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1. Management of suspected and confirmed COVID-19 (SARS-CoV-2) vaccine hypersensitivity.

Author

Worm M, Alexiou A, Bauer A, Treudler R, Wurpts G, Dickel H, Buhl T, Müller S, Jung A, Brehler R, Fluhr J, Klimek L, Mülleneisen N, Pfützner W, Raap U, Roeseler S, Schuh S, Timmermann H, Heine G, Wedi B, and Brockow K

Subjects
Humans, Vaccination adverse effects, COVID-19 prevention & control, COVID-19 Vaccines adverse effects, Hypersensitivity diagnosis, Hypersensitivity epidemiology, Hypersensitivity etiology
Abstract

Background: Systemic allergic reactions to vaccines are very rare. In this study we assessed the management and outcome of suspected SARS-CoV-2 vaccine hypersensitivity., Methods: Totally, 334 individuals underwent an allergy work up regarding SARS-CoV-2 vaccination (group A: 115 individuals suspected to be at increased risk for vaccine-related reactions before vaccination and group B: 219 patients with reactions after COVID vaccination). The large majority of the SPT/IDT with the vaccines were negative; however, we identified in 14.1% (n = 47) a possible sensitization to the SARS-CoV-2 vaccine and/or its ingredients defined as one positive skin test. Of the 219 individuals (group B) who experienced symptoms suspicious for a hypersensitivity reaction after vaccination, 214 were reported after the first vaccination with a mRNA vaccine (157 mRNA (Comirnaty®, 38 Spikevax®) and 18 with a vector vaccine (Vaxzevria®), 5 cases were after the second vaccination., Results: The symptom profile in group B was as follows: skin symptoms occurred in 115 cases (n = 59 angioedema, n = 50 generalized urticaria and n = 23 erythema/flush. Seventy individuals had cardiovascular, 53 respiratory and 17 gastrointestinal symptoms. Of the overall 334 individuals, 78 patients tolerated (re)-vaccination (out of skin test positive/negative 7/19 from group A and 17/35 from group B)., Conclusion: Proven IgE-mediated hypersensitivity to SARS-CoV-2 vaccines is extremely rare and not increased in comparison with reported hypersensitivity to other vaccines. The value of skin tests is unclear and nonspecific reactions, in particular when intradermal testing is applied, should be considered., (© 2022 The Authors. Allergy published by European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd.)

Published
2022
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2. COVID-19 pandemic: Practical considerations on the organization of an allergy clinic-An EAACI/ARIA Position Paper.

Author

Pfaar O, Klimek L, Jutel M, Akdis CA, Bousquet J, Breiteneder H, Chinthrajah S, Diamant Z, Eiwegger T, Fokkens WJ, Fritsch HW, Nadeau KC, O'Hehir RE, O'Mahony L, Rief W, Sampath V, Schedlowski M, Torres MJ, Traidl-Hoffmann C, Wang Y, Zhang L, Bonini M, Brehler R, Brough HA, Chivato T, Del Giacco SR, Dramburg S, Gawlik R, Gelincik A, Hoffmann-Sommergruber K, Hox V, Knol EF, Lauerma A, Matricardi PM, Mortz CG, Ollert M, Palomares O, Riggioni C, Schwarze J, Skypala I, Untersmayr E, Walusiak-Skorupa J, Ansotegui IJ, Bachert C, Bedbrook A, Bosnic-Anticevich S, Brussino L, Canonica GW, Cardona V, Carreiro-Martins P, Cruz AA, Czarlewski W, Fonseca JA, Gotua M, Haahtela T, Ivancevich JC, Kuna P, Kvedariene V, Larenas-Linnemann DE, Abdul Latiff AH, Mäkelä M, Morais-Almeida M, Mullol J, Naclerio R, Ohta K, Okamoto Y, Onorato GL, Papadopoulos NG, Patella V, Regateiro FS, Samoliński B, Suppli Ulrik C, Toppila-Salmi S, Valiulis A, Ventura MT, Yorgancioglu A, Zuberbier T, and Agache I

Subjects
Allergists, COVID-19 prevention & control, Health Personnel, Humans, Hypersensitivity diagnosis, Information Technology, Patient Care Team, Triage, COVID-19 epidemiology, Hypersensitivity therapy, SARS-CoV-2
Abstract

Background: The coronavirus disease 2019 (COVID-19) has evolved into a pandemic infectious disease transmitted by the severe acute respiratory syndrome coronavirus (SARS-CoV-2). Allergists and other healthcare providers (HCPs) in the field of allergies and associated airway diseases are on the front line, taking care of patients potentially infected with SARS-CoV-2. Hence, strategies and practices to minimize risks of infection for both HCPs and treated patients have to be developed and followed by allergy clinics., Method: The scientific information on COVID-19 was analysed by a literature search in MEDLINE, PubMed, the National and International Guidelines from the European Academy of Allergy and Clinical Immunology (EAACI), the Cochrane Library, and the internet., Results: Based on the diagnostic and treatment standards developed by EAACI, on international information regarding COVID-19, on guidelines of the World Health Organization (WHO) and other international organizations, and on previous experience, a panel of experts including clinicians, psychologists, IT experts, and basic scientists along with EAACI and the "Allergic Rhinitis and its Impact on Asthma (ARIA)" initiative have developed recommendations for the optimal management of allergy clinics during the current COVID-19 pandemic. These recommendations are grouped into nine sections on different relevant aspects for the care of patients with allergies., Conclusions: This international Position Paper provides recommendations on operational plans and procedures to maintain high standards in the daily clinical care of allergic patients while ensuring the necessary safety measures in the current COVID-19 pandemic., (© 2020 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Published
2021
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3. White paper on peanut allergy – part 1: Epidemiology, burden of disease, health economic aspects

Author

Lange, Lars, Klimek, Ludger, Beyer, Kirsten, Blümchen, Katharina, Novak, Natalija, Hamelmann, Eckard, Bauer, Andrea, Merk, Hans, Rabe, Uta, Jung, Kirsten, Schlenter, Wolfgang, Ring, Johannes, Chaker, Adam, Wehrmann, Wolfgang, Becker, Sven, Mülleneisen, Norbert, Nemat, Katja, Czech, Wolfgang, Wrede, Holger, Brehler, Randolf, Fuchs, Thomas, Jakob, Thilo, Ankermann, Tobias, Schmidt, Sebastian M., Gerstlauer, Michael, Zuberbier, Torsten, Spindler, Thomas, and Vogelberg, Christian

Published
2021
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5. Immunologisch relevante Aspekte der neuen COVID-19-Impfstoffe

Author

Untersmayr, Eva, Förster-Waldl, Elisabeth, Bonelli, Michael, Boztug, Kaan, Brunner, Patrick M., Eiwegger, Thomas, Eller, Kathrin, Göschl, Lisa, Grabmeier-Pfistershammer, Katharina, Hötzenecker, Wolfram, Jordakieva, Galateja, Moschen, Alexander R., Pfaller, Birgit, Pickl, Winfried, Reinisch, Walter, Wiedermann, Ursula, Klimek, Ludger, Bergmann, Karl-Christian, Brehler, Randolf, Novak, Natalija, Merk, Hans F., Rabe, Uta, Schlenter, Wolfgang W., Ring, Johannes, Wehrmann, Wolfgang, Mülleneisen, Norbert K., Wrede, Holger, Fuchs, Thomas, and Jensen-Jarolim, Erika

Subjects
Immunsuppression, Impfwirkung, COVID-19, Immunantwort, COVID-19-Impfung, Immunmodulation, Leitlinie
Published
2021

6. Praktischer Umgang mit allergischen Reaktionen auf COVID-19-Impfstoffe

Author

Klimek, Ludger, Bergmann, Karl-Christian, Brehler, Randolf, Pfützner, Wolfgang, Worm, Margitta, Hartmann, Karin, Jakob, Thilo, Novak, Natalija, Ring, Johannes, Hamelmann, Eckard, Ankermann, Tobias, Schmidt, Sebastian M., Untersmayr, Eva, Hötzenecker, Wolfram, Jensen-Jarolim, Erika, and Zuberbier, Torsten

Subjects
mRNA-1273, mRNA-Impfstoff, Anaphylaxie, SARS-CoV-2, allergische Reaktion, COVID-19, BNT162b2, Leitlinie
Abstract

Hintergrund: Zur vorbeugenden Behandlung von COVID-19 (Coronaviruserkrankung 2019) wurden in einer beispiellosen weltweiten Forschungsanstrengung Sicherheit und Wirksamkeit neuer Impfstoffplattformen studiert, die noch nie zuvor am Menschen eingesetzt wurden. Weniger als ein Jahr nach der Entdeckung der SARS-CoV-2-Virussequenz (SARS-CoV-2, "severe acute respiratory syndrome coronavirus type 2") wurden diese in zahlreichen Ländern für den Einsatz zugelassen und es wurde mit Massenimpfungen begonnen. Die bislang in der Europäischen Union (EU) zugelassenen mRNA-Impfstoffe (mRNA, "messenger"-RNA) gegen SARS-CoV-2 BNT162b2 und mRNA-1273 basieren auf einer ähnlichen lipidbasierten Nanopartikelträgertechnologie; die Lipidkomponenten unterscheiden sich jedoch. Schwere allergische Reaktionen und Anaphylaxien nach COVID-19-Impfungen sind sehr seltene unerwünschte Nebenwirkungen, die aber aufgrund potenziell letaler Ausgänge viel Aufmerksamkeit erhalten und ein hohes Maß an Verunsicherung ausgelöst haben. Methoden: Das aktuelle Wissen zu anaphylaktischen Reaktionen auf Impfstoffe und speziell zu den derzeit neuen mRNA-COVID-19-Impfstoffen wurde zusammengestellt mittels einer Literaturanalyse durch Recherchen in Medline, Pubmed sowie den nationalen und internationalen Studien- und Leitlinienregistern, der Cochrane Library und dem Internet unter besonderer Berücksichtigung offizieller Webseiten der World Health Oranization (WHO), der Centers for Disease Control and Prevention (CDC), der European Medicines Agency (EMA), des Robert-Koch-Instituts (RKI) und des Paul-Ehrlich-Instituts (PEI). Ergebnisse: Basierend auf der internationalen Literatur und bisheriger Erfahrungen zu schweren allergischen Reaktionen im Kontext der COVID-19-Impfungen werden von einem Expertengremium Empfehlungen für Prophylaxe, Diagnostik und Therapie dieser allergischen Reaktionen gegeben. Schlussfolgerung: Vor einer COVID-19-Impfung mit den derzeit zugelassenen Impfstoffen sind Allergietests für die allermeisten Allergiker nicht notwendig. Bei allergischer/anaphylaktischer Reaktion auf den verabreichten COVID-19-Impfstoff wird eine allergologische Abklärung empfohlen, wie auch für eine kleine potenzielle Risikopopulation vor der ersten Impfung. Die Evaluierung und Zulassung von Testverfahren sollten hierfür erfolgen. Zitierweise: Klimek L, Bergmann K-C, Brehler R, Pfützner W, Zuberbier T, Hartmann K, Jakob T, Novak N, Ring J, Merk H; Hamelmann E, Ankermann T, Schmidt S, Untersmayr E, Hötzenecker W, Jensen-Jarolim E, Brockow K, Mahler V, Worm M. Practical Handling of Allergic Reactions to COVID-19 vaccines. A Position Paper from German and Austrian Allergy Societies AeDA, DGAKI, GPA and ÖGAI. Allergo J Int 2021;30:79-95 https: //doi.org/10.1007/s40629-021-00165-7

Published
2021

7. Anwendung von Biologika bei allergischen und Typ-2-entzündlichen Erkrankungen in der aktuellen Covid-19-Pandemiea, b, c

Author

Klimek, Ludger, Pfaar, Oliver, Worm, Margitta, Eiwegger, Thomas, Hagemann, Jan, Ollert, Markus, Untersmayr, Eva, Hoffmann-Sommergruber, Karin, Vultaggio, Alessandra, Agache, Ioana, Bavbek, Sevim, Bossios, Apostolos, Casper, Ingrid, Chan, Susan, Chatzipetrou, Alexia, Vogelberg, Christian, Firinu, Davide, Kauppi, Paula, Kolios, Antonios, Kothari, Akash, Matucci, Andrea, Palomares, Oscar, Szépfalusi, Zsolt, Pohl, Wolfgang, Hötzenecker, Wolfram, Rosenkranz, Alexander, Bergmann, Karl-Christian, Bieber, Thomas, Buhl, Roland, Buters, Jeroen, Darsow, Ulf, Keil, Thomas, Kleine-Tebbe, Jörg, Lau, Susanne, Maurer, Marcus, Merk, Hans, Mösges, Ralph, Saloga, Joachim, Staubach, Petra, Jappe, Uta, Rabe, Claus, Rabe, Uta, Vogelmeier, Claus, Biedermann, Tilo, Jung, Kirsten, Schlenter, Wolfgang, Ring, Johannes, Chaker, Adam, Wehrmann, Wolfgang, Becker, Sven, Freudelsperger, Laura, Mülleneisen, Norbert, Nemat, Katja, Czech, Wolfgang, Wrede, Holger, Brehler, Randolf, Fuchs, Thomas, Tomazic, Peter-Valentin, Aberer, Werner, Fink Wagner, Antje, Horak, Fritz, Wöhrl, Stefan, Niederberger-Leppin, Verena, Pali-Schöll, Isabella, Roller-Wirnsberger, Regina, Spranger, Otto, Valenta, Rudolf, Akdis, Mübecell, Matricardi, Paolo M., Spertini, François, Khaltaev, Nikolai, Michel, Jean-Pierre, Nicod, Larent, Schmid-Grendelmeier, Peter, Idzko, Marco, Hamelmann, Eckard, Jakob, Thilo, Werfel, Thomas, Wagenmann, Martin, Taube, Christian, Jensen-Jarolim, Erika, Korn, Stephanie, Hentges, Francois, Schwarze, Jürgen, O´Mahony, Liam, Knol, Edward, del Giacco, Stefano, Chivato, Tomás, Bousquet, Jean, Zuberbier, Torsten, Akdis, Cezmi, and Jutel, Marek

Subjects
Titel, SARS-CoV-2, Medizin, Immunology and Allergy, Omalizumab, Benralizumab, Dupilumab, Reslizumab, Covid-19, Telemedizin, Mepolizumab
Published
2020

8. Management von Anaphylaxie-gefährdeten Patienten während der Covid-19-Pandemie

Author

Klimek, Ludger, Worm, Margitta, Lange, Lars, Beyer, Kirsten, Rietschel, Ernst, Vogelberg, Christian, Schnadt, Sabine, Stöcker, Britta, Brockow, Knut, Hagemann, Jan, Bieber, Thomas, Wehrmann, Wolfgang, Becker, Sven, Freudelsperger, Laura, Mülleneisen, Norbert K., Nemat, Katja, Czech, Wolfgang, Wrede, Holger, Brehler, Randolf, Fuchs, Thomas, Dramburg, Stephanie, Matricardi, Paolo, Hamelmann, Eckard, Werfel, Thomas, Wagenmann, Martin, Taube, Christian, Zuberbier, Torsten, and Ring, Johannes

Subjects
Titel, Insektengiftallergie, Anaphylaxie, SARS-CoV-2, Nahrungsmittelallergie, Medikamentenallergie, Immunology and Allergy, Covid-19
Published
2020
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9. Use of biologicals in allergic and type-2 inflammatory diseases during the current COVID-19 pandemic:Position paper of Ärzteverband Deutscher Allergologen (AeDA)A, Deutsche Gesellschaft für Allergologie und Klinische Immunologie (DGAKI)B, Gesellschaft für Pädiatrische Allergologie und Umweltmedizin (GPA)C, Österreichische Gesellschaft für Allergologie und Immunologie (ÖGAI)D, Luxemburgische Gesellschaft für Allergologie und Immunologie (LGAI)E, Österreichische Gesellschaft für Pneumologie (ÖGP)F in co-operation with the German, Austrian, and Swiss ARIA groupsG, and the European Academy of Allergy and Clinical Immunology (EAACI)

Author

Klimek, Ludger, Pfaar, Oliver, Worm, Margitta, Eiwegger, Thomas, Hagemann, Jan, Ollert, Markus, Untersmayr, Eva, Hoffmann-Sommergruber, Karin, Vultaggio, Alessandra, Agache, Ioana, Bavbek, Sevim, Bossios, Apostolos, Casper, Ingrid, Chan, Susan, Chatzipetrou, Alexia, Vogelberg, Christian, Firinu, Davide, Kauppi, Paula, Kolios, Antonios, Kothari, Akash, Matucci, Andrea, Palomares, Oscar, Szépfalusi, Zsolt, Pohl, Wolfgang, Hötzenecker, Wolfram, Rosenkranz, Alexander, Bergmann, Karl-Christian, Bieber, Thomas, Buhl, Roland, Buters, Jeroen, Darsow, Ulf, Keil, Thomas, Kleine-Tebbe, Jörg, Lau, Susanne, Maurer, Marcus, Merk, Hans, Mösges, Ralph, Saloga, Joachim, Staubach, Petra, Jappe, Uta, Rabe, Klaus, Rabe, Uta, Vogelmeier, Claus, Biedermann, Tilo, Jung, Kirsten, Schlenter, Wolfgang, Ring, Johannes, Chaker, Adam, Wehrmann, Wolfgang, Becker, Sven, Freudelsperger, Laura, Mülleneisen, Norbert, Nemat, Katja, Czech, Wolfgang, Wrede, Holger, Brehler, Randolf, Fuchs, Thomas, Tomazic, Peter-Valentin, Aberer, Werner, Fink-Wagner, Antje-Henriette, Horak, Fritz, Wöhrl, Stefan, Niederberger-Leppin, Verena, Pali-Schöll, Isabella, Roller-Wirnsberger, Regina, Spranger, Otto, Valenta, Rudolf, Akdis, Mübecell, Matricardi, Paolo, Spertini, François, Khaltaev, Nicolai, Michel, Jean-Pierre, Nicod, Larent, Schmid-Grendelmeier, Peter, Idzko, Marco, Hamelmann, Eckard, Jakob, Thilo, Werfel, Thomas, Wagenmann, Martin, Taube, Christian, Jensen-Jarolim, Erika, Korn, Stephanie, Hentges, Francois, Schwarze, Jürgen, O Mahony, Liam, Knol, Edward, Del Giacco, Stefano, Chivato Pérez, Tomás, Bousquet, Jean, Bedbrook, Anna, Zuberbier, Torsten, Akdis, Cezmi, Jutel, Marek, Zentrum für Rhinologie und Allergologie [Wiesbaden, Germany], Philipps Universität Marburg, Charité - UniversitätsMedizin = Charité - University Hospital [Berlin], The Hospital for sick children [Toronto] (SickKids), University of Toronto, Johannes Gutenberg - Universität Mainz (JGU), Luxembourg Institute of Health (LIH), University of Southern Denmark (SDU), Medizinische Universität Wien = Medical University of Vienna, Careggi University Hospital [Florence, Italie], Transylvania University, Ankara University School of Medicine [Turkey], Karolinska University Hospital [Stockholm], Karolinska Institutet [Stockholm], University hospital of Zurich [Zurich], Universität Zürich [Zürich] = University of Zurich (UZH), Guy's and St Thomas' Hospital [London], King‘s College London, National Technical University of Athens [Athens] (NTUA), University General Hospital ' Attikon ' [Athens, Greece], University of Athens Medical School [Athens], Universitätsklinikum Carl Gustav Carus Dresden, University of Cagliari, Harvard Medical School [Boston] (HMS), Österreichische Forschungsförderungsgesellschaft, Universidad Complutense de Madrid = Complutense University of Madrid [Madrid] (UCM), Kepler University Hospital, Medizinische Universität Graz, Universitätsklinikum Bonn (UKB), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Helmholtz-Zentrum München (HZM), Technische Universität Munchen - Université Technique de Munich [Munich, Allemagne] (TUM), University of Würzburg = Universität Würzburg, Allergie- & Asthma-Zentrum Berlin Westend, Universitätsklinikum RWTH Aachen - University Hospital Aachen [Aachen, Germany] (UKA), RWTH Aachen University, Universität zu Köln, Clinical Research International Ltd [Hamburg, Germany] (CRI), University Medical Center [Mainz], Universität zu Lübeck [Lübeck], German Research Center for Environmental Health - Helmholtz Center München (GmbH), Universitätsklinikum Tübingen - University Hospital of Tübingen, Eberhard Karls Universität Tübingen = Eberhard Karls University of Tuebingen, Asthma und Allergiezentrum [Leverkusen], Universitätsklinikum Münster [Munster, Germany], University of Göttingen - Georg-August-Universität Göttingen, Universität Wien, Vieillissement et Maladies chroniques : approches épidémiologique et de santé publique (VIMA), Université de Versailles Saint-Quentin-en-Yvelines (UVSQ)-Institut National de la Santé et de la Recherche Médicale (INSERM), European Forum for Research and Education in Allergy and Airway Diseases (EUFOREA), Centre Hospitalier Universitaire Vaudois [Lausanne] (CHUV), University of Geneva [Switzerland], Universitätsspital Zürich (USZ), Universität Bielefeld = Bielefeld University, Justus-Liebig-Universität Gießen (JLU), Medizinische Hochschule Hannover (MHH), Universitatsklinikum Dusseldorf, Dusseldorf Germany, Universitätsklinikum Essen [Universität Duisburg-Essen] (Uniklinik Essen), Centre Hospitalier de Luxembourg [Luxembourg] (CHL), University of Edinburgh, APC Microbiome Ireland, University College Cork (UCC), University Medical Center [Utrecht], Universita degli Studi di Cagliari [Cagliari], University of San Pablo, Humboldt-Universität zu Berlin, Wroclaw Medical University [Wrocław, Pologne], and Technische Universität München [München] (TUM)

Subjects
benralizumab, SARS-CoV-2, COVID-19, mepolizumab, Benralizumab, Omalizumab, Dupilumab, reslizumab, Telemedicine, dupilumab, omalizumab, telemedicine, Reslizumab, Covid-19, [SDV.MHEP]Life Sciences [q-bio]/Human health and pathology, Mepolizumab
Abstract

International audience; Background: Since the beginning of the COVID-19 pandemic, the treatment of patients with allergic and atopy-associated diseases has faced major challenges. Recommendations for "social distancing" and the fear of patients becoming infected during a visit to a medical facility have led to a drastic decrease in personal doctor-patient contacts. This affects both acute care and treatment of the chronically ill. The immune response after SARS-CoV-2 infection is so far only insufficiently understood and could be altered in a favorable or unfavorable way by therapy with monoclonal antibodies. There is currently no evidence for an increased risk of a severe COVID-19 course in allergic patients. Many patients are under ongoing therapy with biologicals that inhibit type 2 immune responses via various mechanisms. There is uncertainty about possible immunological interactions and potential risks of these biologicals in the case of an infection with SARS-CoV-2.Materials and methods: A selective literature search was carried out in PubMed, Livivo, and the internet to cover the past 10 years (May 2010 - April 2020). Additionally, the current German-language publications were analyzed. Based on these data, the present position paper provides recommendations for the biological treatment of patients with allergic and atopy-associated diseases during the COVID-19 pandemic.Results: In order to maintain in-office consultation services, a safe treatment environment must be created that is adapted to the pandemic situation. To date, there is a lack of reliable study data on the care for patients with complex respiratory, atopic, and allergic diseases in times of an imminent infection risk from SARS-CoV-2. Type-2-dominant immune reactions, as they are frequently seen in allergic patients, could influence various phases of COVID-19, e.g., by slowing down the immune reactions. Theoretically, this could have an unfavorable effect in the early phase of a SARS-Cov-2 infection, but also a positive effect during a cytokine storm in the later phase of severe courses. However, since there is currently no evidence for this, all data from patients treated with a biological directed against type 2 immune reactions who develop COVID-19 should be collected in registries, and their disease courses documented in order to be able to provide experience-based instructions in the future.Conclusion: The use of biologicals for the treatment of bronchial asthma, atopic dermatitis, chronic rhinosinusitis with nasal polyps, and spontaneous urticaria should be continued as usual in patients without suspected infection or proven SARS-CoV-2 infection. If available, it is recommended to prefer a formulation for self-application and to offer telemedical monitoring. Treatment should aim at the best possible control of difficult-to-control allergic and atopic diseases using adequate rescue and add-on therapy and should avoid the need for systemic glucocorticosteroids. If SARS-CoV-2 infection is proven or reasonably suspected, the therapy should be determined by weighing the benefits and risks individually for the patient in question, and the patient should be involved in the decision-making. It should be kept in mind that the potential effects of biologicals on the immune response in COVID-19 are currently not known. Telemedical offers are particularly desirable for the acute consultation needs of suitable patients.

Published
2020

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