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Williamson M, Dong S, D'Souza R, Brignardello-Petersen R, Ronzoni S. Outpatient versus inpatient management of preterm prelabor rupture of membranes: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2024. [PMID: 38946314 DOI: 10.1111/aogs.14903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION To compare neonatal, obstetrical, and maternal outcomes associated with outpatient versus inpatient management of pregnancies with preterm prelabor rupture of membranes (PPROM). MATERIAL AND METHODS A search of MEDLINE, EMBASE, the Cochrane Database and Central Register from January 1, 1990 to July 31, 2023 identified randomized controlled trials (RCTs) and cohort studies comparing outpatient with inpatient management for pregnant persons diagnosed with PPROM before 37 weeks' gestation. No language restriction was applied. We applied a random effects model for meta-analysis. Trustworthiness was assessed using recently published guidance and Risk of bias using the RoB 2.0 tool for RCTs and ROBINS-I tool for cohort studies. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach was used to assess the certainty of evidence (COE). Outcomes of interest included perinatal mortality, neonatal morbidities, latency and gestational age at delivery, and maternal morbidities. RCTs and cohort studies were analyzed separately. This study was registered in the International Prospective Register of Systematic Reviewsr: CRD42022295275. RESULTS From 2825 records, two RCTs and 10 cohort studies involving 1876 patients were included in the review and meta-analysis. Outpatient management protocols varied but generally included brief initial hospitalization, strict eligibility criteria, and surveillance with laboratory and ultrasound investigations. Outpatient management showed lower rates of neonatal respiratory distress syndrome (cohort: RR 0.63 [0.52-0.77, very low COE]), longer latency to delivery (RCT: MD 7.43 days [1.14-13.72 days, moderate COE], cohort: MD 8.78 days [2.29-15.26 days, low COE]), higher gestational age at birth (cohort: MD 7.70 days [2.02-13.38 days, low COE]), lower rates of Apgar scores <7 at 5 min of life (cohort: RR 0.66 [0.50-0.89, very low COE]), and lower rates of histological chorioamnionitis (cohort: RR 0.74 [0.62-0.89, low COE]) without increased risks of adverse neonatal, obstetrical, or maternal outcomes. CONCLUSIONS Meta-analysis of data from RCTs and cohort studies with very low-to-moderate certainty of evidence indicates that further high-quality research is needed to evaluate the safety and potential benefits of outpatient management for selected PPROM cases, given the moderate-to-high risk of bias in the included studies.
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Affiliation(s)
- Monica Williamson
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Susan Dong
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rohan D'Souza
- Department of Obstetrics & Gynaecology, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Stefania Ronzoni
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Fetal Medicine Unit, Ontario Fetal Center, Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Le Lann C, Drumez É, Ghesquiere L, Winer N, Dochez V, Misbert É. [Impact of the mode of follow-up of preterm premature rupture of membranes before 36 weeks of gestation on the latency period]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024:S2468-7189(24)00209-5. [PMID: 38734234 DOI: 10.1016/j.gofs.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 02/25/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024]
Abstract
INTRODUCTION Preterm premature rupture of membranes (PPROM) is the main cause of premature delivery, complicating 1-3% of all pregnancies. Conventional hospitalization (CH) is the most frequent mode of follow-up, but homecare (HC) seems to be an alternative. OBJECTIVES Study of the impact of the monitoring mode on the duration of the latency period and on the latency ratio after PPROM, and analysis of the risk factors modifying this ratio. METHODS This was a bicentric retrospective cohort study here-abouts including patients who presented a PPROM between 24 and 36weeks of gestation from 2016 to 2018. Patients had a follow-up in HC at Lille University Hospital center (UHC) and in CH at Nantes UHC according to two different follow-up protocols. The latency ratio corresponded to the real latency period divided by the latency period to theoretical term. RESULTS We included 154 patients: 102 in HC and 52 in CH. The mean latency period was significantly higher in HC: 36.9±21.8 days, corresponding to an 85.5±23.7% latency ratio versus 20.2±12 days, corresponding to an 66.9±29.8% latency ratio in CH (P<0.001). The latency ratio in CH was correlated with term at PPROM (P=0.001). CONCLUSIONS The duration of the latency period seems prolonged for PPROM followed by HC management versus CH in selected populations. This study suggests a benefit to HC in stable patients.
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Affiliation(s)
- Charlotte Le Lann
- Faculté de médecine de Nantes, centre hospitalier universitaire de Nantes, Nantes, France.
| | - Élodie Drumez
- Département de biostatistiques, UDSL, université de Lille, CHRU de Lille, Lille, France
| | - Louise Ghesquiere
- Gynécologie-obstétrique, centre hospitalier universitaire de Lille, Lille, France
| | - Norbert Winer
- Gynécologie-obstétrique, centre hospitalier universitaire de Nantes, France
| | - Vincent Dochez
- Gynécologie-obstétrique, centre hospitalier universitaire de Nantes, France
| | - Émilie Misbert
- Gynécologie-obstétrique, centre hospitalier universitaire de Nantes, France
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Kunze M, Maul H, Kyvernitakis I, Stelzl P, Rath W, Berger R. Statement of the Obstetrics and Prenatal Medicine Working Group (AGG - Preterm Birth Section) on "Outpatient Management for Pregnant Women with Preterm Premature Rupture of Membranes (PPROM)". Geburtshilfe Frauenheilkd 2024; 84:43-47. [PMID: 38178898 PMCID: PMC10764122 DOI: 10.1055/a-2205-1725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 11/05/2023] [Indexed: 01/06/2024] Open
Abstract
Preterm premature rupture of membranes (PPROM) is one of the leading causes of perinatal morbidity and mortality. After a PPROM, more than 50% of pregnant women are delivered within 7 days. Fetal and maternal risks are primarily due to infection and inflammation, placental abruption, umbilical cord complications and preterm birth. Standard care usually consists of an expectant approach. Management includes the administration of antenatal steroids and antibiotic therapy. Patients with PPROM require close monitoring. The management of pregnant women with PPROM (inpatient vs. outpatient) is still the subject of controversial debate. The international guidelines also do not offer a clear stance. The statement presented here discusses the current state of knowledge.
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Affiliation(s)
- Mirjam Kunze
- Klinik für Frauenheilkunde, Universitätsklinikum Freiburg, Freiburg, Germany
| | - Holger Maul
- Frauenkliniken, Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Hamburg, Germany
| | - Ioannis Kyvernitakis
- Frauenkliniken, Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, Hamburg, Germany
| | - Patrick Stelzl
- Universitätsklinik für Gynäkologie, Geburtshilfe und Gynäkologische Endokrinologie, Kepler Universitätsklinikum, Johannes Kepler Universität Linz, Linz, Austria
| | - Werner Rath
- Medizinische Fakultät, Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Richard Berger
- Klinik für Gynäkologie und Geburtshilfe, Marienhaus Klinikum St. Elisabeth, Neuwied, Germany
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Ruggieri S, Guido M, Taccaliti C, Latorre G, Gallini F, Forziati V, Caringella D, Giocolano A, Fantasia I. Conservative management of preterm premature rupture of membranes < 30 weeks of gestational age: Effectiveness of clinical guidelines implementation strategies. Eur J Obstet Gynecol Reprod Biol X 2023; 19:100209. [PMID: 37426941 PMCID: PMC10329107 DOI: 10.1016/j.eurox.2023.100209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 07/11/2023] Open
Abstract
Objective To compare obstetrical and neonatal outcomes in patients with p-PROM (preterm premature rupture of membranes) at less than 30 weeks of gestational age before and after the application of protocols developed on the basis of international guidelines and to identify local barriers and strategies for their implementation. Study design Single and twin pregnancies with p-PROM < 30 weeks of gestation without signs of infection were retrospectively collected. The population was divided in two groups. Group A contained patients treated before the introduction of the protocol, hospitalized from the day of the p-PROM to delivery and treated according to clinicians' practice. Group B included patients managed according to a standardized protocol, treated with home care management under strict surveillance, after 48 h of hospitalization. Results 19 women with 21 newborns in group A and 22 women with 26 newborns in group B were enrolled. Maternal characteristics and p-PROM gestational age were comparable. In group A we observed minor latency time from diagnosis to delivery (1.6 vs 6.5 weeks, p < 0.001) with lower gestational age at delivery (25.8 ± 2 vs 30.7 ± 4.2 weeks, p = 0.00) and lower newborn weight (859 ± 268 vs 1511 ± 917 g, p = 0.002). Concerning neonatal outcomes, in group A there were lower Apgar score at 1 min (4.0 ± 2.1vs 6.3 ± 2, p = 004), longer hospitalization (42 ± 38 vs 68 ± 38 days, p = 0.05) and, even if non statistically significant, major rate of neonatal mortality (11,5% vs 19%, p = 1.00) and of neonatal complications (need of neonatal intensive care unit, sepsis, bronchopulmonary dysplasia, retinopathy of prematurity, mechanical ventilation). Postnatal follow-up showed comparable outcomes at 24 months of correct age. Conclusions Educational and interdisciplinary meetings, along with group performance audit and standardization of procedures are successful strategies to implement guidelines application. Applying this strategy, we developed a protocol according to international guidelines for the treatment of early onset p-PROM based on a standardized conservative management at home, achieving better results compared to hospital management in terms of latency, gestational age at delivery, neonatal weight and neonatal hospitalization.
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Affiliation(s)
- Stefania Ruggieri
- Department of Obstetrics and Gynecology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti 70021, Italy
- Obstetrics & Gynaecology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome 00168, Italy
| | - Maurizio Guido
- Obstetrics & Gynaecology Unit, San Salvatore Hospital, L'Aquila 67100, Italy
- Department of Life, Health and Environmental Sciences, University of L'Aquila, L'Aquila 67100, Italy
| | - Chiara Taccaliti
- Department of Obstetrics and Gynecology, Civitanova Marche Hospital, Civitanova Marche 62012, Italy
| | - Giuseppe Latorre
- Neonatology Unit, General Regional Hospital "F. Miulli", Acquaviva delle Fonti 70021, Italy
| | - Francesca Gallini
- Neonatology Unit, Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome 00168, Italy
| | - Vincenzo Forziati
- Neonatology Unit, General Regional Hospital "F. Miulli", Acquaviva delle Fonti 70021, Italy
| | - Domenico Caringella
- Department of Obstetrics and Gynecology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti 70021, Italy
| | - Alessandra Giocolano
- Department of Obstetrics and Gynecology, General Regional Hospital "F. Miulli", Acquaviva delle Fonti 70021, Italy
| | - Ilaria Fantasia
- Obstetrics & Gynaecology Unit, San Salvatore Hospital, L'Aquila 67100, Italy
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Rath W, Maul H, Kyvernitakis I, Stelzl P. Preterm Premature Rupture of Membranes – Inpatient Versus Outpatient Management: an Evidence-Based Review. Geburtshilfe Frauenheilkd 2022; 82:410-419. [PMID: 35392068 PMCID: PMC8983112 DOI: 10.1055/a-1515-2801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022] Open
Abstract
According to current guidelines, inpatient management until birth is considered standard in pregnant women with preterm premature rupture of membranes (PPROM). With the increasing burden on
obstetric departments and the growing importance of satisfaction and right to self-determination in pregnant women, outpatient management in PPROM is a possible alternative to inpatient
monitoring. The most important criterion for this approach is to ensure the safety of both the mother and the child. Due to the small number of cases (n = 116), two randomised controlled
trials (RCTs) comparing inpatient and outpatient management were unable to draw any conclusions. By 2020, eight retrospective comparative studies (cohort/observational studies) yielded the
following outcomes: no significant differences in the rate of maternal complications (e.g., chorioamnionitis, premature placental abruption, umbilical cord prolapse) and in neonatal
morbidity, significantly prolonged latency period with higher gestational age at birth, higher birth weight of neonates, and significantly shorter length of stay of preterm infants in
neonatal intensive care, shorter hospital stay of pregnant women, and lower treatment costs with outpatient management. Concerns regarding this approach are mainly related to unpredictable
complications with the need for rapid obstetric interventions, which cannot be performed in time in an outpatient setting. Prerequisites for outpatient management are the compliance of the
expectant mother, the adherence to strict selection criteria and the assurance of adequate monitoring at home. Future research should aim at more accurate risk assessment of obstetric
complications through studies with higher case numbers and standardisation of outpatient management under evidence-based criteria.
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Affiliation(s)
- Werner Rath
- Medizinische Fakultät, Gynäkologie und Geburtshilfe, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Holger Maul
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, c/o. Asklepios Klinik Barmbek, Hamburg, Germany
| | - Ioannis Kyvernitakis
- Frauenkliniken der Asklepios Kliniken Barmbek, Wandsbek und Nord-Heidberg, c/o. Asklepios Klinik Barmbek, Hamburg, Germany
| | - Patrick Stelzl
- Universitätsklinik für Gynäkologie, Geburtshilfe und Gynäkologische Endokrinologie, Kepler Universitätsklinikum, Johannes Kepler Universität Linz, Linz, Austria
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Point F, Ghesquiere L, Drumez E, Petit C, Subtil D, Houfflin-Debarge V, Garabedian C. Risk factors associated with shortened latency before delivery in outpatients managed for preterm prelabor rupture of membranes. Acta Obstet Gynecol Scand 2021; 101:119-126. [PMID: 34747005 DOI: 10.1111/aogs.14287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Preterm prelabor rupture of membranes (PPROM) occurs in 3% of pregnancies and is the main cause (~30%) of premature delivery. Home care seems to be a safe alternative for the management of patients with PPROM, who have a longer latency than those with PPROM managed with conventional hospitalization. We aimed to identify the risk factors associated with a shortened latency before delivery in women with PPROM managed as outpatients. MATERIAL AND METHODS The design was a retrospective cohort study and the setting was a Monocentric Tertiary centre (Lille University Hospital, France) from 2009 to 2018. All consecutive patients in home care after PPROM at 24-36 weeks were included. For the main outcome measure we calculated the latency ratio for each patient as the ratio of the real latency period to the expected latency period, expressed as a percentage. The risk factors influencing this latency ratio were evaluated. RESULTS A total of 234 patients were managed at home after PPROM. Mean latency was 35.5 ± 20.7 days, corresponding to an 80% latency ratio. In 196 (83.8%) patients the length of home care was more than 7 days. A lower latency ratio was significantly associated with oligohydramnios (p < 0.001), gestational age at PPROM (p = 0.006), leukocyte count at PPROM more than 12 × 109 /L (p = 0.025), and C-reactive protein concentration more than 5 mg/L at 7 days after PPROM (p = 0.046). Cervical length was not associated with a lower latency ratio. CONCLUSIONS Women with PPROM managed with home care are stable. The main risk factor associated with a reduced latency is oligohydramnios. Outpatients with oligohydramnios should be informed of the probability of a shortened latency period.
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Affiliation(s)
- Florian Point
- Department of Obstetrics, Lille University Hospital, Lille, France
| | | | - Elodie Drumez
- Department of Biostatistics, Lille University Hospital, Lille, France.,University of Lille, ULR 2694, Lille, France
| | - Céline Petit
- Department of Obstetrics, Lille University Hospital, Lille, France
| | - Damien Subtil
- Department of Obstetrics, Lille University Hospital, Lille, France.,University of Lille, ULR 2694, Lille, France
| | - Véronique Houfflin-Debarge
- Department of Obstetrics, Lille University Hospital, Lille, France.,University of Lille, ULR 2694, Lille, France
| | - Charles Garabedian
- Department of Obstetrics, Lille University Hospital, Lille, France.,University of Lille, ULR 2694, Lille, France
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Factors associated with a latency < 7 days after preterm premature rupture of membranes between 22 and 32 weeks of gestation in singleton pregnancies. J Gynecol Obstet Hum Reprod 2021; 50:102194. [PMID: 34224901 DOI: 10.1016/j.jogoh.2021.102194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To identify factors at admission associated with a latency < 7 days after Preterm premature rupture of membranes (PPROM) between 22 and 32 weeks of gestation in singleton pregnancies. MATERIAL AND METHODS A retrospective comparative study of all women with singleton pregnancies admitted for PPROM to an academic tertiary center during the 5-year period of 2015-2019. Women who gave birth < 7 days and ≥ 7 day after PPROM were compared. We determined risk at admission associated with a latency < 7 days after PPROM by logistic regression and identified high-risk subgroups by classification and regression tree (CART) analysis. RESULTS Among 174 eligible births, 76 (44%) women gave birth < 7 days after PPROM and 98 (56%) later. The two groups had similar maternal baseline and obstetric characteristics. In multivariate analysis, the following variables reported at admission were independently associated with a latency < 7 days: painful uterine contractions (aOR 3.9, 95%CI 1.1-7.4), cervical length < 20 mm (aOR 2.4, 95%CI 1.2-4.8), and C reactive protein ≥ 10 mg/L (aOR 2.4, 95% CI 1.3-4.8). Women with painful uterine contractions and cervical length at admission < 20 mm were at highest risk of latency < 7 days (rate: 91%). Conversely, the women at lowest risk were those without uterine contractions, with a cervical length ≥ 20 mm, and C-reactive protein < 10 mg/L at admission (rate: 22%). CONCLUSION Our results may be helpful in determining criteria at admission for selecting women eligible for outpatient care after an initial hospitalization.
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Rouzaire M, Corvaisier M, Roumeau V, Mulliez A, Sendy F, Delabaere A, Gallot D. Predictors of Short Latency Period Exceeding 48 h after Preterm Premature Rupture of Membranes. J Clin Med 2021; 10:E150. [PMID: 33406795 PMCID: PMC7796089 DOI: 10.3390/jcm10010150] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/18/2020] [Accepted: 12/29/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Preterm premature rupture of membranes (PPROM) is a complication responsible for a third of preterm births. Clinical management is initially hospital based, but homecare management is possible if patients are clinically stable 48 h after PPROM. This study set out to determine factors that are predictive of short latency (delivery ≤ 7 days) exceeding 48 h after PPROM, enabling estimation of the prevalence of maternal and neonatal complications and comparison of maternal and fetal outcomes between inpatient and outpatient management. METHOD This was a monocentric retrospective study conducted between 1 January 2010 and 28 February 2017 on all patients experiencing PPROM at 24 to 34 weeks + 6 days and who gave birth after 48 h. Maternal, obstetric, fetal, and neonatal variables were included in the data collected. The primary endpoint was latency, defined as the number of days between rupture of membranes and delivery. RESULTS 170 consecutive patients were analyzed. Short latency could be predicted by the need for tocolysis, a cervical length less than 25 mm at admission and the existence of anamnios. Outpatient follow-up was not found to lead to increased maternal morbidity or neonatal mortality. CONCLUSION Our study highlights predictive factors of short latency exceeding 48 h after PPROM. Knowledge of these factors may provide justification for outpatient monitoring of patients presenting with a long cervix, absence of need for tocolysis and persistence of amniotic fluid and, thus, no risk factors after 48 h of admission.
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Affiliation(s)
- Marion Rouzaire
- Obstetrics and Gynaecology Department, Clermont-Ferrand University Hospital, 63000 Clermont-Ferrand, France; (M.C.); (F.S.); (A.D.); (D.G.)
| | - Marion Corvaisier
- Obstetrics and Gynaecology Department, Clermont-Ferrand University Hospital, 63000 Clermont-Ferrand, France; (M.C.); (F.S.); (A.D.); (D.G.)
| | - Virginie Roumeau
- Obstetrics and Gynaecology Department, Emile Roux Hospital, 12 boulevard du Dr Chantemesse, 43012 Le Puy-en-Velay, France;
| | - Aurélien Mulliez
- Biostatistics Unit (DRCI) Clermont-Ferrand University Hospital, 63000 Clermont-Ferrand, France;
| | - Feras Sendy
- Obstetrics and Gynaecology Department, Clermont-Ferrand University Hospital, 63000 Clermont-Ferrand, France; (M.C.); (F.S.); (A.D.); (D.G.)
| | - Amélie Delabaere
- Obstetrics and Gynaecology Department, Clermont-Ferrand University Hospital, 63000 Clermont-Ferrand, France; (M.C.); (F.S.); (A.D.); (D.G.)
| | - Denis Gallot
- Obstetrics and Gynaecology Department, Clermont-Ferrand University Hospital, 63000 Clermont-Ferrand, France; (M.C.); (F.S.); (A.D.); (D.G.)
- “Translational Approach to Epithelial Injury and Repair” Team, Auvergne University, CNRS, Inserm, GReD, 63000 Clermont-Ferrand, France
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