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Campbell IW. Metformin: a 60-year odyssey with the journey still continuing - a personal commentary from Professor Ian Campbell. Curr Med Res Opin 2022; 38:55-58. [PMID: 34738843 DOI: 10.1080/03007995.2021.2003149] [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] [Indexed: 10/19/2022]
Affiliation(s)
- Ian W Campbell
- Emeritus Professor of Medicine, University of St Andrews, St Andrews, UK
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Imam TH. Changes in metformin use in chronic kidney disease. Clin Kidney J 2017; 10:301-304. [PMID: 28616207 PMCID: PMC5466114 DOI: 10.1093/ckj/sfx017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 02/21/2017] [Indexed: 01/06/2023] Open
Abstract
Metformin is one of the oldest and most widely prescribed antidiabetic medicines worldwide. It is the only such medicine that has shown a reduction of cardiovascular mortality in diabetes mellitus type 2. Since many diabetic patients have chronic kidney disease, its use is often curtailed by practitioners due to fear of lactic acidosis and the US Food and Drug Administration (FDA) warnings that, until recently, had been in place for decades. Current guidelines, though somewhat vague regarding dosages, clearly pave the way for spreading the use of metformin in patients with lower glomerular filtration rates. These guidelines also suggest moving away from just looking at serum creatinine to create a cut-off. Metformin’s costs are lower, and in many underdeveloped countries this is the only medicine available for poor patients. More widespread use of metformin will further help with health care costs, as well as obesity. It will simplify the use of diabetes mellitus type 2 management with lower incidences of hypoglycemia. With all the mounting evidence, the FDA is finally requiring labeling changes regarding recommendations, to allow the use of metformin in patients with much reduced kidney function.
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Affiliation(s)
- Talha H Imam
- Division of Nephrology, Kaiser Permanente, Southern California Permanente Medical Group, Fontana, CA, USA
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Soliman GA, Steenson SM, Etekpo AH. Effects of Metformin and a Mammalian Target of Rapamycin (mTOR) ATP-Competitive Inhibitor on Targeted Metabolomics in Pancreatic Cancer Cell Line. ACTA ACUST UNITED AC 2016; 6. [PMID: 28217402 DOI: 10.4172/2153-0769.1000183] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pancreatic Cancer (PC) is a devastating lethal disease. Therefore, there is an urgent need to develop new intervention strategies. The mammalian Target of Rapamycin (mTOR) is a conserved kinase and master regulator of metabolism and cell growth. mTOR is dysregulated in chronic diseases including diabetes and pancreatic cancer. Recent reports indicate that 50% of Pancreatic Ductal Adenocarcinoma (PDAC) patients are diabetic at the time of diagnosis. Furthermore, the anti-diabetic drug, metformin, which indirectly inhibits mTOR, has emerged as a potential therapeutic target for PC. The objective of this study is to determine the targeted-metabolomics profile in PDAC cell line (HPAF-II) with mTOR inhibition and the interaction between mTOR ATP-competitive inhibitor (Torin 2) and metformin as potential combined therapy in PC. HPAF-II cell lines were cultured in the presence of either Torin 2, metformin, both, or control vehicle. We utilized targeted LC/MS/MS to characterize the alterations in glycolytic and tricarboxylic acid cycle metabolomics, and employed Western Blot analysis for cell signaling activation by phosphorylation. Comparisons between groups were analyzed using one-way Analysis of Variance followed by secondary post-hoc analysis. After 1 h incubation with metformin, AMP concentration was significantly increased compared to other groups (p<0.03). After 24 h, Torin-2 significantly decreased glycolysis intermediates (fructose 1,6-bisphosphate (FBP), and 2-phosphoglycerate/3-phosphoglycerate), TCA intermediate metabolites (citrate/isocitrate, and malate), as well as Nicotinamide Adenine Dinucleotide (NAD+) and Flavin Adenine Dinucleotide (FAD), and ATP levels. When HPAF-II cells were incubated with both Torin-2 and metformin, there was a significant reduction in NAD+ and FAD, suggesting decreased levels of the energy equivalents that are available to the electron transport chain. Targeted metabolomics data indicate that mTOR complexes inhibition by Torin 2 reduced glycolytic intermediates and TCA metabolites in HPAF- II and may synergize with metformin to decrease the electron acceptors NAD+ and FAD which may lead to reduced energy production.
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Affiliation(s)
- Ghada A Soliman
- Department of Health Promotion, Social and Behavioral Health College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, 68198 USA
| | - Sharalyn M Steenson
- Department of Health Promotion, Social and Behavioral Health College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, 68198 USA
| | - Asserewou H Etekpo
- Department of Health Promotion, Social and Behavioral Health College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, 68198 USA
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Lacticemia After Acute Overdose of Metformin in an Adolescent Managed Without Intravenous Sodium Bicarbonate or Extracorporeal Therapy. Pediatr Emerg Care 2015; 31:589-90. [PMID: 26241713 DOI: 10.1097/pec.0000000000000517] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Metformin-associated lactic acidosis or lacticemia has been widely reported as an adverse drug effect in diabetic patients with other significant comorbidities and in acute overdose in adults. Lacticemia has been reported twice in a previously healthy pediatric population, both of which were suicide attempts and required hemodialysis. We report a case of a 17-year-old, nondiabetic, healthy adolescent girl with metformin-associated lacticemia who intentionally overdosed on metformin, had no coingestants, and was treated only with crystalloids. Furthermore, she did not require intravenous bicarbonate administration or extracorporeal removal.
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5
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Abstract
Metformin-associated lactic acidosis (MALA) is a rare but serious clinical entity. It is almost always seen in patients with a serious underlying medical disorder, most often a degree of renal impairment or other factors that are known to predispose to the lactic acidosis. We report a case of MALA in which acute renal failure resulting from hypovolemia secondary to acute gastroenteritis likely precipitated the condition. Early recognition of this condition and initiation of treatment are important. Bicarbonate hemodialysis is the treatment of choice.
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Affiliation(s)
- Chetan Shenoy
- Department of Internal Medicine, Guthrie/Robert Packer Hospital, Sayre, PA 18840, USA.
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6
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Simó R, Hernández C. [Treatment of diabetes mellitus: general goals, and clinical practice management]. Rev Esp Cardiol 2002; 55:845-60. [PMID: 12199981 DOI: 10.1016/s0300-8932(02)76714-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Diabetes mellitus is associated with a marked increased of cardiovascular events. The treatment strategy of diabetes has to be based on the knowledge of its pathophysiology. Thus, insulin is essential for treatment of type 1 diabetic patients because there is a defect in insulin secretion. However, treatment of type 2 diabetic patients is more complex because a defect in both insulin secretion and insulin action exists. Therefore, the treatment selection will depend on the stage of the disease and the individual characteristics of the patient. This article examines the general goals of the treatment and reviews the management of type 2 diabetes.
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MESH Headings
- Administration, Oral
- Angina, Unstable/complications
- Blood Glucose/analysis
- Diabetes Mellitus, Type 1/blood
- Diabetes Mellitus, Type 1/complications
- Diabetes Mellitus, Type 1/drug therapy
- Diabetes Mellitus, Type 1/physiopathology
- Diabetes Mellitus, Type 2/blood
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/drug therapy
- Diabetes Mellitus, Type 2/physiopathology
- Drug Therapy, Combination
- Exercise
- Humans
- Hypoglycemic Agents/administration & dosage
- Hypoglycemic Agents/therapeutic use
- Insulin/administration & dosage
- Insulin/therapeutic use
- Lipids/blood
- Myocardial Infarction/complications
- Risk Factors
- Surgical Procedures, Operative
- Time Factors
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Affiliation(s)
- Rafael Simó
- Sección de Endocrinología, Hospital General Vall d'Hebron, Barcelona, Spain.
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Guagnano MT, Pace - Palitti V, Manigrasso MR, Merlitti D, Soto Parra HM, Sensi S. Non insulin-dependent diabetes mellitus (type 2) secondary failure. Metformin-glibenclamide treatment. Int J Immunopathol Pharmacol 2001; 14:31-43. [PMID: 12622887 DOI: 10.1177/039463200101400106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The goal of sulphonylurea (S) treatment in Non-Insulin-Dependent Diabetes Mellitus (NIDDM - type 2 diabetes) subjects should be to obtain a satisfactory glycemic control (fasting glycemic levels < 140 mg%). The loss of an adequate blood glucose control after an initial variable period of S is known as secondary failure (SF). The number of SF are extremely variable among different trials for many reasons, some of which are patient-related: increased food intake, weight gain, non-compliance, poor physical activity, stress, diseases and÷or impaired pancreatic beta cell function, desensitization after S chronic therapy, reduced absorption, concomitant therapies. Many therapeutic strategies have been proposed to achieve an adequate metabolic control in type 2 diabetes patients: switch to intensive insulin therapy and subsequent return to S therapy; association with insulin; association with sulphonylureas plus biguanides. The association biguanides and S, in particular glibenclamide plus metformin, is now widely used by diabetologists in SF since glibenclamide improves insulin secretion while metformin exerts its antidiabetic.
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Affiliation(s)
- M T Guagnano
- Clinic of Internal Medicine, University of Chieti, Chieti, Italy
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Abstract
Therapeutically administered antidiabetic drugs, notably insulin and the sulfonylureas, are undoubtedly the most common cause of hypoglycemia encountered in clinical practice. Nevertheless, an impressive list of other drugs can produce hypoglycemia unpredictably in seemingly healthy individuals in whom it may masquerade as spontaneous hypoglycemia. Unless the true cause is identified when the patient is first seen, fruitless and expensive overinvestigation may ensue. The most important drugs are discussed herein and brief mention made of those for which coincidence has not been eliminated.
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Affiliation(s)
- V Marks
- Department of Medicine, University of Surrey, Guilford, United Kingdom
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Gilbert RE, Cooper ME, Krum H. Drug administration in patients with diabetes mellitus. Safety considerations. Drug Saf 1998; 18:441-55. [PMID: 9638389 DOI: 10.2165/00002018-199818060-00005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Diabetes mellitus is associated with alterations in a number of key metabolic pathways. Despite theoretical concerns, clinically significant alterations in the pharmacokinetic properties of commonly prescribed drugs are relatively uncommon. Indeed, dose adjustment is rarely required in the setting of well controlled diabetes mellitus. However, significant alterations in drug handling may occur in the context of poor metabolic control or in the presence of complications such as nephropathy. Metformin use may be complicated by lactic acidosis. Fortunately, this is a rare occurrence providing that the agent is not used in circumstances in which it is contraindicated. Indeed, the risk of death from metformin-related lactic acidosis is similar in magnitude to the risk of death related to hypoglycaemia in sulphonylurea-treated patients. The novel hypoglycaemic agent troglitazone may be associated with abnormalities in liver function in approximately 2% of patients. Discontinuation of treatment is followed by normalisation of liver enzyme levels. Current prescribing information recommends frequent monitoring of liver function tests and immediate cessation of therapy if abnormalities develop. In addition to disturbances in intermediary metabolism, diabetes mellitus may also lead to chronic microvascular and marcovascular complications. Thus, in addition to the use of drugs for the control of blood glucose, patients with diabetes mellitus are likely to be prescribed medication for associated conditions such as cardiovascular disease. Such medication includes the ACE inhibitors which are contraindicated in patients with bilateral renal artery stenosis. This complication may be theoretically more common in patients with diabetes mellitus because of accelerated atherosclerosis. However, in clinical practice this is an uncommon occurrence in the absence of clinical features that should alert the treating clinician that an individual patient might be at high risk. Although caution should also be used with beta-blocker therapy in patients with diabetes mellitus, current evidence suggests that, like ACE inhibitors, these drugs may be particularly useful in this patient group.
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Affiliation(s)
- R E Gilbert
- Melbourne University Department of Medicine, Austin & Repatriation Medical Centre, Heidelberg, Victoria, Australia.
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Haupt E, Panten U. [Value of biguanide in therapy of diabetes mellitus]. MEDIZINISCHE KLINIK (MUNICH, GERMANY : 1983) 1997; 92:472-9, 505. [PMID: 9340472 DOI: 10.1007/bf03044916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Biguanides have been used in treatment of diabetes mellitus for over 30 years now. Due to frequent occurrence of lactic acidosis, particularly in patients with serious contraindications to biguanide therapy and in cases of non-compliance with dosage instructions, buformin and phenformin were taken off the market in most European countries at the end of the seventies. Metformin continued to be allowed, since the risk of lactic acidosis is 20 times less than with phenformin or buformin due to the different pharmacokinetic properties of the substance. Plenty of clinical experience has been gained with metformin, documented in a large number of reliable long-term studies. FINDINGS Metformin lowers fasting blood glucose levels by an average of 25% (17 to 37%), postprandial blood glucose by up to 44.5% and HbA1c bei 1.5% (0.8 to 3.1%) Metformin reduces raised plasma insulin levels in cases of metabolic syndrome by as much as 30% and reduces the "insulin requirement" of type 2 insulin-treated diabetics by 15 to 32%. It has well documented effects on various rheological parameters. In overweight type 2 diabetics, metformin shows the same level of hypoglycaemic effect as all of the important sulfonylurea derivatives used in Europe. The active mechanism of these derivatives is, however, concentrated solely on reduction of blood glucose. This mechanism does not take into account the remaining risk constellation involved in insulin resistance. Biguanides, similarly to weight reduction, lead to a reduction of hyperinsulinaemia, which is by contrast exacerbated by sulfonylureas and, in particular, exogenous insulin. CONCLUSION The risk of lactic acidosis can probably be eliminated entirely if dosage instructions and contraindications are observed carefully. The cause of such neglect in 83% of all cases was limited on renal function (serum creatinine > 1.5 mg%). Regarding morbidity and mortality from lactic acidosis, metformin therapy is no riskier than treatment with the sulfonylurea derivative glibenclamide, taking into account the incidence of fatal hypoglycaemias with the latter.
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Affiliation(s)
- E Haupt
- Klinik für Psychiatrie und Psychotherapie, Universität Rostock
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12
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Affiliation(s)
- C J Bailey
- Department of Pharmaceutical and Biological Sciences, Aston University, Birmingham, United Kingdom
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13
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Abstract
The sulphonylureas and the biguanides are widely used as adjuncts to dietary measures in the treatment of non-insulin-dependent (type 2) diabetes mellitus (NIDDM). Adverse effect profiles differ markedly between the sulphonylureas and biguanides, reflecting differences in chemical structure and mode of action. Sulphonylureas are generally well tolerated, although pharmacokinetic differences between these agents have important clinical implications. The main adverse effect associated with sulphonylureas is hypoglycaemia. This effect is a predictable consequence of the principal pharmacological effect of these drugs, i.e. sensitisation of the islet beta-cell to glucose, resulting in enhanced endogenous insulin secretion. Sulphonylurea-induced suppression of hepatic glucose production may cause profound and protracted hypoglycaemia, especially in elderly patients, in individuals with intercurrent illnesses and reduced caloric intake, or when taken in combination with other compounds with hypoglycaemic potential, e.g. alcohol (ethanol). Sulphonylureas with a longer duration of action, notably chlorpropamide and glibenclamide (glyburide), are more liable to induce serious hypoglycaemia, particularly when drug elimination is reduced by renal impairment. Other drugs such as salicylates may potentiate the actions of sulphonylureas, thereby increasing the risk of hypoglycaemia. Biguanide therapy is associated with alterations in lactate homeostasis which under certain clinical circumstances may result in fatal lactic acidosis. Phenformin is associated with a markedly greater risk of lactic acidosis than metformin. Phenformin has been withdrawn in many countries for this reason. All biguanides must be avoided in patients with renal impairment, hepatic dysfunction and cardiac failure--conditions where drug accumulation or disordered lactate metabolism may predispose to lactic acidosis. Phenformin should not be given to individuals who exhibit a severe, genetically conferred hepatic defect of hydroxylation which impedes metabolism of this drug. Less seriously, the biguanides are associated with a relatively high incidence of gastrointestinal adverse effects which limit compliance. Acarbose, a competitive inhibitor of intestinal alpha-glucosidases, has recently been introduced. In contrast to the sulphonylureas and biguanides, acarbose has not been associated with life-threatening adverse effects. This reflects the low systemic absorption of the drug and, predictably, its principal unwanted effects are gastrointestinal disturbances resulting from iatrogenic carbohydrate malabsorption.
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Moore DF, Wood DF, Volans GN. Features, prevention and management of acute overdose due to antidiabetic drugs. Drug Saf 1993; 9:218-29. [PMID: 8240727 DOI: 10.2165/00002018-199309030-00007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Hypoglycaemic medication forms a disparate group of therapeutic compounds including insulin, the sulphonylureas and biguanides. They are all designed to prevent hyperglycaemia and in general are well tolerated. Careful prescribing practice and patient education by the physician can do much to reduce the risk of adverse effects from diabetic therapy. However, the presentation of adverse effects, together with accidental and non-accidental overdose, is a frequent clinical problem. Furthermore, the possible impairment of hypoglycaemic awareness in patients prescribed human insulin has added complexity to diabetic management. The cardinal features of insulin overdose are hypoglycaemia and hypokalaemia. The sulphonylureas predominantly cause hypoglycaemia, while the biguanides may precipitate lactataemia and acidosis. Recognition of hypoglycaemia is therefore crucial in avoidance of toxicity. Intravenous dextrose is the mainstay of therapy following gut decontamination (for the oral agents). The efficacy of glucagon is dependent on hepatic glycogen stores and should therefore be used with caution. Diazoxide is not recommended. More recently, octreotide has been shown to be effective in sulphonylurea overdose. Patients should be admitted and monitored with serial blood sugar measurements for a minimum of 1 to 2 days as clinically warranted.
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Affiliation(s)
- D F Moore
- National Poisons Unit, Guy's Hospital, London, England
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Abstract
Since the withdrawal of phenformin in 1978, the use of metformin has increased from 13,500 to 22,000 patient years/year. During the period 1977-91 a total of 18 cases of metformin-associated acidosis was reported, of which 16 had lactic acidosis. The incidence of reported acidosis and lactic acidosis decreased from 1.50 cases per 10,000 patient years in 1977-81 to 0.24 cases per 10,000 patient years 1987-91, probably due to lower doses doses and reduced usage in the very old. All the reports described patients with several other concomitant diseases, mainly cardiovascular and renal, when the acidosis was diagnosed. It is important continuously to re-evaluate metformin therapy and to stop treatment at the onset of impaired renal or cardiovascular function.
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Affiliation(s)
- B E Wiholm
- Division of Drug Epidemiology, Medical Products Agency, Uppsala, Sweden
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Chalmers J, McBain AM, Brown IRF, Campbell IW. Metformin: Is its use contraindicated in the elderly? ACTA ACUST UNITED AC 1992. [DOI: 10.1002/pdi.1960090205] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
The hyperglycaemia of NIDDM is associated with insulin resistance due, in part, to reduced insulin receptor binding and more especially postreceptor defects. Metformin is an antihyperglycaemic agent which can be used to ameliorate insulin resistance. It appears to act directly on insulin target cells to enhance insulin action. Although metformin may increase insulin-receptor binding, its main effect appears to be directed at the postreceptor level of insulin action. Accordingly the drug potentiates insulin-suppression of hepatic gluconeogenesis and increases insulin-mediated peripheral glucose uptake and metabolism. It does not stimulate insulin release, does not cause weight gain and does not cause clinical hypoglycaemia. The risk of lactate accumulation should be appreciated in patients with renal insufficiency, liver dysfunction and following acute illness with hypoxia, when therapy should be stopped. Although metformin is often bracketed with phenformin in the context of lactic acidosis, different pharmacodynamics and adherence to prescribing guidelines render such a comparison unwarranted.
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Affiliation(s)
- R E Ferner
- Wolfson Unit of Clinical Pharmacology, Royal Victoria Infirmary, Newcastle upon Tyne
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Campbell IW, Duncan C, Patton NW, Broadhead T, Tucker GT, Woods HF. The effect of metformin on glycaemic control, intermediary metabolism and blood pressure in non-insulin-dependent diabetes mellitus. Diabet Med 1987; 4:337-41. [PMID: 2956047 DOI: 10.1111/j.1464-5491.1987.tb00895.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Fourteen non-insulin-dependent diabetics (9 female, 5 male), aged 46 to 64 years, uncontrolled by diet (fasting plasma glucose greater than or equal to 8 mmol/l), were treated with metformin, 1-3 g daily, and followed prospectively at 1 week, then at 2-weekly intervals for 6 months. The fasting plasma glucose fell significantly (p less than 0.01) after 1 week of therapy and HbA1 showed a significant reduction, 13.4 +/- 2.5% (mean +/- SD) to 10.7 +/- 1.8% (normal range 5.1-9.3%) at 8 weeks (p less than 0.001). There was no significant change in body weight, plasma insulin, serum cholesterol or triglycerides, blood lactate, pyruvate, glycerol, alanine, 3-hydroxybutyrate or acetoacetate concentration. Systolic, diastolic, and mean arterial blood pressures, along with resting heart rate remained unchanged. This study shows that metformin effectively lowers plasma glucose without hyperinsulinism or significant rise in fasting blood lactate and other gluconeogenic precursors.
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Abstract
Since their introduction into clinical practice about 30 years ago, the popularity of oral hypoglycaemic agents has waxed and waned. Their use should not lead to the neglect of other facets of management in non-insulin dependent diabetes mellitus, such as diet and exercise, and the introduction of insulin should not be delayed in subjects who are not achieving an adequate control of blood glucose levels. In spite of concerns about the long-term safety and efficacy of oral hypoglycaemic agents that have been raised by the University Group Diabetes Program Study, oral hypoglycaemic agents have an established place in the management of non-insulin dependent diabetes. This article discusses briefly the mechanisms of action and clinical pharmacology of the oral hypoglycaemic agents in common use in Australia, and emphasizes practical issues that are relevant to their clinical use.
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Affiliation(s)
- Richard G. Larkins
- Department of Medicine, University of Melbourne, The Royal Melbourne Hospital, Melbourne, VIC 3050
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