1
|
Kazi M, Almarri F, Shahba AAW, Ahmad A, Albraiki S, Alanazi FK. Nutraceutically-enhanced oral delivery of vitamin D3 via Bio-SNEDDS: Demonstrating in vivo superiority over pediatric formulations. Biochem Biophys Res Commun 2024; 709:149852. [PMID: 38574607 DOI: 10.1016/j.bbrc.2024.149852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 03/21/2024] [Accepted: 03/27/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Vitamin D3 (VD3) deficiency among children in Saudi Arabia remains a pressing concern due to its poor bioavailability and the limitations of current pediatric formulations. To address this challenge, we developed a groundbreaking pediatric self-nanoemulsifying drug delivery system (Bio-SNEDDS) for VD3, fortified with black seed oil and moringa seed oil for dual therapeutic benefits. Through meticulous formulation optimization using ternary phase diagrams and comprehensive testing, our Bio-SNEDDS demonstrated exceptional performance. METHODS Bio-SNEDDS were manufactured by incorporating Black seed oil and moringa seed oil as bioactive nutraceutical excipients along with various cosurfactant and surfactants. Bio-SNEDDS were systematically optimized through ternary phase diagrams, visual tests, droplet size analysis, drug solubilization studies, dispersion assessments, and pharmacokinetic testing in rats compared to Vi-De 3®. RESULTS Pseudoternary phase diagrams identified oil blends producing large nanoemulsion regions optimal for SNEDDS formation. The optimized F1 Bio-SNEDDS showed a mean droplet diameter of 33.7 nm, solubilized 154.46 mg/g VD3 with no metabolite formation, and maintained >88% VD3 in solution during 24 h dispersion testing. Notably, in vivo pharmacokinetic evaluation at a high VD3 dose demonstrated an approximately two-fold greater relative bioavailability over Vi-De 3®, validating the superb oral delivery performance of Bio-SNEDDS even under challenging high-dose conditions. CONCLUSIONS The Bio-SNEDDS provides an effective VD3 delivery strategy with established in vivo superiority over marketed products, along with offering additional health benefits from the natural oils.
Collapse
Affiliation(s)
- Mohsin Kazi
- Department of Pharmaceutics, College of Pharmacy, POBOX- 2457, King Saud University, Riyadh, 11451, Kingdom of Saudi Arabia.
| | - Fahad Almarri
- Department of Pharmaceutics, College of Pharmacy, POBOX- 2457, King Saud University, Riyadh, 11451, Kingdom of Saudi Arabia
| | - Ahmad Abdul-Wahhab Shahba
- Department of Pharmaceutics, College of Pharmacy, POBOX- 2457, King Saud University, Riyadh, 11451, Kingdom of Saudi Arabia
| | - Ajaz Ahmad
- Department of Clinical Pharmacy, College of Pharmacy, POBOX- 2457, King Saud University, Riyadh, 11451, Kingdom of Saudi Arabia
| | - Salem Albraiki
- Department of Pharmaceutics, College of Pharmacy, POBOX- 2457, King Saud University, Riyadh, 11451, Kingdom of Saudi Arabia
| | - Fars Kaed Alanazi
- Department of Pharmaceutics, College of Pharmacy, POBOX- 2457, King Saud University, Riyadh, 11451, Kingdom of Saudi Arabia
| |
Collapse
|
2
|
Childs-Sanford SE, Makowski AJ, Hilliard RL, Wakshlag JJ. EXPERIMENTAL CHOLECALCIFEROL SUPPLEMENTATION IN A HERD OF MANAGED ASIAN ELEPHANTS ( ELEPHAS MAXIMUS). J Zoo Wildl Med 2023; 54:219-230. [PMID: 37428684 DOI: 10.1638/2022-0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 07/12/2023] Open
Abstract
Vitamin D supplementation may pose a significant health risk in species where levels of deficiency, sufficiency, and toxicity have not been clearly established, and species-specific research on vitamin D supplementation should be performed. This study documented the effect of vitamin D supplementation on serum vitamin D metabolites and other analytes of Ca homeostasis in Asian elephants (Elephas maximus). Six adult Asian elephants received PO supplementation with cholecalciferol at 300 IU/kg of body weight (BW) once a week for 24 wk. Serum was analyzed every 4 wk for 25-hydroxyvitamin D2/D3 [25(OH)D]; 24,25-dihydroxyvitamin D2/D3 [24,25(OH)2D]; 1,25-dihydroxyvitamin D [1,25(OH)2D]; parathyroid hormone (PTH); total Ca; ionized Ca (iCa); P; and Mg. After the supplement was discontinued, serum 25(OH)D2/D3 was measured every 4 wk until levels returned to baseline. At the start of the study, the average serum 25(OH)D3 was nondetectable (<1.5 ng/ml). With cholecalciferol supplementation, 25(OH)D3 increased at an average rate of 2.26 ng/ml per month and reached an average concentration of 12.9 ± 3.46 ng/ml at 24 wk. Both 24,25(OH)2D3 and 1,25(OH)2D increased over time with supplementation from an average of <1.5 to 12.9 ng/ml and from 9.67 to 36.4 pg/ml, respectively. PTH, iCa, Ca, P, and Mg remained within reported normal ranges throughout supplementation. After the supplement was discontinued, serum 25(OH)D3 demonstrated a slow decline to baseline, taking an average of 48 wk. Elephants demonstrated significant individual variation in response to supplementation and subsequent return to baseline. Supplementation of Asian elephants with a weekly dose of 300 IU/kg BW cholecalciferol for 24 wk appears to be effective and safe. Additional clinical studies would be necessary to investigate the safety of other routes of administration, dosages, and duration of vitamin D supplementation, as well as associated health benefits.
Collapse
Affiliation(s)
| | - Andrew J Makowski
- Heartland Assays, Iowa State University Research Park, Ames, Iowa 50010, USA
| | - Rachel L Hilliard
- College of Veterinary Medicine, Cornell University, Ithaca, New York 14853, USA
| | - Joseph J Wakshlag
- Department of Clinical Sciences, Cornell University, Ithaca, New York 14853, USA
| |
Collapse
|
3
|
Starek M, Gumułka P, Dąbrowska M. Quality Control of the Dietary Supplements Containing Selected Fat-Soluble Vitamins D and K. Nutrients 2023; 15:nu15071650. [PMID: 37049490 PMCID: PMC10096846 DOI: 10.3390/nu15071650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Nowadays, the most important aspect related to the use of dietary supplements seems to be their quality. There are many reports indicating their insufficient quality primarily related to a much lower content of ingredients or even their absence. Currently, there is an increasing interest in supplementing the diet with various kinds of supplements, including those containing combinations of vitamins and minerals, among which preparations with vitamin D are very popular. This is probably due to the reduced production of this vitamin, depending on the amount of time spent in the sun and the use of UV-filters. Very often, preparations with cholecalciferol also contain vitamin K2, which is associated with their synergistic effect. Therefore, the question arises about the effectiveness of supplementation, which may be correlated with the quality of commonly available dietary supplements. In the presented work, it was undertaken to develop optimal conditions for the qualitative and quantitative determination of vitamins D2, D3 and K2 in dietary supplements available in various forms, using thin-layer chromatography with densitometric detection. As a result, the methodology for analyzing the content of three vitamins from various matrices was developed, optimized and validated in accordance with ICH requirements. The obtained results allow us to conclude that it is reliable and meets the requirements for analytical procedures used in the analysis of medicinal products. Based on the results obtained for examined dietary supplements, it can be stated that the amount of vitamin D3 in analyzed products is basically similar to that declared by the manufacturer, in contrast to vitamin K2, the content of which is diverse. The developed methodology seems to be a good, low-cost and quick way to control the quality of dietary supplements so that they can supplement the human diet and be a wholesome product.
Collapse
Affiliation(s)
- Małgorzata Starek
- Department of Inorganic and Analytical Chemistry, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna St, 30-688 Kraków, Poland
| | - Paweł Gumułka
- Department of Inorganic and Analytical Chemistry, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna St, 30-688 Kraków, Poland
- Doctoral School of Medical and Health Sciences, Jagiellonian University Medical College, 16 Łazarza St, 31-530 Kraków, Poland
| | - Monika Dąbrowska
- Department of Inorganic and Analytical Chemistry, Faculty of Pharmacy, Jagiellonian University Medical College, 9 Medyczna St, 30-688 Kraków, Poland
| |
Collapse
|
4
|
Aljuffali I, Almarri F, Rahman AFMM, Alanazi FK, Alkholief M, Kazi M. Simultaneous Determination of Cholecalciferol and 25- Hydroxycholecalceferol in Lipid-based Self-nanoemulsifying formulations and Marketed Product Vi-de 3® by UHPLC-UV. CURR PHARM ANAL 2019. [DOI: 10.2174/1573412915666190612141228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:
The purpose of the current study was to develop a selective, precise, fast economical
and advanced reverse phase ultra-high-performance liquid chromatography (UHPLC UV)
method and validate it for the simultaneous estimation of cholecalciferol and its analogue 25-
hydroxycholecalciferol in lipid-based self-nano emulsifying formulation (SNEDDS).
Methods:
The chromatographic separation was simply performed on a Dionex® UHPLC systems
(Ultimate 3000, Thermo scientific) by using HSS C18 (2.1x50 mm, 1.8 µm) analytical column. The
elution was carried out isocratically with the mobile phase consisting of acetonitrile and methanol in the
ratio of 50:50 %v/v with a flow rate of 0.4 ml/min, followed by the UV detection at 265 nm. The injection
volume was 1µl and the column temperature was maintained at 45°C. FDA regulatory guidelines
were used to develop and validate the method.
Results:
The current developed UHPLC-UV method was found to be rapid (run time 2 min), and selective
with the high resolution of cholecalciferol and 25-hydroxycholecalciferol (RT=0.530 min & 1.360
min) from different lipid matrices. The method was highly sensitive (Limit of Detection and Lower
Limit of Quantification were 0.13 ppm & 0.51ppm, and 0.15 ppm & 0.54 ppm, respectively). The linearity,
accuracy and precision were determined as suitable over the concentration range of 0.5-50.0 ppm
for both the analytes.
Conclusion:
The proposed UHPLC-UV method can be used for the determination of cholecalciferol
and 25-hydroxycholecalciferol in SNEDDS and marketed Vi-De 3® as pure forms (intact) with no interference
of excipients or drug-related substances.
Collapse
Affiliation(s)
- Ibrahim Aljuffali
- Kayyali Chair for Pharmaceutical Industries, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Fahad Almarri
- Kayyali Chair for Pharmaceutical Industries, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - A. F. M. Motiur Rahman
- Department of Pharmaceutical chemistry, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Fars Kaed Alanazi
- Kayyali Chair for Pharmaceutical Industries, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Musaed Alkholief
- Kayyali Chair for Pharmaceutical Industries, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mohsin Kazi
- Kayyali Chair for Pharmaceutical Industries, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
5
|
Drug Delivery Systems for Vitamin D Supplementation and Therapy. Pharmaceutics 2019; 11:pharmaceutics11070347. [PMID: 31323777 PMCID: PMC6680748 DOI: 10.3390/pharmaceutics11070347] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/11/2019] [Accepted: 07/16/2019] [Indexed: 02/07/2023] Open
Abstract
Vitamin D (VD) is a fat-soluble prohormone well known for its role in regulating calcium and phosphate metabolism. It has been clinically used for many years to prevent rickets in children, osteomalacia, and osteoporosis in adults. VD insufficiency is a common medical condition, and many supplements are available in the market in order to increase serum 25-hydroxy VD levels to recommended amounts. Over the course of the last decades, it has become increasingly clear that calcitriol, an active form of VD, regulates multiple cellular processes with effects on normal and malignant cell growth and differentiation, and on the immune and cardiovascular function. Increasing evidence supports the role of the VD system in cancer prevention and therapy. Due to many pleiotropic and beneficial effects in extra-skeletal disorders, VD has gained potential and become an interesting active for encapsulation into drug delivery systems. The purpose of this review is to present the diversity of drug delivery systems that have been reported for VD or VD derivatives in an orderly manner across the following categories: Oral administration, application on the skin, cancer prevention/therapy, and other diseases or routes of administration.
Collapse
|
6
|
Łagowska K, Bajerska J, Jamka M. The Role of Vitamin D Oral Supplementation in Insulin Resistance in Women with Polycystic Ovary Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Nutrients 2018; 10:E1637. [PMID: 30400199 PMCID: PMC6266903 DOI: 10.3390/nu10111637] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 10/16/2018] [Accepted: 10/22/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To evaluate the effect of vitamin D supplementation (alone or with co-supplementation) on insulin resistance in patients with polycystic ovary syndrome (PCOS). METHODS We performed a literature search of databases (Medline, Scopus, Web of Knowledge, Cochrane Library) and identified all reports of randomized controlled trials (RCTs) published prior to April 2018. We compared the effects of supplementation with vitamin D alone (dose from 1000 IU/d to 60,000 IU/week) or with co-supplements to the administration of placebos in women diagnosed with PCOS. The systematic review and meta-analysis protocol was registered in the International Prospective Register of Systematic Reviews (Prospero) as number CRD42018090572. MAIN RESULTS Eleven of 345 identified studies were included in the analysis; these involved 601women diagnosed with PCOS. Vitamin D as a co-supplement was found to significantly decrease fasting glucose concentrations and the HOMA-IR value. HOMA-IR also declined significantly when vitamin D was supplemented with a dose lower than 4000 IU/d. CONCLUSIONS Evidence from RCTs suggests that the supplementation of PCOS patients with continuous low doses of vitamin D (<4000 IU/d) or supplementation with vitamin D as a co-supplement may improve insulin sensitivity in terms of the fasting glucose concentration (supplementation with vitamin D in combination with other micronutrients) and HOMA-IR (supplementation with vitamin D in continuous low daily doses or as co-supplement).
Collapse
Affiliation(s)
- Karolina Łagowska
- Institute ofHuman Nutrition and Dietetics, Poznań University of Life Sciences, Wojska Polskiego 31, 60-624 Poznań, Poland.
| | - Joanna Bajerska
- Institute ofHuman Nutrition and Dietetics, Poznań University of Life Sciences, Wojska Polskiego 31, 60-624 Poznań, Poland.
| | - Małgorzata Jamka
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznań University of Medical Sciences, Szpitalna 27/33, 60-572 Poznań, Poland.
| |
Collapse
|
7
|
Mohammadi M, Pezeshki A, Mesgari Abbasi M, Ghanbarzadeh B, Hamishehkar H. Vitamin D 3-Loaded Nanostructured Lipid Carriers as a Potential Approach for Fortifying Food Beverages; in Vitro and in Vivo Evaluation. Adv Pharm Bull 2017; 7:61-71. [PMID: 28507938 PMCID: PMC5426735 DOI: 10.15171/apb.2017.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/16/2016] [Accepted: 12/28/2017] [Indexed: 01/08/2023] Open
Abstract
Purpose: Nanostructured lipid carriers (NLCs) composed of solid lipid and oil are a new generation of lipid nanoparticles which have exhibited some merits over traditional used lipid nanoparticles in fortifying food and beverages and nutraceuticals delivery systems such as liposomes and solid lipid nanoparticles. Methods: In this study, Precirol and Compritol as solid lipids, Miglyol and Octyloctanoat as liquid lipids, Tween80, Tween20 and Poloxamer407 as surfactants were used to prepare vitamin D3-loaded NLC dispersion using hot homogenization method. The particle size and size distribution for all formulations were evaluated by immediately after production and during a storage period of 60 days. Results: The Precirol-based NLC showed superiority over Compritol-based NLC in the point of physical stability. Results clearly suggested that an optimum concentration of 3% of Poloxamer407 or 2% of Tween20 was sufficient to cover the surface of nanoparticles effectively and prevent agglomeration during the homogenization process. Octyloctanoat was introduced for the first time as a good substituent for Miglyol in the preparation of NLC formulations. The vitamin D3 Intestinal absorption enhanced by the incorporating in NLCs. Conclusion: It was concluded that NLC showed a promising approach for fortifying beverages by lipophilic nutraceuticals such as vitamin D.
Collapse
Affiliation(s)
- Maryam Mohammadi
- Biotechnology Research Center and Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Food Science and Technology, Faculty of Agriculture, University of Tabriz,Tabriz, Iran
| | - Akram Pezeshki
- Research Center for Pharmaceutical Nanotechnology, Tabriz University of Medical Sciences,Tabriz, Iran.,Department of Food Science and Technology, Faculty of Agriculture, University of Tabriz,Tabriz, Iran
| | | | - Babak Ghanbarzadeh
- Department of Food Science and Technology, Faculty of Agriculture, University of Tabriz,Tabriz, Iran
| | - Hamed Hamishehkar
- Drug Applied Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
8
|
Abstract
There has been renewed interest in vitamin D since numerous recent studies have suggested that besides its well-established roles in bone metabolism and immunity, vitamin D status is inversely associated with the incidence of several diseases, e.g., cancers, cardio-vascular diseases, and neurodegenerative diseases. Surprisingly, there is very little data on factors that affect absorption of this fat-soluble vitamin, although it is acknowledged that dietary vitamin D could help to fight against the subdeficient vitamin D status that is common in several populations. This review describes the state of the art concerning the fate of vitamin D in the human upper gastrointestinal tract and on the factors assumed to affect its absorption efficiency. The main conclusions are: (i) ergocalciferol (vitamin D2), the form mostly used in supplements and fortified foods, is apparently absorbed with similar efficiency to cholecalciferol (vitamin D3, the main dietary form), (ii) 25-hydroxyvitamin D (25OHD), the metabolite produced in the liver, and which can be found in foods, is better absorbed than the nonhydroxy vitamin D forms cholecalciferol and ergocalciferol, (iii) the amount of fat with which vitamin D is ingested does not seem to significantly modify the bioavailability of vitamin D3, (iv) the food matrix has apparently little effect on vitamin D bioavailability, (v) sucrose polyesters (Olestra) and tetrahydrolipstatin (orlistat) probably diminish vitamin D absorption, and (vi) there is apparently no effect of aging on vitamin D absorption efficiency. We also find that there is insufficient, or even no data on the following factors suspected of affecting vitamin D bioavailability: (i) effect of type and amount of dietary fiber, (ii) effect of vitamin D status, and (iii) effect of genetic variation in proteins involved in its intestinal absorption. In conclusion, further studies are needed to improve our knowledge of factors affecting vitamin D absorption efficiency. Clinical studies with labeled vitamin D, e.g., deuterated or (13)C, are needed to accurately and definitively assess the effect of various factors on its bioavailability.
Collapse
Affiliation(s)
- P Borel
- a INSERM, UMR1062, Nutrition, Obesity and Risk of Thrombosis , Marseille , France
| | | | | |
Collapse
|
9
|
Raimundo FV, Faulhaber GAM, Menegatti PK, Marques LDS, Furlanetto TW. Effect of High- versus Low-Fat Meal on Serum 25-Hydroxyvitamin D Levels after a Single Oral Dose of Vitamin D: A Single-Blind, Parallel, Randomized Trial. Int J Endocrinol 2011; 2011:809069. [PMID: 22190928 PMCID: PMC3235461 DOI: 10.1155/2011/809069] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2011] [Revised: 09/15/2011] [Accepted: 09/16/2011] [Indexed: 01/25/2023] Open
Abstract
Background/Aims. Vitamin D(3) is liposoluble, so dietary fat could increase its oral absorption. Our aim was to compare serum 25-hydroxyvitamin D [25(OH)D] after the oral intake of cholecalciferol with a high- or low-fat meal. Methods. In a single-blind, parallel clinical trial, 32 healthy physicians were divided into two groups. In the same day, they ingested 50,000 IU (1.25 mg) of vitamin D(3) with food: group 1 (G1): lipids: 25.6 g and group 2 (G2) lipids: 1.7 g. Serum 25(OH)D (0, 7, and 14 days), and parathyroid hormone (PTH), and calcium (0 and 14 days) were measured. Results. Baseline mean serum 25(OH)D levels were 42.7 ± 19.0 nmol/L in G1 and 36.4 ± 19.0 nmol/L in G2 (P = 0.38). After cholecalciferol, mean serum 25(OH)D was higher in G1 (P < 0.001): 7 days: G1 = 46.2 (38.4-53.9) nmol/L and G2 = 33.7 (25.4-40.1) nmol/L; 14 days: G1 = 53.7 (45.2-62.1) nmol/L and G2 = 33.7 (25.2-42.2) nmol/L. Serum PTH and 25(OH)D were negatively correlated before and after the intake of vitamin D(3), respectively, r = -0.42 (P = 0.02) and r = -0.52 (P = 0.003). Conclusions. A high-fat meal increased the absorption of vitamin D(3), as measured by serum 25(OH)D.
Collapse
Affiliation(s)
- Fabiana Viegas Raimundo
- Programa de Pós-Graduação em Medicina: Ciências Médicas, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2400, 90035-003 Porto Alegre, RS, Brazil
| | | | - Paula Kalinka Menegatti
- Serviço de Medicina Interna, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350/700, 90035-903 Porto Alegre, RS, Brazil
| | - Leonardo da Silva Marques
- Serviço de Medicina Interna, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350/700, 90035-903 Porto Alegre, RS, Brazil
| | - Tania Weber Furlanetto
- Programa de Pós-Graduação em Medicina: Ciências Médicas, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos 2400, 90035-003 Porto Alegre, RS, Brazil
- Serviço de Medicina Interna, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350/700, 90035-903 Porto Alegre, RS, Brazil
- *Tania Weber Furlanetto:
| |
Collapse
|