 unexposed pregnancies. The rates of major malformations were similar in both groups (p = 0.845). There was a higher rate of preterm births (p = 0.019) and low birth weight <2,500 g (p = 0.033) in the gabapentin group. Among infants who were exposed to gabapentin up until delivery, 23 of 61 (38%) were admitted to either the neonatal intensive care unit or special care nursery for observation and/or treatment, vs 6 of 201 (2.9%) live births in the comparison group (p < 0.001). There were 2 cases of possible poor neonatal adaptation syndrome in neonates exposed to gabapentin close to delivery, compared with none in the comparison group, although it must be noted that these infants were concomitantly exposed to other psychotropic drugs. Among the women who took gabapentin, the major indications were pain (n = 90; 43%) and epilepsy (n = 71; 34%); the remainder were for other indications, mostly psychiatric. CONCLUSION Our results suggest that although this sample size is not large enough to make any definitive conclusions, and there was no comparator group treated with other antiepileptic drugs, gabapentin use in pregnancy does not appear to increase the risk for major malformations. This finding and the increased risk for low birth weight and preterm birth require further investigation.
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Affiliation(s)
- Hisaki Fujii
- Motherisk Program, Department of Pediatrics, The Hospital for Sick Children, The University of Toronto, Canada
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BALENDRAN J, CHAMPION D, JAANISTE T, WELSH A. A common sleep disorder in pregnancy: Restless legs syndrome and its predictors. Aust N Z J Obstet Gynaecol 2011; 51:262-4. [DOI: 10.1111/j.1479-828x.2011.01294.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Deak MC, Winkelman JW. The Pharmacologic Management of Restless Legs Syndrome and Periodic Leg Movement Disorder. Sleep Med Clin 2010. [DOI: 10.1016/j.jsmc.2010.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Several kinds of evidence indicate that elevated iron during the 3-8 week embryonic (organogenesis) period of human gestation may be teratogenic. (1) In the embryonic period, the natural maternal absorption of food iron is 30% below the estimated daily iron loss. (2) As compared with maternal serum, embryonic fetal coelomic fluid contains only one-fourth as much iron but nearly six times the quantity of the iron withholding protein, ferritin. (3) In the embryonic period, intraplacental oxygen pressure is 2-3 times lower than in the subsequent fetal growth period. (4) Iron is a strong inducer of emesis which peaks in the embryonic period. (5) In a murine gestation model, iron was neurotoxic at a sharp peak of 8-9 days. Thus it would be prudent, in human pregnancy, to delay any needed iron supplementation until the embryonic period has been completed.
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Affiliation(s)
- E D Weinberg
- Department of Biology & Program in Medical Sciences, Indiana University, Bloomington, IN 47405, USA.
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