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Huynh T. Clinical and Laboratory Aspects of Insulin Autoantibody-Mediated Glycaemic Dysregulation and Hyperinsulinaemic Hypoglycaemia: Insulin Autoimmune Syndrome and Exogenous Insulin Antibody Syndrome. Clin Biochem Rev 2020; 41:93-102. [PMID: 33343044 PMCID: PMC7731936 DOI: 10.33176/aacb-20-00008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Autoimmune glycaemic dysregulation and hyperinsulinaemic hypoglycaemia mediated by insulin autoantibodies is an increasingly recognised but controversial phenomenon described in both exogenous insulin naïve (insulin autoimmune syndrome) and exposed (exogenous insulin antibody syndrome) individuals. There has been a significant proliferation of case reports, clinical studies and reviews in the medical literature in recent years which have collectively highlighted the discrepancy between experts in the field with regard to the nomenclature, definition, proposed pathophysiology, as well as the clinical and biochemical diagnostic criteria associated with the condition. The essential characteristics of the condition are glycaemic dysregulation manifesting as episodes of hyperglycaemia and unpredictable hyperinsulinaemic hypoglycaemia associated with high titres of endogenous antibodies to insulin. Although the hypoglycaemia is often life-threatening and initiation of targeted therapies critical, the diagnosis is often delayed and attributable to various factors including: the fact that existence of the condition is not universally accepted; the need to exclude surreptitious causes of hypoglycaemia; the diverse and often complex nature of the glycaemic dysregulation; and the challenge of diagnostic confirmation. Once confirmed, the available therapeutic options are expansive and the reported responses to these therapies have been variable. This review will focus on our evolving understanding, and the associated diagnostic challenges - both clinical and laboratory - of this complex condition.
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Affiliation(s)
- Tony Huynh
- Department of Endocrinology and Diabetes, Queensland Children’s Hospital, South Brisbane 4101, Australia
- Department of Chemical Pathology, Mater Pathology, South Brisbane 4101, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
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2
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Bonifacio E, Achenbach P. Birth and coming of age of islet autoantibodies. Clin Exp Immunol 2019; 198:294-305. [PMID: 31397889 PMCID: PMC6857083 DOI: 10.1111/cei.13360] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2019] [Indexed: 12/20/2022] Open
Abstract
This review takes the reader through 45 years of islet autoantibody research, from the discovery of islet‐cell antibodies in 1974 to today’s population‐based screening for presymptomatic early‐stage type 1 diabetes. The review emphasizes the current practical value of, and factors to be considered in, the measurement of islet autoantibodies.
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Affiliation(s)
- E Bonifacio
- Technische Universität Dresden, DFG Center for Regenerative Therapies Dresden, Dresden, Germany.,Paul Langerhans Institute Dresden of the Helmholtz Center Munich at University Hospital Carl Gustav Carus and Faculty of Medicine, TU Dresden, Dresden, Germany
| | - P Achenbach
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany.,Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Forschergruppe Diabetes, Munich, Germany
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Affiliation(s)
- T J Wilkin
- Endocrine Section, Southampton General Hospital
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Kanatsuna N, Papadopoulos GK, Moustakas AK, Lenmark Å. Etiopathogenesis of insulin autoimmunity. ANATOMY RESEARCH INTERNATIONAL 2012; 2012:457546. [PMID: 22567309 PMCID: PMC3335545 DOI: 10.1155/2012/457546] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 01/12/2012] [Indexed: 12/12/2022]
Abstract
Autoimmunity against pancreatic islet beta cells is strongly associated with proinsulin, insulin, or both. The insulin autoreactivity is particularly pronounced in children with young age at onset of type 1 diabetes. Possible mechanisms for (pro)insulin autoimmunity may involve beta-cell destruction resulting in proinsulin peptide presentation on HLA-DR-DQ Class II molecules in pancreatic draining lymphnodes. Recent data on proinsulin peptide binding to type 1 diabetes-associated HLA-DQ2 and -DQ8 is reviewed and illustrated by molecular modeling. The importance of the cellular immune reaction involving cytotoxic CD8-positive T cells to kill beta cells through Class I MHC is discussed along with speculations of the possible role of B lymphocytes in presenting the proinsulin autoantigen over and over again through insulin-carrying insulin autoantibodies. In contrast to autoantibodies against other islet autoantigens such as GAD65, IA-2, and ZnT8 transporters, it has not been possible yet to standardize the insulin autoantibody test. As islet autoantibodies predict type 1 diabetes, it is imperative to clarify the mechanisms of insulin autoimmunity.
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Affiliation(s)
- Norio Kanatsuna
- Department of Clinical Sciences, Skåne University Hospital (SUS), Lund University, CRC Ing 72 Building 91:10, 205 02 Malmö, Sweden
| | - George K. Papadopoulos
- Laboratory of Biochemistry and Biophysics, Faculty of Agricultural Technology, Technological Educational Institute of Epirus, 47100 Arta, Greece
| | - Antonis K. Moustakas
- Department of Organic Farming, Technological Educational Institute of Ionian Islands, 27100 Argostoli, Greece
| | - Åke Lenmark
- Department of Clinical Sciences, Skåne University Hospital (SUS), Lund University, CRC Ing 72 Building 91:10, 205 02 Malmö, Sweden
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Bingley PJ, Williams AJK. Validation of Autoantibody Assays in Type 1 Diabetes: Workshop Programme. Autoimmunity 2009; 37:257-60. [PMID: 15518037 DOI: 10.1080/08916930410001710677] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Polly J Bingley
- Department of Clinical Science at North Bristol, University of Bristol, UK.
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Brettschneider S, Morgenthaler NG, Teipel SJ, Fischer-Schulz C, Bürger K, Dodel R, Du Y, Möller HJ, Bergmann A, Hampel H. Decreased serum amyloid beta(1-42) autoantibody levels in Alzheimer's disease, determined by a newly developed immuno-precipitation assay with radiolabeled amyloid beta(1-42) peptide. Biol Psychiatry 2005; 57:813-6. [PMID: 15820240 DOI: 10.1016/j.biopsych.2004.12.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2004] [Revised: 11/12/2004] [Accepted: 12/06/2004] [Indexed: 12/13/2022]
Abstract
BACKGROUND Autoantibodies against amyloid beta (A beta) peptide found in patients with Alzheimer's disease (AD) also occur naturally in the general population independently of the cognitive status. METHODS We compared serum A beta(1-42) autoantibody levels (A beta(1-42)-AL) of 96 AD patients and 30 healthy elderly control subjects (HC), assessing their diagnostic value for AD with a newly developed immunoprecipitation assay with radiolabeled A beta(1-42) peptide. RESULTS We found a highly significant decrease of A beta(1-42)-AL in AD patients (p = .001) independently of age, cognitive status, and apolipoprotein E epsilon4 carrier status. Amyloid beta(1-42) autoantibody levels were correlated with gender in AD, with a higher level occurring in women. When A beta(1-42) autoantibody sensitivity (specificity) was set >80%, specificity (sensitivity) was below 50% to correctly allocate patients and healthy control subjects. CONCLUSIONS Our data indicate a potentially pathophysiologic decrease of serum A beta(1-42) antibodies in AD. Amyloid beta(1-42) antibodies in the serum alone, however, seem not to be useful as a diagnostic marker of AD.
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Yu L, Eisenbarth G, Bonifacio E, Thomas J, Atkinson M, Wasserfall C. The second murine autoantibody workshop: remarkable interlaboratory concordance for radiobinding assays to identify insulin autoantibodies in nonobese diabetic mice. Ann N Y Acad Sci 2004; 1005:1-12. [PMID: 14679035 DOI: 10.1196/annals.1288.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In October 2000, the First Murine Autoantibody Workshop was held as part of an International Workshop on Lessons from Animal Models for Human Type 1 Diabetes. This first workshop identified insulin, but not glutamic acid decarboxylase (GAD) or IA-2, as specific autoantigens of humoral immunity in nonobese diabetic (NOD) mice. The goals of the Second Murine Autoantibody Workshop, part of the Sixth Annual Meeting of the IDS, were to increase the number of participating investigators, attempt standardization of insulin autoantibody (IAA) results across laboratories, identify serologic evidence of humoral immunity to other beta cell antigens, and allow for validation of ELISA assays for autoantibody detection in NOD mice. Sixty-three coded samples (26 pooled NOD sera, 23 pooled C57BL/6 sera, and 14 diluted samples of an anti-insulin monoclonal antibody) were distributed to 12 participating laboratories. This second workshop demonstrated that, for nearly all laboratories, IAA measured by radioimmunoassay (RIA) provided a sensitive and specific assay capable of distinguishing diabetes-prone from nondiabetes-prone mice. Analyses involving the serially diluted anti-insulin monoclonal antibody offered hope that a standard reference unit for reactivity could be established. Surprisingly, two ELISA assays for IAA detection proved remarkably sensitive (i.e., 65% and 92%). However, subsequent absorption studies performed after the workshop (presented at the IDS meeting) brought into question whether ELISA assays for IAA do, in reality, detect anti-insulin immunities and whether assays for GAD and IA-2 autoantibodies distinguish diabetes-prone from nondiabetes-prone mice. In sum, this workshop continued to support the notion that IAA, as determined by RIA, could provide a sensitive and specific marker of anti-beta cell immunity in NOD mice.
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Affiliation(s)
- Liping Yu
- Barbara Davis Center for Childhood Diabetes, University of Colorado Health Sciences Center, Denver, Colorado, USA
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Abstract
Autoantibodies to the hormone insulin arise spontaneously in the insulin autoimmune syndrome and in the prodrome of type I diabetes. Further, administration of insulin to individuals without autoimmune disease routinely results in antibodies that bind autologous hormone. These observations suggest that physiological levels of hormones, such as insulin, are below critical thresholds for signaling tolerance induction, a state termed clonal ignorance. In contrast, studies from our laboratory on the genetic origins and structure of V genes used by insulin antibodies suggest that the anti-insulin repertoire is tightly regulated. We have shown that B cells in mice harboring an insulin antibody transgene are functionally silenced. These findings verify that tolerance is active for small molecules, even when they are present at low concentrations. Despite active tolerance, insulin antibodies are sustained in the repertoire of normal animals by several mechanisms, including activation by TI antigen signals, unique display of conformational epitopes, and the recruitment of B cells previously selected by responses to other antigens. This essay reviews our current understanding of escape pathways for anti-insulin B cells.
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Affiliation(s)
- J W Thomas
- Division of Rheumatology and Clinical Immunology, Vanderbilt University School of Medicine, Nashville, TN 37232-2681, USA.
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Tikhomirov OY, Thomas JW. Alanine scanning mutants of rat proinsulin I show functional diversity of anti-insulin monoclonal antibodies. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2000; 165:3876-82. [PMID: 11034394 DOI: 10.4049/jimmunol.165.7.3876] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In contrast to autoantibodies that are functionally silenced or deleted, IgG Abs that react with autologous insulin routinely follow hormone administration and arise spontaneously in autoimmune (type I) diabetes mellitus. To understand Ab interactions with autologous insulin, rat proinsulin I and 32 alanine substituted analogues were expressed as fusion proteins and used to examine 16 anti-insulin mAb in ELISA. The results identify several amino acid residues that contribute to binding by a large majority (>75%) of mAb, although no single residue is uniformly required for binding by all mAb. Replacements at charged or polar residues on the insulin surface including A4 (Asp), A5 (Gln), A9 (Ser) A12 (Ser), A17 (Gln), A18 (Asn), B13 (Glu), and B21 (Glu) consistently decreased mAb binding. Single alanine substitutions at positions A16 (Leu), A11 (Cys), B8 (Gly), and B15 (Leu) that are predicted to alter the core structure or chain folding vary widely in their impact on Ab binding. mAb that bind insulin preferentially on solid phase (i.e., ELISA) are highly sensitive to replacement of single residues, and substitutions that alter conformation abolish binding. In contrast, high affinity mAb that bind insulin in solution are relatively insensitive to substitutions at single residues, and they maintain binding to all mutants, including those with disrupted conformation. For such high affinity mAb, replacement of long hydrophobic side chains can augment binding, suggesting mAb interactions with insulin include an induced fit. Thus, the ability of insulin to function as a "molten globule" may contribute to the diversity and autoreactivity of the anti-insulin repertoire.
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Affiliation(s)
- O Y Tikhomirov
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
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Seissler J, Amann J, Mauch L, Haubruck H, Wolfahrt S, Bieg S, Richter W, Holl R, Heinze E, Northemann W. Prevalence of autoantibodies to the 65- and 67-kD isoforms of glutamate decarboxylase in insulin-dependent diabetes mellitus. J Clin Invest 1993; 92:1394-9. [PMID: 8376591 PMCID: PMC288282 DOI: 10.1172/jci116714] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
We investigated the presence of autoantibodies to baculovirus-expressed human recombinant 65- and 67-kD isoforms of glutamate decarboxylase (GAD65 and GAD67) in insulin-dependent diabetes mellitus (IDDM). In the immunoprecipitation test using [35S]methionine-labeled GADs antibodies to GAD65 were detected in 13/15 (87%) islet cell antibody (ICA)-positive and in 1/35 (2.9%) ICA-negative first-degree relatives of patients with IDDM, in 6/11 (54.5%) ICA-positive nondiabetic schoolchildren, and in 35/50 (70%) patients with newly diagnosed IDDM. GAD67 antibodies were positive only in five (33%) of the ICA-positive relatives (P < 0.05) and in nine (18%) IDDM patients at onset (P < 0.00001). After onset of IDDM antibodies to GAD65 and GAD67 declined but were still positive in 25 and 9.4% of subjects with long-standing IDDM (> 10 yr). In all study groups antibodies to GAD67 were only detected in GAD65 antibody-positive sera. An immunotrapping enzyme activity assay for GAD65 antibodies was positive in 64/75 (85.3%) of sera that were GAD antibody positive in the immunoprecipitation test (r = 0.870, P < 0.0001). In two (2.7%) sera GAD65 antibodies that block GAD enzyme activity were found. Our data suggest that antibodies to GAD65 but not to GAD67 represent sensitive markers for preclinical and overt IDDM. The immunotrapping assay here described represents a valuable technique for specific and sensitive screening for GAD antibodies.
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Affiliation(s)
- J Seissler
- Department of Internal Medicine, University of Ulm, Germany
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Goday A, Pujol-Borrell R, Fernandez J, Casamitjana R, Rios M, Vilardell E, Gomis R. Effects of a short prednisone regime at clinical onset of type 1 diabetes. Diabetes Res Clin Pract 1993; 20:39-46. [PMID: 8344127 DOI: 10.1016/0168-8227(93)90020-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The effect of corticosteroids on beta cell function and humoral immune response in type 1 diabetes was tested in a 2-month trial conducted on 32 newly diagnosed patients (age 22.8 +/- 1.4 years, mean +/- S.E.M.). Prednisone was administered at immunosuppressive dosage (1 mg.kg-1.day-1) during the initial 10 days and at a maintenance dosage (0.3 mg.kg-1.day-1) for 50 days. Patients (n = 32) were enrolled within 6 weeks after diagnosis and matched in pairs for age, sex, presence of islet cell antibodies (ICA) and glucagon stimulated C-peptide levels. Insulin discontinuation was not contemplated. All the patients who received prednisone became ICA during treatment but in some (4 out of 10) this effect was only transient. Insulin antibodies (IA) were significantly lower in the prednisone group at second and third month (P < 0.05). No patient experienced complete remission but in 10 prednisone and 4 control patients the insulin requirements were below 0.3 IU/kg (P < 0.05). With similar glycemia the fasting C-peptide levels were higher in the treated patients. The profile of the insulin requirements during the follow-up was different in the two groups and at 9 months the prednisone group needed less insulin than the control (P < 0.05). Interestingly, within the prednisone-treated group and after 6 months, the levels of stimulated C-peptide improved significantly among the ICA+ patients while they were steady or declined in ICA- (P < 0.01). The analysis of variance covariance confirmed a positive interaction between ICA and the administration of prednisone on the outcome of beta cell function.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- A Goday
- Endocrinology and Diabetes Unit, Hospital Clinic, University of Barcelona, Spain
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Vardi P, Brik R, Barzilai D. Insulin autoantibodies: reflection of disturbed self-identification and their use in the prediction of type I diabetes. DIABETES/METABOLISM REVIEWS 1991; 7:209-22. [PMID: 1813277 DOI: 10.1002/dmr.5610070402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- P Vardi
- Juvenile Diabetes Unit, Rambam Medical Center, Faculty of Medicine, Haifa, Israel
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Bottazzo GF, Genovese S, Bosi E, Dean BM, Christie MR, Bonifacio E. Novel considerations on the antibody/autoantigen system in type I (insulin-dependent) diabetes mellitus. Ann Med 1991; 23:453-61. [PMID: 1930942 DOI: 10.3109/07853899109148089] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Insulin dependent diabetes (IDDM) has an autoimmune pathogenesis. Included is the presence of antibodies to pancreatic islet cells. The first identified were islet cell antibodies (ICA), detected by indirect immunofluorescence, and which react with all cells within islets. Importantly, the autoantibodies are found several years prior to disease and although a pathogenic role for the autoantibodies is unclear, they have become useful markers of prediabetes. A number of studies of twins discordant for IDDM and of first degree relatives of IDDM patients have established that there is an increased risk for disease in individuals who have ICA, especially when ICA levels are high. This high predictive value of ICA decreases in the general population where the incidence of IDDM is lower than in first degree relatives, and both ICA and the disease risk associated with ICA, appear to be influenced by a genetic susceptibility. This has been sustained in a study of patients with endocrine autoimmunity and ICA (Polyendocrine Study) where the predictive value of very high levels of ICA is less than 50% in patients without a first degree relative with IDDM. Hence, there remain a substantial number of patients with ICA who do not develop disease. From these patients, it was demonstrated that ICA include at least two distinct specificities, one of which is beta cell specific and is not associated with a high risk for IDDM.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- G F Bottazzo
- Department of Immunology, London Hospital Medical College, U.K
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Wilkin TJ. Autoantibodies as mechanisms, markers, and mediators of B-cell disease. DIABETES/METABOLISM REVIEWS 1991; 7:105-20. [PMID: 1794256 DOI: 10.1002/dmr.5610070204] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- T J Wilkin
- Endocrine Section, Southampton General Hospital, U.K
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Andreani D, Di Mario U, Pozzilli P. Prediction, prevention, and early intervention in insulin-dependent diabetes. DIABETES/METABOLISM REVIEWS 1991; 7:61-77. [PMID: 1935536 DOI: 10.1002/dmr.5610070107] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- D Andreani
- Department of Endocrinology, University of Rome La Sapienza, Policlinico Umberto I, Italy
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Affiliation(s)
- C J Greenbaum
- V.A. Medical Center, Department of Medicine, Seattle, WA 98108
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