Detecting congenital malformations - Lessons learned from the Mpepu study, Botswana
Identifieur interne : 000643 ( Main/Exploration ); précédent : 000642; suivant : 000644Detecting congenital malformations - Lessons learned from the Mpepu study, Botswana
Auteurs : Gbolahan Ajibola [Botswana] ; Rebecca Zash [Botswana, États-Unis] ; Roger L. Shapiro [Botswana, États-Unis] ; Oganne Batlang [Botswana] ; Kerapetse Botebele [Botswana] ; Kara Bennett [États-Unis] ; Florence Chilisa [Botswana] ; Erik Von Widenfelt [Botswana] ; Joseph Makhema [Botswana] ; Shahin Lockman [Botswana, États-Unis] ; Lewis B. Holmes [États-Unis] ; Kathleen M. Powis [Botswana, États-Unis]Source :
- PLoS ONE [ 1932-6203 ] ; 2017.
Abstract
A large and increasing number of HIV-infected women are conceiving on antiretroviral treatment (ART). While most antiretrovirals are considered safe in pregnancy, monitoring for rare pregnancy and infant adverse outcomes is warranted.
We conducted a retrospective secondary analysis nested within a clinical trial of infant cotrimoxazole vs. placebo prophylaxis in Botswana (the Mpepu Study). Infants were examined at birth, and at least every 3 months through 18 months of age. Abnormal physical findings and diagnostic testing revealing malformations were documented. Post hoc, a geneticist classified all reported malformations based on available documentation. Structural malformations with surgical, medical or cosmetic importance were classified as major malformations. We present a descriptive analysis of identified malformations.
Between 2011 and 2014, 2,933 HIV-infected women who enrolled in the Mpepu study delivered 2,971 live-born infants. Study staff conducted 2,944 (99%) newborn exams. One thousand eighty-eight (38%) women were taking ART at conception; 1,147 (40%) started ART during pregnancy; 442 (15%) received zidovudine monotherapy; and 223 (7%) received no antiretroviral during pregnancy. Of 33 reported anomalies, 25 (76%) met congenital malformations criteria, 10 (30%) were classified as major malformations, 4 (40%) of which were identified after the birth exam.
Our results highlight the importance of staff training on identification of congenital malformations, programmatic monitoring beyond the birth examination and the value of geneticist involvement in the malformations classification process in resource-limited settings. These elements will be important to fully define antiretroviral drug safety in pregnancy.
Surveillance systems for monitoring the safety of antiretroviral use during pregnancy among HIV-infected women in resource-limited setting are lacking. The World Health Organization’s published programmatic recommendations for such surveillance systems represents the gold standard. We employed data from a clinical trial in Botswana, a country with a generalized HIV epidemic and high antiretroviral uptake by HIV-infected women, to highlight practical opportunities to strengthen congenital malformation surveillance systems in these settings where over 1 million HIV infected pregnant women reside.
Clinical Trials.gov
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DOI: 10.1371/journal.pone.0173800
PubMed: 28339500
PubMed Central: 5365099
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Chan School of Public Health, Boston, Massachusetts, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts</wicri:regionArea><placeName><region type="state">Massachusetts</region></placeName></affiliation></author><author><name sortKey="Shapiro, Roger L" sort="Shapiro, Roger L" uniqKey="Shapiro R" first="Roger L." last="Shapiro">Roger L. Shapiro</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana</addr-line></nlm:aff><country xml:lang="fr">Botswana</country><wicri:regionArea>Botswana Harvard AIDS Institute Partnership, Gaborone</wicri:regionArea><wicri:noRegion>Gaborone</wicri:noRegion></affiliation><affiliation wicri:level="2"><nlm:aff id="aff003"><addr-line>Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Department of Immunology and Infectious Diseases, Harvard T.H. 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Chan School of Public Health, Boston, Massachusetts, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts</wicri:regionArea><placeName><region type="state">Massachusetts</region></placeName></affiliation><affiliation wicri:level="2"><nlm:aff id="aff005"><addr-line>Infectious Disease Unit, Brigham and Women's Hospital, Boston, Massachusetts, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Infectious Disease Unit, Brigham and Women's Hospital, Boston, Massachusetts</wicri:regionArea><placeName><region type="state">Massachusetts</region></placeName></affiliation></author><author><name sortKey="Holmes, Lewis B" sort="Holmes, Lewis B" uniqKey="Holmes L" first="Lewis B." last="Holmes">Lewis B. 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Chan School of Public Health, Boston, Massachusetts, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts</wicri:regionArea><placeName><region type="state">Massachusetts</region></placeName></affiliation></author><author><name sortKey="Shapiro, Roger L" sort="Shapiro, Roger L" uniqKey="Shapiro R" first="Roger L." last="Shapiro">Roger L. Shapiro</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana</addr-line></nlm:aff><country xml:lang="fr">Botswana</country><wicri:regionArea>Botswana Harvard AIDS Institute Partnership, Gaborone</wicri:regionArea><wicri:noRegion>Gaborone</wicri:noRegion></affiliation><affiliation wicri:level="2"><nlm:aff id="aff003"><addr-line>Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts</wicri:regionArea><placeName><region type="state">Massachusetts</region></placeName></affiliation></author><author><name sortKey="Batlang, Oganne" sort="Batlang, Oganne" uniqKey="Batlang O" first="Oganne" last="Batlang">Oganne Batlang</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana</addr-line></nlm:aff><country xml:lang="fr">Botswana</country><wicri:regionArea>Botswana Harvard AIDS Institute Partnership, Gaborone</wicri:regionArea><wicri:noRegion>Gaborone</wicri:noRegion></affiliation></author><author><name sortKey="Botebele, Kerapetse" sort="Botebele, Kerapetse" uniqKey="Botebele K" first="Kerapetse" last="Botebele">Kerapetse Botebele</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana</addr-line></nlm:aff><country xml:lang="fr">Botswana</country><wicri:regionArea>Botswana Harvard AIDS Institute Partnership, Gaborone</wicri:regionArea><wicri:noRegion>Gaborone</wicri:noRegion></affiliation></author><author><name sortKey="Bennett, Kara" sort="Bennett, Kara" uniqKey="Bennett K" first="Kara" last="Bennett">Kara Bennett</name><affiliation wicri:level="2"><nlm:aff id="aff004"><addr-line>Bennett Statistical Consulting, Inc., Ballston Lake, New York, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Bennett Statistical Consulting, Inc., Ballston Lake, New York</wicri:regionArea><placeName><region type="state">État de New York</region></placeName></affiliation></author><author><name sortKey="Chilisa, Florence" sort="Chilisa, Florence" uniqKey="Chilisa F" first="Florence" last="Chilisa">Florence Chilisa</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana</addr-line></nlm:aff><country xml:lang="fr">Botswana</country><wicri:regionArea>Botswana Harvard AIDS Institute Partnership, Gaborone</wicri:regionArea><wicri:noRegion>Gaborone</wicri:noRegion></affiliation></author><author><name sortKey="Von Widenfelt, Erik" sort="Von Widenfelt, Erik" uniqKey="Von Widenfelt E" first="Erik" last="Von Widenfelt">Erik Von Widenfelt</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana</addr-line></nlm:aff><country xml:lang="fr">Botswana</country><wicri:regionArea>Botswana Harvard AIDS Institute Partnership, Gaborone</wicri:regionArea><wicri:noRegion>Gaborone</wicri:noRegion></affiliation></author><author><name sortKey="Makhema, Joseph" sort="Makhema, Joseph" uniqKey="Makhema J" first="Joseph" last="Makhema">Joseph Makhema</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana</addr-line></nlm:aff><country xml:lang="fr">Botswana</country><wicri:regionArea>Botswana Harvard AIDS Institute Partnership, Gaborone</wicri:regionArea><wicri:noRegion>Gaborone</wicri:noRegion></affiliation></author><author><name sortKey="Lockman, Shahin" sort="Lockman, Shahin" uniqKey="Lockman S" first="Shahin" last="Lockman">Shahin Lockman</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana</addr-line></nlm:aff><country xml:lang="fr">Botswana</country><wicri:regionArea>Botswana Harvard AIDS Institute Partnership, Gaborone</wicri:regionArea><wicri:noRegion>Gaborone</wicri:noRegion></affiliation><affiliation wicri:level="2"><nlm:aff id="aff003"><addr-line>Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts</wicri:regionArea><placeName><region type="state">Massachusetts</region></placeName></affiliation><affiliation wicri:level="2"><nlm:aff id="aff005"><addr-line>Infectious Disease Unit, Brigham and Women's Hospital, Boston, Massachusetts, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Infectious Disease Unit, Brigham and Women's Hospital, Boston, Massachusetts</wicri:regionArea><placeName><region type="state">Massachusetts</region></placeName></affiliation></author><author><name sortKey="Holmes, Lewis B" sort="Holmes, Lewis B" uniqKey="Holmes L" first="Lewis B." last="Holmes">Lewis B. Holmes</name><affiliation wicri:level="2"><nlm:aff id="aff006"><addr-line>Genetics Unit, MassGeneral Hospital for Children, Boston, Massachusetts, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Genetics Unit, MassGeneral Hospital for Children, Boston, Massachusetts</wicri:regionArea><placeName><region type="state">Massachusetts</region></placeName></affiliation></author><author><name sortKey="Powis, Kathleen M" sort="Powis, Kathleen M" uniqKey="Powis K" first="Kathleen M" last="Powis">Kathleen M. Powis</name><affiliation wicri:level="1"><nlm:aff id="aff001"><addr-line>Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana</addr-line></nlm:aff><country xml:lang="fr">Botswana</country><wicri:regionArea>Botswana Harvard AIDS Institute Partnership, Gaborone</wicri:regionArea><wicri:noRegion>Gaborone</wicri:noRegion></affiliation><affiliation wicri:level="2"><nlm:aff id="aff003"><addr-line>Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts</wicri:regionArea><placeName><region type="state">Massachusetts</region></placeName></affiliation><affiliation wicri:level="2"><nlm:aff id="aff007"><addr-line>Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts</wicri:regionArea><placeName><region type="state">Massachusetts</region></placeName></affiliation><affiliation wicri:level="2"><nlm:aff id="aff008"><addr-line>Global Health, MassGeneral Hospital for Children, Boston, Massachusetts, United States of America</addr-line></nlm:aff><country xml:lang="fr">États-Unis</country><wicri:regionArea>Global Health, MassGeneral Hospital for Children, Boston, Massachusetts</wicri:regionArea><placeName><region type="state">Massachusetts</region></placeName></affiliation></author></analytic><series><title level="j">PLoS ONE</title><idno type="eISSN">1932-6203</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="sec001"><title>Introduction</title><p>A large and increasing number of HIV-infected women are conceiving on antiretroviral treatment (ART). While most antiretrovirals are considered safe in pregnancy, monitoring for rare pregnancy and infant adverse outcomes is warranted.</p></sec><sec id="sec002"><title>Methods</title><p>We conducted a retrospective secondary analysis nested within a clinical trial of infant cotrimoxazole vs. placebo prophylaxis in Botswana (the Mpepu Study). Infants were examined at birth, and at least every 3 months through 18 months of age. Abnormal physical findings and diagnostic testing revealing malformations were documented. Post hoc, a geneticist classified all reported malformations based on available documentation. Structural malformations with surgical, medical or cosmetic importance were classified as major malformations. We present a descriptive analysis of identified malformations.</p></sec><sec id="sec003"><title>Results</title><p>Between 2011 and 2014, 2,933 HIV-infected women who enrolled in the Mpepu study delivered 2,971 live-born infants. Study staff conducted 2,944 (99%) newborn exams. One thousand eighty-eight (38%) women were taking ART at conception; 1,147 (40%) started ART during pregnancy; 442 (15%) received zidovudine monotherapy; and 223 (7%) received no antiretroviral during pregnancy. Of 33 reported anomalies, 25 (76%) met congenital malformations criteria, 10 (30%) were classified as major malformations, 4 (40%) of which were identified after the birth exam.</p></sec><sec id="sec004"><title>Discussion</title><p>Our results highlight the importance of staff training on identification of congenital malformations, programmatic monitoring beyond the birth examination and the value of geneticist involvement in the malformations classification process in resource-limited settings. These elements will be important to fully define antiretroviral drug safety in pregnancy.</p></sec><sec id="sec005"><title>Significance</title><p>Surveillance systems for monitoring the safety of antiretroviral use during pregnancy among HIV-infected women in resource-limited setting are lacking. The World Health Organization’s published programmatic recommendations for such surveillance systems represents the gold standard. We employed data from a clinical trial in Botswana, a country with a generalized HIV epidemic and high antiretroviral uptake by HIV-infected women, to highlight practical opportunities to strengthen congenital malformation surveillance systems in these settings where over 1 million HIV infected pregnant women reside.</p></sec><sec id="sec006"><title>Trial registration</title><p>Clinical Trials.gov <ext-link ext-link-type="uri" xlink:href="https://clinicaltrials.gov/ct2/show/NCT01229761">NCT01229761</ext-link></p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Shapiro, Rl" uniqKey="Shapiro R">RL Shapiro</name></author><author><name sortKey="Hughes, M" uniqKey="Hughes M">M Hughes</name></author><author><name sortKey="Ogwu, A" uniqKey="Ogwu A">A Ogwu</name></author><author><name sortKey="Kitch, D" uniqKey="Kitch D">D Kitch</name></author><author><name sortKey="Lockman, S" uniqKey="Lockman S">S Lockman</name></author><author><name sortKey="Moffatt, C" uniqKey="Moffatt C">C Moffatt</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Marazzi, Mc" uniqKey="Marazzi M">MC Marazzi</name></author><author><name sortKey="Nielsen Saines, K" uniqKey="Nielsen Saines K">K Nielsen-Saines</name></author><author><name sortKey="Buonomo, E" uniqKey="Buonomo E">E Buonomo</name></author><author><name sortKey="Scarcella, P" uniqKey="Scarcella P">P Scarcella</name></author><author><name sortKey="Germano, P" uniqKey="Germano P">P Germano</name></author><author><name sortKey="Majid, Ma" uniqKey="Majid M">MA Majid</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="De Vincenzi, I" uniqKey="De Vincenzi I">I de Vincenzi</name></author><author><name sortKey="Farley, T" uniqKey="Farley T">T Farley</name></author><author><name sortKey="Gaillard, P" uniqKey="Gaillard P">P Gaillard</name></author><author><name sortKey="Meda, N" uniqKey="Meda N">N Meda</name></author><author><name sortKey="Rollins, N" uniqKey="Rollins N">N Rollins</name></author><author><name sortKey="Luchters, S" uniqKey="Luchters S">S Luchters</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chasela, Cs" uniqKey="Chasela C">CS Chasela</name></author><author><name sortKey="Hudgens, Mg" uniqKey="Hudgens M">MG Hudgens</name></author><author><name sortKey="Jamieson, Dj" uniqKey="Jamieson D">DJ Jamieson</name></author><author><name sortKey="Kayira, D" uniqKey="Kayira D">D Kayira</name></author><author><name sortKey="Hosseinipour, Mc" uniqKey="Hosseinipour M">MC Hosseinipour</name></author><author><name sortKey="Kourtis, Ap" uniqKey="Kourtis A">AP Kourtis</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Thang, Meow Keong" uniqKey="Thang M">Meow-Keong Thang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sitkin, Na" uniqKey="Sitkin N">NA Sitkin</name></author><author><name sortKey="Ozgetiz, D" uniqKey="Ozgetiz D">D Ozgetiz</name></author><author><name sortKey="Donkor, P" uniqKey="Donkor P">P Donkor</name></author><author><name sortKey="Farmer, Dl" uniqKey="Farmer D">DL Farmer</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Holmes, Lb" uniqKey="Holmes L">LB Holmes</name></author><author><name sortKey="Westage, Mn" uniqKey="Westage M">MN Westage</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Smith, Se" uniqKey="Smith S">SE Smith</name></author><author><name sortKey="Ludwig, Jt" uniqKey="Ludwig J">JT Ludwig</name></author><author><name sortKey="Chinchilli, Vm" uniqKey="Chinchilli V">VM Chinchilli</name></author><author><name sortKey="Mehta, K" uniqKey="Mehta K">K Mehta</name></author><author><name sortKey="Stoute, Ja" uniqKey="Stoute J">JA Stoute</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ramogola Masire, D" uniqKey="Ramogola Masire D">D Ramogola-Masire</name></author><author><name sortKey="De Klerk, R" uniqKey="De Klerk R">R de Klerk</name></author><author><name sortKey="Monare, B" uniqKey="Monare B">B Monare</name></author><author><name sortKey="Ratshaa, B" uniqKey="Ratshaa B">B Ratshaa</name></author><author><name sortKey="Friedman, H" uniqKey="Friedman H">H Friedman</name></author><author><name sortKey="Zetola, Nm" uniqKey="Zetola N">NM Zetola</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gulley, Ml" uniqKey="Gulley M">ML Gulley</name></author><author><name sortKey="Morgan, Dr" uniqKey="Morgan D">DR Morgan</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Busby, A" uniqKey="Busby A">A Busby</name></author><author><name sortKey="Ritvanen, A" uniqKey="Ritvanen A">A Ritvanen</name></author><author><name sortKey="Dolk, H" uniqKey="Dolk H">H Dolk</name></author><author><name sortKey="Armstrong, N" uniqKey="Armstrong N">N Armstrong</name></author><author><name sortKey="De Walle, H" uniqKey="De Walle H">H De Walle</name></author><author><name sortKey="Riano Galan, I" uniqKey="Riano Galan I">I Riano-Galan</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Mofenson, Lm" uniqKey="Mofenson L">LM Mofenson</name></author><author><name sortKey="Watts, Dh" uniqKey="Watts D">DH Watts</name></author></analytic></biblStruct></listBibl></div1></back></TEI><affiliations><list><country><li>Botswana</li><li>États-Unis</li></country><region><li>Massachusetts</li><li>État de New York</li></region></list><tree><country name="Botswana"><noRegion><name sortKey="Ajibola, Gbolahan" sort="Ajibola, Gbolahan" uniqKey="Ajibola G" first="Gbolahan" last="Ajibola">Gbolahan Ajibola</name></noRegion><name sortKey="Batlang, Oganne" sort="Batlang, Oganne" uniqKey="Batlang O" first="Oganne" last="Batlang">Oganne Batlang</name><name sortKey="Botebele, Kerapetse" sort="Botebele, Kerapetse" uniqKey="Botebele K" first="Kerapetse" last="Botebele">Kerapetse Botebele</name><name sortKey="Chilisa, Florence" sort="Chilisa, Florence" uniqKey="Chilisa F" first="Florence" last="Chilisa">Florence Chilisa</name><name sortKey="Lockman, Shahin" sort="Lockman, Shahin" uniqKey="Lockman S" first="Shahin" last="Lockman">Shahin Lockman</name><name sortKey="Makhema, Joseph" sort="Makhema, Joseph" uniqKey="Makhema J" first="Joseph" last="Makhema">Joseph Makhema</name><name sortKey="Powis, Kathleen M" sort="Powis, Kathleen M" uniqKey="Powis K" first="Kathleen M" last="Powis">Kathleen M. Powis</name><name sortKey="Shapiro, Roger L" sort="Shapiro, Roger L" uniqKey="Shapiro R" first="Roger L." last="Shapiro">Roger L. Shapiro</name><name sortKey="Von Widenfelt, Erik" sort="Von Widenfelt, Erik" uniqKey="Von Widenfelt E" first="Erik" last="Von Widenfelt">Erik Von Widenfelt</name><name sortKey="Zash, Rebecca" sort="Zash, Rebecca" uniqKey="Zash R" first="Rebecca" last="Zash">Rebecca Zash</name></country><country name="États-Unis"><region name="Massachusetts"><name sortKey="Zash, Rebecca" sort="Zash, Rebecca" uniqKey="Zash R" first="Rebecca" last="Zash">Rebecca Zash</name></region><name sortKey="Bennett, Kara" sort="Bennett, Kara" uniqKey="Bennett K" first="Kara" last="Bennett">Kara Bennett</name><name sortKey="Holmes, Lewis B" sort="Holmes, Lewis B" uniqKey="Holmes L" first="Lewis B." last="Holmes">Lewis B. Holmes</name><name sortKey="Lockman, Shahin" sort="Lockman, Shahin" uniqKey="Lockman S" first="Shahin" last="Lockman">Shahin Lockman</name><name sortKey="Lockman, Shahin" sort="Lockman, Shahin" uniqKey="Lockman S" first="Shahin" last="Lockman">Shahin Lockman</name><name sortKey="Powis, Kathleen M" sort="Powis, Kathleen M" uniqKey="Powis K" first="Kathleen M" last="Powis">Kathleen M. Powis</name><name sortKey="Powis, Kathleen M" sort="Powis, Kathleen M" uniqKey="Powis K" first="Kathleen M" last="Powis">Kathleen M. Powis</name><name sortKey="Powis, Kathleen M" sort="Powis, Kathleen M" uniqKey="Powis K" first="Kathleen M" last="Powis">Kathleen M. Powis</name><name sortKey="Shapiro, Roger L" sort="Shapiro, Roger L" uniqKey="Shapiro R" first="Roger L." last="Shapiro">Roger L. Shapiro</name><name sortKey="Zash, Rebecca" sort="Zash, Rebecca" uniqKey="Zash R" first="Rebecca" last="Zash">Rebecca Zash</name></country></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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