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Siglin J, Restrepo D. A Break in the Case: an Exercise in Clinical Reasoning. J Gen Intern Med 2024; 39:1515-1518. [PMID: 38499722 PMCID: PMC11169111 DOI: 10.1007/s11606-023-08572-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/05/2023] [Indexed: 03/20/2024]
Affiliation(s)
- Jonathan Siglin
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Gray 730, Boston, MA, 02114, USA.
| | - Daniel Restrepo
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St, Gray 730, Boston, MA, 02114, USA
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Hemilä H, Chalker E. Rebound effect explains the divergence in survival after 5 days in a controlled trial on vitamin C for COVID-19 patients. Front Med (Lausanne) 2024; 11:1391346. [PMID: 38841576 PMCID: PMC11151746 DOI: 10.3389/fmed.2024.1391346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 05/06/2024] [Indexed: 06/07/2024] Open
Affiliation(s)
- Harri Hemilä
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Elizabeth Chalker
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
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Hemilä H, de Man AME. Vitamin C deficiency can lead to pulmonary hypertension: a systematic review of case reports. BMC Pulm Med 2024; 24:140. [PMID: 38504249 PMCID: PMC10949735 DOI: 10.1186/s12890-024-02941-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 03/01/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND In the early literature, unintentional vitamin C deficiency in humans was associated with heart failure. Experimental vitamin C deficiency in guinea pigs caused enlargement of the heart. The purpose of this study was to collect and analyze case reports on vitamin C and pulmonary hypertension. METHODS We searched Pubmed and Scopus for case studies in which vitamin C deficiency was considered to be the cause of pulmonary hypertension. We selected reports in which pulmonary hypertension was diagnosed by echocardiography or catheterization, for any age, sex, or dosage of vitamin C. We extracted quantitative data for our analysis. We used the mean pulmonary artery pressure (mPAP) as the outcome of primary interest. RESULTS We identified 32 case reports, 21 of which were published in the last 5 years. Dyspnea was reported in 69%, edema in 53% and fatigue in 28% of the patients. Vitamin C plasma levels, measured in 27 cases, were undetectable in 24 and very low in 3 cases. Diet was poor in 30 cases and 17 cases had neuropsychiatric disorders. Right ventricular enlargement was reported in 24 cases. During periods of vitamin C deficiency, the median mPAP was 48 mmHg (range 29-77 mmHg; N = 28). After the start of vitamin C administration, the median mPAP was 20 mmHg (range 12-33 mmHg; N = 18). For the latter 18 cases, mPAP was 2.4-fold (median) higher during vitamin C deficiency. Pulmonary vascular resistance (PVR) during vitamin C deficiency was reported for 9 cases, ranging from 4.1 to 41 Wood units. PVR was 9-fold (median; N = 5) higher during vitamin C deficiency than during vitamin C administration. In 8 cases, there was direct evidence that the cases were pulmonary artery hypertension (PAH). Probably the majority of the remaining cases were also PAH. CONCLUSIONS The cases analyzed in our study indicate that pulmonary hypertension can be one explanation for the reported heart failure of scurvy patients in the early literature. It would seem sensible to measure plasma vitamin C levels of patients with PH and examine the effects of vitamin C administration.
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Affiliation(s)
- Harri Hemilä
- Department of Public Health, University of Helsinki, POB 41, Helsinki, FI-00014, Finland.
| | - Angelique M E de Man
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands.
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Kinlin LM, Weinstein M. Scurvy: old disease, new lessons. Paediatr Int Child Health 2023; 43:83-94. [PMID: 37795755 DOI: 10.1080/20469047.2023.2262787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/18/2023] [Indexed: 10/06/2023]
Abstract
Scurvy, the condition associated with severe vitamin C deficiency, is believed to be one of the oldest diseases in human history. It was particularly prevalent during the Age of Sail, when long sea voyages without access to fresh food resulted in an epidemic which claimed millions of lives; however, scurvy has existed across time and geography, occurring whenever and wherever diets are devoid of vitamin C. Young children, specifically, were affected by the emergence of 'infantile scurvy' in the 19th century owing to the use of heated milk and manufactured infant foods of poor nutritional quality. Scurvy continues to occur in at-risk groups. In children and youths, it is primarily observed in the context of autism spectrum disorder and feeding problems such as a limited food repertoire and high-frequency single food intake. Diagnosis may be delayed and invasive testing undertaken owing to clinicians' lack of familiarity with the disease, or the mistaken assumption that it is exclusively a disease of the past. The aetiology, clinical manifestations and treatment of scurvy are described. Its long history and current epidemiology are also reviewed, demonstrating that scurvy is very much a disease of the present. It is suggested that future efforts should focus on (i) anticipatory guidance and early nutritional intervention, informed by an understanding of scurvy's epidemiology, with the aim of preventing the disease in those at risk, and (ii) prompt recognition and treatment to minimise morbidity and healthcare costs.Abbreviations: ASD: autism spectrum disorder.
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Affiliation(s)
- Laura M Kinlin
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Weinstein
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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Abrupt termination of vitamin C from ICU patients may increase mortality: secondary analysis of the LOVIT trial. Eur J Clin Nutr 2022; 77:490-494. [PMID: 36539454 PMCID: PMC10115628 DOI: 10.1038/s41430-022-01254-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The LOVIT trial examined the effect of vitamin C on sepsis patients, and concluded that in adults with sepsis receiving vasopressor therapy in the ICU, those who received 4-day intravenous vitamin C had a higher risk of death or persistent organ dysfunction at 28 days than those who received placebo. The aim of this study was to determine whether the abrupt termination of vitamin C administration could explain the increased mortality in the vitamin C group. METHODS We used Cox regression with two time periods to model the distribution of deaths over the first 11 days in the LOVIT trial. RESULTS Compared with a uniform difference between vitamin C and placebo groups over the 11-day follow-up period, addition of a separate vitamin C effect starting from day 5 improved the fit of the Cox model (p = 0.026). There was no difference in mortality between the groups during the 4-day vitamin C administration with RR = 0.97 (95% CI: 0.65-1.44). During the week after the sudden termination of vitamin C, there were 57 deaths in the vitamin C group, but only 32 deaths in the placebo group, with RR = 1.9 (95% CI: 1.2-2.9; p = 0.004). CONCLUSION The increased mortality in the vitamin C group in the LOVIT trial is not explained by ongoing vitamin C administration, but by the abrupt termination of vitamin C. The LOVIT trial findings should not be interpreted as evidence against vitamin C therapy for critically ill patients.
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Hemilä H, Chalker E, de Man AME. Vitamin C May Improve Left Ventricular Ejection Fraction: A Meta-Analysis. Front Cardiovasc Med 2022; 9:789729. [PMID: 35282368 PMCID: PMC8913583 DOI: 10.3389/fcvm.2022.789729] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/21/2022] [Indexed: 01/02/2023] Open
Abstract
Background Vitamin C deprivation can lead to fatigue, dyspnea, oedema and chest pain, which are also symptoms of heart failure (HF). In animal studies vitamin C has improved contractility and mechanical efficiency of the heart. Compared with healthy people, patients with HF have lower vitamin C levels, which are not explained by differences in dietary intake levels, and more severe HF seems to be associated with lower plasma vitamin C levels. This meta-analysis looks at the effect of vitamin C on left ventricular ejection fraction (LVEF). Methods We searched for trials reporting the effects of vitamin C on LVEF. We assessed the quality of the trials, and pooled selected trials using the inverse variance, fixed effect options. We used meta-regression to examine the association between the effect of vitamin C on LVEF level and the baseline LVEF level. Results We identified 15 trials, three of which were excluded from our meta-analysis. In six cardiac trials with 246 patients, vitamin C increased LVEF on average by 12.0% (95% CI 8.1–15.9%; P < 0.001). In six non-cardiac trials including 177 participants, vitamin C increased LVEF on average by 5.3% (95% CI 2.0–8.5%; P = 0.001). In meta-regression analysis we found that the effect of vitamin C was larger in trials with the lowest baseline LVEF levels with P = 0.001 for the test of slope. The meta-regression line crossed the null effect level at a baseline LVEF level close to 70%, with progressively greater benefit from vitamin C with lower LVEF levels. Some of the included trials had methodological limitations. In a sensitivity analysis including only the four most methodologically sound cardiac trials, the effect of vitamin C was not substantially changed. Conclusions In this meta-analysis, vitamin C increased LVEF in both cardiac and non-cardiac patients, with a strong negative association between the size of the vitamin C effect and the baseline LVEF. Further research on vitamin C and HF should be carried out, particularly in patients who have low LVEF together with low vitamin C intake or low plasma levels. Different dosages and different routes of administration should be compared.
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Affiliation(s)
- Harri Hemilä
- Department of Public Health, University of Helsinki, Helsinki, Finland
- *Correspondence: Harri Hemilä
| | - Elizabeth Chalker
- Biological Data Science Institute, Australian National University, Canberra, ACT, Australia
| | - Angelique M. E. de Man
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
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Montalto M, Porceddu E, Pero E, Lupascu A, Gallo A, De Simone C, Nucera E, Aruanno A, Giarretta I, Pola R, Landolfi R. Scurvy: A Disease not to be Forgotten. Nutr Clin Pract 2020; 36:1063-1067. [PMID: 33368529 DOI: 10.1002/ncp.10616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
An 18-year-old man presented to our hospital with muscular pain, diffuse petechiae, spontaneous thigh ecchymosis, edema and pain of the right knee, bilateral pretibial subcutaneous nodules, and gingival hypertrophy and hemorrhage. His history was positive for a mixed anxiety-depressive disorder and a restrictive diet caused by self-diagnosed food allergies. Skin lesions appeared like hyperkeratotic papules with coiled hairs and perifollicular hemorrhages. A diagnosis of scurvy was made upon demonstration of low serum levels of ascorbic acid. An allergy evaluation found cross-reactivity between pollens and food, related to the presence of panallergens. Moreover, we found that our patient was also affected by celiac disease. In conclusion, scurvy should be considered in the differential diagnosis of patients with petechiae and ecchymosis, especially when food restriction, malabsorption, or psychiatric disorders are present.
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Affiliation(s)
- Massimo Montalto
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Enrica Porceddu
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Erika Pero
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Andrea Lupascu
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Antonella Gallo
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Clara De Simone
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Eleonora Nucera
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Arianna Aruanno
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Igor Giarretta
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Roberto Pola
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
| | - Raffaele Landolfi
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli, Istituto di Ricovero e Cura a Carattere Scientifico - Università Cattolica del Sacro Cuore, Roma, Italy
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Benarroch EE. What is the role of ascorbic acid in norepinephrine synthesis and orthostatic hypotension? Neurology 2020; 95:913-916. [DOI: 10.1212/wnl.0000000000010960] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/15/2020] [Indexed: 11/15/2022] Open
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Leopold JA, Maron BA, Loscalzo J. The application of big data to cardiovascular disease: paths to precision medicine. J Clin Invest 2020; 130:29-38. [PMID: 31895052 DOI: 10.1172/jci129203] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Advanced phenotyping of cardiovascular diseases has evolved with the application of high-resolution omics screening to populations enrolled in large-scale observational and clinical trials. This strategy has revealed that considerable heterogeneity exists at the genotype, endophenotype, and clinical phenotype levels in cardiovascular diseases, a feature of the most common diseases that has not been elucidated by conventional reductionism. In this discussion, we address genomic context and (endo)phenotypic heterogeneity, and examine commonly encountered cardiovascular diseases to illustrate the genotypic underpinnings of (endo)phenotypic diversity. We highlight the existing challenges in cardiovascular disease genotyping and phenotyping that can be addressed by the integration of big data and interpreted using novel analytical methodologies (network analysis). Precision cardiovascular medicine will only be broadly applied to cardiovascular patients once this comprehensive data set is subjected to unique, integrative analytical strategies that accommodate molecular and clinical heterogeneity rather than ignore or reduce it.
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Marik PE, Liggett A. Adding an orange to the banana bag: vitamin C deficiency is common in alcohol use disorders. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:165. [PMID: 31077227 PMCID: PMC6511125 DOI: 10.1186/s13054-019-2435-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/12/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND At least a third of the world's population consumes alcohol regularly. Patients with alcohol use disorders (AUDs) are frequently hospitalized for both alcohol-related and unrelated medical conditions. It is well recognized that patients with an AUD are thiamine deficient with thiamine replacement therapy being considered the standard of care. However, the incidence of vitamin C deficiency in this patient population has been poorly defined. METHODS In this retrospective, observational study, we recorded the admission vitamin C level in patients with an AUD admitted to our medical intensive care unit (MICU) over a 1-year period. In addition, we recorded relevant clinical and laboratory data including the day 2 and day 3 vitamin C level following empiric treatment with vitamin C. Septic patients were excluded from this study. RESULTS Sixty-nine patients met the inclusion criteria for this study. The patients' mean age was 53 ± 14 years; 52 patients (75%) were males. Severe alcohol withdrawal syndrome was the commonest admitting diagnosis (46%). Eighteen patients (26%) had cirrhosis as the admitting diagnosis with 18 (13%) patients admitted due to alcohol/drug intoxication. Forty-six patients (67%) had evidence of acute alcoholic hepatitis. The mean admission vitamin C level was 17.0 ± 18.1 μmol/l (normal 40-60 μmol/l). Sixty-one (88%) patients had a level less than 40 μmol/l (subnormal) while 52 patients (75%) had hypovitaminosis C (level < 23 μmol/l). None of the variables recorded predicted the vitamin C level. Various vitamin C replacement dosing strategies were used. A 1.5-g loading dose, followed by 500-mg PO q 6, was effective in restoring blood levels to normal by day 2. CONCLUSION Our results suggest that hypovitaminosis C is exceedingly common in patients with an AUD admitted to an intensive care unit and that all such patients should receive supplementation with vitamin C in addition to thiamine. Additional studies are required to confirm the findings of our observational study and to determine the optimal vitamin C dosing strategy.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 721 Fairfax Ave, Suite 423, Norfolk, VA, 23507, USA.
| | - Amanda Liggett
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 721 Fairfax Ave, Suite 423, Norfolk, VA, 23507, USA. .,Department of Medicine, Eastern Virginia Medical School, 721 Fairfax ave, Norfolk, VA, 23507, USA.
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Uddin MA, Robson C, Dotel R. Disease of the past re-emerging in modern Australian society. BMJ Case Rep 2019; 12:12/4/e228448. [PMID: 31005867 DOI: 10.1136/bcr-2018-228448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 28-year-old man with fever, atraumatic lower limb pain and rash was noted to have multiple areas of ecchymosis involving both lower limbs. He was anaemic and also had a grossly swollen left leg. Differential diagnoses of compartment syndrome, vascular tear, platelet and clotting factor disorders, vasculitis and myositis were ruled out. Scurvy was only considered after failing to reach a diagnosis. A dietary history revealed consumption of a restricted diet with no fresh fruits or vegetables. Diagnosis was supported by an undetectable vitamin C level in blood and a rapid improvement of symptoms on oral vitamin C replacement. Prevalence of vitamin C deficiency in developed countries is also discussed.
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Affiliation(s)
- Mohammed Arif Uddin
- Department of Infectious Diseases, Blacktown Hospital, Blacktown, New South Wales, Australia.,Medical Workforce Unit, BMDH, Western Sydney Local Health District, Penrith, New South Wales, Australia
| | - Christopher Robson
- Department of Infectious Diseases, Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Ravindra Dotel
- Department of Infectious Diseases, Blacktown Hospital, Blacktown, New South Wales, Australia
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Hemilä H, Chalker E. Vitamin C Can Shorten the Length of Stay in the ICU: A Meta-Analysis. Nutrients 2019; 11:E708. [PMID: 30934660 PMCID: PMC6521194 DOI: 10.3390/nu11040708] [Citation(s) in RCA: 155] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/12/2019] [Accepted: 03/18/2019] [Indexed: 12/12/2022] Open
Abstract
A number of controlled trials have previously found that in some contexts, vitamin C can have beneficial effects on blood pressure, infections, bronchoconstriction, atrial fibrillation, and acute kidney injury. However, the practical significance of these effects is not clear. The purpose of this meta-analysis was to evaluate whether vitamin C has an effect on the practical outcomes: length of stay in the intensive care unit (ICU) and duration of mechanical ventilation. We identified 18 relevant controlled trials with a total of 2004 patients, 13 of which investigated patients undergoing elective cardiac surgery. We carried out the meta-analysis using the inverse variance, fixed effect options, using the ratio of means scale. In 12 trials with 1766 patients, vitamin C reduced the length of ICU stay on average by 7.8% (95% CI: 4.2% to 11.2%; p = 0.00003). In six trials, orally administered vitamin C in doses of 1⁻3 g/day (weighted mean 2.0 g/day) reduced the length of ICU stay by 8.6% (p = 0.003). In three trials in which patients needed mechanical ventilation for over 24 hours, vitamin C shortened the duration of mechanical ventilation by 18.2% (95% CI 7.7% to 27%; p = 0.001). Given the insignificant cost of vitamin C, even an 8% reduction in ICU stay is worth exploring. The effects of vitamin C on ICU patients should be investigated in more detail.
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Affiliation(s)
- Harri Hemilä
- Department of Public Health, University of Helsinki, POB 41, FI-00014 Helsinki, Finland.
| | - Elizabeth Chalker
- School of Public Health, University of Sydney, Sydney 2006, Australia.
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Lim DJ, Sharma Y, Thompson CH. Vitamin C and alcohol: a call to action. BMJ Nutr Prev Health 2018; 1:17-22. [PMID: 33235950 PMCID: PMC7678474 DOI: 10.1136/bmjnph-2018-000010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 10/24/2018] [Accepted: 11/01/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
- Daniel James Lim
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Yogesh Sharma
- Department of General Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
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