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Kansy BA, Wehrs TP, Bruderek K, Si Y, Ludwig S, Droege F, Hasskamp P, Henkel U, Dominas N, Hoffmann TK, Horn PA, Schuler M, Gauler TC, Lindemann M, Lang S, Bankfalvi A, Brandau S. HPV-associated head and neck cancer is characterized by distinct profiles of CD8 + T cells and myeloid-derived suppressor cells. Cancer Immunol Immunother 2023; 72:4367-4383. [PMID: 38019346 PMCID: PMC10700222 DOI: 10.1007/s00262-023-03571-8] [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: 06/14/2023] [Accepted: 10/23/2023] [Indexed: 11/30/2023]
Abstract
Patients with HPV--localized head and neck cancer (HNC) show inferior outcomes after surgery and radiochemotherapy compared to HPV-associated cancers. The underlying mechanisms remain elusive, but differences in immune status and immune activity may be implicated. In this study, we analyzed immune profiles of CD8+ T cells and myeloid-derived suppressor cells (MDSC) in HPV+ versus HPV- disease.The overall frequency of CD8+ T cells was reduced in HNC versus healthy donors but substantially increased after curative therapy (surgery and/or radiochemotherapy). In HPV+ patients, this increase was associated with significant induction of peripheral blood CD8+/CD45RA-/CD62L- effector memory cells. The frequency of HPV-antigen-specific CD8+ cells was low even in patients with virally associated tumors and dropped to background levels after curative therapy. Pre-therapeutic counts of circulating monocytic MDSC, but not PMN-MDSC, were increased in patients with HPV- disease. This increase was accompanied by reduced fractions of terminally differentiated CD8+ effector cells. HPV- tumors showed reduced infiltrates of CD8+ and CD45RO+ immune cells compared with HPV+ tumors. Importantly, frequencies of tumor tissue-infiltrating PMN-MDSC were increased, while percentages of Granzyme B+ and Ki-67+ CD8 T cells were reduced in patients with HPV- disease.We report differences in frequencies and relative ratios of MDSC and effector T cells in HPV- HNC compared with more immunogenic HPV-associated disease. Our data provide new insight into the immunological profiles of these two tumor entities and may be utilized for more tailored immunotherapeutic approaches in the future.
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Affiliation(s)
- Benjamin A Kansy
- Research Division, Department of Otorhinolaryngology, West German Cancer Center, University Duisburg-Essen, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Tim P Wehrs
- Research Division, Department of Otorhinolaryngology, West German Cancer Center, University Duisburg-Essen, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Kirsten Bruderek
- Research Division, Department of Otorhinolaryngology, West German Cancer Center, University Duisburg-Essen, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Yu Si
- Research Division, Department of Otorhinolaryngology, West German Cancer Center, University Duisburg-Essen, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany
- Department of Otolaryngology, Head and Neck Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Sonja Ludwig
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Mannheim, Mannheim, Germany
| | - Freya Droege
- Research Division, Department of Otorhinolaryngology, West German Cancer Center, University Duisburg-Essen, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Pia Hasskamp
- Research Division, Department of Otorhinolaryngology, West German Cancer Center, University Duisburg-Essen, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Uta Henkel
- Research Division, Department of Otorhinolaryngology, West German Cancer Center, University Duisburg-Essen, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Nina Dominas
- Research Division, Department of Otorhinolaryngology, West German Cancer Center, University Duisburg-Essen, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany
| | - Thomas K Hoffmann
- Department of Otorhinolaryngology, University Hospital Ulm, Ulm, Germany
| | - Peter A Horn
- Institute for Transfusion Medicine, University Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Martin Schuler
- Department of Medical Oncology, University Duisburg-Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - Thomas C Gauler
- Department of Medical Oncology, University Duisburg-Essen, University Hospital Essen, Essen, Germany
- Department of Radiation Oncology, University Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Monika Lindemann
- Institute for Transfusion Medicine, University Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Stephan Lang
- Research Division, Department of Otorhinolaryngology, West German Cancer Center, University Duisburg-Essen, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany
| | - Agnes Bankfalvi
- Institute of Pathology, University Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Sven Brandau
- Research Division, Department of Otorhinolaryngology, West German Cancer Center, University Duisburg-Essen, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany.
- German Cancer Consortium (DKTK), Partner Site University Hospital Essen, Essen, Germany.
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Lu Y, Yan Y, Li B, Liu M, Liang Y, Ye Y, Cheng W, Li J, Jiao J, Chang S. A Novel Prognostic Model for Oral Squamous Cell Carcinoma: The Functions and Prognostic Values of RNA-Binding Proteins. Front Oncol 2021; 11:592614. [PMID: 34395233 PMCID: PMC8362834 DOI: 10.3389/fonc.2021.592614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 06/08/2021] [Indexed: 12/17/2022] Open
Abstract
PURPOSE The biological roles and clinical significance of RNA-binding proteins (RBPs) in oral squamous cell carcinoma (OSCC) are not fully understood. We investigated the prognostic value of RBPs in OSCC using several bioinformatic strategies. MATERIALS AND METHODS OSCC data were obtained from a public online database, the Limma R package was used to identify differentially expressed RBPs, and functional enrichment analysis was performed to elucidate the biological functions of the above RBPs in OSCC. We performed protein-protein interaction (PPI) network and Cox regression analyses to extract prognosis-related hub RBPs. Next, we established and validated a prognostic model based on the hub RBPs using Cox regression and risk score analyses. RESULTS We found that the differentially expressed RBPs were closely related to the defense response to viruses and multiple RNA processes. We identified 10 prognosis-related hub RBPs (ZC3H12D, OAS2, INTS10, ACO1, PCBP4, RNASE3, PTGES3L-AARSD1, RNASE13, DDX4, and PCF11) and effectively predicted the overall survival of OSCC patients. The area under the receiver operating characteristic (ROC) curve (AUC) of the risk score model was 0.781, suggesting that our model exhibited excellent prognostic performance. Finally, we built a nomogram integrating the 10 RBPs. The internal validation cohort results showed a reliable predictive capability of the nomogram for OSCC. CONCLUSION We established a novel 10-RBP-based model for OSCC that could enable precise individual treatment and follow-up management strategies in the future.
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Affiliation(s)
- Yingjuan Lu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Oral and Maxillofacial Surgery, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- RNA Biomedical Institute, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yongcong Yan
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- RNA Biomedical Institute, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Hepatobiliary Surgery, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Bowen Li
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Oral and Maxillofacial Surgery, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- RNA Biomedical Institute, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Mo Liu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Oral and Maxillofacial Surgery, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yancan Liang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Oral and Maxillofacial Surgery, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- RNA Biomedical Institute, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yushan Ye
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Oral and Maxillofacial Surgery, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Weiqi Cheng
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Oral and Maxillofacial Surgery, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jinsong Li
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Oral and Maxillofacial Surgery, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jiuyang Jiao
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Oral and Maxillofacial Surgery, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Shaohai Chang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
- Department of Oral and Maxillofacial Surgery, Sun Yat Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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Bucheli OTM, Sigvaldadóttir I, Eyer K. Measuring single-cell protein secretion in immunology: Technologies, advances, and applications. Eur J Immunol 2021; 51:1334-1347. [PMID: 33734428 PMCID: PMC8252417 DOI: 10.1002/eji.202048976] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/12/2021] [Accepted: 03/15/2021] [Indexed: 12/19/2022]
Abstract
The dynamics, nature, strength, and ultimately protective capabilities of an active immune response are determined by the extracellular constitution and concentration of various soluble factors. Generated effector cells secrete such mediators, including antibodies, chemo‐ and cytokines to achieve functionality. These secreted factors organize the individual immune cells into functional tissues, initiate, orchestrate, and regulate the immune response. Therefore, a single‐cell resolved analysis of protein secretion is a valuable tool for studying the heterogeneity and functionality of immune cells. This review aims to provide a comparative overview of various methods to characterize immune reactions by measuring single‐cell protein secretion. Spot‐based and cytometry‐based assays, such as ELISpot and flow cytometry, respectively, are well‐established methods applied in basic research and clinical settings. Emerging novel technologies, such as microfluidic platforms, offer new ways to measure and exploit protein secretion in immune reactions. Further technological advances will allow the deciphering of protein secretion in immunological responses with unprecedented detail, linking secretion to functionality. Here, we summarize the development and recent advances of tools that allow the analysis of protein secretion at the single‐cell level, and discuss and contrast their applications within immunology.
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Affiliation(s)
- Olivia T M Bucheli
- ETH Laboratory for Functional Immune Repertoire Analysis, Institute of Pharmaceutical Sciences, D-CHAB, ETH Zürich, Zürich, Switzerland
| | - Ingibjörg Sigvaldadóttir
- ETH Laboratory for Functional Immune Repertoire Analysis, Institute of Pharmaceutical Sciences, D-CHAB, ETH Zürich, Zürich, Switzerland
| | - Klaus Eyer
- ETH Laboratory for Functional Immune Repertoire Analysis, Institute of Pharmaceutical Sciences, D-CHAB, ETH Zürich, Zürich, Switzerland
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Malewicz NM, Walstein K, Heine T, Engler A, Bick A, Cox L, Dötsch A, Westendorf AM, Horn PA, Lindemann M, Peters J, Schäfer ST. Early suppression of peripheral mononuclear blood cells in sepsis in response to stimulation with cytomegalovirus, OKT3, and pokeweed mitogen. J Appl Physiol (1985) 2019; 127:1539-1547. [PMID: 31545153 DOI: 10.1152/japplphysiol.00438.2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Critically ill patients are at risk for sepsis, and immunosuppressive mechanisms may prevail. Whether functional tests are helpful to detect immune alterations is largely unknown. Therefore, we tested the hypotheses that reactivity of peripheral blood mononuclear cells (PBMCs) to secrete interferon-γ (IFNγ) following stimulation in vitro is decreased in patients with early sepsis compared with postoperative patients. IFNγ secretion [enzyme-linked immunospot (ELISpot)] in response to stimulation with cytomegalovirus (CMV), pokeweed mitogen (PWM), muromonab-anti-CD3 (OKT3), and human leukocyte antigen (HLA)-DRA-mRNA expression and serum cytokine concentrations were repeatedly [days 1, 3, 5, and 7 after intensive care unit (ICU) admission] determined in patients with sepsis (n = 7) and patients undergoing major abdominal surgery (radical prostatectomy, cystectomy, n = 10). In a second cohort, HLA-DRA expression was assessed in 80 patients with sepsis, 30 postoperative patients, and 44 healthy volunteers (German clinical trials database no. 00007694). In patients with sepsis, IFNγ secretion (ELISpot) was decreased compared with controls after stimulation with CMV (P = 0.01), OKT3 (P = 0.02), and PWM (P = 0.02 on day 5), whereas unstimulated IFNγ secretion did not differ. HLA-DRA expression was also significantly decreased in patients with sepsis at all time points (P = 0.004) compared with postoperative surgical patients, a finding confirmed in the larger cohort. Reactivity of PBMCs to stimulation with CMV, PWM, and OKT3 as well as HLA-DRA expression was already decreased upon ICU admission in patients with sepsis when compared with postoperative controls, suggesting early depression of acquired immunity. ELISpot assays may help to clinically characterize the time course of immunocompetence in patients with sepsis.NEW & NOTEWORTHY We observed suppression of reactivity to stimulation with cytomegalovirus, muromonab-anti-CD3, and pokeweed mitogen in mononuclear blood cells of patients with early sepsis when compared with postoperative controls. Thus, there is early depression of acquired immunity in sepsis. Enzyme-linked immunospot assays may help to characterize immunocompetence in patients with sepsis.
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Affiliation(s)
- N M Malewicz
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum, Essen, Germany
| | - K Walstein
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum, Essen, Germany
| | - T Heine
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum, Essen, Germany
| | - A Engler
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum, Essen, Germany
| | - A Bick
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum, Essen, Germany
| | - L Cox
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum, Essen, Germany
| | - A Dötsch
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum, Essen, Germany
| | - A M Westendorf
- Institute for Medical Microbiology, Universität Duisburg-Essen & Universitätsklinikum, Essen, Germany
| | - P A Horn
- Institute for Transfusion Medicine, Universität Duisburg-Essen & Universitätsklinikum, Essen, Germany
| | - M Lindemann
- Institute for Transfusion Medicine, Universität Duisburg-Essen & Universitätsklinikum, Essen, Germany
| | - J Peters
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum, Essen, Germany
| | - S T Schäfer
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum, Essen, Germany.,Department of Anaesthesiology, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Munich, Germany
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Cytomegalovirus induces HLA-class-II-restricted alloreactivity in an acute myeloid leukemia cell line. PLoS One 2018; 13:e0191482. [PMID: 29377903 PMCID: PMC5788343 DOI: 10.1371/journal.pone.0191482] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 01/06/2018] [Indexed: 02/07/2023] Open
Abstract
Cytomegalovirus (HCMV) reactivation is found frequently after allogeneic hematopoietic stem cell transplantation (alloSCT) and is associated with an increased treatment-related mortality. Recent reports suggest a link between HCMV and a reduced risk of cancer progression in patients with acute leukemia or lymphoma after alloSCT. Here we show that HCMV can inhibit the proliferation of the acute myeloid leukemia cell line Kasumi-1 and the promyeloid leukemia cell line NB4. HCMV induced a significant up-regulation of HLA-class-II-molecules, especially HLA-DR expression and an increase of apoptosis, granzyme B, perforin and IFN-γ secretion in Kasumi-1 cells cocultured with peripheral blood mononuclear cells (PBMCs). Indolamin-2,3-dioxygenase on the other hand led only to a significant dose-dependent effect on IFN-γ secretion without effects on proliferation. The addition of CpG-rich oligonucleotides and ganciclovir reversed those antiproliferative effects. We conclude that HCMV can enhance alloreactivity of PBMCs against Kasumi-1 and NB4 cells in vitro. To determine if this phenomenon may be clinically relevant further investigations will be required.
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αβ-T-cell depleted donor lymphocyte infusion for leukemia relapse after allogeneic stem cell transplantation. Bone Marrow Transplant 2017; 52:1668-1670. [PMID: 28869619 DOI: 10.1038/bmt.2017.185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Dani SU, Walter GF. Chronic arsenic intoxication diagnostic score (CAsIDS). J Appl Toxicol 2017; 38:122-144. [DOI: 10.1002/jat.3512] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 07/02/2017] [Accepted: 07/12/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Sergio Ulhoa Dani
- Medawar Institute for Medical and Environmental Research; Acangau Foundation; Paracatu MG Brazil
- Department of General Internal Medicine; St. Gallen Cantonal Hospital; Switzerland
- PizolCare Praxis Wartau; Trübbach Switzerland
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Danielzik T, Koldehoff M, Buttkereit U, Beelen DW, Horn PA, Lindemann M. Sensitive detection of rare antigen-specific T cells directed against Wilms' tumor 1 by FluoroSpot assay. Leuk Lymphoma 2017; 59:490-492. [PMID: 28573960 DOI: 10.1080/10428194.2017.1330955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Tina Danielzik
- a Institute for Transfusion Medicine, University Hospital , Essen , Germany
| | - Michael Koldehoff
- b Department of Bone Marrow Transplantation , University Hospital , Essen , Germany
| | - Ulrike Buttkereit
- b Department of Bone Marrow Transplantation , University Hospital , Essen , Germany
| | - Dietrich W Beelen
- b Department of Bone Marrow Transplantation , University Hospital , Essen , Germany
| | - Peter A Horn
- a Institute for Transfusion Medicine, University Hospital , Essen , Germany
| | - Monika Lindemann
- a Institute for Transfusion Medicine, University Hospital , Essen , Germany
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Yap JKW, O'Neill D, Nagenthiran S, Dawson CW, Luesley DM. Current insights into the aetiology, pathobiology, and management of local disease recurrence in squamous cell carcinoma of the vulva. BJOG 2017; 124:946-954. [PMID: 28081287 DOI: 10.1111/1471-0528.14560] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2016] [Indexed: 01/04/2023]
Affiliation(s)
- JKW Yap
- Institute of Cancer and Genomic Sciences; College of Dental and Medical School; University of Birmingham; Edgbaston UK
- Department of Obstetrics and Gynaecology; Birmingham City Hospital; Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
| | - D O'Neill
- Department of Obstetrics and Gynaecology; Birmingham City Hospital; Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
| | - S Nagenthiran
- Department of Obstetrics and Gynaecology; Birmingham City Hospital; Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
| | - CW Dawson
- Institute of Cancer and Genomic Sciences; College of Dental and Medical School; University of Birmingham; Edgbaston UK
| | - DM Luesley
- Institute of Cancer and Genomic Sciences; College of Dental and Medical School; University of Birmingham; Edgbaston UK
- Department of Obstetrics and Gynaecology; Birmingham City Hospital; Sandwell and West Birmingham Hospitals NHS Trust; Birmingham UK
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