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|Alzheimer's Disease and Neurological Disorders|Cellular Signaling|Cytokines|Immunogenicity|
|Metabolic Assays|Methods & Technology|Toxicology|Other Biomarkers|


Immunogenicity

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NEW! Finch, D.K., Sleeman, M.A., Moisan, J., Ferraro, F., Botterell, S., Campbell, J., Cochrane, D., Cruwys, S., England, E., Lane, S., Rendall, E., Sinha, M., Walker, C., Rees, G., Bowen, M.A., Schneider, A., Liang, M., Faggioni, R., Fung, M., Mallinder, P.R., Wilkinson, T., Kolbeck, R., Vaughan, T., Lowe, D.C. (2011) Whole-Molecule Antibody Engineering: Generation of a High-Affinity Anti-IL-6 Antibody with Extended Pharmacokinetics. J Mol Biol. Vol. 411(4):791-807.

Antibody engineering, phage display, antibody library, MedImmune



Matrix tested: Cynomolgus monkey plasma
Summary: In this study, the MSD platform was utilized for the pharmacokinetic evaluation of a potential anti-IL-6 antibody in a single dose study in cynomolgus monkeys.
NEW! Taylor, P.C., Quattrocchi, E., Mallett, S., Kurrasch, R., Petersen, J., Chang, D.J. (2011) Ofatumumab, a fully human anti-CD20 monoclonal antibody, in biological-naive, rheumatoid arthritis patients with an inadequate response to methotrexate: a randomised, double-blind, placebo-controlled clinical trial. Ann Rheum Dis. 2011 Aug 22. [Epub ahead of print]

safety, toxicity, Imperial College London



Matrix tested: Human serum
Summary: In this study, the MSD platform was utilized for the detection of anti-drug antibodies to Ofatumumab, a human anti-CD20 monoclonal antibody, in rheumatoid arthritis patients.
Padhi, D., Jang, G., Stouch, B., Fang, L., Posvar, E. (2011) Single-dose, placebo-controlled, randomized study of AMG 785, a sclerostin monoclonal antibody. J Bone Miner Res. Vol. 26(1):19-26.

bone formation



Analytes tested using MSD® assays: Anti-therapeutic antibodies to AMG 785
Matrix tested: Human serum
Summary: The aim of this phase I clinical study was to examine a new sclerostin monoclonal antibody (AMG 785) with respect to its safety, tolerability, pharmacokinetics and pharmacodynamics in healthy men and post-menopausal women.
Bautista, A.C., Wullner, D., Moxness, M., Swanson, S.J., Chirmule, N., Jawa, V. (2010) Impact of matrix-associated soluble factors on the specificity of the immunogenicity assessment. Bioanalysis. Vol. 2(4): 721-731.

Summary: In this study, three different immunogenicity assay platforms were compared, including ELISA, MESO SCALE DISCOVERY® platform and a real-time surface Plasmon resonance based platform (Biacore 3000). The results showed the effectiveness of Melon Gel pretreatment in combination with avidin high-bind plates from MSD in eliminating the interference due to rheumatoid factor. Recommendations have been provided on the choice of assay designs and platforms that can help eliminate interfering factors that impact the performance of immunogenicity assays.
Brignone, C., Gutierrez, M., Mefti, F., Brain, E., Jarcau, R., Cvitkovic, F., Bousetta, N., Medioni, J., Gligorov, J., Grygar, C., Marcu, M., Triebel, F. (2010) First-line chemoimmunotherapy in metastatic breast carcinoma: combination of paclitaxel and IMP321 (LAG-3Ig) enhances immune responses and antitumor activity. J Transl Med. Vol. 8: 71.
Summary: This study tested the efficacy of IMP321, an anti-cancer agent that binds to MHC class II, in a phase I/II clinical trial, in patients with metastatic breast carcinoma receiving paclitaxel. MSD bridging immunogenicity assay was used to test for anti-IMP321 antibodies.
Matrix tested: Human serum
Carbonell-Estrany, X., Simões, E.A., Dagan, R., Hall, C.B., Harris, B., Hultquist, M., Connor, E.M., Losonsky, G.A.; Motavizumab Study Group. (2010) Motavizumab for prophylaxis of respiratory syncytial virus in high-risk children: a noninferiority trial. Pediatrics. Vol. 125(1):e35-51.
Analytes tested using MSD assays: User developed bridging immunogenicity assay to screen, confirm, and titer anti-drug antibodies
Matrix tested: Human serum
Summary: In this study, the MSD platform as used to develop bridging immunogenicity assays to screen, confirm, and titer anti-drug antibodies against Motavizumab, an investigational monoclonal antibody against respiratory syncytial virus. MSD technology was used to detect both IgG as well as IgE antibodies with high sensitivity and good drug tolerance.
Cludts, I., Meager, A., Thorpe, R., Wadhwa, M. (2010) Detection of neutralizing interleukin-17 antibodies in autoimmune polyendocrinopathy syndrome-1 (APS-1) patients using a novel non-cell based electrochemiluminescence assay. Cytokine. Vol. 50(2):129-37.

IL17, Interleukin, Neutralizing antibodies, Cell based assay, Competitive ligand binding assay



Summary: This study was based on the development of a non-cell based ELISA assay on the MSD platform for the detection of neutralizing antibodies to IL-17A in patients with APS-1. The MSD bridging immunogenicity assay correlated very well with the traditional cell-based ELISA and was determined to be simple to perform, reliable, and more accessible to clinical laboratories than cell-based assays.
Matrix tested: Human serum
Herbst, R.S., Kurzrock, R., Hong, D.S., Valdivieso, M., Hsu, C.P., Goyal, L., Juan, G., Hwang, Y., Wong, S., Hill, J.S., Friberg, G., Lorusso, P. (2010) A First-in-Human Study of Conatumumab in Adult Patients With Advanced Solid Tumors. Clin Clin Cancer Res. Vol. 16(23):5883-91.

IL17, Interleukin, Neutralizing antibodies, Cell based assay, Competitive ligand binding assay



Summary: This study tested the overall tolerability of an investigational monoclonal antibody, conatumumab, an agonist against human death receptor, which is expressed in several tumors. MSD bridging immunogenicity assay was used to test for anti-conatumumab antibodies.
Matrix tested: Human serum
Martin, P. L., Zhou, Z., Van den Bulck, K., Kwok, D., Powers, G., Jiao, Q., Schantz, A., Treacy, G. (2010) Pharmacology and placental transfer of a human av integrin monoclonal antibody in rabbits. Birth Defects Research Part B: Developmental and Reproductive Toxicology. Vol. 89(2): 116–123.

placental transfer, av integrin, alpha v integrin, intetumumab, angiogeneis, embryofetal development



Analytes tested using MSD assays: User developed assay to measure levels of therapeutic antibody on MSD Streptavidin plates
Matrix tested: Rabbit serum and amniotic fluid
Summary: This study examined the feasibility of using rabbit as a model to test the effects of repeated administration of a human monoclonal antibody, intetumumab, on embryofetal development. The ability of antibody to cross the placenta was evaluated.
Mita, A.C., Takimoto, C.H., Mita, M., Tolcher, A., Sankhala, K., Sarantopoulos, J., Valdivieso, M., Wood, L., Rasmussen, E., Sun, Y.N., Zhong, Z.D., Bass, M.B., Le, N., LoRusso, P. (2010) Phase 1 study of AMG 386, a selective angiopoietin 1/2-neutralizing peptibody, in combination with chemotherapy in adults with advanced solid tumors. Clin Cancer Res. Vol. 16(11):3044-56.

Placental growth factor, basic fibroblast growth factor, vascular endothelial growth factor



Analytes tested using MSD assays: Bridging immunogenicity assay to detect anti-drug antibody, PlGF, VEGF-A, VEGFR-1, bFGF, VEGFR-2, Kit
Matrix tested: Human serum
Summary: This paper tested the safety, pharmacokinetic profile and antitumor activity of AMG 386 (reduces angiogenesis by selectively neutralizing Ang1 and Ang2) in adult patients with advanced solid tumors.
Myler, H.A., McVay, S., Kratzsch, J. (2010) Troubleshooting PEG-hGH detection supporting pharmacokinetic evaluation in growth hormone deficient patients. J Pharmacol Toxicol Methods. Vol. 61(2):92-7.

Acid dissociation, Drug detection methods, Growth hormone, Human serum, Pharmacokinetics, Total versus free ligand binding assays



Summary: Pharmacokinetic evaluation of clinical samples containing pegylated human growth hormone was done on the MSD platform by using an anti-PEG IgM monoclonal antibody as the capture reagent and a neutralizing anti-hGH IgG polyclonal antibody as the detection reagent.
Special Techniques: Acid dissociation of samples was done to enable the detection of epitopes masked by pegylation of the drug
Matrix tested: Human serum
Oh, C.K., Faggioni, R., Jin, F., Roskos, L.K., Wang, B., Birrell, C., Wilson, R., Molfino, N. (2010) An open-label, single-dose bioavailability study of the pharmacokinetics of CAT-354 after subcutaneous and intravenous administration in healthy males. British Journal of Clinical Pharmacology. 24 Feb 2010.

Acid dissociation, anti drug antibody, asthma, phase I


Summary: This study was based on the characterization of the pharmacokinetics of CAT-354 (anti-IL-13 human monoclonal antibody) following subcutaneous and intravenous administrations of 150 mg and 300 mg doses.
Special Techniques: Acid dissociation of samples was done to enable the detection of masked epitopes
Matrix tested: Human serum
Schlain, B., Amaravadi, L., Donley, J., Wickramasekera, A., Bennett, D., Subramanyam, M. (2010) A novel gamma-fitting statistical method for anti-drug antibody assays to establish assay cut points for data with non-normal distribution. J Immunol Methods. Vol. 352(1-2):161-8.

Immunogenicity, anti drug antibody, Cut point, Nonparametric, Gamma distribution, Screening assay



Summary: This paper describes a new 3-parameter gamma fit for non-normal immunogenicity data distributions, which tend to be unimodal and positively skewed. Gamma based cut points were found to be more accurate compared to normal or log-normal methods and more precise compared with the nonparametric percentile method.
Tatarewicz, S., Miller, J.M., Swanson, S.J., Moxness, M.S. (2010) Rheumatoid factor interference in immunogenicity assays for human monoclonal antibody therapeutics. J Immunol Methods. Vol. 357(1-2):10-6.

Rheumatoid Factor, Rheumatoid Arthritis, Therapeutic monoclonal antibody, Immunogenicity, HAHA, Aggregation, Interference



Summary: The role of interference by rheumatoid factors in HAHA (human anti-human antibody) immunoassays has been investigated in this paper using a highly sensitive bridging assay on MSD platform. Stability studies of the ruthenium and biotin conjugated therapeutic antibody and the integrity of the reagents were tested using SE-HPLC (Size exclusion high performance liquid chromatography).
Special Techniques: Size exclusion high performance liquid chromatography was done to test integrity of the reagents
Matrix tested: Human serum
Wadhwa, M., Thorpe, R. (2010) Unwanted immunogenicity: lessons learned and future challenges. Bioanalysis. Vol. 2(6):1073-1084.

direct ELISA, bridging ELISA, electrochemiluminescence, radioimmunoprecipitation, surface plasmon resonance



Summary: This article reviewed the current status, strategies and challenges related to assessing the immunogenicity of therapeutic proteins, with the main focus on available bioanalytical methods for measurement of immunogenicity. The authors noted the many advantages of MSD technology, including high throughput, simple protocols, excellent sensitivity, large dynamic range, low matrix effects and tolerance to residual therapeutic agent. The authors also remarked on the superiority of an ECL method in detecting antibodies of both high and low affinities in comparison with ELISA and SPR methods.
Zhong, Z.D., Dinnogen, S., Hokom, M., Ray, C., Weinreich, D., Swanson, S.J., Chirmule, N. (2010) Identification and inhibition of drug target interference in immunogenicity assays. J Immunol Methods. Vol. 355(1-2):21-8.

Angiopoietin, Anti-drug antibody, Drug target interference, Immunoassay, Immunogenicity, acid dissociation



Summary: This paper reports the development and validation of a sensitive bridging ECL immunoassay to detect anti drug antibodies (ADA) against AMG 386, which is a peptide-Fc fusion protein that inhibits angiogenesis.
Special Techniques: Acid dissociation of samples was done to enable antibody-drug complex dissociation before analysis
Matrix tested: Human serum
Hu, J., Gupta, S., Swanson, S.J., Zhuang, Y. (2009) A bioactive drug quantitation based approach for the detection of anti-drug neutralizing antibodies in human serum. J Immunol Methods. Vol. 345(1-2):70-9.

Immunogenicity, Neutralizing antibodies



Summary: The development of an immunoassay on MSD plates for the detection of effective neutralizing antibodies (Nabs) to Hepatocyte Growth Factor (HGF) antibody has been described here. The assay measured the level of biologically active drug concentration rather than detecting the mere presence of Nabs.
Matrix tested: Human serum
Loizos, N., Lariccia, L., Weiner, J., Griffith, H., Boin, F., Hummers, L., Wigley, F., Kussie, P. (2009) Lack of detection of agonist activity by antibodies to platelet-derived growth factor receptor alpha in a subset of normal and systemic sclerosis patient sera. Arthritis Rheum. Vol. 60(4):1145-51.

sclerosis, auto-antibodies



Summary: The presence of anti-platelet-derived growth factor receptor alpha (anti-PDGFRa) antibodies in the serum of patients with systemic sclerosis (SSc; scleroderma) was investigated to test whether auto-antibodies to PDGFRa are pathologically important in scleroderma. Bridging assays were developed on MSD plates to detect auto-antibodies specific for human PDGFRa, PDGFRß, colony-stimulating factor receptor 1 (CSFR1), epidermal growth factor receptor (EGFR), and a PDGFRa nonglycosylated form.
Matrix tested: Human serum
Loyet, K.M., Deng, R., Liang, W.C., Wu, Y., Lowman, H.B., Deforge, L.E. (2009) Technology comparisons for anti-therapeutic antibody and neutralizing antibody assays in the context of an anti-TNF pharmacokinetic study. J Immunol Methods. Vol. 345(1-2):17-28.

Anti-therapeutic antibody, Neutralizing antibody, Anti-TNF, Flow cytometry, Cynomolgus monkey



Summary: BioVeris and MSD platforms were compared in this paper for the development of immunoassay to detect anti-therapeutic antibody (ATA) against anti-TNF monoclonal antibody. To determine whether ATAs blocked binding of the anti-TNF mAbs, neutralizing antibody assays were done using MSD and flow cytometry.
Special Techniques: Bioveris, Flow cytometry, MSD
Matrix tested: Cynomolgus serum
Marchese, R.D., Puchalski, D., Miller, P., Antonello, J., Hammond, O., Green, T., Rubinstein, L.J., Caulfield, M.J., Sikkema, D. (2009) Optimization and validation of a multiplex, electrochemiluminescence-based detection assay for the quantitation of immunoglobulin g serotype-specific antipneumococcal antibodies in human serum. Clin Vaccine Immunol. Vol. 16 (3):387-96.

polysaccharide, Streptococcus pneumoniae, ELISA, Luminex



Summary: Immunogenicity of Pneumovax 23 vaccine was tested in this paper by developing and validating an MSD assay to measure the antibody response in human serum to eight serotypes within the vaccine in a single microtiter well. MSD was compared to ELISA and Luminex for assay development.
Special Techniques: Polysaccharides were directly immobilized to MSD plates without chemical conjugations for this assay
Matrix tested: Human serum
Ray, C.A., Patel, V., Shih, J., Macaraeg, C., Wu, Y., Thway, T., Ma, M., Lee, J.W., Desilva, B. (2009) Application of multi-factorial design of experiments to successfully optimize immunoassays for robust measurements of therapeutic proteins. J Pharm Biomed Anal. Vol. 49(2):311-8.

Tecan Evo pipettor, ELISA



Summary: In this paper, the authors describe a multi-factorial design of experiments (DOE) method as a tool for optimizing bridging immunoassays in therapeutic drug measurement and in immunogenicity assessment.
Matrix tested: Cynomolgus monkey serum, human serum
Thompson, I., McGiven, J., Sawyer, J., Thirlwall, R., Commander, N., Stack, J. (2009) Competitive electrochemiluminescence (ECL) wash and no-wash immunoassays for the detection of serum antibodies to smooth Brucella strains. Clin Vaccine Immunol. Vol. 16(5):765-71.

Veterinary Laboratories Agency, Brucella, bovine



Summary: In this study, the customer successfully converted existing competitive ELISA to MSD ECL assays for veterinary serodiagnosis of brucellosis. The potential of wash and no-wash MSD assays was assessed.
Matrix tested: Bovine serum
Yao, K., Honarmand, S., Espinosa, A., Akhyani, N., Glaser, C., Jacobson, S. (2009) Detection of human herpesvirus-6 in cerebrospinal fluid of patients with encephalitis. Ann Neurol. Vol. 65(3):257-67.
Summary: This study investigated whether Human Herpesvirus-6 is a causative agent of encephalitis by determining the presence of viral sequence using Polymerase Chain Reaction (PCR) and assessing HHV-6 antibody reactivity in the cerebrospinal fluid of encephalitis patients.
Special Techniques: PCR, DNA sequencing
Matrix tested: Human cerebrospinal fluid (CSF)
Zalevsky, J., Leung, I.W., Karki, S., Chu, S.Y., Zhukovsky, E.A., Desjarlais, J.R., Carmichael, D.F., Lawrence, C.E. (2009) The impact of Fc engineering on an anti-CD19 antibody: increased Fcgamma receptor affinity enhances B-cell clearing in nonhuman primates. Blood. Vol. 113(16):3735-43.

Pharmacokinetics, non-human primate



Summary: This study determined the effectiveness of an Fc engineered anti-CD19 antibody in the treatment of B-cell malignancies in Cynomolgus monkeys. Immunogenicity of the parent-drug as well as Fc engineered version was tested by measurement of anti-drug antibodies with MSD assays.
Matrix tested: Cynomolgus monkey serum
Swanson, S. Evaluation of Antibodies in Clinical Trials of Cytokines in Cytokines in Human Health: Methods in Pharmacology and Toxicology. ed. House, R.V.and Descotes, J. (2008) Humana Press. Pages 259-274.

RIP, bioassay, surface plasmon resonance, Biacore, ELISA, ECL, electrochemiluminescence, radioimmunoprecipitation assay


Summary: This article reviews the immunogenicity of different cytokine drugs in terms of the factors causing it, the different methods for measurement and provides examples of immunogenicity issues of therapeutic cytokines.
Matrix tested: Cynomolgus monkey serum
Wadhwa, M., Thorpe, R. (2008) Assessment of Unwanted Immunogenicity in Immunogenicity of Biopharmaceuticals. Springer, New York. Pages 57-73.

RIP, bioassay, surface plasmon resonance, Biacore


Summary: This is a review article that describes the different methods and strategies to measure immunogenicity of therapeutic agents, and offers guidance on data interpretation. ELISA, electrochemiluminescent (ECL) assays, radioimmunoprecipitation (RIPA) assays, biosensor-based assays (such as Biacore) and cell-based neutralization assays have been described here to assess immunogenicity.
White, J.T., Martell, L.A., Van Tuyl, A., Boyer, R., Warness, L., Taniguchi, G.T., Foehr, E. (2008) Development, Validation, and Clinical Implementation of an Assay to Measure Total Antibody Response to Naglazyme(R) (Galsulfase). AAPS Journal. Vol. 10(2):363-72.

bridging immunoassay, enzyme replacement therapy, immunogenicity



Summary: Immunogenicity of the therapeutic agent, Naglazyme, was assessed in this study using a solution phase bridged immunoassay on the MSD platform.
Matrix tested: Human serum
Yao, K., Gagnon, S., Akhyani, N., Williams, E., Fotheringham, J., Frohman, E., Stuve, O., Monson, N., Racke, M.K., Jacobson, S. (2008) Reactivation of human herpesvirus-6 in natalizumab treated multiple sclerosis patients. PLoS ONE. Vol. 3(4):e2028.
Summary: This study tested whether Human Herpesvirus-6 (HHV-6) is reactivated in multiple sclerosis (MS) patients treated with Natalizumab by examining sera and matched cerebrospinal fluid (CSF) from MS patients who were treated with natalizumab and comparing to MS patients not treated with the drug.
Matrix tested: Human serum and cerebrospinal fluid (CSF)
Liang, M., Klakamp S.L., Funelas, C., Lu, H., Lam, B., Herl, C., Umble, A., Drake, A.W., Pak, M., Ageyeva, N., Pasumarthi, R., Roskos, L. (2007) Detection of High- and Low-Affinity Antibodies Against a Human Monoclonal Antibody Using Various Technology Platforms. Assay and Drug Dev Technol. Vol. 5(5): 1-8.
Summary: ELISA, MSD and Bioveris technologies were compared to determine the limit of detection of several anti-drug antibodies (ADAs) with a broad range of affinities to a human monoclonal antibody, ABX10.
Matrix tested: Human serum
Liu, P.M, Handl, H., Zou, L, Kim, B. (2007) Immunobiological aspects of therapeutic antibodies and related characterization approaches. Curr Opin Drug Discov Devel. Vol. 10(5):515-22.
Summary: This review discusses the immunological and biological characteristics of therapeutic antibodies and the recent technologies that have been developed to help attain a better understanding of their mechanism of action.
Lofgren, J.A., Dhandapani, S., Pennucci, J.J., Abbott, C.M., Mytych, D.T., Kaliyaperumal, A., Swanson, S.J., Mullenix, M.C. (2007) Comparing ELISA and surface plasmon resonance for assessing clinical immunogenicity of panitumumab. J Immunol. 178(11):7467-72.

Acid dissociation, anti-epidermal growth factor receptor, biacore



Summary: In this paper, the immunogenicity of panitumumab was determined using two methods, ELISA and Biacore. Neutralizing antibodies against panitumumab were detected using MSD platform.
Special Techniques: Acid dissociation of samples was done to reduce drug interference
Matrix tested: Human serum
Lu, Y., Young, J., Meng, Y.G. (2007) Electrochemiluminescence to detect surface proteins on live cells. Current Op Pharmacology. Vol. 7:541-546.
Summary: This paper discusses the development of an electrochemiluminescence assay method to be used as a tool to detect surface proteins on cells and compares it to traditional flow cytometry and cell based ELISA methods.
Special Techniques: Flow cytometry, cell based ELISA
Matrix tested: Human umbilical vein endothelial cells (HUVEC)
Swanson, S. J. (2007) Immunogenicity Issues in the Development of Therapeutic Proteins. Intl J Pharm Med. Vol. 21(3):207-216.

RIP, bioassay, surface plasmon resonance, Biacore



Summary: This is a review article that describes the different factors that result in immunogenicity of therapeutic agents and the various platforms as well as strategies that are available for measuring immunogenicity. The different methods listed here include ELISA, electrochemiluminescent (ECL) assays, radioimmunoprecipitation (RIPA) assays, biosensor-based assays (such as Biacore) and bioassays such as cell-based assays.
Gillespie, B., Zia-Amirhosseini, P., Salfi, M., Kakkar, T., Wang, J., Gupta, S., Smith, B., Robson, R., Sullivan J.T. (2006) Effect of renal function on the pharmacokinetics of palifermin. J Clin Pharmacol. Vol. 46(12):1460-8.
Summary: Pharmacokinetic evaluation of palifermin drug was conducted in this study using MSD platform to assess the safety and tolerability of a single palifermin dose in subjects with varying degrees of renal function.
Matrix tested: Human serum
Lu, Y., Wong, W.L., Meng, Y.G. (2006) A high throughput electrochemiluminescent cell-binding assay for therapeutic anti-CD20 antibody selection. J Immunological Methods. Vol. 314(1-2):74-9.

Anti-CD20, Humanization, humanized, Cell binding assay, CHO, Chinese Hamster Ovary



Summary: A high-throughput ECL based cell-binding assay was developed in this study for measuring relative binding affinities of anti-CD20 antibody drug candidates to efficiently support humanization process.
Special Techniques: Cell binding assay was developed on MSD platform and compared to a pre-existing cell based ELISA
Matrix tested: Human serum
Zia-Amirhosseini, P., Salfi, M., Leese, P., Yates, W., Danilenko, D.M., Ring, B., Cesano, A., Sullivan, J.T. (2006) Pharmacokinetics, pharmacodynamics, and safety assessment of palifermin (rHuKGF) in healthy volunteers. Clinical Pharmacology & Therapeutics. Vol. 79: 558-569.

anti drug antibody, cancer therapy/p>


Summary: This paper is based on a randomized, double-blind, placebo-controlled study investigating the pharmacokinetics, pharmacodynamics, and safety of palifermin in healthy volunteers after single, escalating doses.
Special Techniques: Human sera were screened for anti-palifermin antibodies using MSD and the reactive samples were then tested in a cell-based ELISA to test for neutralizing antibodies to palifermin
Matrix tested: Human serum

* Pub Med (www.pubmed.gov) is a service of the U.S. National Library of Medicine and the National Institutes of Health



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