1
|
West ME, Spielberg DR, Roach DJ, Willmering MM, Bdaiwi AS, Cleveland ZI, Woods JC. Short-term structural and functional changes after airway clearance therapy in cystic fibrosis. J Cyst Fibros 2023; 22:926-932. [PMID: 36740542 DOI: 10.1016/j.jcf.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 01/10/2023] [Accepted: 01/30/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND Airway clearance therapy (ACT) with a high-frequency chest wall oscillation (HFCWO) vest is a common but time-consuming treatment. Its benefit to quality of life for cystic fibrosis (CF) patients is well established but has been questioned recently as new highly-effective modulator therapies begin to change the treatment landscape. 129Xe ventilation MRI has been shown to be very sensitive to lung obstruction in mild CF disease, making it an ideal tool to identify and quantify subtle, regional changes. METHODS 20 CF patients (ages 20.7 ± 5.1 years) refrained from performing ACT before arriving for a single-day visit. Multiple-breath washout (MBW), spirometry, Xe MRI, and ultrashort echo-time (UTE) MRI were obtained twice-before and after patients performed ACT using their prescribed HFCWO vests (average 4.7 ± 0.5 h). UTE MRIs were scored for structural abnormalities, and standard functional metrics were obtained from MBW, spirometry, and Xe MRI-FEV1,pp, LCI2.5, and VDPN4, respectively. RESULTS Spirometry and Xe MRI detected significant improvements in lung function post-ACT. 15/20 patients showed improvements from a baseline median of 92% FEV1,pp. Similarly, 16/20 patients showed improvements in Xe MRI from a baseline median of 15.2% VDPN4. Average individual changes were +2.6% in FEV1,pp and -1.3% in VDPN4, but without spatial correlations to easily-identifiable causative structural defects (e.g. mucus plugs or bronchiectasis) on UTE MRI. CONCLUSIONS Lung function improved after a single instance of HFCWO-vest ACT and was detectable by spirometry and Xe MRI. The only common structural abnormalities were mucus plugs, which corresponded to ventilation defects, but ventilation defects were often present without visible abnormalities.
Collapse
Affiliation(s)
- Michael E West
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States
| | - David R Spielberg
- Division of Pulmonary Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, Illinois, 60611, United States
| | - David J Roach
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States
| | - Matthew M Willmering
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States
| | - Abdullah S Bdaiwi
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States; Department of Biomedical Engineering, University of Cincinnati, Cincinnati, OH, 45229, United States
| | - Zackary I Cleveland
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States; Department of Biomedical Engineering, University of Cincinnati, Cincinnati, OH, 45229, United States; Department of Pediatrics, University of Cincinnati Medical Center, Cincinnati, OH, 45229, United States; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States
| | - Jason C Woods
- Center for Pulmonary Imaging Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States; Department of Pediatrics, University of Cincinnati Medical Center, Cincinnati, OH, 45229, United States; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, United States; Department of Physics, University of Cincinnati, Cincinnati, OH, 45229, United States.
| |
Collapse
|
2
|
Britto CJ, Ratjen F, Clancy JP. Emerging Approaches to Monitor and Modify Care in the Era of Cystic Fibrosis Transmembrane Conductance Regulators. Clin Chest Med 2022; 43:631-646. [PMID: 36344071 DOI: 10.1016/j.ccm.2022.06.006] [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: 11/06/2022]
Abstract
As we characterize the clinical benefits of highly effective modulator therapy (HEMT) in the cystic fibrosis (CF) population, our paradigm for treating and monitoring disease continues to evolve. More sensitive approaches are necessary to detect early disease and clinical progression. This article reviews evolving strategies to assess disease control and progression in the HEMT era. This article also explores developments in pulmonary function monitoring, advanced respiratory imaging, tools for the collection of patient-reported outcomes, and their application to profile individual responses, guide therapeutic decisions, and improve the quality of life of people with CF.
Collapse
Affiliation(s)
- Clemente J Britto
- Yale Adult Cystic Fibrosis Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale University School of Medicine.
| | - Felix Ratjen
- Division of Respiratory Medicine, Translational Medicine, University of Toronto Hospital for Sick Children, 555 University Avenue, Toronto Ontario M5G 1X8, Canada
| | | |
Collapse
|
3
|
Mayer-Hamblett N, Nichols DP, Odem-Davis K, Riekert KA, Sawicki GS, Donaldson SH, Ratjen F, Konstan MW, Simon N, Rosenbluth DB, Retsch-Bogart G, Clancy JP, VanDalfsen JM, Buckingham R, Gifford AH. Evaluating the Impact of Stopping Chronic Therapies after Modulator Drug Therapy in Cystic Fibrosis: The SIMPLIFY Clinical Trial Study Design. Ann Am Thorac Soc 2021; 18:1397-1405. [PMID: 33465316 PMCID: PMC8513667 DOI: 10.1513/annalsats.202010-1336sd] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 01/15/2021] [Indexed: 12/31/2022] Open
Abstract
The care for individuals with cystic fibrosis (CF) with at least one F508del mutation will greatly change as a result of the unparalleled clinical benefits observed with the new triple-combination CFTR (CF transmembrane regulator)-modulator therapy elexacaftor/tezacaftor/ivacaftor (ETI). Incorporating ETI into the standard of care creates new motivation and opportunity to consider reductions in overall treatment burden and evaluate whether other chronic medications can now be safely discontinued without loss of clinical benefit. SIMPLIFY is a master protocol poised to test the impact of discontinuing versus continuing two commonly used chronic therapies in people with CF who are at least 12 years of age or older and stable on ETI therapy. The protocol is composed of two concurrent randomized controlled trials designed to evaluate the independent short-term effects of discontinuing hypertonic saline or dornase alfa, enabling individuals on both therapies to participate in one or both trials. The primary objective for each trial is to determine whether discontinuing treatment is noninferior to continuing treatment after establishment of ETI, as measured by the 6-week absolute change in the percent-predicted forced expiratory volume in 1 second. Developing this study required a balance between ideal study-design principles and feasibility. SIMPLIFY will be the largest multicenter, randomized, controlled medication-withdrawal study in CF. This study is uniquely positioned to provide timely evidence on whether the daily treatment burden can be reduced among individuals on CFTR-modulator therapy. Clinical trial registered with www.clinicaltrials.gov (NCT04378153).
Collapse
Affiliation(s)
- Nicole Mayer-Hamblett
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
- Department of Pediatrics and
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - David P Nichols
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
- Department of Pediatrics and
| | - Katherine Odem-Davis
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| | - Kristin A Riekert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Greg S Sawicki
- Division of General Pediatrics and Respiratory Diseases, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | - Felix Ratjen
- Division of Respiratory Translational Medicine Program, SickKids Research Institute, Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Michael W Konstan
- Department of Pediatrics, Rainbow Babies and Children's Hospital and School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Noah Simon
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
- Department of Biostatistics, University of Washington, Seattle, Washington
| | - Daniel B Rosenbluth
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, Washington University, St. Louis, Missouri
| | - George Retsch-Bogart
- Division of Pediatric Pulmonology, University of North Carolina, Chapel Hill, Chapel Hill, North Carolina
| | - John P Clancy
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Jill M VanDalfsen
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| | - Rachael Buckingham
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Hospital, Seattle, Washington
| | - Alex H Gifford
- Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire
| |
Collapse
|
4
|
Varilek BM, Isaacson MJ. The dance of cystic fibrosis: Experiences of living with cystic fibrosis as an adult. J Clin Nurs 2020; 29:3553-3564. [PMID: 32608531 DOI: 10.1111/jocn.15397] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/01/2020] [Accepted: 06/21/2020] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES This study sought to understand the experience of living with cystic fibrosis (CF) as an adult. BACKGROUND Cystic fibrosis is one of the most difficult chronic diseases to manage long term because of numerous challenges faced on a day-to-day basis. The majority of studies focus on improving symptom response to new treatment regimens with the hope of prolonging life. Yet few qualitative studies explore the experience of adults with CF. What is missing from the current literature are the voices of people living with CF, especially as they age. DESIGN This study follows a hermeneutic phenomenology design guided by Martin Heidegger's philosophy. METHODS Semi-structured interviews were conducted with nine adults living with CF. Hermeneutic phenomenology guided the data interpretation. This manuscript follows COREQ reporting guidelines. RESULTS Hermeneutic analysis revealed the overarching theme The Dance of Cystic Fibrosis which is supported by five themes: (a) the paradox of control, (b) living deaths, (c) dancing with death, (d) relearning to dance, and (e) role of the dance partner. CONCLUSIONS The experience of living with CF as an adult is multidimensional and unique to each person. Despite the uniqueness, there is a shared experience that manifested as The Dance of Cystic Fibrosis. As life expectancy continues to increase for persons with CF, it is essential that researchers and healthcare professionals intentionally consider the life-prolonging effects of the treatment regimen alongside the persons' experience with those effects. RELEVANCE TO CLINICAL PRACTICE Nurses at all levels of practice should be prepared to address the multifaceted experience of living with CF through thoughtful incorporation of open-ended questions. This allows patients to share their experience with nurses, augmenting their practice of delivering holistic care.
Collapse
Affiliation(s)
- Brandon M Varilek
- College of Nursing, Graduate Nursing, South Dakota State University, Sioux Falls, SD, USA
| | - Mary J Isaacson
- College of Nursing, Graduate Nursing, South Dakota State University, Rapid City, SD, USA
| |
Collapse
|
5
|
Answering the call to address cystic fibrosis treatment burden in the era of highly effective CFTR modulator therapy. J Cyst Fibros 2019; 19:762-767. [PMID: 31761739 DOI: 10.1016/j.jcf.2019.11.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND We recognize an unprecedented opportunity to study the effects of withdrawing one or more chronic treatments in people with CF (PwCF) who benefit greatly from CFTR modulator therapy, but feasibility and acceptance of such a study within the community is unknown. METHODS We surveyed PwCF, their families, and their acquaintances between November 16, 2018, and December 2, 2018, and CF clinicians between December 19, 2018, and January 2, 2019, about treatment withdrawal research. We sought feedback from these groups about their level of interest in this research, the consistency with which they were taking modulator and non-modulator treatments, the ways in which they conceptualized health changes, and what chronic non-modulator treatments they were most interested in stopping. We also asked for stakeholder perspectives on the design of a treatment withdrawal trial, but we intend to report these perspectives elsewhere. RESULTS Eighty percent (541/675) of CF community respondents and 95% (206/218) of CF clinicians said that a trial of treatment simplification should be performed in the context of highly effective modulator therapy. Most current CFTR modulator users (292/359, 81%) have not stopped another chronic treatment. Worsening lung function by spirometry or increased daily symptoms were important health indicators. PwCF, their families, and/or their acquaintances ranked airway clearance techniques and inhaled antibiotics as the most burdensome treatments. CONCLUSIONS There is considerable support among the CF community and CF clinicians in the U.S. for controlled trials to assess the safety and impact of treatment simplification in patients taking highly effective modulator therapy.
Collapse
|
6
|
Nichols DP. Breathing Easier: A Well-tolerated Corrector for F508del. Am J Respir Crit Care Med 2018; 197:152-154. [DOI: 10.1164/rccm.201709-1957ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- David P. Nichols
- Seattle Children’s HospitalUniversity of Washington School of MedicineSeattle, Washington
| |
Collapse
|
7
|
Narayanan S, Mainz JG, Gala S, Tabori H, Grossoehme D. Adherence to therapies in cystic fibrosis: a targeted literature review. Expert Rev Respir Med 2017; 11:129-145. [DOI: 10.1080/17476348.2017.1280399] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Jochen G. Mainz
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany
| | - Smeet Gala
- Market Access Solutions LLC. (MKTXS), Raritan, NJ, USA
| | - Harold Tabori
- Cystic Fibrosis Center for Children and Adults, Jena University Hospital, Jena, Germany
| | - Daniel Grossoehme
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
8
|
Nichols DP, Happoldt CL, Bratcher PE, Caceres SM, Chmiel JF, Malcolm KC, Saavedra MT, Saiman L, Taylor-Cousar JL, Nick JA. Impact of azithromycin on the clinical and antimicrobial effectiveness of tobramycin in the treatment of cystic fibrosis. J Cyst Fibros 2016; 16:358-366. [PMID: 28025037 DOI: 10.1016/j.jcf.2016.12.003] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/30/2016] [Accepted: 12/01/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Concomitant use of oral azithromycin and inhaled tobramycin occurs in approximately half of US cystic fibrosis (CF) patients. Recent data suggest that this combination may be antagonistic. METHODS Test the hypothesis that azithromycin reduces the clinical benefits of tobramycin by analyses of clinical trial data, in vitro modeling of P. aeruginosa antibiotic killing, and regulation of the MexXY efflux pump. RESULTS Ongoing administration of azithromycin associates with reduced ability of inhaled tobramycin, as compared with aztreonam, to improve lung function and quality of life in a completed clinical trial. In users of azithromycin FEV1 (L) increased 0.8% during a 4-week period of inhaled tobramycin and an additional 6.4% during a subsequent 4-week period of inhaled aztreonam (P<0.005). CFQ-R respiratory symptom score decreased 1.8 points during inhaled tobramycin and increased 8.3 points during subsequent inhaled aztreonam (P<0.001). A smaller number of trial participants not using azithromycin had similar improvement in lung function and quality of life scores during inhaled tobramycin and inhaled aztreonam. In vitro, azithromycin selectively reduced the bactericidal effects tobramycin in cultures of clinical strains of P. aeruginosa, while up regulating antibiotic resistance through MexXY efflux. CONCLUSIONS Azithromycin appears capable of reducing the antimicrobial benefits of tobramycin by inducing adaptive bacterial stress responses in P. aeruginosa, suggesting that these medications together may not be optimal chronic therapy for at least some patients.
Collapse
Affiliation(s)
- Dave P Nichols
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, United States.
| | - Carrie L Happoldt
- Department of Pediatrics, National Jewish Health, Denver, CO, United States
| | - Preston E Bratcher
- Department of Pediatrics, National Jewish Health, Denver, CO, United States
| | - Silvia M Caceres
- Department of Medicine, National Jewish Health, Denver, CO, United States; University of Colorado School of Medicine, Aurora, CO, United States
| | - James F Chmiel
- Department of Pediatrics, Rainbow Babies & Children's Hospital, Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Kenneth C Malcolm
- Department of Medicine, National Jewish Health, Denver, CO, United States; University of Colorado School of Medicine, Aurora, CO, United States
| | - Milene T Saavedra
- Department of Medicine, National Jewish Health, Denver, CO, United States; University of Colorado School of Medicine, Aurora, CO, United States
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Medical Center, New York, NY, United States
| | - Jennifer L Taylor-Cousar
- Department of Pediatrics, National Jewish Health, Denver, CO, United States; Department of Medicine, National Jewish Health, Denver, CO, United States; University of Colorado School of Medicine, Aurora, CO, United States
| | - Jerry A Nick
- Department of Medicine, National Jewish Health, Denver, CO, United States; University of Colorado School of Medicine, Aurora, CO, United States
| |
Collapse
|
9
|
Jordan CL, Noah TL, Henry MM. Therapeutic challenges posed by critical drug-drug interactions in cystic fibrosis. Pediatr Pulmonol 2016; 51:S61-S70. [PMID: 27662106 DOI: 10.1002/ppul.23505] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 05/28/2016] [Accepted: 06/02/2016] [Indexed: 12/19/2022]
Abstract
This review seeks to re-introduce cystic fibrosis (CF) clinicians to the pharmacology of drug-drug interactions among medications commonly used in CF and provide a framework for understanding these interactions among medications outside the scope of this discussion. We here focus on drugs impacted by the cytochrome P-450 (CYP450) enzyme system and on interactions involving antimicrobials, psychotropic medications, and cystic fibrosis transmembrane conductance regulator (CFTR) modulators. Particular attention is needed when prescribing rifampin, azole antifungals and the CFTR modulators, ivacaftor, and lumacaftor/ivacaftor, in combination with other medications. The complexities of these interactions provide a strong rationale for case management by pharmacists and pharmacologists as a routine part of CF care. Pediatr Pulmonol. 2016;51:S61-S70. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Cameron L Jordan
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina.
| | - Terry L Noah
- Division of Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Marianna M Henry
- Division of Pulmonology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| |
Collapse
|
10
|
Sashidhara KV, Singh LR, Choudhary D, Arun A, Gupta S, Adhikary S, Palnati GR, Konwar R, Trivedi R. Design, synthesis and in vitro evaluation of coumarin–imidazo[1,2-a]pyridine derivatives against cancer induced osteoporosis. RSC Adv 2016. [DOI: 10.1039/c6ra15674f] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The potential of coumarin–imidazo[1,2-a]pyridine hybrids to prevent bone loss in patients with bone metastases is discussed.
Collapse
Affiliation(s)
- Koneni V. Sashidhara
- Medicinal and Process Chemistry Division
- CSIR-Central Drug Research Institute
- Lucknow
- India
| | - L. Ravithej Singh
- Medicinal and Process Chemistry Division
- CSIR-Central Drug Research Institute
- Lucknow
- India
| | | | - Ashutosh Arun
- Endocrinology Division
- CSIR-Central Drug Research Institute
- Lucknow
- India
| | - Sampa Gupta
- Medicinal and Process Chemistry Division
- CSIR-Central Drug Research Institute
- Lucknow
- India
| | - Sulekha Adhikary
- Endocrinology Division
- CSIR-Central Drug Research Institute
- Lucknow
- India
| | - Gopala Reddy Palnati
- Medicinal and Process Chemistry Division
- CSIR-Central Drug Research Institute
- Lucknow
- India
| | - Rituraj Konwar
- Endocrinology Division
- CSIR-Central Drug Research Institute
- Lucknow
- India
| | - Ritu Trivedi
- Endocrinology Division
- CSIR-Central Drug Research Institute
- Lucknow
- India
| |
Collapse
|