1
|
Zevenbergen C, Groeneweg S, Swagemakers SMA, de Jong A, Medici-Van den Herik E, Rispens M, Klootwijk W, Medici M, de Rijke YB, Meima ME, Larsen PR, Chavatte L, Venter D, Peeters RP, Van der Spek PJ, Visser WE. Functional Analysis of Genetic Variation in the SECIS Element of Thyroid Hormone Activating Type 2 Deiodinase. J Clin Endocrinol Metab 2019; 104:1369-1377. [PMID: 30423129 DOI: 10.1210/jc.2018-01605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 11/08/2018] [Indexed: 01/05/2023]
Abstract
CONTEXT Thyroid hormone is important for normal brain development. The type 2 deiodinase (D2) controls thyroid hormone action in the brain by activating T4 to T3. The enzymatic activity of D2 depends on the incorporation of selenocysteine for which the selenocysteine-insertion sequence (SECIS) element located in the 3' untranslated region is indispensable. We hypothesized that mutations in the SECIS element could affect D2 function, resulting in a neurocognitive phenotype. OBJECTIVE To identify mutations in the SECIS element of DIO2 in patients with intellectual disability and to test their functional consequences. DESIGN, SETTING, AND PATIENTS The SECIS element of DIO2 was sequenced in 387 patients with unexplained intellectual disability using a predefined pattern of thyroid function tests. SECIS element read-through in wild-type or mutant D2 was quantified by a luciferase reporter system in transfected cells. Functional consequences were assessed by quantifying D2 activity in cell lysate or intact cell metabolism studies. RESULTS Sequence analysis revealed 2 heterozygous mutations: c.5703C>T and c.5730A>T, which were also present in the unaffected family members. The functional evaluation showed that both mutations did not affect D2 enzyme activity in cell lysates or intact cells, although the 5730A>T mutation decreased SECIS element read-through by 75%. In the patient harboring the c.5730A>T variant, whole genome sequencing revealed a pathogenic deletion of the STXBP1 gene. CONCLUSIONS We report on two families with mutations in the SECIS element of D2. Although functional analysis showed that nucleotide 5730 is important for normal SECIS element read-through, the two variants did not segregate with a distinct phenotype.
Collapse
Affiliation(s)
- Chantal Zevenbergen
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | - Stefan Groeneweg
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | - Sigrid M A Swagemakers
- Department of Bioinformatics, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
- Department of Pathology, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | | | - Evita Medici-Van den Herik
- Department of Child Neurology, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | | | - Wim Klootwijk
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | - Marco Medici
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | - Yolanda B de Rijke
- Department of Clinical Chemistry, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | - Marcel E Meima
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | - P Reed Larsen
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Laurent Chavatte
- Centre International de Recherche en Infectiologie, CIRI, INSERM U1111, CNRS/ENS/UCBL1 UMR5308, Lyon, France
| | - Deon Venter
- Department of Pathology, Mater Health Services, South Brisbane, Queensland, Australia
| | - Robin P Peeters
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | - Peter J Van der Spek
- Department of Bioinformatics, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
- Department of Pathology, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| | - W Edward Visser
- Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, University Medical Center, Rotterdam, Netherlands
| |
Collapse
|
2
|
Abstract
This article reviews those pathologic lesions which are associated with clinical and/or biochemical hyperthyroidism. Beginning with the descriptive pathology of classical Graves' disease and the less common toxic nodular goiter and hyper-functioning thyroid nodules, this paper describes the effects of non-thyroidal hormones, glandular function (including pituitary and hypothalamic lesions), ectopic production of thyroid stimulating proteins by non-thyroidal neoplasms, exogenous drug reactions causing hyper-function and finally conditions associated with a mechanic- destructive cause of hyperthyroidism.
Collapse
|
3
|
Zevenbergen C, Korevaar TIM, Schuette A, Peeters RP, Medici M, Visser TJ, Schomburg L, Visser WE. Association of antiepileptic drug usage, trace elements and thyroid hormone status. Eur J Endocrinol 2016; 174:425-32. [PMID: 26701870 DOI: 10.1530/eje-15-1081] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 12/23/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Levels of thyroid hormone (TH) and trace elements (copper (Cu) and selenium (Se)) are important for development and function of the brain. Anti-epileptic drugs (AEDs) can influence serum TH and trace element levels. As the relationship between AEDs, THs, and trace elements has not yet been studied directly, we explored these interactions. METHOD In total 898 participants, from the Thyroid Origin of Psychomotor Retardation study designed to investigate thyroid parameters in subjects with intellectual disability (ID), had data available on serum Se, Cu, thyroid stimulating hormone (TSH), free thyroxine (FT4), tri-iodothyronine (T3), reverse T3, T4, and thyroxine-binding globulin (TBG); 401 subjects were on AED treatment. Differences in trace elements according to medication usage was investigated using ANOVA, and associations between trace elements and thyroid parameters were analysed using (non-) linear regression models. RESULTS Study participants were not deficient in any of the trace elements analyzed. AED (carbamazepine, valproate and phenytoin) usage was negatively associated with serum Se and showed compound-specific associations with Cu levels. After correction for drug usage, Se was positively associated with TSH levels, negatively associated with FT4 levels, and positively with T3 levels. Cu was positively associated with T4, T3, and rT3, which was largely dependent on TBG levels. CONCLUSION The subjects with ID did not display profound deficiencies in trace element levels. AEDs were associated with serum Se and Cu levels, while serum Se and Cu were also associated with thyroid parameters. Further studies on the underlying mechanisms and potential clinical importance are warranted.
Collapse
Affiliation(s)
- Chantal Zevenbergen
- Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Tim I M Korevaar
- Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Andrea Schuette
- Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Robin P Peeters
- Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Marco Medici
- Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Theo J Visser
- Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - Lutz Schomburg
- Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
| | - W Edward Visser
- Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany Department of Internal MedicineRotterdam Thyroid CenterErasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The NetherlandsInstitut für Experimentelle EndokrinologieCharité-Universitätsmedizin Berlin, Augustenburger Platz 1, D-13353 Berlin, Germany
| |
Collapse
|
4
|
Paragliola RM, Prete A, Kaplan PW, Corsello SM, Salvatori R. Treatment of hypopituitarism in patients receiving antiepileptic drugs. Lancet Diabetes Endocrinol 2015; 3:132-40. [PMID: 24898833 DOI: 10.1016/s2213-8587(14)70081-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Evidence suggests that there may be drug interactions between antiepileptic drugs and hormonal therapies, which can present a challenge to endocrinologists dealing with patients who have both hypopituitarism and neurological diseases. Data are scarce for this subgroup of patients; however, data for the interaction of antiepileptic drugs with the pituitary axis have shown that chronic use of many antiepileptic drugs, such as carbamazepine, oxcarbazepine, and topiramate, enhances hepatic cytochrome P450 3A4 (CYP3A4) activity, and can decrease serum concentrations of sex hormones. Other antiepileptic drugs increase sex hormone-binding globulin, which reduces the bioactivity of testosterone and estradiol. Additionally, the combined oestrogen-progestagen contraceptive pill might decrease lamotrigine concentrations, which could worsen seizure control. Moreover, sex hormones and their metabolites can directly act on neuronal excitability, acting as neurosteroids. Because carbamazepine and oxcarbazepine can enhance the sensitivity of renal tubules, a reduction in desmopressin dose might be necessary in patients with central diabetes insipidus. Although the effects of antiepileptic drugs in central hypothyroidism have not yet been studied, substantial evidence indicates that several antiepileptic drugs can increase thyroid hormone metabolism. However, although it is reasonable to expect a need for a thyroxine dose increase with some antiepileptic drugs, the effect of excessive thyroxine in lowering seizure threshold should also be considered. There are no reports of significant interactions between antiepileptic drugs and the efficacy of human growth hormone therapy, and few data are available for the effects of second-generation antiepileptic drugs on hypopituitarism treatment.
Collapse
Affiliation(s)
- Rosa Maria Paragliola
- Unit of Endocrinology, Facoltà di Medicina Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Prete
- Unit of Endocrinology, Facoltà di Medicina Università Cattolica del Sacro Cuore, Rome, Italy
| | - Peter W Kaplan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore MD, USA
| | | | - Roberto Salvatori
- Department of Medicine, Division of Endocrinology, Metabolism and Diabetes and Pituitary Center, Johns Hopkins University School of Medicine, Baltimore MD, USA.
| |
Collapse
|
5
|
Zevenbergen C, Klootwijk W, Peeters RP, Medici M, de Rijke YB, Huisman SA, Goeman H, Boot E, de Kuijper G, de Waal KH, Meima ME, Larsen PR, Visser TJ, Visser WE. Functional analysis of novel genetic variation in the thyroid hormone activating type 2 deiodinase. J Clin Endocrinol Metab 2014; 99:E2429-36. [PMID: 25140401 DOI: 10.1210/jc.2014-2281] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Thyroid hormones (TH) are important for normal brain development and abnormal TH regulation in the brain results in neurocognitive impairments. The type 2 deiodinase (D2) is important for local TH control in the brain by generating the active hormone T3 from its precursor T4. Dysfunction of D2 likely results in a neurocognitive phenotype. No mutations in D2 have been reported yet. OBJECTIVE The objective of the study was to identify D2 mutations in patients with intellectual disability and to test their functional consequences. DESIGN, SETTING, AND PATIENTS The patients were selected from the multicenter Thyroid Origin of Psychomotor Retardation study, which is a cohort of 946 subjects with unexplained intellectual disability. Based on characteristic serum TH values, the coding region of the DIO2 gene was sequenced in 387 patients. Functional consequences were assessed by in vitro D2 assays or intact cell metabolism studies using cells transfected with wild-type or mutant D2. RESULTS Sequence analysis revealed two heterozygous mutations: c.11T>A (p.L4H) in three subjects and c.305C>T (p.T102I) in one subject. Sequence analysis of family members revealed several carriers, but no segregation was observed with thyroid parameters or neurocognitive phenotype. Extensive tests with different in vitro D2 assays did not show differences between wild-type and mutant D2. CONCLUSION This study describes the identification and functional consequences of novel genetic variation in TH activating enzyme D2. Family studies and functional tests suggest that these variants do not underlie the neurocognitive impairment. Altogether our data provide evidence of the existence of rare but apparently harmless genetic variants of D2.
Collapse
Affiliation(s)
- Chantal Zevenbergen
- Department of Internal Medicine (C.Z., W.K., R.P.P., M.M., Y.B.d.R., M.E.M., T.J.V., W.E.V.), Rotterdam Thyroid Center (C.Z., W.K., R.P.P., M.M., M.E.M., T.J.V., W.E.V.), Department of Clinical Chemistry (Y.B.d.R.), Erasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands; Prinsenstichting (S.A.H.), Kwadijkerpark 8, 1444 JE Purmerend, The Netherlands; Ipse De Bruggen (H.G., E.B.), Spoorlaan 19, 2471 PB Zwammerdam, The Netherlands; Vanboeijenoord (G.d.K.), Industrieweg 14-16, 9400 RA Assen, The Netherlands; 's Heeren Loo Groot Schuilenburg (K.H.d.W.), Laan Van Groot Schuylenburg 310-320, 7325 BG Apeldoorn, The Netherlands; and Department of Internal Medicine (R.L.), Brigham and Women's Hospital, Boston, Massachusetts 02115
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
6
|
de Winter CF, Echteld MA, Evenhuis HM. Chronic kidney disease in older people with intellectual disability: results of the HA-ID study. RESEARCH IN DEVELOPMENTAL DISABILITIES 2014; 35:726-732. [PMID: 24287320 DOI: 10.1016/j.ridd.2013.11.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 11/04/2013] [Accepted: 11/06/2013] [Indexed: 06/02/2023]
Abstract
With increasing longevity and cardiovascular events, chronic kidney disease may also become a significant problem in older people with intellectual disability (ID). We studied prevalence and associations of chronic kidney disease as part of the Healthy Ageing and Intellectual Disability (HA-ID) study, a large Dutch cross-sectional study among people with ID aged 50 years and over, using creatinine and cystatin-C measurement in plasma. Glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. Equations based on creatinine (as the MDRD equation) may underestimate kidney dysfunction in people with sarcopenia, because low muscle mass leads to a low creatinine production. Therefore, also prevalence of chronic kidney disease was studied in the sarcopenic group, using different GFR equations. Prevalence of chronic kidney disease, among 635 participants, was 15.3%, which equals prevalence in the general Dutch population. In the group of participants with sarcopenia (n=82), the CKD-EPI equation based on creatinine and cystatin-C gave a higher prevalence of chronic kidney disease than did the MDRD equation, but confidence intervals were very wide. Chronic kidney disease was associated with higher age, Down syndrome, obesity, hypercholesterolemia and hypothyroid disease. GFR should be measured in all older people with ID and polypharmacy, and in older people with ID and Down syndrome as part of the regular health checks. Moreover, if sarcopenia is present and information on GFR is required, this should not be measured based on creatinine only, but additional measures, such as cystatin-C, should be taken into account.
Collapse
Affiliation(s)
- C F de Winter
- Intellectual Disability Medicine, Erasmus Medical Center Rotterdam, Department of General Practice, Rotterdam, The Netherlands; Reinaerde, Den Dolder, The Netherlands.
| | - M A Echteld
- Intellectual Disability Medicine, Erasmus Medical Center Rotterdam, Department of General Practice, Rotterdam, The Netherlands
| | - H M Evenhuis
- Intellectual Disability Medicine, Erasmus Medical Center Rotterdam, Department of General Practice, Rotterdam, The Netherlands
| |
Collapse
|
7
|
Visser WE, van Mullem AAA, Visser TJ, Peeters RP. Different causes of reduced sensitivity to thyroid hormone: diagnosis and clinical management. Clin Endocrinol (Oxf) 2013; 79:595-605. [PMID: 23834164 DOI: 10.1111/cen.12281] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 06/05/2013] [Accepted: 07/01/2013] [Indexed: 11/30/2022]
Abstract
Normal thyroid hormone (TH) metabolism and action require adequate cellular TH signalling. This entails proper function of TH transporters in the plasma membrane, intracellular deiodination of TH and action of the bioactive hormone T3 at its nuclear receptors (TRs). The present review summarizes the discoveries of different syndromes with reduced sensitivity at the cellular level. Mutations in the TH transporter MCT8 cause psychomotor retardation and abnormal thyroid parameters. Mutations in the SBP2 protein, which is required for normal deiodination, give rise to a multisystem disorder including abnormal thyroid function tests. Mutations in TRβ1 are a well-known cause of resistance to TH with mostly a mild phenotype, while only recently, patients with mutations in TRα1 were identified. The latter patients have slightly abnormal TH levels, growth retardation and cognitive defects. This review will describe the mechanisms of disease, clinical phenotype, diagnostic testing and suggestions for treatment strategies for each of these syndromes.
Collapse
Affiliation(s)
- W Edward Visser
- Department of Internal Medicine, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | | | | |
Collapse
|
8
|
Visser WE, Vrijmoeth P, Visser FE, Arts WFM, van Toor H, Visser TJ. Identification, functional analysis, prevalence and treatment of monocarboxylate transporter 8 (MCT8) mutations in a cohort of adult patients with mental retardation. Clin Endocrinol (Oxf) 2013; 78:310-5. [PMID: 22924588 DOI: 10.1111/cen.12023] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 06/26/2012] [Accepted: 08/20/2012] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Monocarboxylate transporter 8 (MCT8) is an essential thyroid hormone (TH) transporter as humans with MCT8 mutations have severe neurological and endocrine abnormalities. The objectives are (i) to identify novel MCT8 mutations and (ii) to assess their functional relevance; (iii) to describe the effects of block-and-replace treatment in an MCT8 patient. DESIGN The TOP-R study is a cross-sectional nation-wide multicentre study. PATIENTS Subjects with unexplained mental retardation (MR) were screened for MCT8 mutations. RESULTS We identified three mutations: p.F501del (previously described), p.L492P and p.T162T. The F501del and L492P mutants, but not the T162T mutant, showed diminished T3, T4 and rT3 transport in transfected cells. TH transport in T162T fibroblasts was also not affected. One patient was treated with block-and-replace therapy to normalize serum TH levels. The results indicated a slow onset of the decrease in serum T4 and T3 by successive treatment with methimazole and PTU, and eventually their complete normalization by administration of LT4 with PTU but not with methimazole. The frequency of MCT8 mutations in males with X-linked MR approximately 3·9%. CONCLUSIONS We identified several MCT8 mutations in a cohort of subjects with unexplained MR. We demonstrated the pathogenicity of two missense mutations. The synonymous variant did not affect TH transport. Block-and-replace therapy of one patient reversed the TH abnormalities. Our data suggest a decreased TH secretion rate and an increased T4 to T3 conversion by the type I deiodinase in patients with MCT8 mutations. Our study indicates that MCT8 mutations are a relatively frequent cause of X-linked MR.
Collapse
Affiliation(s)
- W Edward Visser
- Department of Internal Medicine, Erasmus Medical Center, Dr Molewaterplein 50, Rotterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|