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Fontana G, Badalamenti N, Bruno M, Maggi F, Dell’Annunziata F, Capuano N, Varcamonti M, Zanfardino A. Biological Properties of Oleanolic Acid Derivatives Bearing Functionalized Side Chains at C-3. Int J Mol Sci 2024; 25:8480. [PMID: 39126048 PMCID: PMC11312724 DOI: 10.3390/ijms25158480] [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: 07/03/2024] [Revised: 07/27/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024] Open
Abstract
Triterpene acids are a class of pentacyclic natural carboxylic compounds endowed with a variety of biological activities including antitumor, antimicrobial, and hepatoprotective effects. In this work, several oleanolic acid derivatives were synthesized by structurally modifying them on the C-3 position. All synthesized derivatives were evaluated for possible antibacterial and antiviral activity, and among all the epimers, 6 and 7 demonstrated the best biological activities. Zone-of-inhibition analyses were conducted against two strains, E. coli as a Gram-negative and S. aureus as a Gram-positive model. Subsequently, experiments were performed using the microdilution method to determine the minimum inhibitory concentration (MIC). The results showed that only the derivative with reduced hydrogen bonding ability on ring A possesses remarkable activity toward E. coli. The conversion from acid to methyl ester implies a loss of activity, probably due to a reduced affinity with the bacterial membrane. Before the antiviral activity, the cytotoxicity of triterpenes was evaluated through a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Samples 6 and 7 showed less than 50% cytotoxicity at 0.625 and 1 mg/mL, respectively. The antiviral activity against SARS-CoV-2 and PV-1 did not indicate that triterpene acids had any inhibitory capacity in the sub-toxic concentration range.
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Affiliation(s)
- Gianfranco Fontana
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), University of Palermo, Viale delle Scienze, 90128 Palermo, Italy; (G.F.); (N.B.); (M.B.)
- NBFC, National Biodiversity Future Center, 90133 Palermo, Italy
| | - Natale Badalamenti
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), University of Palermo, Viale delle Scienze, 90128 Palermo, Italy; (G.F.); (N.B.); (M.B.)
- NBFC, National Biodiversity Future Center, 90133 Palermo, Italy
| | - Maurizio Bruno
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), University of Palermo, Viale delle Scienze, 90128 Palermo, Italy; (G.F.); (N.B.); (M.B.)
- NBFC, National Biodiversity Future Center, 90133 Palermo, Italy
- Centro Interdipartimentale di Ricerca “Riutilizzo Bio-Based degli Scarti da Matrici Agroalimentari” (RIVIVE), University of Palermo, Viale delle Scienze, 90128 Palermo, Italy
| | - Filippo Maggi
- Chemistry Interdisciplinary Project (ChIP) Research Center, University of Camerino, Via Madonna delle Carceri, 62032 Camerino, Italy
| | - Federica Dell’Annunziata
- Department of Medicine, Surgery and Dentistry, “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (F.D.); (N.C.)
- Department of Experimental Medicine, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Nicoletta Capuano
- Department of Medicine, Surgery and Dentistry, “Scuola Medica Salernitana”, University of Salerno, 84081 Baronissi, Italy; (F.D.); (N.C.)
| | - Mario Varcamonti
- Department of Biology, University of Naples, Federico II, Via Cinthia, 80126 Naples, Italy; (M.V.); (A.Z.)
| | - Anna Zanfardino
- Department of Biology, University of Naples, Federico II, Via Cinthia, 80126 Naples, Italy; (M.V.); (A.Z.)
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Dyer CJ, De Waele JJ, Roberts JA. Antibiotic dose optimisation in the critically ill: targets, evidence and future strategies. Curr Opin Crit Care 2024:00075198-990000000-00194. [PMID: 39150038 DOI: 10.1097/mcc.0000000000001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW To highlight the recent evidence for antibiotic pharmacokinetics and pharmacodynamics (PK/PD) in enhancing patient outcomes in sepsis and septic shock. We also summarise the limitations of available data and describe future directions for research to support translation of antibiotic dose optimisation to the clinical setting. RECENT FINDINGS Sepsis and septic shock are associated with poor outcomes and require antibiotic dose optimisation, mostly due to significantly altered pharmacokinetics. Many studies, including some randomised controlled trials have been conducted to measure the clinical outcome effects of antibiotic dose optimisation interventions including use of therapeutic drug monitoring. Current data support antibiotic dose optimisation for the critically ill. Further investigation is required to evolve more timely and robust precision antibiotic dose optimisation approaches, and to clearly quantify whether any clinical and health-economic benefits support expanded use of this treatment intervention. SUMMARY Antibiotic dose optimisation appears to improve outcomes in critically ill patients with sepsis and septic shock, however further research is required to quantify the level of benefit and develop a stronger knowledge of the role of new technologies to facilitate optimised dosing.
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Affiliation(s)
- Christopher J Dyer
- Herston Institute of Infectious Diseases (HeIDI), Metro North Health
- Pharmacy Department
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital (RBWH), Herston, Australia
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital
- Dept of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jason A Roberts
- Herston Institute of Infectious Diseases (HeIDI), Metro North Health
- Pharmacy Department
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital (RBWH), Herston, Australia
- UQ Centre for Clinical Research (UQCCR), Faculty of Medicine, University of Queensland, Herston, Australia
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Roger C. Understanding antimicrobial pharmacokinetics in critically ill patients to optimize antimicrobial therapy: A narrative review. JOURNAL OF INTENSIVE MEDICINE 2024; 4:287-298. [PMID: 39035618 PMCID: PMC11258509 DOI: 10.1016/j.jointm.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 07/23/2024]
Abstract
Effective treatment of sepsis not only demands prompt administration of appropriate antimicrobials but also requires precise dosing to enhance the likelihood of patient survival. Adequate dosing refers to the administration of doses that yield therapeutic drug concentrations at the infection site. This ensures a favorable clinical and microbiological response while avoiding antibiotic-related toxicity. Therapeutic drug monitoring (TDM) is the recommended approach for attaining these goals. However, TDM is not universally available in all intensive care units (ICUs) and for all antimicrobial agents. In the absence of TDM, healthcare practitioners need to rely on several factors to make informed dosing decisions. These include the patient's clinical condition, causative pathogen, impact of organ dysfunction (requiring extracorporeal therapies), and physicochemical properties of the antimicrobials. In this context, the pharmacokinetics of antimicrobials vary considerably between different critically ill patients and within the same patient over the course of ICU stay. This variability underscores the need for individualized dosing. This review aimed to describe the main pathophysiological changes observed in critically ill patients and their impact on antimicrobial drug dosing decisions. It also aimed to provide essential practical recommendations that may aid clinicians in optimizing antimicrobial therapy among critically ill patients.
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Affiliation(s)
- Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nîmes-Caremeau University Hospital, Nîmes, France
- UR UM 103 IMAGINE (Initial Management and prévention of orGan failures IN critically ill patiEnts), Faculty of Medicine, Montpellier University, Montpellier, France
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Gauthier A, Tlili L, Battu S, Le Moan C, Ploy MC, Lalloue F, Bégaud G, Barraud O. Sedimentation field-flow fractionation for rapid phenotypic antimicrobial susceptibility testing: a pilot study. J Antimicrob Chemother 2024; 79:1450-1455. [PMID: 38708644 DOI: 10.1093/jac/dkae132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 04/16/2024] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND The increase in antibiotic resistance is a major public health issue. The development of rapid antimicrobial susceptibility testing (AST) methods is becoming a priority to ensure early and appropriate antibiotic therapy. OBJECTIVES To evaluate sedimentation field-flow fractionation (SdFFF) as a method for performing AST in less than 3 h. METHODS SdFFF is based on the detection of early biophysical changes in bacteria, using a chromatographic-type technology. One hundred clinical Escherichia coli strains were studied. A calibrated bacterial suspension was incubated for 2 h at 37°C in the absence (untreated) or presence (treated) of five antibiotics used at EUCAST breakpoint concentrations. Bacterial suspensions were then injected into the SdFFF machine. For each E. coli isolate, retention times and elution profiles of antibiotic-treated bacteria were compared with retention times and elution profiles of untreated bacteria. Algorithms comparing retention times and elution profiles were used to determine if the strain was susceptible or resistant. Performance evaluation was done according to CLSI and the ISO standard 20776-2:2021 with broth microdilution used as the reference method. RESULTS AST results from SdFFF were obtained in less than 3 h. SdFFF showed high categorical agreement (99.8%), sensitivity (99.5%) and specificity (100.0%) with broth microdilution. Results for each antimicrobial were also in agreement with the ISO 20776-2 recommendations, with sensitivity and specificity of ≥95.0%. CONCLUSIONS This study showed that SdFFF can be used as a rapid, accurate and reliable phenotypic AST method with a turnaround time of less than 3 h.
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Affiliation(s)
- Audrey Gauthier
- Inserm, CHU Limoges, RESINFIT, UMR 1092, University of Limoges, 87000 Limoges, France
- Inserm, CHU Limoges, CAPTuR, UMR 1308, University of Limoges, 87000 Limoges, France
- DAMOCLES Diagnostics, 87000 Limoges, France
| | - Linda Tlili
- Inserm, CHU Limoges, RESINFIT, UMR 1092, University of Limoges, 87000 Limoges, France
| | - Serge Battu
- Inserm, CHU Limoges, CAPTuR, UMR 1308, University of Limoges, 87000 Limoges, France
- DAMOCLES Diagnostics, 87000 Limoges, France
| | - Coline Le Moan
- Inserm, CHU Limoges, CAPTuR, UMR 1308, University of Limoges, 87000 Limoges, France
| | - Marie-Cécile Ploy
- Inserm, CHU Limoges, RESINFIT, UMR 1092, University of Limoges, 87000 Limoges, France
| | - Fabrice Lalloue
- Inserm, CHU Limoges, CAPTuR, UMR 1308, University of Limoges, 87000 Limoges, France
| | - Gaëlle Bégaud
- Inserm, CHU Limoges, CAPTuR, UMR 1308, University of Limoges, 87000 Limoges, France
- DAMOCLES Diagnostics, 87000 Limoges, France
| | - Olivier Barraud
- Inserm, CHU Limoges, RESINFIT, UMR 1092, University of Limoges, 87000 Limoges, France
- DAMOCLES Diagnostics, 87000 Limoges, France
- CHU Limoges, Inserm, CIC1435, 87000 Limoges, France
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Lekkala S, Inverardi N, Yuh J, Wannomae KK, Tierney P, Sekar A, Muratoglu OK, Oral E. Antibiotic-Loaded Ultrahigh Molecular Weight Polyethylenes. Macromol Biosci 2024; 24:e2300389. [PMID: 38095273 PMCID: PMC11018474 DOI: 10.1002/mabi.202300389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/20/2023] [Indexed: 01/09/2024]
Abstract
The occurrence of periprosthetic joint infections (PJI) after total joint replacement constitutes a great burden for the patients and the healthcare system. Antibiotic-loaded polymethylmethacrylate (PMMA) bone cement is often used in temporary spacers during antibiotic treatment. PMMA is not a load-bearing solution and needs to be replaced by a functional implant. Elution from the ultrahigh molecular weight polyethylene (UHMWPE) bearing surface for drug delivery can combine functionality with the release of clinically relevant doses of antibiotics. In this study, the feasibility of incorporating a range of antibiotics into UHMWPE is investigated. Drug stability is assessed by thermo-gravimetric analysis and nuclear magnetic resonance spectroscopy. Drug-loaded UHMWPEs are prepared by compression molding, using eight antibiotics at different loading. The predicted intra-articular concentrations of drugs eluted from UHMWPE are above minimum inhibitory concentration for at least 3 weeks against Staphylococci, which are the major causative bacteria for PJI. The antibacterial efficacy is confirmed for samples covering 2% of a representative knee implant in vitro over 72 h, showing that a small fraction of the implant surface loaded with antibiotics may be sufficient against Staphylococci.
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Affiliation(s)
- Sashank Lekkala
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Nicoletta Inverardi
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Jean Yuh
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Keith K. Wannomae
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Peyton Tierney
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Amita Sekar
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Orhun K. Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02114, USA
| | - Ebru Oral
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA 02114, USA
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Migliorisi G, Calvo M, Collura A, Di Bernardo F, Perez M, Scalia G, Stefani S. The Rapid Phenotypic Susceptibility Testing in Real-Life Experience: How the MIC Values Impact on Sepsis Fast Diagnostic Workflow. Diagnostics (Basel) 2023; 14:56. [PMID: 38201365 PMCID: PMC10802849 DOI: 10.3390/diagnostics14010056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/22/2023] [Accepted: 12/25/2023] [Indexed: 01/12/2024] Open
Abstract
The MIC value definition faithfully reflects antimicrobial sensitivity, profoundly impacting the infection's clinical outcome. Our study aimed to evaluate the Accelerate PhenoTM System in defining the importance of fast phenotypic susceptibility data. A number of 270 monomicrobial samples simultaneously underwent standard procedures and fast protocols after a contemporary Gram stain. Finally, we provided Turn-around Time (TAT) and statistical evaluations. The fast technology required a medium value of 7 h to complete ID and AST profiles. Although there were some spectrum limitations, it revealed an optimal success rate in microbial identification directly from positive blood cultures. The Gram-negative AST reached a 98.9% agreement between the Accelerate Pheno™ System and the standard method. In addition, the Gram-positive AST gathered a 98.7% agreement comparing the same systems. The chance to rapidly provide precise MIC values is one of the last frontiers in clinical microbiology, especially in high-prevalence antimicrobial resistance areas.
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Affiliation(s)
- Giuseppe Migliorisi
- U.O.C. Laboratory Analysis A.O.U. “Policlinico—San Marco”, Via Santa Sofia 78, 95123 Catania, Italy; (M.C.); (S.S.)
| | - Maddalena Calvo
- U.O.C. Laboratory Analysis A.O.U. “Policlinico—San Marco”, Via Santa Sofia 78, 95123 Catania, Italy; (M.C.); (S.S.)
| | - Antonina Collura
- U.O.C. Clinical Microbiology, “Civico-Di Cristina-Benfratelli” Hospital, Piazza Nicola Leotta 4, 90127 Palermo, Italy
| | - Francesca Di Bernardo
- U.O.C. Clinical Microbiology, “Civico-Di Cristina-Benfratelli” Hospital, Piazza Nicola Leotta 4, 90127 Palermo, Italy
| | - Marianna Perez
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123 Catania, Italy
| | - Guido Scalia
- U.O.C. Laboratory Analysis A.O.U. “Policlinico—San Marco”, Via Santa Sofia 78, 95123 Catania, Italy; (M.C.); (S.S.)
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123 Catania, Italy
| | - Stefania Stefani
- U.O.C. Laboratory Analysis A.O.U. “Policlinico—San Marco”, Via Santa Sofia 78, 95123 Catania, Italy; (M.C.); (S.S.)
- Department of Biomedical and Biotechnological Sciences, University of Catania, Via Santa Sofia 97, 95123 Catania, Italy
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7
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Golikova MV, Strukova EN, Alieva KN, Ageevets VA, Avdeeva AA, Sulian OS, Zinner SH. Meropenem MICs at Standard and High Inocula and Mutant Prevention Concentration Inter-Relations: Comparative Study with Non-Carbapenemase-Producing and OXA-48-, KPC- and NDM-Producing Klebsiella pneumoniae. Antibiotics (Basel) 2023; 12:antibiotics12050872. [PMID: 37237775 DOI: 10.3390/antibiotics12050872] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 05/28/2023] Open
Abstract
The minimal inhibitory concentration (MIC) is conventionally used to define in vitro levels of susceptibility or resistance of a specific bacterial strain to an antibiotic and to predict its clinical efficacy. Along with MIC, other measures of bacteria resistance exist: the MIC determined at high bacterial inocula (MICHI) that allow the estimation of the occurrence of inoculum effect (IE) and the mutant prevention concentration, MPC. Together, MIC, MICHI and MPC represent the bacterial "resistance profile". In this paper, we provide a comprehensive analysis of such profiles of K. pneumoniae strains that differ by meropenem susceptibility, ability to produce carbapenemases and specific carbapenemase types. In addition, we have analyzed inter-relations between the MIC, MICHI and MPC for each tested K. pneumoniae strain. Low IE probability was detected with carbapenemase-non-producing K. pneumoniae, and high IE probability was detected with those that were carbapenemase-producing. MICs did not correlate with the MPCs; significant correlation was observed between the MICHIs and the MPCs, indicating that these bacteria/antibiotic characteristics display similar resistance properties of a given bacterial strain. To determine the possible resistance-related risk due to a given K. pneumoniae strain, we propose determining the MICHI. This can more or less predict the MPC value of the particular strain.
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Affiliation(s)
- Maria V Golikova
- Department of Pharmacokinetics & Pharmacodynamics, Gause Institute of New Antibiotics, 11 Bolshaya Pirogovskaya Street, 119021 Moscow, Russia
| | - Elena N Strukova
- Department of Pharmacokinetics & Pharmacodynamics, Gause Institute of New Antibiotics, 11 Bolshaya Pirogovskaya Street, 119021 Moscow, Russia
| | - Kamilla N Alieva
- Department of Pharmacokinetics & Pharmacodynamics, Gause Institute of New Antibiotics, 11 Bolshaya Pirogovskaya Street, 119021 Moscow, Russia
| | - Vladimir A Ageevets
- Pediatric Research and Clinical Center for Infectious Diseases, 9 Prof. Popov Street, 197022 St. Petersburg, Russia
| | - Alisa A Avdeeva
- Pediatric Research and Clinical Center for Infectious Diseases, 9 Prof. Popov Street, 197022 St. Petersburg, Russia
| | - Ofeliia S Sulian
- Pediatric Research and Clinical Center for Infectious Diseases, 9 Prof. Popov Street, 197022 St. Petersburg, Russia
| | - Stephen H Zinner
- Department of Medicine, Harvard Medical School, Mount Auburn Hospital, 330 Mount Auburn St., Cambridge, MA 02138, USA
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Novy E, Martinière H, Roger C. The Current Status and Future Perspectives of Beta-Lactam Therapeutic Drug Monitoring in Critically Ill Patients. Antibiotics (Basel) 2023; 12:antibiotics12040681. [PMID: 37107043 PMCID: PMC10135361 DOI: 10.3390/antibiotics12040681] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Beta-lactams (BL) are the first line agents for the antibiotic management of critically ill patients with sepsis or septic shock. BL are hydrophilic antibiotics particularly subject to unpredictable concentrations in the context of critical illness because of pharmacokinetic (PK) and pharmacodynamics (PD) alterations. Thus, during the last decade, the literature focusing on the interest of BL therapeutic drug monitoring (TDM) in the intensive care unit (ICU) setting has been exponential. Moreover, recent guidelines strongly encourage to optimize BL therapy using a PK/PD approach with TDM. Unfortunately, several barriers exist regarding TDM access and interpretation. Consequently, adherence to routine TDM in ICU remains quite low. Lastly, recent clinical studies failed to demonstrate any improvement in mortality with the use of TDM in ICU patients. This review will first aim at explaining the value and complexity of the TDM process when translating it to critically ill patient bedside management, interpretating the results of clinical studies and discussion of the points which need to be addressed before conducting further TDM studies on clinical outcomes. In a second time, this review will focus on the future aspects of TDM integrating toxicodynamics, model informed precision dosing (MIPD) and “at risk” ICU populations that deserve further investigations to demonstrate positive clinical outcomes.
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Affiliation(s)
- Emmanuel Novy
- Department of Anesthesiology and Critical Care Medicine, Institut Lorrain du Coeur Et Des Vaisseaux, University Hospital of Nancy, Rue du Morvan, 54511 Vandoeuvre-les Nancy, France
- SIMPA, UR 7300, Faculté de Médecine, Maïeutique et Métiers de la Santé, Campus Brabois Santé, University of Lorraine, 54000 Nancy, France
| | - Hugo Martinière
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nimes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 09, 30029 Nimes, France
| | - Claire Roger
- Department of Anesthesiology and Intensive Care, Pain and Emergency Medicine, Nimes-Caremeau University Hospital, Place du Professeur Robert Debré, CEDEX 09, 30029 Nimes, France
- UR UM 103 IMAGINE, Faculty of Medicine, Montpellier University, 30029 Nimes, France
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