scholarly journals Recurrent Vulvovaginal Candidosis and Cluster Analysis of Clinical Signs and Symptoms: A Laboratory-Based Investigation

2020 ◽  
Vol 6 (3) ◽  
pp. 113
Author(s):  
Aleksandra Ignjatović ◽  
Valentina Arsić-Arsenijević ◽  
Milan Golubović ◽  
Saša Đenić ◽  
Stefan Momčilović ◽  
...  
Keyword(s):  
Cluster Analysis ◽  
Clinical Characteristics ◽  
Antifungal Susceptibility ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
In Vitro Susceptibility ◽  
Major Health Problem ◽  
Vulvovaginal Candidosis ◽  
Clinical Signs And Symptoms

Recurrent vulvovaginal candidosis (RVVC) represents a major health problem that significantly affects a patient’s quality of life (QoL). This infection presents with a plethora of clinical manifestation, and this is the first study that carries out a cluster analysis of these signs and symptoms (SS). The goals are to evaluate the distribution of species causing RVVC, their in-vitro susceptibility to antifungals, and the patient’s QoL. Additionally, the clinical characteristics are analyzed using cluster analysis. Prospective analysis of data was performed for women diagnosed with RVVC in the period from January 2016 to December 2019 based on the analysis of data from a single-center’s records. The standard mycological methods and antifungal susceptibility testing were done. Clinical characteristics and QoL were examined by appropriate questions. The cluster analysis was used to identify clusters of SS. A total of 320 women were diagnosed. The dominant species was Candida (C.) albicans. Non-albicans Candida (NAC) yeast was found in 24.4%, and the most common was C. glabrata. Interestingly, Saccharomyces (S.) cerevisiae was detected in 2%. All of the isolated species, except C. parapsilosis and C. kefyr, demonstrated reduced susceptibility to antifungals. We confirmed the emergence of the NAC species and S. cerevisiae with reduced susceptibility to antifungals. Cluster analysis represented by a dendrogram revealed three SS clusters: irritation, uncommon, and discharge, but further studies are needed to examine the relationship between clusters, Candida strains, and outcomes.

scholarly journals A scoping review protocol to identify clinical signs, symptoms and biomarkers indicative of biofilm presence in chronic wounds

2021 ◽  
Vol 4 ◽  
pp. 71
Author(s):  
John D. Ivory ◽  
Akke Vellinga ◽  
James O'Gara ◽  
Georgina Gethin
Keyword(s):  
Chronic Wounds ◽  
Evidence Synthesis ◽  
Demographic Data ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Third Party ◽  
Scoping Reviews ◽  
Clinical Signs And Symptoms ◽  
High Level

Introduction: Wound healing is characterised by haemostatic, inflammatory, proliferative and remodelling phases. In the presence of comorbidities such as diabetes, healing can stall and chronic wounds may result. Infection is detrimental to these wounds and associated with poor outcomes. Wounds are contaminated with microbes and debris, and factors such as host resistance, bacterial virulence, species synergy and bioburden determine whether a wound will deteriorate to critically colonised/infected states. Biofilms are sessile microbial communities, exhibiting high-level antibiotic tolerance and resistance to host defences. Biofilm in critically colonised wounds can contribute to delayed healing. Little is known about clinical presentation and diagnosis of wound biofilms. Objective: To identify from the literature clinical signs, symptoms and biomarkers that may indicate biofilm presence in chronic wounds. Methods: This review will be guided by the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR), and the Joanna Briggs Institute Manual for Evidence Synthesis. Studies of any design in any language recruiting adult patients with  venous, diabetic, pressure or mixed arterial-venous ulcers and reporting data on clinical signs/symptoms of biofilm are eligible. Searches of Medline, Embase, CINAHL, Cochrane Central and BASE will be conducted from inception to present. Reference scanning and contact with content experts will be employed. Title/abstract screening and full text selection will be executed by two reviewers independently. Discrepancies will be resolved by discussion between reviewers or through third party intervention. Data will be extracted by a single reviewer and verified by a second. Clinical signs and symptoms data will be presented in terms of study design, setting and participant demographic data. Discussion: Understanding biofilm impact on chronic wounds is inconsistent and based largely on in vitro research. This work will consolidate clinical signs, symptoms and biomarkers of biofilm in chronic wounds reported in the literature.

scholarly journals Omalizumab for Severe Asthma: Beyond Allergic Asthma

2018 ◽  
Vol 2018 ◽  
pp. 1-10 ◽  
Author(s):  
C. C. Loureiro ◽  
L. Amaral ◽  
J. A. Ferreira ◽  
R. Lima ◽  
C. Pardal ◽  
...  
Keyword(s):  
Allergic Asthma ◽  
Severe Asthma ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Allergen Exposure ◽  
Response To Therapy ◽  
Double Blind ◽  
Clinical Signs And Symptoms ◽  
Underlying Mechanisms

Different subsets of asthma patients may be recognized according to the exposure trigger and the frequency and severity of clinical signs and symptoms. Regarding the exposure trigger, generally asthma can be classified as allergic (or atopic) and nonallergic (or nonatopic). Allergic and nonallergic asthma are distinguished by the presence or absence of clinical allergic reaction and in vitro IgE response to specific aeroallergens. The mechanisms of allergic asthma have been extensively studied with major advances in the last two decades. Nonallergic asthma is characterized by its apparent independence from allergen exposure and sensitization and a higher degree of severity, but little is known regarding the underlying mechanisms. Clinically, allergic and nonallergic asthma are virtually indistinguishable in exacerbations, although exacerbation following allergen exposure is typical of allergic asthma. Although they both show several distinct clinical phenotypes and different biomarkers, there are no ideal biomarkers to stratify asthma phenotypes and guide therapy in clinical practice. Nevertheless, some biomarkers may be helpful to select subsets of atopic patients which might benefit from biologic agents, such as omalizumab. Patients with severe asthma, uncontrolled besides optimal treatment, notwithstanding nonatopic, may also benefit from omalizumab therapy, although currently there are no randomized double-blind placebo controlled clinical trials to support this suggestion. However, omalizumab discontinuation according to each patient’s response to therapy and pharmacoeconomical analysis are questions that remain to be answered.

Vulvovaginal Candidosis: Comparison of 3-Day Treatment with 2% Butoconazole Nitrate Cream and 6-Day Treatment with 1% Clotrimazole Cream

1988 ◽  
Vol 16 (5) ◽  
pp. 367-375 ◽  
Author(s):  
A. J. Hajman
Keyword(s):  
Day Treatment ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Response To Treatment ◽  
Adverse Experiences ◽  
Vaginal Secretions ◽  
Vulvovaginal Candidosis ◽  
Clinical Signs And Symptoms ◽  
Butoconazole Nitrate ◽  
Single Blind

Sixty-three women with laboratory confirmed diagnoses of vulvovaginal candidosis were enrolled into this randomized, single-blind, parallel comparison of treatment with 2% butoconazole nitrate cream for 3 days and 1% clotrimazole cream for 6 days. Approximately 1 week after treatment ended both medications had substantially relieved vulvovaginal discharge, itching, burning, erythema and swelling. Both fungal cultures and potassium hydroxide stained preparations of vaginal secretions were negative for 93.3% of the butoconazole nitrate-treated patients. Comparable results for clotrimazole-treated patients were 80.6% and 77.4%, respectively. Both treatments improved the clinical signs and symptoms of candidosis. More butoconazole nitrate-treated patients (53.3%) had a ‘very good’ clinical response to treatment than clotrimazole-treated patients (38.7%). None of these differences was statistically significant, nor were statistically significant differences found between the percentages of patients considered clinically, microbiologically, or therapeutically cured in each group. No adverse experiences were associated with either treatment. Thus, the 3-day butoconazole nitrate regimen was considered as efficacious and safe as the 6-day clotrimazole regimen.

scholarly journals Endodontic retreatment due to secondary periapical injury: case report

2020 ◽  
Vol 9 (6) ◽  
pp. 503-506
Author(s):  
Monica Soares de Albuquerque ◽  
Armiliana Soares Nascimento ◽  
Cácio Lopes Mendes ◽  
Leonardo José Rodrigues de Oliveira ◽  
Marília de Lima Soares ◽  
...  
Keyword(s):  
Root Canal ◽  
Clinical Signs ◽  
In Vitro Study ◽  
Signs And Symptoms ◽  
Endodontic Treatment ◽  
Endodontically Treated Teeth ◽  
Clinical Signs And Symptoms ◽  
Endodontic Retreatment

Pulp diseases commonly happens because of the actions of bacteriological factors and show their characteristic signs and symptoms over the time. With pulp necrosis, a degenerative process starts and when there is no early treatment, it is possible to occur periapical lesions as a result of aggression to the pulp. In cases of periapical secondary lesions, clinical signs and symptoms persist and are related to secondary infection due to persistent bacterial contamination, also to operative factors, inadequate obturation or poor coronary restoration. This study aimed to report a case of endodontic retreatment and clinical and radiographic follow-up for 8 years, of chronic periapical abscess case, in which after retreatment, clinical signs and symptoms are no longer observed and bone neoformation is noticed. Descriptors: Periapical Diseases; Endodontics; Periapical Abscess. Referências Alani AH. Endodontic treatment of bilaterally occurring four-rooted maxillary second molars: case report. J Can Dent Assoc. 2003;69(11):733–35. Slowey RR. Radiographic aids in the detection of extra root canals. Oral Surg Oral Med Oral Pathol 1974;37(5):762-72 Bergenholtz G, Malmcrona E, Milthon R. Endodontic treatment and periapical status I. Radiographic evaluation of the frequency of endodontically treated teeth. Tandl€akartidningen. 1973; 65:64–73 (In Swedish, English summary). Buckley M, Spangberg LS. The prevalence and technical quality of endodontic treatment in an American subpopulation. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1995;79(1):92–100. Saunders WP, Saunders EM, Sadiq J, Cruickshank E. Technical standard of root canal treatment in an adult Scottish sub-population. Br Dent J. 1997;182(10):382-86. Segura-Egea JJ, Jimenez-Pinzon A, Poyato-Ferrera M, Velasco-Ortega E, Rios-Santos JV. Periapical status and quality of root fillings and coronal restorations in an adult Spanish population. Int Endod J. 2004;37(8):525-30. Kabak Y, Abbott PV. Prevalence of apical  periodontitis and the quality of endodontic treatment in an adult Belarusian population. Int Endod J. 2005;38(4):238-45. Glickman GN. AAE consensus conference on diagnostic terminology: background and perspectives. J Endod. 2009;35:1619. Gutmann JL, Harrison JW. Surgical endodontics: an online study guide. Blackwell Scientific Publications; 1991. Molven O, Halse A, Grung B. Incomplete healing (scar tissue) after periapical surgery - radiographic findings 8 to 12 years after treatment. J Endod. 1996;22(5):264-68. Macedo, IL Retratamento endodôntico: opção terapêutica do insucesso endodôntico. BJHR. 2018;1(2):421-31. Souza VC et al. Tratamento do insucesso endodôntico. Rev Odontol Bras Central. 2018; 27:44-48. Bender IB, Seltzer S, Soltanoff W. Endodontic success – a reappraisal of criteria. Oral Surg Oral Med Oral Pathol. 1966; 22(6):790–802. Rubinstein R A, Kim S. Long-term follow-up of cases considered healed one year after apical microsurgery. J Endod. 2002; 28(5):378-83. Estrela C et al. Characterization of successful root canal treatment. Braz Dent J. 2014; 25(1):3-11 http://dx.doi.org/10.1590/0103-6440201302356 Kaled GH et al. Retratamento endodôntico: análise comparativa da efetividade da remoção da obturação dos canais radiculares realizada por três métodos. RGO, Rev. gaúch. odontol. (Online). 2011;59(1):103-8. Rossi-Fedele G, Ahmed HMA. Assessment of rootcanal filling removal effectiveness using micro–computedtomography: a systematic review. J Endod. 2017;43(4):520-26 Barbosa SV, Burkhard DH, Spanberg LSV. Cytotoxic effects of gutta-percha solvents. J Endod. 1994; 20(1):6-8. Zakariasen KL, Brayton SM, Collinson DM. Efficient and effective root canal retreatment without chloroform. J Canad Dent Assoc. 1990; 56(6):509-12. Pecora JD, Spano JC, Barbin EL. In vitro study on the softening of gutta-percha cones in endodontic retreatment. Brazilian. Braz Dent Journal. 1993; 4(1): 43-7. Scelza MF et al. Comparative SEM evaluation of three solvents used in endodontic retreatment: an ex vivo study. Journal of Applied Oral Science. 2008; 16(1):24-9. Marques da Silva B et al. Effectiveness of ProTaper, D-RaCe, and Mtwo retreatment files with and without supplementary instruments in the removal of root canal filling material. Int Endod J. 2012; 45(10):927-32 Song M1 et al. Analysis of the cause of failure in nonsurgical endodontic treatment by microscopic inspection during endodontic microsurgery. J Endod. 2011;37(11):1516-9. Albuquerque MS et al. Sealing Capacity of Bulk-fill Resin in Endodontically Treated Teeth. The Journal of Contemporary Dental Practice. 2019; 20(3): 311-17 Zancan RF, Vivan RR, Lopes MRM et al. Antimicrobial activity and physicochemical properties of calcium hydroxide pastes used as intracanal medication. J Endod. 2016. 42(12):1822-28. Buttler TK, Crawford JJ. The detoxifying effect of varying concentrations of sodium hypochlorite on endotoxins. J Endod. 1982; 8(2):59-66. Foley DB, Weine FS, Hagen JC, deObarrio JJ. Effectiveness of selected irrigants in the elimination of bacteroides meloninogenicus from the root canal system: an in vitro study. J Endod. 1983; 9(6):236-41. Abou-Ran M, Oglesby SW. The effects of temperature, concentration and tissue type on the solvent ability of sodium hypochlorite. J Endod. 1981; 7(8):376-7. Lee JK et al. Physicochemical Properties of Epoxy Resin-Based and Bioceramic-Based Root Canal Sealers. Bioinorg Chem Appl. 2017; 1-8.  Kandemir DG, Caliskan MK. A prospective Ramdomized  Comparative Study of Cold Lateral Condensation Versus Core/Guta Percha in Teeth with Periapical Lesions. J Endod. 2016; 42(2):206-10 Karaman E, Keskin B, Inan U. Three-year clinical evaluation of class II posterior composite restorations placed with different techniques and flowable composite linings in endodontically treated teeth. Clin Oral Investig. 2017; 21(2):709-16.

scholarly journals A scoping review protocol to identify clinical signs, symptoms and biomarkers indicative of biofilm presence in chronic wounds

2021 ◽  
Vol 4 ◽  
pp. 71
Author(s):  
John D. Ivory ◽  
Akke Vellinga ◽  
James O'Gara ◽  
Georgina Gethin
Keyword(s):  
Chronic Wounds ◽  
Evidence Synthesis ◽  
Demographic Data ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Third Party ◽  
Scoping Reviews ◽  
Clinical Signs And Symptoms ◽  
High Level

Introduction: Wound healing is characterised by haemostatic, inflammatory, proliferative and remodelling phases. In the presence of comorbidities such as diabetes, healing can stall and chronic wounds may result. Infection is detrimental to these wounds and associated with poor outcomes. Wounds are contaminated with microbes and debris, and factors such as host resistance, bacterial virulence, species synergy and bioburden determine whether a wound will deteriorate to critically colonised/infected states. Biofilms are sessile microbial communities, exhibiting high-level antibiotic tolerance and resistance to host defences. Biofilm in critically colonised wounds can contribute to delayed healing. Little is known about clinical presentation and diagnosis of wound biofilms. Objective: To identify from the literature clinical signs, symptoms and biomarkers that may indicate biofilm in chronic wounds. Methods: This review will be guided by the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR), and the Joanna Briggs Institute Manual for Evidence Synthesis. Studies of any design in any language recruiting adult patients with  venous, diabetic, pressure or mixed arterial-venous ulcers and reporting data on clinical signs/symptoms of biofilm are eligible. Searches of Medline, Embase, CINAHL, Cochrane Central, Scopus, Web of Science, Google scholar and BASE will be conducted from inception to present. Reference scanning and contact with content experts will be employed. Title/abstract screening and full text selection will be executed by two reviewers independently. Discrepancies will be resolved by discussion between reviewers or through third party intervention. Data will be extracted by a single reviewer and verified by a second. Clinical signs and symptoms data will be presented in terms of study design, setting and participant demographic data. Discussion: Understanding biofilm impact on chronic wounds is inconsistent and based largely on in vitro research. This work will consolidate clinical signs, symptoms and biomarkers of biofilm in chronic wounds reported in the literature.

scholarly journals Pseudocyesis as a healing mechanism for psychological trauma

2020 ◽  
Vol 14 (1) ◽  
Author(s):  
Georgia Nektaria Porfyri ◽  
Anastasia Konsta ◽  
Anthoula Tsolaki ◽  
Ioannis Diakogiannis ◽  
Ioanna Ierodiakonou-Benou
Keyword(s):  
Somatic Symptom ◽  
Present Report ◽  
Clinical Signs ◽  
Rare Condition ◽  
Signs And Symptoms ◽  
Psychological Trauma ◽  
Vitro Fertilization ◽  
Clinical Signs And Symptoms ◽  
Patient’S History

Pseudocyesis, a rare condition characterized by clinical signs and symptoms of pregnancy except for the actual existence of a fetus, is a somatic symptom disorder associated with a variety of biological, psychological and social factors. The present report aims to present the case of a 45-year old patient with pseudocyesis from a psychodynamic perspective. According to a psychodynamic perspective and based on patient’s history, pseudocyesis functioned as a mental healing mechanismfor the trauma of long-standing infertility, the trauma of eight unsuccessful and painful in vitro fertilization attempts and above all, the trauma of finally giving birth to a non-healthy child.

scholarly journals Study of clinical profile of chronic kidney disease in non-diabetic patients

2021 ◽  
Author(s):  
Ravi Kumar U. ◽  
Shashank J. ◽  
Narayana Swamy
Keyword(s):  
Diabetes Mellitus ◽  
Cardiovascular Disease ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Diabetic Patients ◽  
Hypertensive Nephropathy ◽  
Major Health Problem ◽  
Clinical Signs And Symptoms

Background: Chronic kidney disease (CKD) encompasses a spectrum of different pathophysiological processes associated with abnormal kidney function and a progressive decline in glomerular filtration rate. Cardiovascular disease is one of the major cause of morbidity and mortality in patients at every stage of CKD. Diabetes mellitus and hypertension together being major cause for CKD. Hypertension is a common cause for CKD and an independent risk factor for cardiovascular disease. This study mainly focused on the causes of CKD other than diabetes mellitus. An early detection and appropriate intervention of these patients will possibly help prevent progression of renal disease.Methods:We assessed 55 non diabetic CKD patients who presented to the OPD/IPD in Victoria hospital, Bowring and Lady Curzon hospital and other hospitals affiliated to Bangalore medical college and research institute during period June 2018 to December 2019. A detailed history and clinical examination was performed and patients were subjected to necessary investigations.Results: The commonest etiology for CKD was found to be hypertensive nephropathy followed by glomerulonephritis. Common symptoms were generalized weakness, lower limb swelling. Commonest signs are pallor, pedal edema and hypertension.Conclusions:CKD is a major health problem. Diabetic nephropathy is the commonest cause for CKD followed by hypertensive nephropathy and glomerulonephritis. Anaemia, pedal oedema, oliguria and generalised weakness were the major presenting clinical signs and symptoms in CKD. This condition when detected in early stages and managed can slow down the progression of CKDs and delay the need of renal replacement therapy.  

scholarly journals Suppression of colitis in mice by Cl-amidine: a novel peptidylarginine deiminase inhibitor

2011 ◽  
Vol 300 (6) ◽  
pp. G929-G938 ◽  
Author(s):  
Alexander A. Chumanevich ◽  
Corey P. Causey ◽  
Bryan A. Knuckley ◽  
Justin E. Jones ◽  
Deepak Poudyal ◽  
...  
Keyword(s):  
Clinical Signs ◽  
Signs And Symptoms ◽  
Inflammatory Cells ◽  
Irreversible Reaction ◽  
Calcium Dependent ◽  
Inflammatory Conditions ◽  
Bowel Diseases ◽  
Clinical Signs And Symptoms

Inflammatory bowel diseases (IBDs), mainly Crohn's disease and ulcerative colitis, are dynamic, chronic inflammatory conditions that are associated with an increased colon cancer risk. Inflammatory cell apoptosis is a key mechanism for regulating IBD. Peptidylarginine deiminases (PADs) catalyze the posttranslational conversion of peptidylarginine to peptidylcitrulline in a calcium-dependent, irreversible reaction and mediate the effects of proinflammatory cytokines. Because PAD levels are elevated in mouse and human colitis, we hypothesized that a novel small-molecule inhibitor of the PADs, i.e., chloramidine (Cl-amidine), could suppress colitis in a dextran sulfate sodium mouse model. Results are consistent with this hypothesis, as demonstrated by the finding that Cl-amidine treatment, both prophylactic and after the onset of disease, reduced the clinical signs and symptoms of colitis, without any indication of toxic side effects. Interestingly, Cl-amidine drives apoptosis of inflammatory cells in vitro and in vivo, providing a mechanism by which Cl-amidine suppresses colitis. In total, these data help validate the PADs as therapeutic targets for the treatment of IBD and further suggest Cl-amidine as a candidate therapy for this disease.

scholarly journals 146. antifungal Susceptibility Patterns of candida Parapsilosis Bloodstream Isolates in the US, 2008–2018

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S203-S203
Author(s):  
Brenda L Tesini ◽  
Meghan Lyman ◽  
Brendan R Jackson ◽  
Anita Gellert ◽  
William Schaffner ◽  
...  
Keyword(s):  
Candida Species ◽  
Regional Variation ◽  
Antifungal Susceptibility ◽  
Bloodstream Infections ◽  
Emerging Infections ◽  
In Vitro Susceptibility ◽  
Fluconazole Resistance ◽  
The Us ◽  
Susceptibility Patterns

Abstract Background Multidrug resistant Candida is an increasing concern. C. parapsilosis in particular has decreased in vitro susceptibility to echinocandins. As a result, fluconazole had been favored for C. parapsilosis treatment. However, there is growing concern about increasing azole resistance among Candida species. We report on antifungal susceptibility patterns of C. parapsilosis in the US from 2008 through 2018. Methods Active, population-based surveillance for candidemia through the Centers for Disease Control and Prevention’s (CDC) Emerging Infections Program was conducted between 2008–2018, eventually encompassing 9 states (GA, MD,OR, TN, NY, CA, CO, MN, NM). Each incident isolate was sent to the CDC for species confirmation and antifungal susceptibility testing (AFST). Frequency of resistance was calculated and stratified by year and state using SAS 9.4 Results Of the 8,704 incident candidemia isolates identified, 1,471 (15%) were C. parapsilosis; the third most common species after C. albicans and C. glabrata. AFST results were available for 1,340 C. parapsilosis isolates. No resistance was detected to caspofungin (MIC50 0.25) or micafungin (MIC50 1.00) with only one (< 1%) isolate resistant to anidulafungin (MIC50 1.00). In contrast, 84 (6.3%) isolates were resistant to fluconazole and another 44 (3.3%) isolates had dose-dependent susceptibility to fluconazole (MIC50 1.00). Fluconazole resistance increased sharply from an average of 4% during 2008–2014 to a peak of 14% in 2016 with a subsequent decline to 6% in 2018 (see figure). Regional variation is also observed with fluconazole resistance ranging from 0% (CO, MN, NM) to 42% (NY) of isolates by site. Conclusion The recent marked increase in fluconazole resistance among C. parapsilosis highlights this pathogen as an emerging drug resistant pathogen of concern and the need for ongoing antifungal resistance surveillance among Candida species. Our data support the empiric use of echinocandins for C. parapsilosis bloodstream infections and underscore the need to obtain AFST prior to fluconazole treatment. Furthermore, regional variation in fluconazole resistance emphasizes the importance of understanding local Candida susceptibility patterns. Disclosures Lee Harrison, MD, GSK (Consultant)Merck (Consultant)Pfizer (Consultant)Sanofi Pasteur (Consultant)

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