eskdaill medical

T:01536 522633   121 Lower Street, Kettering, Northants, NN16 8DN.

NHS Direct Health News

NHS Choices: Behind the headlines   + / -  
last updated: Thu, 24 Apr 2014 21:41:21 GMT

 Thu, 24 Apr 2014 11:00:00 GMT Can mental trauma be passed on through sperm?

"Traumatic experiences can be inherited, as major shocks alter how cells in the body work," The Daily Telegraph reports.

But before you start blaming mum and dad for your problems, the research it reports on only involved mice.

The study looked at how traumatic stress in the early life of male mice influenced the genetic material in their sperm.

Researchers “traumatised” male mice during their first weeks of life by separating them from their mother. They then gave the male mice a series of behavioural tests. They found that those separated from their mothers didn’t show a rodent’s natural avoidance for open and brightly lit spaces.

The researchers then extracted sperm from the “traumatised” male mice and found it had several changes to small molecules (RNA) involved in genetic regulation. These molecules are believed to play a role in transferring the effects of our environmental experiences to our DNA.

They then showed the behaviour of offspring was similarly affected purely by injecting the sperm RNA from the traumatised male into an already fertilised egg cell from an untraumatised female. On behavioural tests they found that the offspring displayed the same behavioural tendencies as the “traumatised” male mice.

This suggests that the small RNA molecules could have a role in transferring the effects of traumatic experiences to our genetic material.

While this study may appear to confirm the sentiment of Phillip Larkin’s famous poem, This Be the Verse (in which parents are blamed for the faults of their children using post-watershed language), trying to untangle the genetic as opposed to any environmental parental effects on your current mental health is an extremely complex task.

 

Where did the story come from?

The study was carried out by researchers from University of Zürich and Swiss Federal Institute of Technology in Zürich, Switzerland, and the Gurdon Institute, Cambridge, UK. The study was supported by the Austrian Academy of Sciences, the University of Zürich, the Swiss Federal Institute of Technology, Roche, the Swiss National Science Foundation, and The National Center of Competence in Research “Neural Plasticity and Repair”. One researcher received funding from a Gonville and Caius College fellowship.

The study was published in the peer-reviewed scientific journal Nature Neuroscience.

The Daily Telegraph and the Mail Online’s reporting of this study was of poor quality. Both news sources gave the impression the research findings could be directly applied to humans.

The Mail in particular gives a very misleading impression, saying that, “children of people who have experienced extremely traumatic events are more likely to develop mental health problems”. They also say that “changes are so strong they can even influence a man’s grandchildren”. Only much further in, the article does correctly begin to discuss the real nature of the research.

Still, these massive leaps towards the implications for humans should not be made from this animal research.

 

What kind of research was this?

This was animal research aiming to look at how traumatic stress in the early life of a mouse influenced its genetic material. They also looked at how injecting sperm from traumatised males into female eggs cells affected the biological processes and behaviour of the offspring.

The researchers explain that though an individual’s characteristics and risk of diseases are largely determined by their genetics, environmental factors, such as traumatic experiences in early life, can also have an important effect on an individual. How this happens is not known for certain.

This research centred on looking at the possible effect of environmental trauma on what are called small non-coding RNAs (sncRNAs). These molecules are believed to be the intermediary between genes and the environment, and are thought to relay signals from the environment to our DNA, affecting gene activity. Previous research has implicated sncRNAs as the possible cause for the abnormal functioning of genes in many diseases. Furthermore, sncRNAs are said to be abundant in the mature sperm of mammals. So they may have a role in transferring the effects of environmental experiences to the next generation.

 

What did the research involve?

The researchers began their study by examining the sncRNA of adult male mouse sperm under normal conditions. They identified several groups of sncRNA that mapped to the genetic material of the sperm. They then looked at the effect that traumatic experiences in the early life of the male mouse had on their sperm sncRNA.

These early life traumatic experiences were the unpredictable separation of the male mouse from its mother. Female mice and their offspring were randomly selected to be unpredictably separated for three hours of the day between days one and 14 after birth.

Meanwhile, the group of control animals were left undisturbed.

After weaning, the mice were housed in small social groups of other mice who had been subjected to the same treatment.

The “traumatised” and control male mice were then given a series of behavioural tests. In a maze test they were put on a platform with two open and two closed walls.

The researchers looked at the time it took the mice to enter the open parts of the maze, and observed their body movements such as rearing and protective and non-protective postures. This is based on the mouse’s natural avoidance for open and unknown spaces. They then placed them in a light-dark box, which was split by dividers into light and dark parts, and looked at the time spent in each compartment. This was based on the natural aversion of rodents for brightly lit areas.

Mice who behave “unnaturally” are said to have an “an altered response to aversive conditions"; a possible sign of stress and trauma.

As another test, they observed them swimming and floating when placed in a tank of water from which there was no way to escape. Mice that quickly gave up trying to escape are said to have increased levels of "behavioural despair" – they literally gave up trying to leave the tank.

They also looked at the mice’s metabolism, by measuring their blood sugar and insulin levels, and measuring their calorie intake.

Samples of mature sperm were also extracted from the male mice and the sperm RNA was analysed. The researchers then injected RNA extracted from the sperm of “traumatised” or control mice into fertilised eggs cells. The reason for this was likely to have been an attempt to isolate the effects of the sncRNA, rather than just fertilising “wholesale” with the sperm of the traumatised males.

Not isolating the effects could mean that other genetic material, proteins and molecules could also have had an influence.

The researchers repeated the behavioural tests with the offspring to see if any behavioural traits had been inherited.

 

What were the basic results?

On the behavioural tests, the researchers found that male mice that had been traumatised were quicker to enter the open spaces than the control mice (they were not displacing the natural fear of unknown spaces).

Similarly, on the light-dark test the separated male mice spent longer in the lit compartments (they were not displacing the natural avoidance of brightly lit spaces).

When placed in the water tank the separated mice spent more time floating rather than swimming compared to the control mice.

The researchers found that the trauma led to changes in many different sncRNAs in the sperm of the young male mice.

On the repeat behavioural tests on the subsequent offspring, the same observed tendencies of the traumatised male mice seem to have been transferred to the next generation. Also the traumatised male mice themselves didn’t seem to have different metabolism from controls, but the next generation seemed to have an increased metabolic rate. They had increased sensitivity to insulin, and lower body weight despite increased calorie intake.

 

How did the researchers interpret the results?

The researchers conclude that their findings, “provide evidence for the idea that RNA-dependent processes contribute to the transmission of acquired traits in mammals. They underscore the importance of sncRNAs in [sex] cells and highlight their sensitivity to early traumatic stress”.

 

Conclusion

This animal study supported the theory that small chain RNA molecules may act as the interface between the environment and our genetics.

The researchers found that the sperm extracted from male mice that had been “traumatised” by being randomly separated from their mothers did show several changes to the small RNA molecules.

These traumatised mice also displayed fewer natural mouse tendencies compared to controls – namely, they did not show the natural aversion for open and brightly lit spaces.

These effects did then seem to be transferred into the offspring when some of this sperm RNA was directly injected into already fertilised eggs cells. On behavioural tests the resulting offspring displayed the same behavioural tendencies as the “traumatised” male mice.

This suggests that the small RNA molecules could have a role in transferring the effects of traumatic experiences to the genetic material of mammals which could be passed onto subsequent generations.

However, extrapolating the findings of this highly artificial study into the complex sphere of human emotions and behaviour is unwise.

A direct comparison between mice and humans is difficult. Maternal separation at a young age is only one possibility in a vast multitude of possible stressors that can affect a human.

Similarly, any offspring’s genetic propensity towards behavioural and mental health will also be greatly influenced by the various environmental exposures and events they experience in their own lives.

Overall, this furthers scientific understanding of how small RNA molecules may be involved in transferring the effects of traumatic experiences to our genetic material and how this may then be passed on to subsequent generations.

However, it does not prove that children of men exposed to trauma are more likely to have mental health conditions, as some of the media indicated.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Trauma can be inherited from parents. The Daily Telegraph, April 14 2014

How the trauma of life is passed down in SPERM, affecting the mental health of future generations. Mail Online, April 23 2014

Links To Science

Gapp K, Jawaid A, Sarkies P, et al. Implication of sperm RNAs in transgenerational inheritance of the effects of early trauma in mice. Nature Neuroscience. Published online April 13 2014

 Thu, 24 Apr 2014 10:30:00 GMT Lung and pancreatic cancers may be on the rise

"Lung cancer will soon become the biggest cancer killer among women," the Mail Online reports, while ITV News reveals that pancreatic cancer "poses [a] growing threat". Both headlines are prompted by a study that has estimated future cancer trends across the EU.

The researchers estimate there will be approximately 1.32 million deaths from the eight most common cancers in 2014. They predict that in women, deaths from breast and colorectal cancers will decrease, but lung cancer rates are expected to increase by 8%.

This increase had been linked to what has been termed the "Mad Men effect" – the fact that during the early 1960s, cigarettes were aggressively marketed towards women as an alleged slimming aid. Women who took up the habit then may be paying the price for it now.

The report also looked specifically at pancreatic cancer as previous reports have shown unfavourable trends for this type of cancer. Cancer of the pancreas is a very serious form of cancer that is both difficult to detect and treat.

Because pancreatic cancer causes few symptoms in its early stages, the condition is often not diagnosed until the cancer is relatively advanced.

People with advanced pancreatic cancer have an average life expectancy of around seven months. Pancreatic cancer is the only cancer predicted to increase in both men and women.

The main limitation of this type of study is that figures included in the report are best guesses, so figures and trends may not reflect actual figures that occur.

 

Where did the story come from?

The study was carried out by researchers from the University of Milan and the University Hospital of Lausanne. It was funded by the Swiss League against Cancer, the Swiss Cancer Research Foundation, and the Italian Association for Cancer Research.

The study was published in the peer-reviewed medical journal, Annals of Oncology.

The story was picked up by a number of UK media sources. The Mail Online and The Independent failed to inform the reader that the report provides estimates of deaths from cancers based on extrapolations of data from 2009. As such, the predictions are subject to assumptions made by the researchers.

ITV News and MSN News took a different tack, highlighting the potential growing threat of pancreatic cancers. As with lung cancer, rates of pancreatic cancers are based on extrapolated data. But if such a trend did occur, this would be worrying because of the current poor prognosis for this type of cancer.

 

What kind of research was this?

This was a modelling study based on official death certification data from various cancers. It aimed to predict the rates of deaths from cancer across Europe and six European countries for the year 2014.

This report is an update of previous estimates of deaths from cancers across Europe, which used similar methods. This type of study is therefore useful at looking at trends in these cancers over time as it can be compared to past reports.

However, the figures provided in this report are predictions, so they may not represent the amount of actual deaths from cancers that occur.

 

What did the research involve?

To predict deaths from cancers for the year 2014, researchers used official population and death certificate data obtained from the World Health Organization (WHO) and Eurostat for the following cancers:

  • stomach
  • colorectum
  • pancreas
  • lung
  • breast
  • uterus
  • prostate
  • leukaemia (blood cell cancers)

They also estimated total deaths from cancers.

For the European Union, figures were used for the period 1970 to 2009. The most recently available data was used for the following six major European countries:

  • France
  • Germany
  • Italy
  • Poland
  • Spain
  • UK

Based on the available data, the researchers predicted age-specific deaths from cancer from birth to over the age of 80 in five-year age groups.

Using statistical techniques, the predicted age-specific numbers of deaths and population data were then used to estimate the predicted death rates from cancer for 2014.

 

What were the basic results?

The main predictions from the report were:

  • In the European Union, approximately 1.32 million deaths from cancer are predicted in 2014 (742,500 men and 581,100 women). The researchers say this resembles a death rate of 138.1 per 100,000 for men (indicating a decrease of 7% since 2009) and 84.7 per 100,000 for women (indicating a decrease of 5% since 2009).
  • In women, breast and colorectal cancers are predicted to decrease (9% decrease for breast cancer and 7% decrease for colorectal cancer), but lung cancer rates are predicted to increase by 8%.
  • In men, predicted rates of the three major cancers in 2014 are lower than in 2009 – lung (decrease of 8%), colorectum (decrease of 4%) and prostate (decrease of 10%).
  • Pancreatic cancer is the only cancer predicted to increase in both men and women.
  • Trends across the European Union for the 20-49 age group are predicted to become more favourable for men, but slight increases are predicted for women.

 

How did the researchers interpret the results?

The researchers conclude that cancer death predictions for 2014 confirm the overall favourable cancer death trend in the European Union, translating to an overall 26% reduction in men since its peak in 1988, and 20% in women.

It is predicted that more than 250,000 deaths will be avoided in 2014 compared with the peak rate. They say notable exceptions are for female lung cancer and pancreatic cancer in both sexes.

Lead researcher Professor Carlo La Vecchia, from the University of Milan, is quoted in the media as saying: "The increased death rate [for pancreatic cancer] is cause for concern because the prognosis for this tumour is bleak, with less than 5% of pancreatic cancer patients surviving for five years after diagnosis.

"As so few patients survive, the increase in deaths is very closely related to the increase in incidence of this disease. This makes pancreatic cancer a priority for finding better ways to prevent and control it, and better treatments."

In their discussion, the researchers say the total male cancer death rate is 63% higher than the female rate, but that the male rate is falling faster.

They indicate this difference is mainly because of the different smoking pattern history among men and women.

It is expected that lung cancer will become the main cause of cancer death for women in the next few years.

But the data gathered by the researchers is not unremittingly gloomy. They predict that deaths associated with cancers responsive to treatment – such as leukaemia, breast and prostate cancer – will continue to fall.

This is the result of a combination of improved early diagnosis and screening, as well as improved treatments and disease management.

 

Conclusion

This type of study provides useful estimates of possible deaths in 2014 from eight different types of cancers, including breast, lung and pancreatic cancer.

The study's strengths include that it used official data from the World Health Organization (WHO) and Eurostat. Similar methods from previous reports on this topic were also used so that comparisons could be made and trends predicted.

The main limitation of this type of study is that the figures included in the report are estimates based on data from 2009 of cancer deaths for 2014.

The predicted figures and trends may not reflect new disease management or treatment initiatives that have occurred since 2009 as they include extrapolations of the trends seen in previous data.

There may now be a case for shifting more resources into researching new methods of managing lung cancer in women and pancreatic cancer in both sexes.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Lung disease to become the biggest cancer killer among women because of the number who took up smoking in 1960s. Mail Online, April 24 2014

Pancreatic cancer 'poses growing threat'. ITV News, April 23 2014

Lung cancer set to catch breast cancer as the deadliest cancer amongst women. The Independent, April 24 2014

Deadly threat of pancreatic cancer. MSN News, April 24 2014

Links To Science

Malvezzi M, Bertuccio P, Levi F, et al. European cancer mortality predictions for the year 2014. Annals of Oncology. Published online April 23 2014

 Wed, 23 Apr 2014 10:00:00 GMT Kidney damage 'killing thousands,' study claims

“Failures in basic hospital care are resulting in more than 1,000 deaths a month from … acute kidney injury,” The Independent reports. A study commissioned by the NHS estimates that up to 40,000 people may be dying from this preventable condition.

The study aimed to discover the prevalence of acute kidney injury (AKI – previously called acute kidney failure) among adult inpatients in NHS hospitals.

AKI is characterised by a rapid decline in kidney function, which can have many underlying causes. The condition can have a high risk of multiple organ failure and death.

The researchers used data from the Hospital Episode Statistics (HES), which covers all NHS hospital admissions in England. They compared this with more detailed information on AKI obtained from three Kent hospitals to see whether the overall HES data was giving a reliable indication of the true prevalence of the condition in NHS hospitals.

The results suggest that the prevalence of AKI among hospital inpatients could be much higher than previously thought.

Overall, it was estimated that around 14% of hospital inpatients could have AKI. The mortality associated with this is also high – accounting for an estimated 40,000 inpatient deaths over any given year.

Previous research has suggested that around 20-30% of AKI cases could be prevented, and the study highlights the importance of recognising people who could be at risk of developing the condition.

The health watchdog NICE published guidelines on AKI in 2013.

 

Where did the story come from?

The study was carried out by researchers from Insight Health Economics (London); East Kent Hospitals University NHS Foundation Trust (Canterbury); NHS Improving Quality (Newcastle upon Tyne); and Salford Royal NHS Foundation Trust (Salford). Funding was provided by NHS Kidney Care.

The study was published in the peer-reviewed medical journal Nephrology Dialysis Transplantation and has been made available on an open access basis, meaning it is free to read online.

All the media headlines have focused on the angle that thousands of people are dying of thirst due to alleged poor care. This has been taken from the “avoidable” aspect of this acute kidney injury – where previous research (specifically the previous National Confidential Enquiry into Patient Outcome and Death) has shown that up to a third of cases could be prevented.

However, the research itself only looks at the prevalence, costs and outcomes of AKI.

It does not focus on identifying possible reasons for the high number of cases or ways they could be avoided.

Based on the evidence made available in the study, claims that 40,000 people are “dying of thirst” are unsupported.

 

What kind of research was this?

This was a modelling study, which had a number of related goals:

  • Examining the prevalence of AKI across the NHS.
  • Estimating the impact that AKI has upon mortality, length of hospital study, quality of life and healthcare costs.

Acute kidney injury (AKI), previously termed acute kidney failure, is the term used to describe when there is sudden damage to the kidneys. There is no widely accepted standard definition of AKI and there may be a number of difference causes.

Criteria tend to be based upon:

  • A sudden rise of blood creatinine levels above a certain threshold level (creatinine is a breakdown product produced by the muscles, and is a good indicator of kidney function).
  • A decrease in urine output below a certain threshold level.

It is a serious illness that has a high mortality risk, though the specific mortality risk will be highly variable, depending on the individual (such as whether there are complications, or the person has existing kidney damage or other medical problems).

Importantly, as previous research has highlighted, there are concerns that many cases of AKI could be prevented, which would cause considerable reductions in illness, deaths and healthcare costs. The 2009 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) found that around a third of AKI cases occurring while in hospital were avoidable. Furthermore, only half of patients with AKI received an overall standard of care that was considered “good”.

This modelling study using fairly reliable data on NHS hospital admissions and is valuable research for estimating health outcomes of AKI and costs to the NHS.

 

What did the research involve?

This study used routinely collected national data for the NHS in England, in order to look at the prevalence of AKI in adults. They then estimated the impact of AKI on mortality, other health outcomes and cost to the NHS.

The researchers used Hospital Episode Statistics (HES), which is derived from records for each patient admitted to each NHS hospital. HES data includes the patient’s demographic details and medical information, including diagnoses, procedures, length of stay and in-hospital mortality.

They looked at recorded diagnoses of AKI (according to the International Classification of Diseases) between 2010 and 2011. 

However, the HES data does not include information on patients' AKI stage, kidney function prior to hospital admission or kidney function after being discharged from hospital.

As the researchers say, AKI is often poorly recorded in patient notes, so the national findings were compared with data collected by the three hospitals of the East Kent Hospitals University NHS Foundation Trust (EKHUFT).

This involved looking at laboratory records and identifying cases of AKI based on blood creatinine levels, using the Acute Kidney Injury Network (AKIN) classification system.

Comparing these two sources of information, they estimated the under-recording of AKI in patient notes.

They also used both data sets to estimate the possible distribution of AKI cases across the NHS according to stage, and to estimate the person’s previous and future kidney function.

They then used statistical models to estimate the impact of AKI on mortality, number of days in critical care and overall hospital stay.

 

What were the basic results?

AKI prevalence

The HES data indicated that AKI was recorded for 2.4% of hospital admissions during 2010/11 (142,705 out of 3,792,951 admissions). Prevalence ranged from 0.3% of patients aged 18 to 39, to 5.7% of people aged ≥80.

During the six-month period of EKHUFT data, laboratory research indicated that AKI was present in 15% of admissions, though the EKHUFT population is older than the overall HES population. 

When standardising for age, it was 14% of admissions. 

Over a third of patients (38%) in EKHUFT who had AKI during the study period had pre-existing chronic kidney disease. Three-quarters of those had AKI when they were admitted to hospital, suggesting that their condition was not due to poor hospital care.

AKI mortality

Using the HES data, just over a quarter (28%) of people with AKI recorded during their admission died before hospital discharge. The odds of in-hospital death were 10-fold greater in a person with AKI compared to those without. Mortality rates increased with age. 

From EKHUFT data, it was shown that 14% of people with AKI died before being discharged from hospital. In over half of all in-patient deaths during the six-month study period, the person had AKI recorded.

Analysis from HES data suggests that AKI was associated with around 15,000 excess deaths among inpatients in England in 2010/11.

However, extrapolating from EKHUFT data suggests that the number of excess inpatient deaths associated with AKI in England may be above 40,000.

Length of hospital stay

When using HES data, the average duration of hospital stay was 16.5 days for AKI-admissions, compared to just 5.1 days for admissions without AKI recorded. A person with AKI had a length of stay 2.6 times longer than someone without AKI; using the EKHUFT data, it was 1.6 times longer. From the EKHUFT critical care information, 60% of critical care bed days over the period were in people recorded to have AKI.

Long term outcomes and costs

Post-discharge information was not available from HES; using the EKHUFT data, 0.56% of people with AKI were receiving renal replacement therapy (such as dialysis) at 90 days, though more than half had pre-existing chronic kidney disease. 

Using the HES data, there were estimated to be almost 1,000,000 excess bed days due to AKI.

Based on the EKHUFT data, the number of excess bed days may be as high as 2.5 million, with over 160,000 of these spent in critical care beds. The total inpatient costs of AKI recorded in HES was estimated at £380 million.

When extrapolating from EKHUFT data, the cost could be as high as £1.02 billion – just over 1% of the NHS budget. To put that figure into context, that is enough to hire an additional 47,500 trainee nurses.

The lifetime costs of post-discharge care for people with AKI during admission was estimated at £179 million, with a loss of 1.4 quality of life years for each person with AKI who was admitted to hospital.

 

How did the researchers interpret the results?

The researchers conclude that the prevalence of AKI among people admitted to hospital may be considerably higher than previously thought, and up to 80% of cases may not be adequately captured by routine hospital data. AKI is associated with large numbers of in-hospital deaths and with high NHS costs.

 

Conclusion

This valuable study provides an estimate of the likely prevalence of AKI among inpatients in NHS hospitals. Comparison of HES data with laboratory data obtained from the three EKHUFT hospitals (where the AKIN classification system was used to define AKI cases), suggests that prevalence could be much higher than thought, and that there could be considerable under-recording of cases in the NHS.

The study also highlights the high mortality associated with AKI – accounting for an estimated 40,000 excess inpatient deaths. AKI was also associated with considerable loss to quality of life. Looking at the financial burden, this study estimated that AKI accounted for just over 1% of the NHS budget in 2010/11.

However, the study had its limitations. These figures are based on estimates only and centred on extrapolating data for HES based on data from the three EKHUFT hospitals. As noted, these hospitals have a different patient demographic from all NHS hospitals across England as a whole. There was also a lack of longer-term outcome data beyond 90 days after a patient was discharged from hospital.

Also, as the researchers say, this study only provides information on AKI recorded for adult hospital inpatients. There is no information on the number of cases that develop in the community.

The media has focused on the “preventable” aspect of AKI. Previous NCEPOD data has reported that up to a third of AKI cases could be predicated and prevented.

The researchers discuss how many of the failings identified by this report related to omissions in basic medical care. These include performing regular observations, checking the person’s fluid and mineral (electrolyte) balance, and a lack of adequate senior review. However, though the researchers mention fluid balance, at no point in this research paper do they say that “thousands are dying because of thirst”.

Notably, based on EKHUFT data, AKI was present at the point of admission in 75% of admissions where it was recorded, possibly noting a point for early recognition and management.

As the researchers say: “if 20% of AKI cases were prevented, the figures presented in this report suggest that the gross savings to the NHS could be in the region of £200 million a year, equivalent to 0.2% of the NHS budget in England”.

The research highlights the importance of recognising people who could be at risk of developing AKI and ensuring that they receive appropriate care and management.

Analysis by Bazian. Edited by NHS ChoicesFollow Behind the Headlines on TwitterJoin the Healthy Evidence forum.

Links To The Headlines

Failure to spot kidney illness ‘kills 1,000 a month’. The Independent, April 22 2014

Hospital kidney deaths 'unacceptable', says doctor. ITV News, April 22 2014

Thousands die through thirst in hospital. The Times, April 22 2014

Thousands die of thirst and poor care in NHS. The Daily Telegraph, April 22 2014

Tragedy of 3,000 patients that die of thirst in hospitals every month. Daily Express, April 22 2014

Links To Science

Kerr M, Bedford M, Matthews B, O’ Donoghue D. The economic impact of acute kidney injury in England. Nephrology Dialysis Transplantation. Published online April 21 2014


 

 
A FedWeb Site