scholarly journals Serum Metabolomics Identifies Altered Bioenergetics, Signaling Cascades in Parallel with Exposome Markers in Crohn’s Disease

Molecules ◽  
2019 ◽  
Vol 24 (3) ◽  
pp. 449 ◽  
Author(s):  
Yunjia Lai ◽  
Jingchuan Xue ◽  
Chih-Wei Liu ◽  
Bei Gao ◽  
Liang Chi ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
High Resolution Mass Spectrometry ◽  
Signaling Cascades ◽  
Compound Identification ◽  
Serum Samples ◽  
Therapy Assessment ◽  
Integral Role ◽  
Important Pathway ◽  
Biomarker Research

: Inflammatory bowel disease (IBD) has stimulated much interest due to its surging incidences and health impacts in the U.S. and worldwide. However, the exact cause of IBD remains incompletely understood, and biomarker is lacking towards early diagnostics and effective therapy assessment. To tackle these, the emerging high-resolution mass spectrometry (HRMS)-based metabolomics shows promise. Here, we conducted a pilot untargeted LC/MS metabolomic profiling in Crohn’s disease, for which serum samples of both active and inactive cases were collected, extracted, and profiled by a state-of-the-art compound identification workflow. Results show a distinct metabolic profile of Crohn’s from control, with most metabolites downregulated. The identified compounds are structurally diverse, pointing to important pathway perturbations ranging from energy metabolism (e.g., β-oxidation of fatty acids) to signaling cascades of lipids (e.g., DHA) and amino acid (e.g., L-tryptophan). Importantly, an integral role of gut microbiota in the pathogenesis of Crohn’s disease is highlighted. Xenobiotics and their biotransformants were widely detected, calling for massive exposomic profiling for future cohort studies as such. This study endorses the analytical capacity of untargeted metabolomics for biomarker development, cohort stratification, and mechanistic interpretation; the findings might be valuable for advancing biomarker research and etiologic inquiry in IBD.

scholarly journals Targeted 1H NMR metabolomics and immunological phenotyping of human fresh blood and serum samples discriminate between healthy individuals and inflammatory bowel disease patients treated with anti-TNF

2021 ◽  
Author(s):  
Sara Notararigo ◽  
Manuel Martín-Pastor ◽  
Juan E. Viñuela Roldán ◽  
Adriano Quiroga ◽  
J. Enrique Dominguez-Munoz ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Inflammatory Bowel Disease ◽  
Crohn’S Disease ◽  
Clinical Practice ◽  
Crohn's Disease ◽  
T Lymphocyte ◽  
Fresh Blood ◽  
Serum Samples ◽  
Nmr Metabolomics ◽  
Inflammatory Bowel

Abstract Inflammatory bowel disease is a multifactorial etiology, associated with environmental factors that can trigger both debut and relapses. A high level of tumor necrosis factor-α in the gut is the main consequence of immune system imbalance. The aim of treatment is to restore gut homeostasis. In this study, fresh blood and serum samples were used to identify biomarkers and to discriminate between Crohn’s disease and ulcerative colitis patients under remission treated with anti-TNF. Metabolomics based on Nuclear Magnetic Resonance spectroscopy (NMR) was used to detect unique biomarkers for each class of patients. Blood T lymphocyte repertories were characterized, as well as cytokine and transcription factor profiling, to complement the metabolomics data. Higher levels of homoserine-methionine and isobutyrate were identified as biomarkers of Crohn’s disease with ileocolic localization. For ulcerative colitis, lower levels of creatine-creatinine, proline, and tryptophan were found that reflect a deficit in the absorption of essential amino acids in the gut. T lymphocyte phenotyping and its functional profiling revealed that the overall inflammation was lower in Crohn’s disease patients than in those with ulcerative colitis. These results demonstrated that NMR metabolomics could be introduced as a high-throughput evaluation method in routine clinical practice to stratify both types of patients related to their pathology. Key messages NMR metabolomics is a non-invasive tool that could be implemented in the normal clinical practice for IBD to assess beneficial effect of the treatment. NMR metabolomics is a useful tool for precision medicine, in order to sew a specific treatment to a specific group of patients. Finding predictors of response to IFX would be desirable to select patients affected by IBD. Immunological status of inflammations correlates with NMR metabolomics biomarkers.

Ustekinumab serum concentrations are associated with clinical outcomes in Crohn’s disease – a regional multi-center pilot study

2020 ◽  
Vol 58 (05) ◽  
pp. 439-444 ◽  
Author(s):  
Anne Kerstin Thomann ◽  
Lucas-Alexander Schulte ◽  
Anna-Maria Globig ◽  
Peter Hoffmann ◽  
Thomas Klag ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Pilot Study ◽  
Crohn's Disease ◽  
Clinical Response ◽  
Roc Curve ◽  
Response To Therapy ◽  
Therapeutic Drug ◽  
Serum Concentrations ◽  
Serum Samples ◽  
Area Under Roc Curve

Abstract Background and aim The role of therapeutic drug monitoring (TDM) in ustekinumab (UST) therapy for Crohn’s disease (CD) has not been established, as only few studies have analyzed the relationship between UST serum concentrations and clinical outcome. In this pilot study, we retrospectively examined the potential of UST-concentrations (cUST) 8 weeks after induction (cUSTw8) to predict clinical response at week 16. Methods Serum samples and clinical data from patients (n = 72) with moderate to severely active CD who received intravenous induction with UST were retrospectively analyzed. cUST were quantitated using liquid chromatography-tandem mass spectrometry (LC-MSMS). A receiver-operating characteristic (ROC) curve and area under ROC curve (AUROC) was computed to analyze the predictive potential of cUSTw8 for clinical response at week 16 and to determine the minimal therapeutic UST trough concentration. Results Forty-four patients (61 %) achieved clinical response to UST therapy at week 16. cUSTw8 was moderately effective to predict clinical response with a minimal therapeutic cUSTw8 of 2.0 mg/l (AUC 0.72, p = 0.001). Conclusion Trough concentrations of UST 8 weeks after induction predict clinical response to therapy in week 16 with moderate sensitivity and specificity. TDM using LC-MSMS could prove beneficial in personalized UST therapy of patients with CD by identifying individuals with subtherapeutic concentrations who might benefit from dose escalation.

scholarly journals P454 Serum oncostatin M predicts mucosal healing in Crohn’s disease patients treated with infliximab

2020 ◽  
Vol 14 (Supplement_1) ◽  
pp. S406-S406
Author(s):  
L Bertani ◽  
L Antonioli ◽  
M Fornili ◽  
M Fornai ◽  
G Tapete ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Treatment Response ◽  
Predictive Marker ◽  
Mucosal Healing ◽  
Oncostatin M ◽  
Spearman Correlation ◽  
Drug Infusion ◽  
Serum Samples ◽  
Faecal Calprotectin

Abstract Background A number of Crohn’s Disease (CD) patients fail to respond to infliximab (IFX) treatment. For this reason, the identification of a biomarker suitable to predict treatment outcome represents one of the most intriguing challenges for gastroenterologists. Oncostatin M (OSM) is a member of the interleukin 6 cytokine family, which is upregulated significantly in CD inflamed intestinal mucosa. OSM has been suggested as a promising biomarker to predict the responsiveness to anti-TNF therapy in patients with inflammatory bowel diseases. The aim of the present study was to evaluate the suitability of the evaluation of OSM serum levels as a predictive marker of treatment response to IFX. Methods We included CD patients treated with IFX during 2017 and 2018. All patients underwent a colonoscopy at week 54, when treatment response was evaluated in terms of mucosal healing (MH, defined as disappearance of ulcers). At baseline and after 14 weeks of treatment, OSM was evaluated by ELISA on serum samples collected before drug infusion. We assessed also faecal calprotectin (FC) at baseline and week 14. Mann-Whitney test was used to evaluate the correlation between OSM and FC levels at baseline and week 14 with MH at week 54. Spearman correlation between OSM and FC values at baseline and week 14 was computed as well. Logistic regression models to predict MH at week 54 were carried out by the Akaike Information Criterion (AIC) and Area Under the Curve (AUC). Results In a cohort of 45 patients (24 males) included in the study, 27 displayed MH. At baseline, OSM levels were significantly lower in treatment responders than non-responders (p < 0.001). Similar results were obtained at week 14, when FC levels also were lower in responders than non-responders (p < 0.001 for both OSM and FC). OSM values at baseline and week 14 were significantly associated (Spearman correlation = 0.92, p < 0.001). The diagnostic accuracy of binary OSM at baseline in predicting MH (AIC = 26, AUC = 0.93) was greater than that of binary FC at week 14 (AIC = 34.7, AUC = 0.89). Conclusion These preliminary data suggest that OSM and FC are able to predict the outcome of treatment with IFX. Of note, at variance with FC, the predictive capability of OSM was appreciable at baseline, thus allowing to propose OSM as a promising biomarker for driving therapeutic choices in Crohn’s disease patients.

scholarly journals P302 Diagnostic accuracy of a serum-based biomarker panel for endoscopic activity in ulcerative colitis

2020 ◽  
Vol 14 (Supplement_1) ◽  
pp. S304-S304
Author(s):  
A HOLMER ◽  
B Boland ◽  
S Singh ◽  
H Le ◽  
J Neill ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Diagnostic Accuracy ◽  
Operating Characteristic ◽  
Mucosal Inflammation ◽  
Serum Samples ◽  
Receiver Operating Characteristic Curves ◽  
Biomarker Panel ◽  
Endoscopic Remission

Abstract Background The endoscopic healing index (EHI, Monitr, Prometheus Biosciences, San Diego, CA) is a serum-based biomarker panel available for identifying mucosal inflammation in Crohn’s disease.[1] We aimed to study its performance for identifying mucosal inflammation in ulcerative colitis. Methods EHI was analysed on serum samples paired with endoscopies from adult patients (≥18 years) participating in a prospective biobank (June 2014 to December 2017). Area under receiver operating characteristic curves (AUROC) were used to assess the accuracy of EHI for endoscopic improvement (EI; Mayo endoscopic sub-score [MES] 0–1) and endoscopic remission (ER; MES 0). Sensitivity for EHI was calculated using a cut-off previously identified for Crohn’s disease which optimised performance for ruling out endoscopic activity (20 points). Alternative cut-offs were explored. Results A total of 114 patients were included, with an overall prevalence of 56% and 44% for EI and ER. The AUROC was 0.79 (95% CI 0.70–0.87) for EI and 0.70 (95% CI 0.61–0.80) for ER. A cut-off of 20 points had a sensitivity of 94% (95% CI 83–99%) for ruling out moderate to severe (MES 2–3) endoscopic activity, and a sensitivity of 84% (95% CI 72–92%) for ruling out mild to severe (MES 1–3) endoscopic activity. A cut off of 40 points or higher had > 90% specificity for ruling in moderate to severe (MES 2–3) or mild to severe (MES 1–3) endoscopic activity. (Table 1) Conclusion EHI has favourable accuracy in identifying the presence of mucosal inflammation in patients with ulcerative colitis. Although it was not developed and validated for ulcerative colitis, further validation is warranted. Reference

scholarly journals Serum adipokines as non-invasive biomarkers in Crohn’s disease

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Lorena Ortega Moreno ◽  
Ancor Sanz-Garcia ◽  
Marina J. Fernández de la Fuente ◽  
Ricardo Arroyo Solera ◽  
Samuel Fernández-Tomé ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Area Under The Curve ◽  
Healthy Controls ◽  
High Concentration ◽  
Serum Samples ◽  
Receiver Operating Characteristic Curves ◽  
Non Invasive ◽  
Healthy Control

Abstract Adipose tissue secretes molecules that can promote activity in Crohn’s disease. We aimed to evaluate the role of serum adipokines as possible biomarkers in Crohn’s disease. Serum samples were obtained from 40 patients with endoscopically active or quiescent Crohn’s disease and 36 healthy controls. Serum leptin, ghrelin, resistin and adiponectin levels were analysed by Multiplex in a Luminex 200 system technology. Receiver Operating Characteristic curves were performed to evaluate the adipokines discriminatory capacity. A logistic regression adjusted by possible confounders (i.e. gender, age, BMI) was performed for those adipokines that showed an area under the curve > 0.7. No differences were found in age, gender or BMI among groups. Distribution for serum resistin was different among the three groups of study, and only this adipokine showed an area under the curve of 0.75 comparing actives patients and healthy control groups. Resistin median concentration was selected as a cut-off for a logistic regression analysis; odds ratio along its 95% confidence interval adjusted by gender, age, and BMI yielded a value of 5.46 (1.34–22.14) comparing actives patients and healthy controls. High concentration of serum resistin is probably associated to activity, being this association independent of gender, age or BMI.

scholarly journals P281 A serum biomarker panel can accurately identify the presence of mucosal ulcers in patients with Crohn’s disease

2020 ◽  
Vol 14 (Supplement_1) ◽  
pp. S292-S293
Author(s):  
A HOLMER ◽  
B Boland ◽  
S Singh ◽  
J Neill ◽  
H Le ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Mucosal Inflammation ◽  
Routine Practice ◽  
Operating Characteristics ◽  
Serum Samples ◽  
Ulcer Size ◽  
Biomarker Panel ◽  
Disease Characteristics ◽  
Point Increase

Abstract Background Ulcer healing is the primary endoscopic treatment target in Crohn’s disease (CD) in routine practice. A novel serum-based biomarker panel named endoscopic healing index (EHI, Monitr, Prometheus Biosciences, San Diego, CA) was developed and validated for identifying mucosal inflammation as assessed by the simple endoscopic score for CD (SES-CD).1 We aimed to define the operating characteristics of EHI in routine practice for mucosal ulcers specifically. Methods EHI was analysed on serum samples paired with endoscopies from adult patients (≥18 years) participating in a prospective biobank (June 2014 to December 2018). Patients with an ileal pouch-anal anastomosis or an ileostomy were excluded. The performance of EHI for endoscopic disease activity was evaluated for subcomponents of SES-CD scores (0–60) including ulcer presence and size, extent of ulcerated surface, extent of affected surface, and presence of strictures. Diagnostic performance was assessed using previously identified cut-offs for optimal EHI performance in CD for ruling out endoscopic activity (20 points) and ruling in endoscopic activity (50 points). Logistic regression was performed to identify confounders of EHI (patient factors, disease characteristics) and for the strength of association between EHI and ulcers (presence, size). Results A total of 205 CD patients were included in the analysis (50% male, median age 37 years). EHI values were significantly higher with increasing ulcer size (p < 0.001). An EHI cut-off of 20 points exhibited modest sensitivity for ruling out any ulcers (85%, 95% CI 77–91), and large (0.5–20 mm) or very large (>20 mm) ulcers specifically (92%, 95% CI 84–97). An EHI cut-off of 50 points had modest specificity for ruling in the presence of any ulcers (85%, 95% CI 76–92), and large or very large ulcers specifically (87%, 95% CI 79–92). After accounting for the total extent of inflamed mucosa, extent of strictured mucosa, and disease location, each 20-point increase in EHI was independently associated with an incremental 1.7-fold increased probability for the presence of a large or very large ulcer (aOR 1.7, 95% CI 1.1–2.6). Conclusion EHI values were associated with ulcer size independent of inflammatory or stricture burden, and accurately identified the presence of ulcers and large or very large ulcers specifically. A cut-off of 50 points can reliably rule in the presence of ulcers and allow for treatment adjustment without endoscopy. A cut-off of 20 points can reliably rule out the presence of ulcers and signal completion of treatment adjustment algorithms. Reference

scholarly journals Serum Syndecan-1 Levels and Its Relationship to Disease Activity in Patients with Crohn’s Disease

2015 ◽  
Vol 2015 ◽  
pp. 1-6 ◽  
Author(s):  
Cem Çekiç ◽  
Adnan Kırcı ◽  
Sezgin Vatansever ◽  
Fatih Aslan ◽  
Huriye Erbak Yılmaz ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Disease Activity ◽  
Activity Index ◽  
Normal Population ◽  
Disease Activity Index ◽  
Serum Levels ◽  
Control Group ◽  
Serum Samples ◽  
Reactive Protein

Background. Syndecan-1 (SDC-1), a member of the family of heparan sulfate proteoglycans, plays an important role in the resolution of inflammation. This study aimed to investigate the relationship between SDC-1 and disease activity in Crohn’s disease (CD).Methods. Serum samples of 54 patients with CD and 30 healthy controls were obtained. First, SDC-1 levels of the CD patients were compared to the control group. Subsequently, SDC-1 levels were analyzed in patients with CD in active and remission periods. Finally, SDC-1 efficacy in predicting disease activity was evaluated by performing correlation analysis between SDC-1 and C-reactive protein (CRP) and Crohn’s disease activity index (CDAI).Results. SDC-1 level was higher in the CD group (61.9 ± 42.6 ng/mL) compared with the control group (34.1 ± 8.0 ng/mL)p=0.03. SDC-1 levels were higher in active CD patients (97.1 ± 40.3 ng/mL) compared with those in remission (33.7 ± 13.5 ng/mL)p<0.001. A significant positive correlation was found between SDC-1 and CRP (r=0.687,p<0.001) and between SDC-1 and CDAI (r=0.747,p<0.001).Conclusion. Serum levels of SDC-1 are higher in CD compared to the normal population and can be an effective marker of disease severity.

scholarly journals A Novel Model Based on Serum Biomarkers to Predict Primary Non-Response to Infliximab in Crohn’s Disease

2021 ◽  
Vol 12 ◽  
Author(s):  
Li Li ◽  
Rirong Chen ◽  
Yingfan Zhang ◽  
Gaoshi Zhou ◽  
Baili Chen ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Clinical Symptoms ◽  
Activity Index ◽  
Serum Biomarkers ◽  
Infliximab Treatment ◽  
Large Area ◽  
Discovery Cohort ◽  
Serum Samples ◽  
Patient Cohort

BackgroundInfliximab is effective in inducing and maintaining remission in patients with Crohn’s disease (CD), but primary non-response (PNR) occurs in 10-30% of cases. We investigated whether serum biomarkers are effective in predicting PNR in patients with CD.MethodsFrom January 2016 to April 2020, a total of 260 patients were recruited to this prospective and retrospective cohort study. Serum samples were collected at baseline and week 2 of infliximab treatment. Serum levels of 35 cytokines were assessed in 18 patients from the discovery cohort and were further evaluated in the 60-patient cohort 1. Then, candidate cytokines and other serological biomarkers were used to construct a predictive model by logistic regression in a 182-patient cohort 2. PNR was defined based on the change of CD activity index or clinical symptoms.ResultsAmong the 35 cytokines, matrix metalloproteinase 3(MMP3) and C-C motif ligand 2 (CCL2) were two effective serum biomarkers associated with PNR in both the discovery cohort and cohort 1. In cohort 2, serum level of MMP3, CCL2 and C-reactive protein (CRP) at 2 weeks after infliximab injection were independent predictors of PNR, with odds ratios (95% confidence interval) of 1.108(1.059-1.159), 0.940(0.920-0.965) and 1.102(1.031-1.117), respectively. A PNR classifier combining these three indicators had a large area under the curve [0.896(95% CI:0.895-0.897)] and negative predictive value [0.918(95%CI:0.917-0.919)] to predict PNR to infliximab.ConclusionsMMP3, CCL2, and CRP are promising biomarkers in prediction of PNR to infliximab, and PNR classifier could accurately predict PNR and may be useful in clinical practice for therapy selection.

scholarly journals Evaluation of “Indigenous Absorbed ELISA Kit” for the Estimation of Seroprevalence of Mycobacterium avium Subspecies paratuberculosis Antibodies in Human Beings in North India

2011 ◽  
Vol 2011 ◽  
pp. 1-5 ◽  
Author(s):  
A. V. Singh ◽  
S. V. Singh ◽  
D. K. Verma ◽  
R. Yadav ◽  
P. K. Singh ◽  
...  
Keyword(s):  
Ulcerative Colitis ◽  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Human Serum ◽  
Mycobacterium Avium ◽  
Human Subjects ◽  
North India ◽  
Serum Samples ◽  
Elisa Kit ◽  
Human Serum Samples

In present pilot study aimed to estimate, presence of Mycobacterium avium subspecies paratuberculosis (MAP) antibodies in the human serum samples originating from North India using “Indigenous absorbed ELISA kit” (ELISA kit). The phase I, “ELISA kit” was optimized using protoplasmic antigen from native isolate of MAP “Indian Bison type” recovered from the biopsies of Crohn's disease patients. The phase II, sensitivity and specificity of the kit were estimated as 40.0 and 83.3%, respectively, when evaluated in 40 human serum samples (5 Crohn's disease and 22 ulcerative colitis patients and 13 healthy human subjects) with defined MAP status with respect to stool culture. Seroprevalence of MAP antibodies was higher in CD patients (80.0%) as compared to ulcerative colitis patients (4.5%) and normal human subjects (15.3%). The phase III, seroprevalence of MAP antibodies was estimated as 23.4%, on the basis of the screening of 452 human serum samples (without history) from different geographical regions of North India. Region-wise, 34.0, 33.3, 32.8, 25.0, 23.0, 17.7, and 12.5% samples were positive from the states of Punjab, Uttarakhand, New Delhi, Himachal Pradesh, Haryana, Uttar Pradesh and Jammu and Kashmir, respectively. Study reported moderately higher presence of MAP antibodies in human population, which necessitates programs to reduce the bioburden of MAP in the environment and in animal population.

scholarly journals A Pilot Clinical Study on Post-Operative Recurrence Provides Biological Clues for a Role of Candida Yeasts and Fluconazole in Crohn’s Disease

2021 ◽  
Vol 7 (5) ◽  
pp. 324
Author(s):  
Boualem Sendid ◽  
Nicolas Salvetat ◽  
Helène Sarter ◽  
Severine Loridant ◽  
Catherine Cunisse ◽  
...  
Keyword(s):  
Crohn’S Disease ◽  
Crohn's Disease ◽  
Surgical Resection ◽  
University Hospital ◽  
Serum Samples ◽  
Pilot Clinical Study ◽  
Galectin 3 ◽  
Small Cohort ◽  
To Receive

Background and aims: This study prompted by growing evidence of the relationship between the yeast Candida albicans and Crohn’s disease (CD) was intended to assess the effect of a 6-month course of the antifungal fluconazole (FCZ) on post-operative recurrence of CD. Methods: Mycological samples (mouth swabs and stools) and serum samples were collected from 28 CD patients randomized to receive either FCZ (n = 14) or placebo (n = 14) before surgical resection. Serological analysis focused on levels of calprotectin, anti-glycan antibodies, and antibody markers of C. albicans pathogenic transition. Levels of galectin-3 and mannose binding lectin (MBL) involved in C. albicans sensing and inflammation were also measured. Results: 1, 2, 3, and 6 months after surgery, endoscopy revealed recurrence in 5/12 (41.7%) patients in the FCZ group and 5/9 (55.6%) in the placebo group, the small cohort preventing any clinical conclusions. In both groups, surgery was followed by a marked decrease in C. albicans colonization and biomarkers of C. albicans pathogenic transition decreased to non-significant levels. Anti-glycan antibodies also decreased but remained significant for CD. Galectin-3 and calprotectin also decreased. Conversely, MBL levels, which inversely correlated with anti-C. albicans antibodies before surgery, remained stable. Building biostatistical multivariate models to analyze he changes in antibody and lectin levels revealed a significant relationship between C. albicans and CD. Conclusion: Several combinations of biomarkers of adaptive and innate immunity targeting C. albicans were predictive of CD recurrence after surgery, with area under the curves (AUCs) as high as 0.86. FCZ had a positive effect on biomarkers evolution. ClinicalTrials.gov ID: NCT02997059, 19 December 2016. University Hospital Lille, Ministry of Health, France. Effect of Fluconazole on the Levels of Anti-Saccharomyces cerevisiae Antibodies (ASCA) After Surgical Resection for Crohn’s Disease. Multicenter, Randomized, and Controlled in Two Parallel Groups Versus Placebo.

Sign in / Sign up

Export Citation Format

Share Document