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Geditz MCK, Lindner W, Lämmerhofer M, Heinkele G, Kerb R, Ramharter M, Schwab M, Hofmann U. Simultaneous quantification of mefloquine (+)- and (-)-enantiomers and the carboxy metabolite in dried blood spots by liquid chromatography/tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2013; 968:32-9. [PMID: 24315337 DOI: 10.1016/j.jchromb.2013.11.035] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Revised: 11/04/2013] [Accepted: 11/17/2013] [Indexed: 11/30/2022]
Abstract
Mefloquine (MQ), a racemic mixture of (+)-(11S,12R)- and (-)-(11R,12S)-MQ, has been used for treatment and prophylaxis of malaria for almost 30 years. MQ is metabolized by the cytochrome P450 3A subfamily to 4-carboxymefloquine (CMQ), which shows no antimalarial activity in vitro. Highly stereospecific pharmacokinetics of MQ have been reported, although with contradictory results. This might be due to incorrect assignment of the absolute configuration as shown only recently. Gastrointestinal as well as neuropsychiatric adverse events were described after prophylaxis and treatment with MQ. Data are indicating that the tolerability of the enantiomers may vary considerably. An involvement of the main metabolite CMQ in the development of neuropsychiatric adverse events has also been supposed. Due to these inconsistent results we established a novel liquid chromatography/tandem mass spectrometry (LC-MS/MS) method for the simultaneous quantification of MQ enantiomers and the metabolite CMQ to investigate the attribution of efficacy and adverse effects to the single enantiomers as well as the main metabolite. Separation of the MQ enantiomers was achieved on a quinidine-based zwitterionic chiral stationary phase column, CHIRALPAK(®) ZWIX(-) (3.0×150mm, 3μm) in an isocratic run using a pre-mixed eluent consisting of methanol/acetonitrile/water (49:49:2 v/v) with 25mM formic acid and 12.5mM ammonium formate. We used stable isotope-labelled analogues as internal standards. The method was validated according to the FDA guidelines. With a linear calibration range from 5 to 2000nM for the MQ enantiomers and from 13 to 2600nM for CMQ respectively, the method was successfully applied to dried blood spot (DBS) samples from patients under prophylactic MQ treatment. The method was also applicable for plasma samples.
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Affiliation(s)
- Mirjam C K Geditz
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tuebingen, Auerbachstrasse 112, 70376 Stuttgart, Germany
| | - Wolfgang Lindner
- Department of Analytical Chemistry, University of Vienna, Währinger Straße 38, 1090 Vienna, Austria
| | - Michael Lämmerhofer
- Institute of Pharmaceutical Science, University of Tuebingen, Auf der Morgenstelle 8, 72076 Tuebingen, Germany
| | - Georg Heinkele
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tuebingen, Auerbachstrasse 112, 70376 Stuttgart, Germany
| | - Reinhold Kerb
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tuebingen, Auerbachstrasse 112, 70376 Stuttgart, Germany
| | - Michael Ramharter
- Department of Medicine I, Division of Infectious Diseases and Tropical Medicine, Medical University Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria; Institut für Tropenmedizin, Universitaet Tuebingen, Wilhelmstrasse 27, 72074 Tuebingen, Germany
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tuebingen, Auerbachstrasse 112, 70376 Stuttgart, Germany; Department of Clinical Pharmacology, University Hospital, Auf der Morgenstelle 8, 72076 Tuebingen, Germany
| | - Ute Hofmann
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tuebingen, Auerbachstrasse 112, 70376 Stuttgart, Germany.
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Two-step liquid-phase microextraction and high-performance liquid chromatography for the simultaneous analysis of the enantiomers of mefloquine and its main metabolite carboxymefloquine in plasma. Anal Bioanal Chem 2009; 393:1805-13. [DOI: 10.1007/s00216-009-2620-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2008] [Revised: 01/08/2009] [Accepted: 01/12/2009] [Indexed: 11/26/2022]
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Khaliq Y, Gallicano K, Tisdale C, Carignan G, Cooper C, McCarthy A. Pharmacokinetic interaction between mefloquine and ritonavir in healthy volunteers. Br J Clin Pharmacol 2001; 51:591-600. [PMID: 11422019 PMCID: PMC2014486 DOI: 10.1046/j.1365-2125.2001.01393.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AIMS To evaluate the pharmacokinetic interaction between ritonavir and mefloquine. METHODS Healthy volunteers participated in two separate, nonfasted, three-treatment, three-period, longitudinal pharmacokinetic studies. Study 1 (12 completed): ritonavir 200 mg twice daily for 7 days, 7 day washout, mefloquine 250 mg once daily for 3 days then once weekly for 4 weeks, ritonavir restarted for 7 days simultaneously with the last mefloquine dose. Study 2 (11 completed): ritonavir 200 mg single dose, mefloquine 250 mg once daily for 3 days then once weekly for 2 weeks, ritonavir single dose repeated 2 days after the last mefloquine dose. Erythromycin breath test (ERMBT) was administered with and without drug treatments in study 2. RESULTS Study 1: Ritonavir caused less than 7% changes with high precision (90% CIs: -12% to 11%) in overall plasma exposure (AUC(0,168 h)) and peak concentration (Cmax) of mefloquine, its two enantiomers, and carboxylic acid metabolite, and in the metabolite/mefloquine and enantiomeric AUC ratios. Mefloquine significantly decreased steady-state ritonavir plasma AUC(0,12 h) by 31%, Cmax by 36%, and predose levels by 43%, and did not affect ritonavir binding to plasma proteins. Study 2: Mefloquine did not alter single-dose ritonavir pharmacokinetics. Less than 8% changes in AUC and Cmax were observed with high variability (90%CIs: -26% to 45%). Mefloquine had no effect on the ERMBT whereas ritonavir decreased activity by 98%. CONCLUSIONS Ritonavir minimally affected mefloquine pharmacokinetics despite strong inhibition of CYP3A4 activity from a single 200 mg dose. Mefloquine had variable effects on ritonavir pharmacokinetics that were not explained by hepatic CYP3A4 activity or ritonavir protein binding.
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Affiliation(s)
- Yasmin Khaliq
- Clinical Investigation Unit, The Ottawa Hospital – General CampusOttawa, Ontario, Canada
- Department of Pharmacy, Ottawa Hospital Research Institute, The Ottawa Hospital – General CampusOttawa, Ontario, Canada
| | - Keith Gallicano
- Clinical Investigation Unit, The Ottawa Hospital – General CampusOttawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital Research Institute, The Ottawa Hospital – General CampusOttawa, Ontario, Canada
- Department of Ottawa Hospital Research Institute, The Ottawa Hospital – General CampusOttawa, Ontario, Canada
| | - Christine Tisdale
- Department of Pharmacy, Ottawa Hospital Research Institute, The Ottawa Hospital – General CampusOttawa, Ontario, Canada
| | - Germain Carignan
- Clinical Investigation Unit, The Ottawa Hospital – General CampusOttawa, Ontario, Canada
- Department of Ottawa Hospital Research Institute, The Ottawa Hospital – General CampusOttawa, Ontario, Canada
| | - Curtis Cooper
- Department of Medicine, Ottawa Hospital Research Institute, The Ottawa Hospital – General CampusOttawa, Ontario, Canada
| | - Anne McCarthy
- Department of Medicine, Ottawa Hospital Research Institute, The Ottawa Hospital – General CampusOttawa, Ontario, Canada
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Okereke CS. Management of HIV-infected pregnant patients in malaria-endemic areas: therapeutic and safety considerations in concomitant use of antiretroviral and antimalarial agents. Clin Ther 1999; 21:1456-96; discussion 1427-8. [PMID: 10509844 DOI: 10.1016/s0149-2918(00)80004-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Chemotherapy in pregnancy is an intricate process requiring prudent use of pharmacologic agents. Malarial infection during pregnancy is often fatal, and prophylaxis against the causative parasite necessitates rational therapeutic intervention. Various agents have been used for prophylaxis against malaria during pregnancy, including chloroquine, mefloquine, proguanil, pyrimethamine, and pyrimethamine-sulfadoxine. Use of these agents has been based on a risk-benefit criterion, without appropriate toxicologic or teratologic evaluation. Some of the aforementioned prophylactic agents have been shown to alter glutathione levels and may exacerbate the oxidation-reduction imbalance attendant on HIV infection. HIV-infected patients traveling to or residing in malaria-endemic areas require protection from malarial infection to avoid placing themselves in double jeopardy. Zidovudine (AZT) is recommended for the prevention of vertical transmission of HIV-1 from mother to child. Other agents, such as lamivudine alone or in combination with AZT, nevirapine, or the HIV-1 protease inhibitors, are either being considered or are currently undergoing trials for use in preventing vertical transmission of HIV-1 or managing HIV infection in infants and children. Although the potential for antimalarial agents to cause congenital malformations is low when they are used alone, their ability to cause problems when combined with antiretroviral drugs needs to be evaluated. In developing countries that have high birth rates, a high endemicity of malaria, and alarming rates of new cases of HIV, prophylaxis against both diseases with combination agents during pregnancy is a challenge.
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Affiliation(s)
- C S Okereke
- Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Roger Williams Medical Centre, Providence, USA
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Schlagenhauf P, Steffen R, Lobel H, Johnson R, Letz R, Tschopp A, Vranjes N, Bergqvist Y, Ericsson O, Hellgren U, Rombo L, Mannino S, Handschin J, Stürchler D. Mefloquine tolerability during chemoprophylaxis: focus on adverse event assessments, stereochemistry and compliance. Trop Med Int Health 1996; 1:485-94. [PMID: 8765456 DOI: 10.1046/j.1365-3156.1996.d01-85.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This longitudinal study of travellers to Africa taking mefloquine (MQ) chemoprophylaxis aimed to quantify and assess non-serious adverse events (AE) occurring during short-term prophylaxis and relate these to concentrations of racemic MQ, its enantiomers and metabolite. A total of 420 volunteers (52% F) participated. AEs with some impact on activities were reported by 11.2% of participants including 7.9% of neurological/psychiatric symptoms. Women were more likely to report AEs (P = 0.02). The standardized questionnaires used showed more pathological indicators in travellers who reported subjective AE with significantly more dizziness, distress, sleep disturbances and a high total mood disturbance (TMD) in the AE group. There was, however, no significant performance deficit in computerized psychomotor tests in those experiencing AE. Furthermore, no significant differences were observed in enantiomer ratios, metabolite concentrations, or racemic MQ levels in participants with or without AEs suggesting that these factors are not the main predictors of mefloquine intolerability.
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Affiliation(s)
- P Schlagenhauf
- Institute for Social and Preventive Medicine, University of Zürich
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Crevoisier CA, Joseph I, Fischer M, Graf H. Influence of hemodialysis on plasma concentration-time profiles of mefloquine in two patients with end-stage renal disease: a prophylactic drug monitoring study. Antimicrob Agents Chemother 1995; 39:1892-5. [PMID: 7486943 PMCID: PMC162850 DOI: 10.1128/aac.39.8.1892] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Prophylactic drug monitoring of mefloquine and its carboxylic acid metabolite were studied in two patients with end-stage renal disease undergoing long-term hemodialysis treatment. The patients, short-term travellers to areas where malaria is endemic, took 250 mg of mefloquine (Lariam) once weekly for 2 weeks before and during their 3-week stay abroad and for one week after their return. Pre- and postdialysis blood samples were drawn before their departure and after their return. The concentration-time profiles of mefloquine and its metabolite in plasma samples taken before and after the 3- to 4-h dialysis sessions were similar. Mefloquine and its metabolite could not be detected in the dialysate. These findings show that mefloquine and its metabolite are not, or are very poorly, removed by hemodialysis. Concentrations in plasma and accumulation kinetics were similar to those reported for healthy volunteers and were associated with high prophylactic efficacy against malaria. No special dosage adjustments have to be made in patients undergoing hemodialysis treatment to achieve concentrations in plasma similar to those in healthy volunteers. The prophylactic dose of mefloquine could be given before, during, or after the hemodialysis session.
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Gimenez F, Pennie RA, Koren G, Crevoisier C, Wainer IW, Farinotti R. Stereoselective pharmacokinetics of mefloquine in healthy Caucasians after multiple doses. J Pharm Sci 1994; 83:824-7. [PMID: 9120814 DOI: 10.1002/jps.2600830613] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Mefloquine (MQ) is a chiral antimalarial agent effective against chloroquine-resistant Plasmodium falciparum. It is commercially available as a racemic mixture of the (+) and (-) enantiomers for oral administration. The pharmacokinetics of the (+) and (-) enantiomers of MQ were studied in eight healthy volunteers after administration of a first oral dose of 250 mg of racemic MQ and at steady state after 13 repeated doses of 250 mg given at 1-week intervals. Plasma samples were collected, and concentrations of each enantiomer were determined using a previously described achiral-chiral double column-switching liquid chromatographic method. At each time point, higher plasma concentrations values were found for the (-) enantiomer (p < 0.001). At steady state, Cmax values of (-)-MQ were higher than those of (+)-MQ (1.42 +/- 0.19 versus 0.26 +/- 0.05 mg/L; p < 0.001). Similarly, the plasma concentrations 7 days after the final dose were higher for (-)-MQ (1.01 +/- 0.26 versus 0.11 +/- 0.04 mg/L; p < 0.001). AUC values at steady state were also higher for (-)-MQ (197.3 +/- 36.7 versus 30.1 +/- 8.9 mg/L x h; p < 0.001). The terminal half-life values (T1/2beta) were longer for (-)-MQ (430.4 +/- 225.2 versus 172.8 +/- 56.5 h; p < 0.001). This study shows that the pharmacokinetics of MQ is highly stereoselective.
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Affiliation(s)
- F Gimenez
- Hôpital Pitié Salpêtrière, Pharmacie, Pharmacocinétique, Paris, France
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Palmer KJ, Holliday SM, Brogden RN. Mefloquine. A review of its antimalarial activity, pharmacokinetic properties and therapeutic efficacy. Drugs 1993; 45:430-75. [PMID: 7682911 DOI: 10.2165/00003495-199345030-00009] [Citation(s) in RCA: 129] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Mefloquine is an orally administered blood schizontocide. Initial dose-finding and comparative studies performed between 1977 and 1989 demonstrated efficacy of mefloquine as prophylaxis in nonimmune individuals and in the suppression and treatment of malaria in adults and children caused by multidrug-resistant Plasmodium falciparum. It was also effective against P. vivax infection, while data concerning the treatment of P. ovale and P. malariae infections were limited. In an attempt to delay the emergence of resistance to this promising antimalarial agent, mefloquine was combined with sulfadoxine and pyrimethamine. Although initial clinical trials indicated that this regimen was effective in preventing and treating falciparum malaria, recent treatment failures, the potential for severe dermatological reactions and lack of therapeutic advantage over mefloquine alone has prompted the World Health Organization to recommended that the combination be no longer used for treatment or prophylaxis of malaria. Mefloquine is generally well tolerated in both adults and children, with nausea, vomiting, diarrhoea, headache, dizziness, rash, pruritus and abdominal pain being the most common adverse effects, although it is difficult to distinguish between disease- and treatment-related events. The incidence of these adverse effects is similar to or lower than those observed with other antimalarial agents. Cardiovascular changes, such as bradycardia, occasionally occur. The most notable adverse effects associated with mefloquine are neuropsychiatric disturbances; precipitation of such events should be closely monitored and requires termination of prophylaxis or therapy. The eventual emergence of resistance to mefloquine, as with many other antimalarial agents, was inevitable. Mefloquine resistance is established in certain areas of Thailand and may be becoming a growing problem in other regions of the world. In order to preserve the efficacy of mefloquine in non-resistant areas, this useful agent should be used with care and only prescribed for prophylaxis in travellers and treatment in areas of multidrug-resistant plasmodia. Future options to combat mefloquine resistance may include the combination of mefloquine with other antimalarial agents such as qinghaosu derivatives. Thus, with cautious use and possible combination with other agents, mefloquine is likely to remain an important treatment option for falciparum malaria, a widespread parasitic disease for which an increasing number of drugs have proved inadequate.
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Affiliation(s)
- K J Palmer
- Adis International Limited, Auckland, New Zealand
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Hassan Alin M, Björkman A, Landberg-Lindgren A, Ashton M. The effect of artemisinine, its derivatives and mefloquine against chloroquine-resistant strains of Plasmodium falciparum in vitro. Trans R Soc Trop Med Hyg 1992; 86:365-7. [PMID: 1440803 DOI: 10.1016/0035-9203(92)90220-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A 48 h in vitro test of the efficacy of artemisinine, dihydroartemisinine, artemether, mefloquine and chloroquine was carried out against 3 chloroquine-resistant strains of Plasmodium falciparum, strains K1 and T996 from Thailand and LS21 from India. A sigmoid Emax model was fitted to all in vitro inhibition data for each combination of drug and strain. Strains K1 and LS21 were strongly resistant to chloroquine, whereas T996 was partially resistant. Artemisinine, dihydroartemisinine and artemether were active against all strains, with complete growth inhibition at 10(-7) M. Artemether and dihydroartemisinine were both more potent than artemisinine, with 50% effective (EC50) values of 0.57-1.6 nM and 0.36-3.1 nM respectively; the EC50 of artemisinine was 1.5-6.1 nM for the 3 strains. The EC50 values for mefloquine were 46-185 nM. At higher concentrations, strains K1 and LS21 were fully inhibited, while with strain T996 mefloquine did not fully inhibit even at the highest concentration, 1.28 x 10(-6) M. It is concluded that artemisinine and its derivatives were highly effective against the 3 chloroquine-resistant strains, one of which showed borderline resistance to mefloquine.
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Affiliation(s)
- M Hassan Alin
- Department of Biopharmaceutics and Pharmacokinetics, Uppsala University, Sweden
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Bangchang KN, Karbwang J, Back DJ. Mefloquine metabolism by human liver microsomes. Effect of other antimalarial drugs. Biochem Pharmacol 1992; 43:1957-61. [PMID: 1596283 DOI: 10.1016/0006-2952(92)90638-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A number of drugs have been studied for their effect on the metabolism of the antimalarial drug mefloquine by human liver microsomes (N = 6) in vitro. The only metabolite generated was identified as carboxymefloquine by co-chromatography with the authentic standard. Ketoconazole caused marked inhibition of carboxymefloquine formation with IC50 and Ki values of 7.5 and 11.2 microM, respectively. The inhibition of ketoconazole, a known inhibitor of cytochrome P450 isozymes, and the dependency of metabolite formation on the presence of NADPH indicated that cytochrome P450 isozyme(s) catalysed metabolite production. Of compounds actually or likely to be coadministered with mefloquine to malaria patients only primaquine and quinine produced marked inhibition (IC50, 17.5 and 122 microM; Ki, 8.6 and 28.5 microM, respectively). However, despite these in vitro data with primaquine, clinical studies have failed to show any significant effect of single dose primaquine on the pharmacokinetics of mefloquine. With quinine, because peak plasma concentrations are very close to the Ki value, there is likely to be inhibition of mefloquine metabolism in patients receiving both drugs. Sulfadoxine, artemether, artesunate and tetracycline did not significantly inhibit carboxymefloquine formation.
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Affiliation(s)
- K N Bangchang
- Department of Pharmacology and Therapeutics, University of Liverpool, U.K
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Basco LK, Gillotin C, Gimenez F, Farinotti R, Le Bras J. Absence of antimalarial activity or interaction with mefloquine enantiomers in vitro of the main human metabolite of mefloquine. Trans R Soc Trop Med Hyg 1991; 85:208-9. [PMID: 1887471 DOI: 10.1016/0035-9203(91)90022-q] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- L K Basco
- Department of Parasitology, Hôpital Bichat-Claude Bernard, Paris, France
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