Streptokinase reduces Streptococcus dysgalactiae subsp. equisimilis biofilm formation.


Journal

BMC microbiology
ISSN: 1471-2180
Titre abrégé: BMC Microbiol
Pays: England
ID NLM: 100966981

Informations de publication

Date de publication:
30 Sep 2024
Historique:
received: 19 09 2023
accepted: 23 09 2024
medline: 1 10 2024
pubmed: 1 10 2024
entrez: 30 9 2024
Statut: epublish

Résumé

Streptococcus dysgalactiae subspecies equisimilis (SDSE) is increasingly recognized as an emerging cause of invasive diseases including necrotizing soft tissue infections (NSTIs). In contrast to the closely related Streptococcus pyogenes, SDSE infections mainly affect older and comorbid patients. Biofilm formation has been demonstrated in soft tissue biopsies of S. pyogenes NSTI cases. Here, we show that bacterial aggregations indicative of biofilms are also present in SDSE NSTI. Although streptokinase (Ska) activity and biofilm formation did not correlate in a diverse set of clinical SDSE isolates, addition of exogenous Ska at an early time point prevented biofilm formation for selected strains. Deletion of ska in SDSE S118 strain resulted in increased biofilm forming capacity. Ska-deficient mutant strain was characterized by a higher metabolic activity and consequent metabolome profiling of biofilms identified higher deposition of a wide range of metabolites as compared to the wild-type. Our results argue that Ska suppresses biofilm formation in SDSE independent of its original plasminogen converting activity. However, the impact of biofilms and its consequences for patient outcomes in streptococcal NSTIs remain to be elucidated.

Sections du résumé

BACKGROUND BACKGROUND
Streptococcus dysgalactiae subspecies equisimilis (SDSE) is increasingly recognized as an emerging cause of invasive diseases including necrotizing soft tissue infections (NSTIs). In contrast to the closely related Streptococcus pyogenes, SDSE infections mainly affect older and comorbid patients. Biofilm formation has been demonstrated in soft tissue biopsies of S. pyogenes NSTI cases.
RESULTS RESULTS
Here, we show that bacterial aggregations indicative of biofilms are also present in SDSE NSTI. Although streptokinase (Ska) activity and biofilm formation did not correlate in a diverse set of clinical SDSE isolates, addition of exogenous Ska at an early time point prevented biofilm formation for selected strains. Deletion of ska in SDSE S118 strain resulted in increased biofilm forming capacity. Ska-deficient mutant strain was characterized by a higher metabolic activity and consequent metabolome profiling of biofilms identified higher deposition of a wide range of metabolites as compared to the wild-type.
CONCLUSIONS CONCLUSIONS
Our results argue that Ska suppresses biofilm formation in SDSE independent of its original plasminogen converting activity. However, the impact of biofilms and its consequences for patient outcomes in streptococcal NSTIs remain to be elucidated.

Identifiants

pubmed: 39350011
doi: 10.1186/s12866-024-03540-w
pii: 10.1186/s12866-024-03540-w
doi:

Substances chimiques

Streptokinase EC 3.4.-
Bacterial Proteins 0

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Pagination

378

Informations de copyright

© 2024. The Author(s).

Références

Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clin Infect Dis. 2007;44(5):705–10.
pubmed: 17278065 doi: 10.1086/511638
Madsen MB, Skrede S, Perner A, Arnell P, Nekludov M, Bruun T, et al. Patient’s characteristics and outcomes in necrotising soft-tissue infections: results from a scandinavian, multicentre, prospective cohort study. Intensive Care Med. 2019;45(9):1241–51.
pubmed: 31440795 doi: 10.1007/s00134-019-05730-x
Stevens DL, Bryant AE. Necrotizing soft-tissue infections. N Engl J Med. 2017;377(23):2253–65.
pubmed: 29211672 doi: 10.1056/NEJMra1600673
Skrede S, Bruun T, Rath E, Oppegaard O. Microbiological etiology of necrotizing soft tissue infections. Adv Exp Med Biol. 2020;1294:53–71.
pubmed: 33079363 doi: 10.1007/978-3-030-57616-5_5
Bruun T, Kittang BR, De Hoog BJ, Aardal S, Flaatten HK, Langeland N, et al. Necrotizing soft tissue infections caused by Streptococcus pyogenes and Streptococcus dysgalactiae subsp. equisimilis of groups C and G in western Norway. Clin Microbiol Infect. 2013;19(12):E545–50.
pubmed: 23795951 doi: 10.1111/1469-0691.12276
Kittang BR, Bruun T, Langeland N, Mylvaganam H, Glambek M, Skrede S. Invasive group A, C and G streptococcal disease in western Norway: virulence gene profiles, clinical features and outcomes. Clin Microbiol Infection: Official Publication Eur Soc Clin Microbiol Infect Dis. 2011;17(3):358–64.
doi: 10.1111/j.1469-0691.2010.03253.x
Kittang BR, Langeland N, Mylvaganam H. Distribution ofemmtypes and subtypes among noninvasive group A, C and G streptococcal isolates in western Norway. APMIS. 2008;116(6):457–64.
pubmed: 18754319 doi: 10.1111/j.1600-0463.2008.00976.x
Bert F, Lambert-Zechovsky N. Analysis of a case of recurrent bacteraemia due to group a Streptococcus equisimilis by pulsed-field gel electrophoresis. Infection. 1997;25(4):250–1.
pubmed: 9266266 doi: 10.1007/BF01713156
Brandt CM, Haase G, Schnitzler N, Zbinden R, Lutticken R. Characterization of blood culture isolates of Streptococcus dysgalactiae subsp. equisimilis possessing Lancefield’s group A antigen. J Clin Microbiol. 1999;37(12):4194–7.
pubmed: 10565964 doi: 10.1128/JCM.37.12.4194-4197.1999 pmcid: 85928
Chochua S, Rivers J, Mathis S, Li Z, Velusamy S, McGee L, et al. Emergent Invasive Group A Streptococcus dysgalactiae subsp. equisimilis, United States, 2015–2018. Emerg Infect Dis. 2019;25(8):1543–7.
pubmed: 31158071 doi: 10.3201/eid2508.181758 pmcid: 6649341
Ishihara H, Ogura K, Miyoshi-Akiyama T, Nakamura M, Kaya H, Okamoto S. Prevalence and genomic characterization of Group A Streptococcus dysgalactiae subsp. equisimilis isolated from patients with invasive infections in Toyama prefecture, Japan. Microbiol Immunol. 2020;64(2):113–22.
pubmed: 31750556 doi: 10.1111/1348-0421.12760
Katsukawa C, Tamaru A, Morikawa Y. [Streptococcus dysgalactiae subsp. equisimilis possessing Lancefield’s group A antigen]. Kansenshogaku Zasshi. 2002;76(3):155–60.
pubmed: 11974882 doi: 10.11150/kansenshogakuzasshi1970.76.155
Tanaka D, Isobe J, Watahiki M, Nagai Y, Katsukawa C, Kawahara R, et al. Genetic features of clinical isolates of Streptococcus dysgalactiae subsp. equisimilis possessing Lancefield’s group A antigen. J Clin Microbiol. 2008;46(4):1526–9.
pubmed: 18305132 doi: 10.1128/JCM.02188-07 pmcid: 2292899
Shimomura Y, Okumura K, Murayama SY, Yagi J, Ubukata K, Kirikae T, et al. Complete genome sequencing and analysis of a Lancefield group G Streptococcus dysgalactiae subsp. equisimilis strain causing streptococcal toxic shock syndrome (STSS). BMC Genomics. 2011;12:17.
pubmed: 21223537 doi: 10.1186/1471-2164-12-17 pmcid: 3027156
Walker MJ, McArthur JD, McKay F, Ranson M. Is plasminogen deployed as a Streptococcus pyogenes virulence factor? Trends Microbiol. 2005;13(7):308–13.
pubmed: 15936195 doi: 10.1016/j.tim.2005.05.006
Boxrud PD, Verhamme IM, Bock PE. Resolution of conformational activation in the kinetic mechanism of Plasminogen activation by Streptokinase*. J Biol Chem. 2004;279(35):36633–41.
pubmed: 15215240 doi: 10.1074/jbc.M405264200
Boxrud PD, Fay WP, Bock PE. Streptokinase binds to Human Plasmin with High Affinity, perturbs the plasmin active site, and induces expression of a substrate Recognition Exosite for Plasminogen*. J Biol Chem. 2000;275(19):14579–89.
pubmed: 10799544 doi: 10.1074/jbc.275.19.14579
Banerjee A, Chisti Y, Banerjee UC. Streptokinase—a clinically useful thrombolytic agent. Biotechnol Adv. 2004;22(4):287–307.
pubmed: 14697452 doi: 10.1016/j.biotechadv.2003.09.004
Nitzsche R, Köhler J, Kreikemeyer B, Oehmcke-Hecht S. Streptococcus pyogenes escapes killing from Extracellular histones through Plasminogen binding and activation by Streptokinase. J Innate Immun. 2016;8(6):589–600.
pubmed: 27533300 doi: 10.1159/000448039 pmcid: 6738899
Hollands A, Gonzalez D, Leire E, Donald C, Gallo RL, Sanderson-Smith M, et al. A bacterial Pathogen co-opts host plasmin to resist killing by Cathelicidin Antimicrobial Peptides*. J Biol Chem. 2012;287(49):40891–7.
pubmed: 23038245 doi: 10.1074/jbc.M112.404582 pmcid: 3510793
Siemens N, Kittang BR, Chakrakodi B, Oppegaard O, Johansson L, Bruun T, et al. Increased cytotoxicity and streptolysin O activity in group G streptococcal strains causing invasive tissue infections. Sci Rep. 2015;5(1):16945.
pubmed: 26601609 doi: 10.1038/srep16945 pmcid: 4658506
Siemens N, Chakrakodi B, Shambat SM, Morgan M, Bergsten H, Hyldegaard O et al. Biofilm in group a streptococcal necrotizing soft tissue infections. JCI Insight. 2016;1(10).
Skutlaberg DH, Wiker HG, Mylvaganam H, Group IS, Norrby-Teglund A, Skrede S. Consistent Biofilm formation by Streptococcus pyogenes emm 1 isolated from patients with necrotizing soft tissue infections. Front Microbiol. 2022;13:822243.
pubmed: 35250938 doi: 10.3389/fmicb.2022.822243 pmcid: 8895234
Bergsten H, Medina LMP, Morgan M, Moll K, Skutlaberg DH, Skrede S, et al. Adjunctive rifampicin increases antibiotic efficacy in Group A Streptococcal tissue infection models. Antimicrob Agents Chemother. 2021;65(11). https://doi.org/10.1128/aac.00658-21 .
Redanz S, Standar K, Podbielski A, Kreikemeyer B. Heterologous expression of sahH reveals that biofilm formation is Autoinducer-2-independent in Streptococcus sanguinis but is Associated with an Intact activated methionine cycle. J Biol Chem. 2012;287(43):36111–22.
pubmed: 22942290 doi: 10.1074/jbc.M112.379230 pmcid: 3476279
Redanz S, Treerat P, Mu R, Redanz U, Zou Z, Koley D, et al. Pyruvate secretion by oral Streptococci modulates hydrogen peroxide dependent antagonism. ISME J. 2020;14(5):1074–88.
pubmed: 31988475 doi: 10.1038/s41396-020-0592-8 pmcid: 7174352
Sambrook JFE, Maniatis T. Molecular cloning: a laboratory manual. 2nd ed. Cold Spring Harbor, NY: Cold Spring Harbor Laboratory; 1989.
Bolger AM, Lohse M, Usadel B. Trimmomatic: a flexible trimmer for Illumina sequence data. Bioinformatics. 2014;30(15):2114–20.
pubmed: 24695404 doi: 10.1093/bioinformatics/btu170 pmcid: 4103590
Bankevich A, Nurk S, Fau - Antipov D, Antipov D, Fau - Gurevich AA, Gurevich Aa Fau - Dvorkin M, Dvorkin M. Fau - Kulikov AS, Kulikov As Fau - Lesin VM, SPAdes: a new genome assembly algorithm and its applications to single-cell sequencing. (1557–8666 (Electronic)).
Aziz RK, Bartels D, Best AA, DeJongh M, Disz T, Edwards RA, et al. The RAST server: Rapid annotations using Subsystems Technology. BMC Genomics. 2008;9(1):75.
pubmed: 18261238 doi: 10.1186/1471-2164-9-75 pmcid: 2265698
Letunic I, Bork P. Interactive tree of life (iTOL) v5: an online tool for phylogenetic tree display and annotation. Nucleic Acids Res. 2021;49(W1):W293–6.
pubmed: 33885785 doi: 10.1093/nar/gkab301 pmcid: 8265157
Falugi F, Zingaretti C, Pinto V, Mariani M, Amodeo L, Manetti AGO, et al. Sequence Variation in Group A Streptococcus Pili and Association of Pilus Backbone Types with Lancefield T Serotypes. J Infect Dis. 2008;198(12):1834–41.
pubmed: 18928376 doi: 10.1086/593176
Kulisek ES, Holm SE, Johnston KH. A chromogenic assay for the detection of plasmin generated by plasminogen activator immobilized on nitrocellulose using a para-nitroanilide synthetic peptide substrate. Anal Biochem. 1989;177(1):78–84.
pubmed: 2525884 doi: 10.1016/0003-2697(89)90017-1
Shumba P, Sura T, Moll K, Chakrakodi B, Tolken LA, Hossmann J, et al. Neutrophil-derived reactive agents induce a transient SpeB negative phenotype in Streptococcus pyogenes. J Biomed Sci. 2023;30(1):52.
pubmed: 37430325 doi: 10.1186/s12929-023-00947-x pmcid: 10331992
Troitzsch A, Loi VV, Methling K, Zuhlke D, Lalk M, Riedel K et al. Carbon source-dependent reprogramming of anaerobic metabolism in Staphylococcus aureus. J Bacteriol. 2021;203(8).
Wider G, Dreier L. Measuring protein concentrations by NMR spectroscopy. J Am Chem Soc. 2006;128(8):2571–6.
pubmed: 16492040 doi: 10.1021/ja055336t
Leonard A, Gierok P, Methling K, Gomez-Mejia A, Hammerschmidt S, Lalk M. Metabolic inventory of Streptococcus pneumoniae growing in a chemical defined environment. Int J Med Microbiol. 2018;308(6):705–12.
pubmed: 29398251 doi: 10.1016/j.ijmm.2018.01.001
Surabhi S, Jachmann LH, Lalk M, Hammerschmidt S, Methling K, Siemens N. Bronchial epithelial cells accumulate citrate intracellularly in response to Pneumococcal Hydrogen Peroxide. ACS Infect Dis. 2021;7(11):2971–8.
pubmed: 34623132 doi: 10.1021/acsinfecdis.1c00372
Cook SM, Skora A, Gillen CM, Walker MJ, McArthur JD. Streptokinase variants from Streptococcus pyogenes isolates display altered plasminogen activation characteristics – implications for pathogenesis. Mol Microbiol. 2012;86(5):1052–62.
pubmed: 23106864 doi: 10.1111/mmi.12037
Zhang Y, Liang Z, Hsueh H-T, Ploplis VA, Castellino FJ. Characterization of Streptokinases from Group A Streptococci reveals a strong functional relationship that supports the Coinheritance of Plasminogen-binding M protein and cluster 2b Streptokinase*. J Biol Chem. 2012;287(50):42093–103.
pubmed: 23086939 doi: 10.1074/jbc.M112.417808 pmcid: 3516755
Hogan S, O’Gara JP, O’Neill E. Novel treatment of Staphylococcus aureus device-related infections using fibrinolytic agents. Antimicrob Agents Chemother. 2018;62(2).
Jorgensen NP, Zobek N, Dreier C, Haaber J, Ingmer H, Larsen OH et al. Streptokinase Treatment reverses Biofilm-Associated Antibiotic Resistance in Staphylococcus aureus. Microorganisms. 2016;4(3).
Walker MJ, Hollands A, Sanderson-Smith ML, Cole JN, Kirk JK, Henningham A, et al. DNase Sda1 provides selection pressure for a switch to invasive group a streptococcal infection. Nat Med. 2007;13(8):981–5.
pubmed: 17632528 doi: 10.1038/nm1612
Davidson FM. The activation of plasminogen by staphylokinase: comparison with Streptokinase. Biochem J. 1960;76(1):56–61.
pubmed: 13814337 doi: 10.1042/bj0760056 pmcid: 1204599
Jørgensen NP, Zobek N, Dreier C, Haaber J, Ingmer H, Larsen OH, et al. Streptokinase Treatment reverses Biofilm-Associated Antibiotic Resistance in Staphylococcus aureus. Microorganisms. 2016;4(3):36.
pubmed: 27681928 doi: 10.3390/microorganisms4030036 pmcid: 5039596
Kwiecinski J, Peetermans M, Liesenborghs L, Na M, Björnsdottir H, Zhu X, et al. Staphylokinase Control of Staphylococcus aureus Biofilm formation and detachment through host plasminogen activation. J Infect Dis. 2015;213(1):139–48.
pubmed: 26136471 doi: 10.1093/infdis/jiv360
Kreikemeyer B, Nakata M, Köller T, Hildisch H, Kourakos V, Standar K, et al. The < i > Streptococcus pyogenes Serotype M49 Nra-Ralp3 Transcriptional Regulatory Network and its control of virulence factor expression from the Novel < i > eno ralp3 epf sagA pathogenicity region. Infect Immun. 2007;75(12):5698–710.
pubmed: 17893125 doi: 10.1128/IAI.00175-07 pmcid: 2168351
Bessen DE, Lizano S. Tissue tropisms in group a streptococcal infections. Future Microbiol. 2010;5(4):623–38.
pubmed: 20353302 doi: 10.2217/fmb.10.28
Kimura KR, Nakata M, Sumitomo T, Kreikemeyer B, Podbielski A, Terao Y, et al. Involvement of T6 pili in Biofilm formation by serotype M6 Streptococcus pyogenes. J Bacteriol. 2012;194(4):804–12.
pubmed: 22155780 doi: 10.1128/JB.06283-11 pmcid: 3272948
Siemens N, Fiedler T, Normann J, Klein J, Münch R, Patenge N, et al. Effects of the ERES Pathogenicity Region Regulator Ralp3 on Streptococcus pyogenes serotype M49 virulence factor expression. J Bacteriol. 2012;194(14):3618–26.
pubmed: 22544273 doi: 10.1128/JB.00227-12 pmcid: 3393516
Cho KH, Caparon MG. Patterns of virulence gene expression differ between biofilm and tissue communities of Streptococcus pyogenes. Mol Microbiol. 2005;57(6):1545–56.
pubmed: 16135223 doi: 10.1111/j.1365-2958.2005.04786.x
Courtney HS, Ofek I, Penfound T, Nizet V, Pence MA, Kreikemeyer B, et al. Relationship between expression of the family of M proteins and lipoteichoic acid to Hydrophobicity and biofilm formation in Streptococcus pyogenes. PLoS ONE. 2009;4(1):e4166.
pubmed: 19132104 doi: 10.1371/journal.pone.0004166 pmcid: 2613554
Churchward G, Bates C, Gusa AA, Stringer V, Scott JR. Regulation of Streptokinase expression by CovR/S in Streptococcus pyogenes: CovR acts through a single high-affinity binding site. Microbiology. 2009;155(2):566–75.
pubmed: 19202105 doi: 10.1099/mic.0.024620-0
Kreikemeyer B, Boyle MDP, Buttaro BA, Heinemann M, Podbielski A. Group A streptococcal growth phase-associated virulence factor regulation by a novel operon (Fas) with homologies to two-component-type regulators requires a small RNA molecule. Mol Microbiol. 2001;39(2):392–406.
pubmed: 11136460 doi: 10.1046/j.1365-2958.2001.02226.x
Steiner K, Malke H. <i > rela-independent amino acid starvation response network of < i > Streptococcus pyogenes</i >. J Bacteriol. 2001;183(24):7354–64.
pubmed: 11717294 doi: 10.1128/JB.183.24.7354-7364.2001 pmcid: 95584
Krüger L, Herzberg C, Wicke D, Bähre H, Heidemann JL, Dickmanns A, et al. A meet-up of two second messengers: the c-di-AMP receptor DarB controls (p)ppGpp synthesis in Bacillus subtilis. Nat Commun. 2021;12(1):1210.
pubmed: 33619274 doi: 10.1038/s41467-021-21306-0 pmcid: 7900238
Li L, Li Y, Zhu F, Cheung AL, Wang G, Bai G, et al. New mechanistic insights into Purine Biosynthesis with Second Messenger c-di-AMP in relation to Biofilm-Related Persistent Methicillin-Resistant Staphylococcus aureus infections. mBio. 2021;12(6):e0208121.
pubmed: 34724823 doi: 10.1128/mBio.02081-21
McDonough KA, Rodriguez A. The myriad roles of cyclic AMP in microbial pathogens: from signal to sword. Nat Rev Microbiol. 2012;10(1):27–38.
doi: 10.1038/nrmicro2688
Fahmi T, Port GC, Cho KH. c-di-AMP: an essential molecule in the signaling pathways that regulate the viability and virulence of Gram-positive Bacteria. Genes. 2017;8(8):197.
pubmed: 28783096 doi: 10.3390/genes8080197 pmcid: 5575661
Zeden MS, Kviatkovski I, Schuster CF, Thomas VC, Fey PD, Gründling A. Identification of the main glutamine and glutamate transporters in Staphylococcus aureus and their impact on c-di-AMP production. Mol Microbiol. 2020;113(6):1085–100.
pubmed: 31997474 doi: 10.1111/mmi.14479 pmcid: 7299772
Fahmi T, Faozia S, Port GC, Cho KH. The second Messenger c-di-AMP regulates Diverse Cellular pathways involved in stress response, Biofilm formation, Cell Wall Homeostasis, SpeB expression, and virulence in Streptococcus pyogenes. Infect Immun. 2019;87(6). https://doi.org/10.1128/iai.00147-19 .
Shibamura-Fujiogi M, Wang X, Maisat W, Koutsogiannaki S, Li Y, Chen Y, et al. GltS regulates biofilm formation in methicillin-resistant Staphylococcus aureus. Commun Biology. 2022;5(1):1284.
doi: 10.1038/s42003-022-04239-2
Cusumano ZT, Caparon MG. Citrulline protects Streptococcus pyogenes from acid stress using the Arginine Deiminase Pathway and the F
pubmed: 25645553 doi: 10.1128/JB.02517-14 pmcid: 4352666
Cusumano ZT, Watson ME, Caparon MG. Streptococcus pyogenes Arginine and Citrulline Catabolism promotes infection and modulates innate immunity. Infect Immun. 2014;82(1):233–42.
pubmed: 24144727 doi: 10.1128/IAI.00916-13 pmcid: 3911826

Auteurs

Lea A Tölken (LA)

Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany.

Janine V Neufend (JV)

Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany.

Oddvar Oppegaard (O)

Department of Medicine, Haukeland University Hospital, Bergen, Norway.
Department of Clinical Science, University of Bergen, Bergen, Norway.

Karen Methling (K)

Department of Cellular Biochemistry and Metabolomics, Institute of Biochemistry, University of Greifswald, Greifswald, Germany.

Kirsten Moll (K)

Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden.

Sylvio Redanz (S)

Department of Translational Rheumatology and Immunology, Institute of Musculoskeletal Medicine, University of Münster, Münster, Germany.

Miriam M D Katsburg (MMD)

Center for Infection Medicine, Institute of Microbiology and Epizootics, Freie Universität Berlin, Berlin, Germany.

Murtadha Q Ali (MQ)

Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany.

Patience Shumba (P)

Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany.

Bernd Kreikemeyer (B)

Institute for Microbiology, Virology and Hygiene, University Medicine Rostock, Rostock, Germany.

Steinar Skrede (S)

Department of Medicine, Haukeland University Hospital, Bergen, Norway.
Department of Clinical Science, University of Bergen, Bergen, Norway.

Marcus Fulde (M)

Center for Infection Medicine, Institute of Microbiology and Epizootics, Freie Universität Berlin, Berlin, Germany.

Anna Norrby-Teglund (A)

Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden.

Michael Lalk (M)

Department of Cellular Biochemistry and Metabolomics, Institute of Biochemistry, University of Greifswald, Greifswald, Germany.

Bård R Kittang (BR)

Department of Clinical Science, University of Bergen, Bergen, Norway.
Haraldsplass Deaconess Hospital, Bergen, Norway.

Nikolai Siemens (N)

Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany. nikolai.siemens@uni-greifswald.de.

Articles similaires

[Redispensing of expensive oral anticancer medicines: a practical application].

Lisanne N van Merendonk, Kübra Akgöl, Bastiaan Nuijen
1.00
Humans Antineoplastic Agents Administration, Oral Drug Costs Counterfeit Drugs

Smoking Cessation and Incident Cardiovascular Disease.

Jun Hwan Cho, Seung Yong Shin, Hoseob Kim et al.
1.00
Humans Male Smoking Cessation Cardiovascular Diseases Female
Humans United States Aged Cross-Sectional Studies Medicare Part C
1.00
Humans Yoga Low Back Pain Female Male

Classifications MeSH