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Annu. Rev. Med. 2006. 57:195206 doi: 10.1146/annurev.med.57.011205.135654 Copyright c 2006 by Annual Reviews.
All rights reserved First published online as a Review in Advance on Aug. 31, 2005
PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME

Geoffrey M. Habermacher, Judd T. Chason, and Anthony J. Schaeffer
Annu. Rev. Med. 2006.57:195-206. Downloaded from arjournals.annualreviews.org by b-on: Instituto Politecnico de Lisboa (IPL) on 01/10/08. For personal use only.
Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611; email: eghabermacher@hotmail.com, JuddChason@md.northwestern.edu, ajschaeffer@northwestern.edu
Key Words
prostate, infection, inammation
Abstract We review the diagnosis, categorization, and treatment of prostatitis/ chronic pelvic pain syndrome based on the National Institutes of Health (NIH) classication. Prostatitis is an extremely common syndrome that aficts 2%10% of men. Formerly a purely clinical diagnosis, prostatitis is now classied within a complex series of syndromes (NIH category IIV prostatitis) that vary widely in clinical presentation and response to treatment. Acute bacterial prostatitis (category I) and chronic bacterial prostatitis (category II) are characterized by uropathogenic infections of the prostate gland that respond well to antimicrobial treatment. In contrast, chronic prostatitis/chronic pelvic pain syndrome (category III), which accounts for 90%95% of prostatitis cases, is of unknown etiology and is marked by a mixture of pain, urinary, and ejaculatory symptoms with no uniformly effective therapy. Asymptomatic inammatory prostatitis (category IV) is an incidental nding of unknown clinical signicance. This review describes the current status of prostatitis syndromes and explores the future prospects of new diagnostic tools and therapies.
INTRODUCTION
The diagnosis of prostatitis has evolved dramatically over the past 40 years, from an ill-dened inammatory/infectious condition affecting the prostate to a set of specic subtypes of prostatitis with a range of clinical presentations and appropriate therapies. Prostatitis is an extremely common condition worldwide; 2%10% of men experience it during their lifetime (13). In addition, prostatitis is the most common presenting diagnosis for men <50 years of age in the outpatient urologic clinic setting (4). The original four-part classication of prostatitis consisted of acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, and prostatodynia (5). This classication set the foundation for the categorization of subtypes of prostatitis based on data gathered from men using the four-glass lower urinary tract segmented localization study developed by Meares & Stamey (6), as described below. Recently, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Chronic Prostatitis Workshop proposed a modied classication
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system of prostatitis syndromes (7). This NIH classication redened the earlier categories of nonbacterial prostatitis and prostatodynia as category III and category IV prostatitis. The NIH categories are as follows: Category I: Acute bacterial prostatitis (rare, 2%5% of cases). Acute infection of the prostate gland marked by a combination of local symptoms (e.g., dysuria, urinary frequency, and suprapubic/pelvic/perineal pain) and systemic symptoms (e.g., fevers, chills, malaise); uropathogen typically identied as causal organism; responsive to antimicrobial therapy.
Category II: Chronic bacterial prostatitis (rare, 2%5% of cases). Chronic infection of prostate gland characterized by intermittent local symptoms only (e.g., dysuria, urinary frequency, and suprapubic/pelvic/perineal pain); uropathogen typically identied as causal organism; responsive to antimicrobial therapy. Category III: Chronic nonbacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) (common, 90%95% of cases). Syndrome involving local symptoms (pelvic pain, urinary symptoms, and ejaculatory symptoms); no identiable uropathogen or infectious cause; treatment often fails to alleviate symptoms. The National Institutes of Health Chronic Prostatitis Symptom Index questionnaire (NIH-CPSI) is the primary validated tool used to quantify the severity of Category III prostatitis in the absence of any currently available biomarkers (discussed further below). Category III prostatitis is described as inammatory (IIIA) or noninammatory (IIIB) based on the presence or absence of leukocytes in the prostatic uid (see below for details). Category IV: Asymptomatic inammatory prostatitis (prevalence unknown). Incidental observation of leukocytes in prostate secretions or prostate tissue obtained during evaluation for other disorders, e.g., leukocytes noted in prostate biopsies performed for elevated prostate-specic antigen (PSA). No infectious pathogens present; no treatment necessary. Further discussion of the NIH prostatitis classications requires a brief review of the tools used to diagnose and differentiate these categories. A thorough history and physical exam, including a complete genitourinary exam with digital rectal exam (DRE), urinalysis with microscopic evaluation, and urine culture, are mandatory in all cases of possible prostatitis. Optional or situation-specic diagnostic maneuvers include the Meares-Stamey four-glass lower urinary tract segmented localization test, NIH-CPSI questionnaire, and urologic consultation. The four-glass localization test (6) provides critical uid and culture data that enable correct identication of category II or chronic prostatitis. This test involves the collection of sequential urine and prostatic uid specimens before, during, and after prostatic massage. The rst collected sample is the initial 10 mL of voided urine (voided bladder 1 or VB1representing urethral ora and/or inammation), followed by a midstream urine sample collected after 200 mL has been voided (VB2representing bladder
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ora and/or inammation). At this point prostatic massage is performed by the physician and the resultant expressed prostatic secretions are collected, followed by the nal voided urine sample (VB3). These samples are then sent for culture and microscopic analysis. The Chronic Prostatitis Collaborative Research Network developed and validated the NIH-CPSI to quantify the severity of CP/CPPS symptoms (8), providing an objective outcome measure for therapy and investigation. The NIH-CPSI (see Figure 1) consists of 13 questions that ask patients to quantify pain symptoms, urinary symptoms, and impact on quality of life. The answers can easily be converted into numeric values for data analysis and outcome assessment. The NIH-CPSI has become the primary instrument used for the quantication of CP/CPPS and has already been used in multiple placebo-controlled clinical trials (9, 10).
Figure 1 The National Institutes of Health Chronic Prostatitis Symptom Index questionnaire.
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NIH CATEGORY I PROSTATITIS (ACUTE BACTERIAL PROSTATITIS)

Acute bacterial prostatitis (NIH category I) typically represents an ascending infection of the prostate gland with uropathogenic bacteria (Escherichia coli, Klebsiella spp., Enterobacter spp., Serratia marcescens, Pseudomonas aeruginosa) (1113). The clinical presentation of category I prostatitis is often dramatic and can be a medical emergency necessitating inpatient hospitalization. Classically, patients with category I prostatitis manifest an acute onset of local and systemic symptoms. The systemic symptoms are consistent with sepsis, including fevers, chills, and malaise. The local symptoms typically include perineal prostatic pain, dysuria, and obstructive urinary symptoms (e.g., frequency, incomplete emptying, double voiding, or inability to void). The diagnostic work-up for patients thought to have category I prostatitis includes history, physical examination (with gentle DRE), urinalysis with microscopic evaluation, urine culture, and blood cultures (if systemic symptoms are present). The Meares-Stamey localization test is contraindicated in these patients because prostate massage can disseminate bacteria and exacerbate symptoms. On history, special emphasis should be placed on assessing for immunocompromised status, recent urinary tract infections, and recent urologic instrumentation (e.g., prostate biopsies, urinary catheters, etc.). The physical exam should include a thorough genitourinary exam with gentle DRE to evaluate for tenderness, uctulance, and masses. The prostate exam will usually reveal a tender, rm, and occasionally boggy prostate. Bladder palpation (or ultrasound residual) is also advised to assess for urinary retention, which is a common result of category I prostatitis. Initial therapy for category I prostatitis with systemic symptoms is hospital admission, intravenous antimicrobials (e.g., -lactam and aminoglycoside or uoroquinolone), intravenous hydration, and urinary drainage (if urinary retention present). If urinary retention is an issue, then gentle Foley catheter placement should be attempted. If catheter placement fails, a urologic consultation for suprapubic urinary drainage should be initiated. Following resolution of systemic symptoms and return of urine culture data, a long-term (34 weeks) course of outpatient oral antimicrobials is indicated. Based on pharmacokinetics studies of antibiotic levels in prostatic uid and stroma, the recommended oral antibiotics include uoroquinolones and trimethoprimsulfamethoxazole (14). At this juncture, four issues merit discussion: (a) prostatic abscess; (b) work-up of male urinary tract infection (UTI); (c) work-up of hematuria (gross or microscopic); and (d) PSA elevations during episodes of prostatitis or UTI. Prostatic abscess is a rare complication of category I prostatitis that occurs primarily in immunocompromised patients. A recent report (15) following HIVinfected men with category I prostatitis observed prostate abscess formation in 12 of 17 men using transrectal ultrasound. Prostatic abscesses that do not resolve with conservative medical therapy will require transurethral resection and drainage.
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Category I patients have complicated UTIs (16) and require the evaluation of a urologist as well as imaging (intravenous pyelogram, ultrasound, computed tomography, or magnetic resonance imaging) of the upper and lower urinary tracts (cystoscopy). These imaging studies enable complete evaluation of the urinary tract and identication of any potentially curable causes of UTI (e.g., stones, diverticula, anatomic abnormalities). Gross or microscopic hematuria noted during the diagnosis of prostatitis must also be thoroughly evaluated with imaging and urologic consultation. PSA values obtained concurrent with an active infection of the prostate gland are often extremely elevated owing to inammation of the prostate (17). The prudent course is to recheck the PSA value and urine culture following resolution of the acute prostatitis episode. If the urine culture is negative in the absence of intravenous and oral antimicrobials, and the prostatitis has resolved clinically, then an elevated PSA should prompt further investigation for possible prostate cancer. In contrast, elevated PSA values obtained in patients with category III or category IV prostatitis require follow-up if a concurrently drawn urine culture is negative. In summary, NIH category I prostatitis is an acute uropathogenic infection of the prostate that can be a medical emergency necessitating inpatient treatment with intravenous antimicrobials, hydration, and urinary drainage. On resolution of the septic/systemic symptoms, patients should receive a long course of the appropriate oral antimicrobials.Urologic consultation, as well as imaging of the upper and lower urinary tract, is also indicated following resolution of the prostatitis episode in order to fully evaluate the patient for other preventable causes of male UTI (see Figure 2 for diagnostic/treatment algorithm). Interestingly, category I prostatitis rarely transforms into category II (chronic prostatitis).
NIH CATEGORY II PROSTATITIS (CHRONIC BACTERIAL PROSTATITIS)

NIH category II prostatitis is dened as a chronic or persistent infection of the prostate in which a pathogen is demonstrated by the Meares-Stamey localization test but systemic symptoms are absent. Studies reveal that category II prostatitis accounts for 2%5% of patients with prostatitis (18, 19). It is similar to category I prostatitis in that the most commonly identied pathogen is E. coli, which accounts for 80% of cases. The remaining pathogens include Klebsiella spp., P. aeruginosa, and Proteus spp. Clinically, category II prostatitis usually manifests with intermittent cystitislike urinary symptoms rarely involving appreciable discomfort or pain. Symptoms of cystitis must be conrmed by urine culture to document the UTI. A history of documented recurrent UTIs is also highly suggestive of category II prostatitis (see Figure 2). Studies have shown that 25%43% of patients with category II prostatitis have a history of recurrent UTI (20, 21).
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Figure 2 Diagnostic/treatment algorithm for a patient with symptoms of chronic prostatitis/ chronic pelvic pain syndrome.
The appropriate diagnostic work-up for patients suspected of having category II prostatitis includes history, physical exam, urinalysis, and MearesStamey localization test, as well as urologic referral for evaluation of complicated UTI. The subsequent treatment of category II prostatitis involves a 48-week course of prostate-penetrating antimicrobials (uoroquinolone or trimethoprimsulfamethoxazole). A series of studies have shown a 60%80% cure rate for category II prostatitis following 1- to 3-month courses of various uoroquinolones (22, 23). Cure rates with trimethoprim have ranged from 44% to 50% (24). As shown in these studies, approximately one third of category II prostatitis patients have recurrences following initial treatment. The etiology of these treatment failures is unknown; however, some investigators speculate that prostatic calculi may play a role in sequestering pathogens and shielding them from the effects of antibiotics (25). Investigational modes of therapy, including intraprostatic injection of antibiotics (26) and radical transurethral prostate resection (27), have also been used to treat some treatment-refractory category II prostatitis patients, with modest results. The nal alternative for treatment-refractory category II prostatitis patients is long-term antimicrobial suppression, the dosage of which can be titrated to prevent recurrent cystitis episodes (28, 29).
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NIH CATEGORY III PROSTATITIS (CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME)

Category III prostatitis is the most common prostatitis syndrome, comprising 90%95% of prostatitis cases (18). Its clinical presentation includes symptoms of pain or discomfort in the pelvic region and possibly urinary or ejaculatory symptoms. Pelvic pain is a prerequisite symptom for diagnosis of CPPS because studies have shown that this is the most internally consistent symptom differentiating category III prostatitis from other mimicking conditions (30). Common manifestations of pelvic pain include perineal, suprapubic, coccygial, rectal, urethral, and testicular/scrotal pain. The urinary complaints associated with category III prostatitis/CPPS usually involve frequency, dysuria, and incomplete emptying. In addition, a subset of these patients experience ejaculatory pain. The NIH classication subdivides category III prostatitis into inammatory (IIIA) and noninammatory (IIIB) forms based on the presence or absence of leukocytes in expressed prostatic uid. However, this subdivision has yet to prove clinically relevant (31, 32). Some studies show that 5% of men diagnosed with category III prostatitis do eventually have a bacterial pathogen isolated from the urine or prostatic uid (33), suggesting a possible infectious cause in a subset of cases. In addition to leukocytes, multiple inammatory/cytokine, hormonal, and neuronal markers have been studied as putative diagnostic markers for category III prostatitis; results have been mixed (see Future Directions). The clinical heterogeneity of category III prostatitis and the absence of a diagnostic marker pose a signicant hurdle to proper evaluation and treatment of this syndrome. Although the diagnostic work-up for category III prostatitis is controversial, the authors recommend a history, physical exam with DRE, administration of the NIH-CPSI, urinalysis and urine culture (pre- and post-DRE), and urologic referral. (The collection of urine cultures pre- and post-DRE can provide some localization information and act as a surrogate to the Meares-Stamey test.) Additional studies that may assist in diagnosis include the formal four-glass Meares-Stamey localization test, postvoid residual volume assessment, and urine cytology. The etiology of category III prostatitis remains unclear despite many studies of possible infectious, inammatory, hormonal, and neuronal causes (34). One emerging theory suggests that an inciting event (infection, trauma, etc.) in the prostate leads to inammatory changes and, ultimately, the symptoms of category III prostatitis. Some investigators have suggested that the condition may be a cluster of related syndromes without a single unifying cause. In some cases, the prostate may not be responsible for the symptoms. The current consensus suggests that the development of category III prostatitis arises from a complex interaction of immune, endocrine, and neuronal events as well as the psychological status of the individual (34). The appropriate treatment of category III prostatitis is a subject of intense investigation. Prior studies demonstrating minimally effective or ineffective therapies
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include trials of antimicrobials (10, 35, 36), alpha-blockers (3639), anti-inammatories (36, 40), phytotherapy (41, 42), biofeedback (43, 44), thermal therapies (45), and pelvic oor training (44). However, the majority of these studies were underpowered and not controlled. A recent NIH double-blinded placebo-controlled study (9) performed using ciprooxacin and tamsulosin as pharmacotherapy for CPPS on 488 patients highlights some of the challenges of treating this syndrome. No signicant benet was demonstrated of either drug alone or in combination; however, many of the patients in this study had previously failed multiple therapies (including antimicrobials and alpha-blockers) and probably represent a cohort of treatment-refractory CPPS patients. The efcacy of antimicrobial agents as monotherapy or in combination with alpha-blockers is still in question for treatment-naive patients with CPPS. Therefore, current treatment recommendations are primarily based on modest improvements observed in a few clinical trials. As summarized in Figure 3, the Chronic Prostatitis Collaboration Research Network has recommended the following treatment for patients newly diagnosed with category III prostatitis: a single 46-week course of antimicrobial medication (uoroquinolone or trimethoprim-sulfamethoxazole), which can be repeated if signicant symptomatic benet is derived from the initial course. Second-line pharmacotherapy includes alpha-blockers (e.g., tamsulosin, alfuzosin, terazosin) and anti-inammatory medications. These second-line medications may be used alone or combined with antimicrobial therapy. Third-line pharmacotherapies for category III prostatitis include nasteride, pentosan polysulfate, and phytotherapies (e.g., cernilton and quercetin); these agents have not been thoroughly tested but may show some efcacy based on small trials. Lastly, nonpharmacologic therapies such as biofeedback, pelvic oor training, and various thermal treatments have been shown in small trials to alleviate symptoms in some category III prostatitis patients. It should be emphasized that category III prostatitis is often a diagnosis of exclusion. Thus, it is important that the clinician entertain the possibility of mimicking conditions as diverse as lower urinary tract obstruction, testicular cancer, bladder stones, ejaculatory duct obstruction, radiculopathies, and other chronic pain syndromes (e.g., bromyalgia). However, ongoing investigation into novel diagnostic methods and well-controlled clinical trials hold the promise of a useful biomarker and effective therapy for category III prostatitis.
NIH CATEGORY IV PROSTATITIS (ASYMPTOMATIC INFLAMMATORY PROSTATITIS)

NIH category IV prostatitis is dened as an asymptomatic inammatory prostatitis, which is typically found incidentally either on examination of expressed prostatic uid (leukocytes present) or prostate biopsies (inammatory inltrate observed). Epidemiologic studies estimate the prevalence of category IV prostatitis to be as high as 32.2% in a population of men with elevated PSA (47). In a related
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Figure 3 Treatment algorithm for a patient newly diagnosed with NIH category III prostatitis.
study, Carver et al. (48) showed that men with category IV prostatitis have a signicantly higher mean PSA score. However, no studies have shown a link between category IV prostatitis and prostate cancer. Thus, category IV prostatitis represents an incidentally noted asymptomatic condition with unknown clinical signicance.
FUTURE DIRECTIONS
The NIH classication of prostatitis syndromes, combined with advancements such as the NIH-CPSI questionnaire, provides a structure for ongoing research into the etiology and effective treatment of prostatitis/CPPS. Category I and II prostatitis
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are straightforward infections of the prostate, which are relatively well understood and responsive to available therapies. In contrast, category III prostatitis/CPPS lacks a clear etiology or effective therapy. Recent studies on elevated cytokine levels within the prostatic uid of individuals with category III prostatitis may shed new light on the etiology of this syndrome (49, 50). In addition, research into other chronic pain syndromes such as bromyalgia may offer insights in to category III prostatitis via an improved understanding of the molecular basis of pain (51). Future trials using novel pharmacotherapies (e.g., anticytokines) alone or in combination with nonpharmacologic treatment modalities (e.g., biofeedback and pelvic oor training) may hold the key to an effective therapy. The Annual Review of Medicine is online at http://med.annualreviews.org LITERATURE CITED
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Annual Review of Medicine Volume 57, 2006
CONTENTS
ANGIOGENESIS, Judah Folkman ADVANCES IN RADIATION ONCOLOGY, Mohamed Elshaikh,

Mats Ljungman, Randall Ten Haken, and Allen S. Lichter
1 19
BORTEZOMIB: PROTEASOME INHIBITION AS AN EFFECTIVE ANTICANCER THERAPY, Paul G. Richardson, Constantine Mitsiades,
Teru Hideshima, and Kenneth C. Anderson 33 49 65 83
CHEMOPREVENTION OF PROSTATE CANCER, Eric A. Klein EFFECTIVE CANCER THERAPY THROUGH IMMUNOMODULATION,
Thomas A. Waldmann
MOLECULAR APPROACHES IN PEDIATRIC ONCOLOGY, Chand Khanna

and Lee J. Helman
MOLECULAR IMAGING IN THE DEVELOPMENT OF CANCER THERAPEUTICS, Johannes Czernin, Wolfgang A. Weber,
and Harvey R. Herschman 99
PHARMACOGENOMICS AND INDIVIDUALIZED DRUG THERAPY,

Michel Eichelbaum, Magnus Ingelman-Sundberg, and William E. Evans 119 139 155 167
AVIAN FLU TO HUMAN INFLUENZA, David B. Lewis EMERGING THERAPEUTICS FOR CHRONIC HEPATITIS B,
Mark E. Mailliard and John L. Gollan
THE ROTAVIRUS VACCINE SAGA, Alan R. Shaw WEST NILE VIRUS: EPIDEMIOLOGY AND CLINICAL FEATURES OF AN EMERGING EPIDEMIC IN THE UNITED STATES, Edward B. Hayes
and Duane J. Gubler
181 195 207 223 243 265 v
PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME,

Geoffrey M. Habermacher, Judd T. Chason, and Anthony J. Schaeffer
CELIAC DISEASE, Peter H.R. Green and Bana Jabri AMYLOIDOSIS, Mark B. Pepys SURGICAL TREATMENT OF MORBID OBESITY, Peter F. Crookes THERAPEUTIC APPROACHES TO PRESERVE ISLET MASS IN TYPE 2 DIABETES, Laurie L. Baggio and Daniel J. Drucker
vi
CONTENTS
ENZYME REPLACEMENT FOR LYSOSOMAL DISEASES,

Roscoe O. Brady 283 297 313 331 349 365 381 403 419
GENETIC BASIS OF LIPODYSTROPHIES AND MANAGEMENT OF METABOLIC COMPLICATIONS, Anil K. Agarwal and Abhimanyu Garg NUCLEAR RECEPTORS IN LIPID METABOLISM: TARGETING THE HEART OF DYSLIPIDEMIA, Simon W. Beaven and Peter Tontonoz HEMOCHROMATOSIS: GENETICS AND PATHOPHYSIOLOGY,
Ernest Beutler
THERAPEUTIC USE OF CALCIMIMETICS, Steven C. Hebert TOWARD A UNIFIED THEORY OF RENAL PROGRESSION,
Raymond C. Harris and Eric G. Neilson
CD4+ CD25+ REGULATORY T CELLS AND THEIR THERAPEUTIC POTENTIAL, David A. Randolph and C. Garrison Fathman UMBILICAL CORD BLOOD TRANSPLANTATION AND BANKING,
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Annu. Rev. Med. 2006. 57:195206 doi: 10.1146/annurev.med.57.011205.135654 Copyright c 2006 by Annual Reviews.

PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME

prostate, infection, inammation

PROSTATITIS/CHRONIC PELVIC PAIN

NIH CATEGORY I PROSTATITIS (ACUTE BACTERIAL PROSTATITIS)

PROSTATITIS/CHRONIC PELVIC PAIN

NIH CATEGORY II PROSTATITIS (CHRONIC BACTERIAL PROSTATITIS)

PROSTATITIS/CHRONIC PELVIC PAIN

NIH CATEGORY III PROSTATITIS (CHRONIC PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME)

NIH CATEGORY IV PROSTATITIS (ASYMPTOMATIC INFLAMMATORY PROSTATITIS)

PROSTATITIS/CHRONIC PELVIC PAIN

Annual Review of Medicine Volume 57, 2006

ANGIOGENESIS, Judah Folkman ADVANCES IN RADIATION ONCOLOGY, Mohamed Elshaikh,

MOLECULAR APPROACHES IN PEDIATRIC ONCOLOGY, Chand Khanna

PHARMACOGENOMICS AND INDIVIDUALIZED DRUG THERAPY,

181 195 207 223 243 265 v

PROSTATITIS/CHRONIC PELVIC PAIN SYNDROME,

ENZYME REPLACEMENT FOR LYSOSOMAL DISEASES,

NEW DIRECTIONS IN CARDIAC TRANSPLANTATION, Abdulaziz Al-khaldi

NEW TREATMENTS FOR NEUROPATHIC PAIN, Andrew S.C. Rice

PLANT, SYNTHETIC, AND ENDOGENOUS CANNABINOIDS IN MEDICINE,

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