1
|
Coetzee A, Hall DR, Langenegger EJ, van de Vyver M, Conradie M. Pregnancy and diabetic ketoacidosis: fetal jeopardy and windows of opportunity. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2023; 4:1266017. [PMID: 38047210 PMCID: PMC10693403 DOI: 10.3389/fcdhc.2023.1266017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/26/2023] [Indexed: 12/05/2023]
Abstract
Background Diabetic ketoacidosis (DKA) during pregnancy poses significant risks to both the mother and fetus, with an increased risk of fetal demise. Although more prevalent in women with Type I diabetes (T1D); those with Type 2 diabetes (T2D) and gestational diabetes mellitus (GDM) can also develop DKA. A lack of information about DKA during pregnancy exists worldwide, including in South Africa. Objective This study examined the characteristics and outcomes associated with DKA during pregnancy. Methods The study took place between 1 April 2020 and 1 October 2022. Pregnant women with DKA, admitted to Tygerberg Hospital's Obstetric Critical Care Unit (OCCU) were included. Maternal characteristics, precipitants of DKA, adverse events during treatment, and maternal-fetal outcomes were examined. Results There were 54 episodes of DKA among 47 women. Most DKA's were mild and occurred in the third trimester. Pregestational diabetes dominated (31/47; 60%), with 47% having T1D and 94% requiring insulin. Seven women (7/47, 15%; T2D:6, T1D:1) had two episodes of DKA during the same pregnancy. Most women (32/47; 68%) were either overweight or obese. Yet, despite the T2D phenotype, biomarkers indicated that auto-immune diabetes was prevalent among women without any prior history of T1D (6/21; 29%). Twelve women (26%) developed gestational hypertension during pregnancy, and 17 (36%) pre-eclampsia. Precipitating causes of DKA included infection (14/54; 26%), insulin disruption (14/54; 26%) and betamethasone administration (10/54; 19%). More than half of the episodes of DKA involved hypokalemia (35/54, 65%) that was associated with fetal death (P=0.042) and hypoglycemia (28/54, 52%). Preterm birth (<37 weeks' gestation) occurred in 85% of women. No maternal deaths were recorded. A high fetal mortality rate (13/47; 28%) that included 11 spontaneous intrauterine deaths and two medical terminations, was observed. Conclusion Women with DKA have a high risk of fetal mortality as well as undiagnosed auto-immune diabetes. There is a strong link between maternal hypokalemia and fetal loss, suggesting an opportunity to address management gaps in pregnant women with DKA.
Collapse
Affiliation(s)
- Ankia Coetzee
- Department of Medicine, Division of Endocrinology Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - David R. Hall
- Department of Obstetrics and Gynecology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Eduard J. Langenegger
- Department of Obstetrics and Gynecology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Mari van de Vyver
- Department of Medicine, Division of Clinical Pharmacology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Magda Conradie
- Department of Obstetrics and Gynecology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| |
Collapse
|
2
|
Kaser S, Sourij H, Clodi M, Schneeweiß B, Laggner AN, Luger A. [Treatment of acute diabetic metabolic crises in adults (Update 2023) : Hyperglycemic hyperosmolar state and ketoacidotic metabolic disorder]. Wien Klin Wochenschr 2023; 135:237-241. [PMID: 37101045 PMCID: PMC10133381 DOI: 10.1007/s00508-023-02174-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/28/2023]
Abstract
Diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) represent potentially life-threatening situations in adults. Therefore, rapid comprehensive diagnostic and therapeutic measures with close monitoring of vital and laboratory parameters are required. The treatment of DKA and HHS is essentially the same and replacement of the mostly substantial fluid deficit with several liters of a physiological crystalloid solution is the first and most important step. Serum potassium concentrations need to be carefully monitored to guide its substitution. Regular insulin or rapid acting insulin analogues can be initially administered as an i.v. bolus followed by continuous infusion. Insulin should be switched to subcutaneous injections only after correction of the acidosis and stable glucose concentrations within an acceptable range.
Collapse
Affiliation(s)
- Susanne Kaser
- Department für Innere Medizin 1, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Harald Sourij
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Graz, Österreich
| | - Martin Clodi
- Abteilung für Innere Medizin, Krankenhaus Barmherzige Brüder Linz, Linz, Österreich
| | - Bruno Schneeweiß
- Intensivstation, Klinische Abteilung für Gastroenterologie und Hepatologie Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Anton N Laggner
- Universitätsklinik für Notfallmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Anton Luger
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Spitalgasse 23, 1090, Wien, Österreich.
| |
Collapse
|
3
|
Coregliano-Ring L, Goia-Nishide K, Rangel ÉB. Hypokalemia in Diabetes Mellitus Setting. Medicina (B Aires) 2022; 58:medicina58030431. [PMID: 35334607 PMCID: PMC8954285 DOI: 10.3390/medicina58030431] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/26/2022] [Accepted: 03/01/2022] [Indexed: 11/22/2022] Open
Abstract
Diabetes mellitus is a public health problem that affects millions of people worldwide regardless of age, sex, and ethnicity. Electrolyte disturbances may occur as a consequence of disease progression or its treatment, in particular potassium disorders. The prevalence of hypokalemia in diabetic individuals over 55 years of age is up to 1.2%. In patients with acute complications of diabetes, such as diabetic ketoacidosis, this prevalence is even higher. Potassium disorders, either hypokalemia or hyperkalemia, have been associated with increased all-cause mortality in diabetic individuals, especially in those with associated comorbidities, such as heart failure and chronic kidney disease. In this article, we discuss the main conditions for the onset of hypokalemia in diabetic individuals, briefly review the pathophysiology of acute complications of diabetes mellitus and their association with hypokalemia, the main signs, symptoms, and laboratory parameters for the diagnosis of hypokalemia, and the management of one of the most common electrolyte disturbances in clinical practice.
Collapse
Affiliation(s)
- Lucas Coregliano-Ring
- Department of Medicine, Nephrology Division, Federal University of São Paulo, São Paulo 04038-901, Brazil; (L.C.-R.); (K.G.-N.)
| | - Kleber Goia-Nishide
- Department of Medicine, Nephrology Division, Federal University of São Paulo, São Paulo 04038-901, Brazil; (L.C.-R.); (K.G.-N.)
- Instituto Israelita de Ensino e Pesquisa, Albert Einstein Hospital, São Paulo, São Paulo 05652-900, Brazil
| | - Érika Bevilaqua Rangel
- Department of Medicine, Nephrology Division, Federal University of São Paulo, São Paulo 04038-901, Brazil; (L.C.-R.); (K.G.-N.)
- Instituto Israelita de Ensino e Pesquisa, Albert Einstein Hospital, São Paulo, São Paulo 05652-900, Brazil
- Correspondence:
| |
Collapse
|
4
|
Iannazzo D, Espro C, Ferlazzo A, Celesti C, Branca C, Neri G. Electrochemical and Fluorescent Properties of Crown Ether Functionalized Graphene Quantum Dots for Potassium and Sodium Ions Detection. NANOMATERIALS (BASEL, SWITZERLAND) 2021; 11:2897. [PMID: 34835661 PMCID: PMC8625964 DOI: 10.3390/nano11112897] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 10/23/2021] [Accepted: 10/27/2021] [Indexed: 01/01/2023]
Abstract
The concentration of sodium and potassium ions in biological fluids, such as blood, urine and sweat, is indicative of several basic body function conditions. Therefore, the development of simple methods able to detect these alkaline ions is of outmost importance. In this study, we explored the electrochemical and optical properties of graphene quantum dots (GQDs) combined with the selective chelating ability of the crown ethers 15-crown-5 and 18-crown-6, with the final aim to propose novel composites for the effective detection of these ions. The results obtained comparing the performances of the single GQDs and crown ethers with those of the GQDs-15-crown-5 and GQDs-18-crown-6 composites, have demonstrated the superior properties of these latter. Electrochemical investigation showed that the GQDs based composites can be exploited for the potentiometric detection of Na+ and K+ ions, but selectivity still remains a concern. The nanocomposites showed the characteristic fluorescence emissions of GQDs and crown ethers. The GQDs-18-crown-6 composite exhibited ratiometric fluorescence emission behavior with the variation of K+ concentration, demonstrating its promising properties for the development of a selective fluorescent method for potassium determination.
Collapse
Affiliation(s)
- Daniela Iannazzo
- Department of Engineering, University of Messina, Contrada Di Dio, I-98166 Messina, Italy; (A.F.); (C.C.); (G.N.)
| | - Claudia Espro
- Department of Engineering, University of Messina, Contrada Di Dio, I-98166 Messina, Italy; (A.F.); (C.C.); (G.N.)
| | - Angelo Ferlazzo
- Department of Engineering, University of Messina, Contrada Di Dio, I-98166 Messina, Italy; (A.F.); (C.C.); (G.N.)
| | - Consuelo Celesti
- Department of Engineering, University of Messina, Contrada Di Dio, I-98166 Messina, Italy; (A.F.); (C.C.); (G.N.)
| | - Caterina Branca
- Department of Mathematical and Computer Sciences, Physical Sciences and Earth Sciences, University of Messina, I-98166 Messina, Italy;
| | - Giovanni Neri
- Department of Engineering, University of Messina, Contrada Di Dio, I-98166 Messina, Italy; (A.F.); (C.C.); (G.N.)
| |
Collapse
|
5
|
Taye GM, Bacha AJ, Taye FA, Bule MH, Tefera GM. Diabetic Ketoacidosis Management and Treatment Outcome at Medical Ward of Shashemene Referral Hospital, Ethiopia: A Retrospective Study. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2021; 14:11795514211004957. [PMID: 33911912 PMCID: PMC8047941 DOI: 10.1177/11795514211004957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 02/25/2021] [Indexed: 12/12/2022]
Abstract
Background: Diabetic Ketoacidosis (DKA) is the most common and yet potentially life-threatening acute complication of diabetes that progresses rapidly to death and requires immediate medical intervention. Objective: To assess the DKA management and treatment outcome/in-hospital mortality and its predictors among hospitalized patients with DKA at the Medical ward of Shashemene Referral Hospital (SRH). Method: A retrospective study was conducted at the Medical Ward of SRH from 01 February 2015 to 31 January 2017. A systematic random sampling technique was used to select study subjects based on the inclusion criteria. Thus, of 236 reviewed charts, only 225 patients with DKA fulfilled inclusion criteria. Treatment outcome was considered good for patients who have shown improvement at discharge, while poor for patients who left against medical advice or died in the hospital. Logistic regression analysis was done to determine independent predictors for treatment outcome/in-hospital mortality using SPSS version 20 with statistical significant at P ⩽ .05. Results: Of 225 patients with DKA, 124 (55.1%) were male. Regular insulin was prescribed to all patients and antibiotics were administered to 87 (38.7%). Potassium supplementation was given only for 28 (12.4%). Non-adherence to insulin treatment (n = 91; 40.4%) and infection (n = 66; 29.3%) were the principal DKA precipitating factors. Even though 73.8% of hospitalized patients with DKA have shown good treatment outcomes, DKA contributed 12% in-hospital mortality. The result of multivariate logistic regression analysis shown that hypoglycemia is the only independent predictor for in-hospital mortality[P = .03]. Moreover, the independent predictors for poor DKA treatment outcome were found to be smoker [P = .04], Urinary tract infection (UTI) relative to other co-morbid condition [P < .001], severe hypokalemia which increase risk of poor treatment outcome by around 4 times [P = .02], and use of Metronidazole as a concurrent medication relative to other concurrent medication [P = .03]. Conclusion: There was a high in-hospital mortality rate due to correctable causes. This mortality is unacceptable as it was majorly related to the poor practice of potassium supplementation and hypoglycemia due to insulin. Thus, clinicians and stakeholders should have to focus on modifiable factors (hypokalemia, UTI, and hypoglycemia) to reduce poor treatment outcome/in-hospital mortality.
Collapse
Affiliation(s)
- Getu Melesie Taye
- Department of Pharmacy, Pharmacology Unit, Ambo University, Ambo, Ethiopia
| | - Amente Jorise Bacha
- Department of Pharmacy, Clinical Pharmacy Unit, Ambo University, Ambo, Ethiopia
| | - Fetene Abeje Taye
- Department of Pharmacy, Medicinal Chemistry Unit, Ambo University, Ambo, Ethiopia
| | - Mohammed Hussen Bule
- Department of Pharmacy, Medicinal Chemistry Unit, Ambo University, Ambo, Ethiopia
| | | |
Collapse
|
6
|
Castellanos L, Tuffaha M, Koren D, Levitsky LL. Management of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes Mellitus. Paediatr Drugs 2020; 22:357-367. [PMID: 32449138 DOI: 10.1007/s40272-020-00397-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetic ketoacidosis (DKA) is the end result of insulin deficiency in type 1 diabetes mellitus (T1D). Loss of insulin production leads to profound catabolism with increased gluconeogenesis, glycogenolysis, lipolysis, and muscle proteolysis causing hyperglycemia and osmotic diuresis. High levels of counter-regulatory hormones lead to enhanced ketogenesis and the release of 'ketone bodies' into the circulation, which dissociate to release hydrogen ions and cause an overwhelming acidosis. Dehydration, hyperglycemia, and ketoacidosis are the hallmarks of this condition. Treatment is effective repletion of insulin, fluids and electrolytes. Newer approaches to early diagnosis, treatment, and prevention may diminish the risk of DKA and its childhood complications including cerebral edema. However, the potential for some technical and pharmacologic advances in the management of T1D to increase DKA events must be recognized.
Collapse
Affiliation(s)
- Luz Castellanos
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA
| | - Marwa Tuffaha
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA
| | - Dorit Koren
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA
| | - Lynne L Levitsky
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA.
| |
Collapse
|
7
|
Kaser S, Sourij H, Clodi M, Schneeweiß B, Laggner AN, Luger A. [Treatment of acute diabetic metabolic crises in adults (Update 2019) : Hyperglycemic hyperosmolar state and ketoacidotic metabolic disorders]. Wien Klin Wochenschr 2019; 131:196-199. [PMID: 30980160 DOI: 10.1007/s00508-018-1423-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) represent potentially life-threatening situations in adults. Therefore, rapid comprehensive diagnostic and therapeutic measures with close monitoring of vital and laboratory parameters are required. The treatment of DKA and HHS is essentially the same and replacement of the mostly substantial fluid deficit with several liters of a physiological crystalloid solution is the first and most important step. Serum potassium concentrations need to be carefully monitored to guide its substitution. Regular insulin or rapid acting insulin analogues can be initially administered as an i.v. bolus followed by continuous infusion. Insulin should be switched to subcutaneous injections only after correction of the acidosis and stable glucose concentrations within an acceptable range.
Collapse
Affiliation(s)
- Susanne Kaser
- Department für Innere Medizin 1, Medizinische Universität Innsbruck, Innsbruck, Österreich.,Christian Doppler Labor für Insulinresistenz, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Harald Sourij
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Graz, Österreich
| | - Martin Clodi
- Abteilung für Innere Medizin, Krankenhaus Barmherzige Brüder Linz, Linz, Österreich
| | - Bruno Schneeweiß
- Abteilung für Innere Medizin, Landeskrankenhaus Kirchdorf, Kirchdorf, Österreich
| | - Anton N Laggner
- Universitätsklinik für Notfallmedizin, Medizinische Universität Wien, Wien, Österreich
| | - Anton Luger
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| |
Collapse
|
8
|
Gallo de Moraes A, Surani S. Effects of diabetic ketoacidosis in the respiratory system. World J Diabetes 2019; 10:16-22. [PMID: 30697367 PMCID: PMC6347653 DOI: 10.4239/wjd.v10.i1.16] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/08/2018] [Accepted: 12/13/2018] [Indexed: 02/05/2023] Open
Abstract
Diabetes affects approximately 30 million persons in the United States. Diabetes ketoacidosis is one of the most serious and acute complications of diabetes. At the time of presentation and during treatment of diabetic ketoacidosis (DKA), several metabolic and electrolyte derangements can ultimately result in respiratory compromise. Most commonly, hypokalemia, hypomagnesemia and hypophosphatemia can eventually lead to respiratory muscles failure. Furthermore, tachypnea, hyperpnea and more severely, Kussmaul breathing pattern can develop. Also, hydrostatic and non-hydrostatic pulmonary edema can occur secondary to volume shifts into the extracellular space and secondary to increased permeability of the pulmonary capillaries. The presence of respiratory failure in patients with DKA is associated with higher morbidity and mortality. Being familiar with the causes of respiratory compromise in DKA, and how to treat them, may represent better outcomes for patients with DKA.
Collapse
Affiliation(s)
- Alice Gallo de Moraes
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Salim Surani
- Division of Pulmonary, Critical Care and Sleep Medicine, Texas A and M University, Corpus Christy, TX 78412, United States
| |
Collapse
|
9
|
Kempegowda P, Chandan JS, Coombs B, De Bray A, Jawahar N, James S, Ghosh S, Narendran P. Regular performance feedback may be key to maintain good quality DKA management: results from a five-year study. BMJ Open Diabetes Res Care 2019; 7:e000695. [PMID: 31497304 PMCID: PMC6708258 DOI: 10.1136/bmjdrc-2019-000695] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 06/25/2019] [Accepted: 07/08/2019] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES We postulate that performance feedback is a prerequisite to ensure sustained improvement in diabetic ketoacidosis (DKA) management. DESIGN The study was based on 'theory of change' concept that suggests changes of primary drivers determine the main outcome. A set of secondary drivers can be implemented to achieve improvements in these primary drivers and thus the main outcome. SETTING This study was conducted at a large tertiary care center in the West Midlands, UK. The region has above average prevalence of diabetes and DKA admissions in the country. PARTICIPANTS All participants diagnosed with DKA as per national guidelines, except those managed in intensive care unit from April 2014 to March 2018, were included in this study. INTERVENTIONS Monthly feedback of performance was the main intervention. Development of a real-time live DKA audit tool, automatic referral system of DKA to the specialist team, electronic monitoring of blood gas measurements and education and redesigning of local (trust) guidelines were the other interventions in this study. MAIN OUTCOME MEASURES Total DKA duration, appropriateness of fixed rate intravenous insulin infusion, fluid prescription, glucose monitoring, ketone monitoring and referral to specialists. RESULTS There was a significant reduction in the duration of DKA postintervention compared with baseline results. However, in the absence of regular feedback, the duration of DKA showed an upward trend nearing baseline values. Similar trends were noted in secondary drivers influencing DKA duration. CONCLUSION Based on these results, we recommend regular audit and feedback is required to sustain improvements in DKA management.
Collapse
Affiliation(s)
- Punith Kempegowda
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Joht Singh Chandan
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Benjamin Coombs
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anne De Bray
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Nitish Jawahar
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sunil James
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sandip Ghosh
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Parth Narendran
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| |
Collapse
|