1
|
McDonald JS, McDonald RJ. Risk of Acute Kidney Injury Following IV Iodinated Contrast Media Exposure: 2023 Update, From the AJR Special Series on Contrast Media. AJR Am J Roentgenol 2023. [PMID: 37791729 DOI: 10.2214/ajr.23.30037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Iodinated contrast material (ICM) has revolutionized the field of diagnostic radiology through improvements in diagnostic performance and expansion in clinical indications for radiographic and CT examinations. Historically, nephrotoxicity was a feared complication of ICM use, thought to be associated with a significant risk of morbidity and mortality. Such fears often precluded use of ICM in imaging evaluations, commonly at the expense of diagnostic performance and timely diagnosis. Over the past 20 years, the nephrotoxic risk of ICM has become a topic of debate, as more recent evidence from higher-quality studies now suggest that many cases of what was considered contrast-induced acute kidney injury (CI-AKI) were likely cases of mistaken causal attribution; most of these cases represented either acute kidney injury (AKI) caused by any of myriad other known factors that can adversely affect renal function and were coincidentally present at the time of contrast media exposure (contrast-associated AKI (CA-AKI)) or a manifestation of the normal variation in renal function that increases with worsening renal function. This review discusses the current state of knowledge on CI-AKI and CA-AKI including the incidence, risk factors, outcomes, and prophylactic strategies in the identification and management of these clinical conditions.
Collapse
Affiliation(s)
- Jennifer S McDonald
- From the Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN
| | - Robert J McDonald
- From the Department of Radiology, College of Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
2
|
Murugan R, Boudreaux-Kelly MY, Kellum JA, Palevsky PM, Weisbord S. Kidney Cell Cycle Arrest and Cardiac Biomarkers and Acute Kidney Injury Following Angiography: The Prevention of Serious Adverse Events Following Angiography (PRESERVE) Study. Kidney Med 2023; 5:100592. [PMID: 36874509 PMCID: PMC9976574 DOI: 10.1016/j.xkme.2022.100592] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Rationale & Objective Recent studies in patients with chronic kidney disease (CKD) indicate that most cases of contrast-associated acute kidney injury (CA-AKI) are mild and are not associated with elevation in kidney injury biomarkers. We used highly sensitive kidney cell cycle arrest and cardiac biomarkers to assess the risk of CA-AKI and major adverse kidney events in patients with CKD undergoing angiography. Study Design A retrospective study. Setting & Participants A subset of 922 participants from the Prevention of Serious Adverse Events following Angiography trial. Predictors Pre- and postangiography urinary tissue inhibitor of matrix metalloproteinase [TIMP]-2 and insulin growth factor binding protein [IGFBP]-7 were measured in 742 subjects, and plasma β natriuretic peptide (BNP) and high-sensitivity C-reactive protein (hs-CRP), and serum troponin (Tn) in 854 participants using samples obtained 1-2 hours before and 2-4 hours after angiography. Outcomes CA-AKI and major adverse kidney events. Analytical Approach We fitted logistic regression to examine association and area under the receiver operating characteristic curves for risk prediction. Results There were no differences in postangiography urinary [TIMP-2]•[IGFBP7], plasma BNP, serum Tn, and hs-CRP concentrations among patients with and without CA-AKI and major adverse kidney events. However, higher pre- and postangiography median plasma BNP (pre: 200.0 vs 71.5, pg/mL, P = 0.05; post: 165.0 vs 81 pg/mL, P = 0.02); serum Tn (pre: 0.03 vs 0.01, ng/mL, P < 0.001; post, 0.04 vs 0.02, ng/mL, P = 0.01); and hs-CRP (pre: 9.55 vs 3.40 mg/L, P = 0.01; post: 9.90 vs 3.20 mg/L, P = 0.002) concentrations were associated with major adverse kidney events, although their discriminatory capacity was only modest (area under the receiver operating characteristic curves <0.7). Limitations Most participants were men. Conclusions Most mild CA-AKI cases are not associated with urinary cell cycle arrest biomarker elevation. Significant elevation in preangiography cardiac biomarkers may reflect patients with more significant cardiovascular disease that may predispose to poor long-term outcomes independent of CA-AKI status.
Collapse
Affiliation(s)
- Raghavan Murugan
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - John A. Kellum
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Paul M. Palevsky
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Steven Weisbord
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Biomarker Effectiveness Analysis in Contrast Nephropathy (BEACON) Study Investigators
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| |
Collapse
|
3
|
Ramírez-Guerrero G, Lucero C, Villagrán-Cortés F, Hauway E, Torres-Cifuentes V, Baghetti-Hernández R, Vera-Calzaretta A, Ronco C, Garay O. Acute kidney injury in neurocritical patients: a retrospective cohort study. Int Urol Nephrol 2023:10.1007/s11255-023-03502-7. [PMID: 36800139 DOI: 10.1007/s11255-023-03502-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND /OBJECTIVE Acute kidney injury (AKI) is a significant complication in critical care units (CCU). Non-neurological complications such as AKI are an independent predictor of poor clinical outcomes, with an increase in morbidity and mortality, financial costs, and worse functional recovery. This work aims to estimate the incidence of AKI and evaluate the risk factors and complications of AKI in neurocritical patients hospitalized in the CCU. METHODS A retrospective cohort study was conducted. Patients admitted to the neurocritical care unit between 2016 and 2018 with a stay longer than 48 h were retrospectively analyzed in regard to the incidence, risk factors, and outcomes of AKI. RESULTS The study population comprised 213 neurocritical patients. The incidence of AKI was 23.5%, with 58% KDIGO 1 and 2% requiring renal replacement therapy. AKI was an independent predictor of prolonged use of mechanical ventilation, cerebral edema, and mortality. Cerebral edema [OR 4.40 (95% CI 1.98-9.75) p < 0.001] and a change in chloride levels greater than 4 mmol/L at 48 h (OR 2.44 (95% CI 1.10-5.37) p = 0.027) were risk factors for developing AKI in the first 14 days of hospitalization. CONCLUSION There is a high incidence of AKI in neurocritical patients; it is associated with worse clinical outcomes regardless of the CCU admission etiology or AKI severity.
Collapse
Affiliation(s)
- Gonzalo Ramírez-Guerrero
- Critical Patients Unit, Carlos Van Buren Hospital, San Ignacio #725, Valparaiso, Chile. .,Dialysis and Renal Transplantation Unit, Carlos Van Buren Hospital, Valparaiso, Chile. .,Departamento de Medicina Interna, Facultad de Medicina, Universidad de Valparaíso, Valparaiso, Chile.
| | - Cristian Lucero
- Critical Patients Unit, Carlos Van Buren Hospital, San Ignacio #725, Valparaiso, Chile.,Departamento de Medicina Interna, Facultad de Medicina, Universidad de Valparaíso, Valparaiso, Chile
| | - Francisco Villagrán-Cortés
- Critical Patients Unit, Carlos Van Buren Hospital, San Ignacio #725, Valparaiso, Chile.,Dialysis and Renal Transplantation Unit, Carlos Van Buren Hospital, Valparaiso, Chile.,Departamento de Medicina Interna, Facultad de Medicina, Universidad de Valparaíso, Valparaiso, Chile
| | - Ernesto Hauway
- Critical Patients Unit, Carlos Van Buren Hospital, San Ignacio #725, Valparaiso, Chile.,Departamento de Medicina Interna, Facultad de Medicina, Universidad de Valparaíso, Valparaiso, Chile
| | - Vicente Torres-Cifuentes
- Critical Patients Unit, Carlos Van Buren Hospital, San Ignacio #725, Valparaiso, Chile.,Dialysis and Renal Transplantation Unit, Carlos Van Buren Hospital, Valparaiso, Chile.,Departamento de Medicina Interna, Facultad de Medicina, Universidad de Valparaíso, Valparaiso, Chile.,Nephrology, Dialysis and Transplantation Unit, Las Higueras Hospital, Talcahuano, Chile
| | - Romyna Baghetti-Hernández
- Critical Patients Unit, Carlos Van Buren Hospital, San Ignacio #725, Valparaiso, Chile.,Dialysis and Renal Transplantation Unit, Carlos Van Buren Hospital, Valparaiso, Chile.,Departamento de Medicina Interna, Facultad de Medicina, Universidad de Valparaíso, Valparaiso, Chile.,Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Aldo Vera-Calzaretta
- Departamento de Kinesiología, Facultad de Ciencias de la Salud, Universidad de Atacama, Copiapó, Chile
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy.,International Renal Research Institute of Vicenza, Vicenza, Italy
| | - Osvaldo Garay
- Critical Patients Unit, Carlos Van Buren Hospital, San Ignacio #725, Valparaiso, Chile.,Dialysis and Renal Transplantation Unit, Carlos Van Buren Hospital, Valparaiso, Chile.,Departamento de Medicina Interna, Facultad de Medicina, Universidad de Valparaíso, Valparaiso, Chile
| |
Collapse
|
4
|
Abstract
Intravenous contrast media (CM) is often used in clinical practice to enhance CT scan imaging. For many years, contrast-induced nephropathy (CIN) was thought to be a common occurrence and to result in dire consequences. When treating patients with abnormal renal function, it is not unusual that clinicians postpone, cancel, or replace contrast-enhanced imaging with other, perhaps less informative tests. New studies however have challenged this paradigm and the true risk attributable to intravenous CM for the occurrence of CIN has become debatable. In this article, we review the latest relevant medical literature and aim to provide an evidence-based answer to questions surrounding the risk, outcomes, and potential mitigation strategies of CIN after intravenous CM administration.
Collapse
Affiliation(s)
- Jean-Sebastien Rachoin
- Department of Critical Care Medicine, Cooper University Health Care, Camden, NJ, USA.,Division of Hospital Medicine, Cooper University Health Care, Camden, NJ, USA
| | - Yanika Wolfe
- Department of Critical Care Medicine, Cooper University Health Care, Camden, NJ, USA
| | - Sharad Patel
- Department of Critical Care Medicine, Cooper University Health Care, Camden, NJ, USA
| | - Elizabeth Cerceo
- Division of Hospital Medicine, Cooper University Health Care, Camden, NJ, USA
| |
Collapse
|
5
|
Pickkers P, Darmon M, Hoste E, Joannidis M, Legrand M, Ostermann M, Prowle JR, Schneider A, Schetz M. Acute kidney injury in the critically ill: an updated review on pathophysiology and management. Intensive Care Med 2021; 47:835-50. [PMID: 34213593 DOI: 10.1007/s00134-021-06454-7] [Citation(s) in RCA: 135] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/04/2021] [Indexed: 01/10/2023]
Abstract
Acute kidney injury (AKI) is now recognized as a heterogeneous syndrome that not only affects acute morbidity and mortality, but also a patient’s long-term prognosis. In this narrative review, an update on various aspects of AKI in critically ill patients will be provided. Focus will be on prediction and early detection of AKI (e.g., the role of biomarkers to identify high-risk patients and the use of machine learning to predict AKI), aspects of pathophysiology and progress in the recognition of different phenotypes of AKI, as well as an update on nephrotoxicity and organ cross-talk. In addition, prevention of AKI (focusing on fluid management, kidney perfusion pressure, and the choice of vasopressor) and supportive treatment of AKI is discussed. Finally, post-AKI risk of long-term sequelae including incident or progression of chronic kidney disease, cardiovascular events and mortality, will be addressed.
Collapse
|
6
|
Lakhal K, Robert-Edan V, Ehrmann S. In the Name of Contrast-Induced Acute Kidney Injury…. Chest 2021; 157:751-752. [PMID: 32252919 DOI: 10.1016/j.chest.2019.12.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/19/2019] [Accepted: 12/22/2019] [Indexed: 02/08/2023] Open
Affiliation(s)
- Karim Lakhal
- Service d'Anesthésie-Réanimation, hôpital Laënnec, Centre Hospitalier Universitaire de Nantes, Nantes, France.
| | - Vincent Robert-Edan
- Service d'Anesthésie-Réanimation, hôpital Laënnec, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, INSERM CIC 1415, CRICS-TriggerSep network, CHRU Tours, Tours, France; Centre d'étude des pathologies respiratoires INSERM U1100), Université de Tours, Tours, France
| |
Collapse
|
7
|
Lakhal K, Ehrmann S, Robert-Edan V. Iodinated contrast medium: Is there a re(n)al problem? A clinical vignette-based review. Crit Care 2020; 24:641. [PMID: 33168006 PMCID: PMC7653744 DOI: 10.1186/s13054-020-03365-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022] Open
Abstract
As we were taught, for decades, that iodinated contrast-induced acute kidney injury should be dreaded, considerable efforts were made to find out effective measures in mitigating the renal risk of iodinated contrast media. Imaging procedures were frequently either downgraded (unenhanced imaging) or deferred as clinicians felt that the renal risk pertaining to contrast administration outweighed the benefits of an enhanced imaging. However, could we have missed the point? Among the abundant literature about iodinated contrast-associated acute kidney injury, recent meaningful advances may help sort out facts from false beliefs. Hence, there is increasing evidence that the nephrotoxicity directly attributable to modern iodinated CM has been exaggerated. Failure to demonstrate a clear benefit from most of the tested prophylactic measures might be an indirect consequence. However, the toxic potential of iodinated contrast media is well established experimentally and should not be overlooked completely when making clinical decisions. We herein review these advances in disease and pathophysiologic understanding and the associated clinical crossroads through a typical case vignette in the critical care setting.
Collapse
Affiliation(s)
- Karim Lakhal
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Boulevard Jacques-Monod, Saint-Herblain, 44093, Nantes, France.
| | - Stephan Ehrmann
- Médecine Intensive Réanimation, CIC INSERM 1415, CRICS-TriggerSep Network, CHRU Tours, Tours France and Centre d'étude des Pathologies Respiratoires INSERM U1100, Université de Tours, Tours, France
| | - Vincent Robert-Edan
- Service d'Anesthésie-Réanimation, Hôpital Laënnec, Centre Hospitalier Universitaire, Boulevard Jacques-Monod, Saint-Herblain, 44093, Nantes, France
| |
Collapse
|
8
|
Panagiotou A, Trendelenburg M, Heijnen IAFM, Moser S, Bonati LH, Breidthardt T, Fahrni G, Kaiser C, Jeger R, Osthoff M. A Randomized Trial of Recombinant Human C1-Esterase-Inhibitor in the Prevention of Contrast-Induced Kidney Injury. JACC Cardiovasc Interv 2020; 13:833-842. [PMID: 32171721 DOI: 10.1016/j.jcin.2019.11.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/22/2019] [Accepted: 11/12/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVES This study sought to determine the efficacy profile and safety of recombinant human C1 esterase inhibitor (rhC1INH) in the prevention of contrast-associated acute kidney injury after elective coronary angiography. BACKGROUND Contrast-associated acute kidney injury is caused by tubular cytotoxicity and ischemia/reperfusion injury. rhC1INH is effective in reducing renal ischemia/reperfusion injury in experimental models. METHODS In this placebo-controlled, double-blind, single-center trial 77 patients with chronic kidney disease were randomized to receive 50 IU/kg rhC1INH before and 4 h after elective coronary angiography or placebo. The primary outcome was the peak change of urinary neutrophil gelatinase-associated lipocalin within 48 h, a surrogate marker of kidney injury. RESULTS Median peak change of urinary neutrophil gelatinase-associated lipocalin was lower in the rhC1INH group (4.7 ng/ml vs. 22.5 ng/ml; p = 0.038) in the per-protocol population but not in the modified intention-to-treat analysis, and in patients with percutaneous coronary interventions (median, 1.8 ng/ml vs. 26.2 ng/ml; p = 0.039 corresponding to a median proportion peak change of 11% vs. 205%; p = 0.002). The incidence of a cystatin C increase ≥10% within 24 h was lower in the rhC1INH group (16% vs. 33%; p = 0.045), whereas the frequency of contrast-associated acute kidney injury was comparable. Adverse events during a 3-month follow-up were similarly distributed. CONCLUSIONS Administration of rhC1INH before coronary angiography may attenuate renal injury as reflected by urinary neutrophil gelatinase-associated lipocalin and cystatin C. The safety profile of rhC1INH was favorable in a patient population with multiple comorbidities. (Recombinant Human C1 Esterase Inhibitor in the Prevention of Contrast-induced Nephropathy in High-risk Subjects [PROTECT]; NCT02869347).
Collapse
Affiliation(s)
- Anneza Panagiotou
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Marten Trendelenburg
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland; Department of Clinical Research and Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Ingmar A F M Heijnen
- Division of Medical Immunology, Laboratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Stephan Moser
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Leo H Bonati
- Division of Neurology and Stroke Center, Department of Clinical Research, University Hospital Basel and University of Basel, Basel Switzerland
| | - Tobias Breidthardt
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Gregor Fahrni
- Department of Cardiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Christoph Kaiser
- Department of Cardiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Raban Jeger
- Department of Cardiology, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Michael Osthoff
- Division of Internal Medicine, University Hospital Basel, Basel, Switzerland; Department of Clinical Research and Department of Biomedicine, University of Basel, Basel, Switzerland.
| |
Collapse
|
9
|
Bencivenga MA, Bowling PA, Fiallos JO, Gehling AM, Stafford RG, Long SY, Fetterer DP, Bocan TM, Hofer CC. Investigation of Various Intramuscular Volumes Delivered to the Semimembranosus Muscle of Cavia porcellus. J Am Assoc Lab Anim Sci 2020; 59:310-321. [PMID: 32156326 DOI: 10.30802/aalas-jaalas-19-000101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The goal of this study is to provide quantitative data on the ideal volume for intramuscular (IM) injections into the semimembranosus muscle of guinea pigs weighing between 320 to 410 grams. This evaluation comprised 2 experiments. The first was to assess dispersion leakage of intramuscularly injected iohexol, a radiocontrast agent commonly used in Computed Tomography (CT), based on analysis of in vivo imaging. The second used varying volumes of intramuscularly injected sodium chloride (0.9% NaCl) to assess pain and pathology associated with IM injection. Hartley guinea pigs were injected IM with varying volumes of either iohexol or sodium chloride (150, 300, 500, 1000 and 1500 μL). In the iohexol experiment, results suggest IM volumes of 150 and 300 μL remain within the target muscle. In the experiment using sodium chloride, pain and pathology did not increase as IM volume increased. The pathology noted was related to needle tract through the musculature rather than the volume size of the injectate. The results did not reveal a correlation between volume of IM 0.9% NaCl and pain levels. We conclude that volume size correlates more with precision and accuracy of delivery into the intended muscle tissue. Regarding tissue distribution, our findings also suggest that the optimal capacity for IM injection in the semimembranosus muscle should be less than 500 μL.
Collapse
Affiliation(s)
- Michael A Bencivenga
- Comparative Medicine Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland;,
| | - Philip A Bowling
- Comparative Medicine Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland
| | - Jimmy O Fiallos
- Comparative Medicine Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland
| | - Alicia M Gehling
- Comparative Medicine Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland
| | - Robert G Stafford
- In Vivo Imaging, Translational Sciences, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland
| | - Simon Y Long
- Pathology Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland
| | - David P Fetterer
- Statistics Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland
| | - Thomas M Bocan
- In Vivo Imaging, Translational Sciences, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland
| | - Christian C Hofer
- Comparative Medicine Division, United States Army Medical Research Institute of Infectious Diseases, Frederick, Maryland
| |
Collapse
|