Abstract
Skeletal muscle biopsy is a long-established diagnostic used primarily as a diagnostic tool for neuromuscular disorders characterized by reduced muscle function and strength. For anatomical and functional characteristics, leg muscles and especially the vastus lateralis have been most commonly investigated. Percutaneous needles, which overcame the more invasive open biopsies, were introduced more than 50 years ago, with the original instruments named after Bergstrom [1], in honor of his pioneering work in their development (Fig. 8.1). When adequate suction is applied and a sufficient amount of muscle tissue is recovered, muscle biopsy allows for multiple measurements as well as the assessment of different anatomical or physiological parameters. Fiber and cell isolation, incubation, or culture are also possible and enable additional ex vivo studies. Muscular dystrophies, mitochondrial myopathies, and conditions often characterized by impaired muscle strength and function were early and obvious targets for diagnostic and research applications of muscle biopsy. Needle biopsy has been further extensively applied in the study of exercise physiology and pathophysiology, with the goal of investigating the regulation of mitochondrial function and substrate oxidation. In recent years, studies in the fields of obesity and diabetes have also focused on muscle mitochondrial function, and muscle biopsies have become increasingly common in human metabolic assessments.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Preview
Unable to display preview. Download preview PDF.
References
Bergstrom J (1975) Percutaneous needle biopsy of skeletal muscle in physiological and clinical research. Scand J Clin Lab Invest 35:609–616
Saunders PU, Pyne DB, Telford RD, Hawley JA (2004) Factors affecting running economy in trained distance runners. Sports Med 34:465–485
Tessari P, Inchiostro S, Biolo G, Vincenti E, Sabadin L (1991) Effects of acute systemic hyperinsulinemia on forearm muscle proteolysis in healthy man. J Clin Invest 88:27–33
Nair KS, Ford GC, Ekberg K, Fernqvist-Forbes E, Wahren J (1995) Protein dynamics in whole body and in splanchnic and leg tissues in type I diabetic patients. J Clin Invest 95:2926–2937
Stephens FB, Constantin-Teodosiu D, Greenhaff PL (2007) New insights concerning the role of carnitine in the regulation of fuel metabolism in skeletal muscle. J Physiol 581:431–444
Kim YI, Lee FN, Choi WS, Lee S, Youn JH (2006) Insulin regulation of skeletal muscle PDK4 mRNA expression is impaired in acute insulin-resistant states. Diabetes 55:2311–2337
Winder WW, Hardie DG (1999) AMP-activated protein kinase, a metabolic master switch: possible roles in type 2 diabetes. Am J Physiol 277:E1–E10
Long YC, Zierath JR (2006) AMP-activated protein kinase signaling in metabolic regulation. J Clin Invest 116:1776–1783
Cantó C, Auwerx J (2009) PGC-1alpha, SIRT1 and AMPK, an energy sensing network that controls energy expenditure. Curr Opin Lipidol 20:98–105
Lagouge M, Argmann C, Gerhart-Hines Z, Meziane H, Lerin C, Daussin F, Messadeq N, Milne J, Lambert P, Elliott P, Geny B, Laakso M, Puigserver P, Auwerx J (2006) Resveratrol improves mitochondrial function and protects against metabolic disease by activating SIRT1 and PGC-1alpha. Cell 127:1109–1122
Cantó C, Jiang LQ, Deshmukh AS, Mataki C, Coste A, Lagouge M, Zierath JR, Auwerx J (2010) Interdependence of AMPK and SIRT1 for metabolic adaptation to fasting and exercise in skeletal muscle. Exercise Cell Metab 11:213–219
Holloszy JO (2008) Regulation by exercise of skeletal muscle content of mitochondria and GLUT4. J Physiol Pharmacol 59 Suppl 7:5–18
Lanza IR, Short DK, Short KR, Raghavakaimal S, Basu R, Joyner MJ, McConnell JP, Nair KS (2008) Endurance exercise as a countermeasure for aging. Diabetes 57:2933–2942
Wojtaszewski JF, MacDonald C, Nielsen JN (2003) Regulation of 5′AMP-activated protein kinase activity and substrate utilization in exercising human skeletal muscle. Am J Physiol Endocrinol Metab 284:E813–E822
Adhihetty PJ, Irrcher I, Joseph AM, Ljubicic V, Hood DA (2003) Plasticity of skeletal muscle mitochondria in response to contractile activity. Exp Physiol 88:99–107
Finck BN, Kelly DP (2006) PGC-1 coactivators: inducible regulators of energy metabolism in health and disease. J Clin Invest 116:615–622
Colman RJ, Anderson RM, Johnson SC, Kastman EK, Kosmatka KJ, Beasley TM, Allison DB, Cruzen C, Simmons HA, Kemnitz JW, Weindruch R (2009) Caloric restriction delays disease onset and mortality in rhesus monkeys. Science 325:201–204
Fontana L, Meyer TE, Klein S, Holloszy JO (2004) Long-term calorie restriction is highly effective in reducing the risk for atherosclerosis in humans. Proc Natl Acad Sci U S A 101:6659–6663
Barazzoni R, Zanetti M, Bosutti A, Biolo G, Vitali-Serdoz L, Stebel M, Guarnieri G (2005) Moderate caloric restriction, but not physiological hyperleptinemia per se, enhances mitochondrial oxidative capacity in rat liver and skeletal muscle—tissue-specific impact on tissue triglyceride content and AKT activation. Endocrinology 146:2098–2106
Nisoli E, Tonello C, Cardile A, Cozzi V, Bracale R, Tedesco L, Falcone S, Valerio A, Cantoni O, Clementi E, Moncada S, Carruba MO (2005) Calorie restriction promotes mitochondrial biogenesis by inducing the expression of eNOS. Science 310:314–317
Zangarelli A, Chanseaume E, Morio B, Brugère C, Mosoni L, Rousset P, Giraudet C, Patrac V, Gachon P, Boirie Y, Walrand S (2006) Synergistic effects of caloric restriction with maintained protein intake on skeletal muscle performance in 21-month-old rats: a mitochondria-mediated pathway. FASEB J 20:2439–2450
Harman D (1981) The aging process. Proc Natl Acad Sci 78:7124–7128
Sinclair DA (2005) Toward a unified theory of caloric restriction and longevity regulation. Mech Ageing Dev 126:987–1002
Rachek LI, Musiyenko SI, LeDoux SP, Wilson GL (2007) Palmitate induced mitochondrial deoxyribonucleic acid damage and apoptosis in l6 rat skeletal muscle cells. Endocrinology 148:293–299
Pimenta AS, Gaidhu MP, Habib S, So M, Fediuc S, Mirpourian M, Musheev M, Curi R, Ceddia RB (2008) Prolonged exposure to palmitate impairs fatty acid oxidation despite activation of AMP-activated protein kinase in skeletal muscle cells. J Cell Physiol 217:478–485
Hirabara SM, Curi R, Maechler P (2010) Saturated fatty acid-induced insulin resistance is associated with mitochondrial dysfunction in skeletal muscle cells. J Cell Physiol 222:187–194
Yuzefovych L, Wilson G, Rachek L (2010) Different effects of oleate vs. palmitate on mitochondrial function, apoptosis, and insulin signaling in L6 skeletal muscle cells: role of oxidative stress. Am J Physiol Endocrinol Metab 299:E1096–E105
Brandt JM, Djouadi F, Kelly DP (1998) Fatty acids activate transcription of the muscle carnitine palmitoyltransferase I gene in cardiac myocytes via the peroxisome proliferator-activated receptor alpha. J Biol Chem 273:23786–23792
Iossa S, Lionetti L, Mollica MP, Crescenzo R, Botta M, Barletta A, Liverini G (2003) Effect of high-fat feeding on metabolic efficiency and mitochondrial oxidative capacity in adult rats. Br J Nutr 90:953–960
Sparks LM, Xie H, Koza RA, Mynatt R, Hulver MW, Bray GA, Smith SR (2005) A high-fat diet coordinately downregulates genes required for mitochondrial oxidative phosphorylation in skeletal muscle. Diabetes 54:1926–1933
Turner N, Bruce CR, Beale SM, Hoehn KL, So T, Rolph MS, Cooney GJ (2007) Excess lipid availability increases mitochondrial fatty acid oxidative capacity in muscle: evidence against a role for reduced fatty acid oxidation in lipid-induced insulin resistance in rodents. Diabetes 56:2085–2092
Garcia-Roves P, Huss JM, Han DH, Hancock CR, Iglesias-Gutierrez E, Chen M, Holloszy JO (2007) Raising plasma fatty acid concentration induces increased biogenesis of mitochondria in skeletal muscle. Proc Natl Acad Sci U S A 104:10709–10713
Bigrigg JK, Heigenhauser GJ, Inglis JG, LeBlanc PJ, Peters SJ (2009) Carbohydrate refeeding after a high-fat diet rapidly reverses the adaptive increase in human skeletal muscle PDH kinase activity. Am J Physiol Regul Integr Comp Physiol 297:R885–R891
Medikayala S, Piteo B, Zhao X, Edwards JG (2011) Chronically elevated glucose compromises myocardial mitochondrial DNA integrity by alteration of mitochondrial topoisomerase function. Am J Physiol Cell Physiol 300:C338–C348
Aas V, Hessvik NP, Wettergreen M, Hvammen AW, Hallén S, Thoresen GH, Rustan AC (2011) Chronic hyperglycemia reduces substrate oxidation and impairs metabolic switching of human myotubes. Biochim Biophys Acta 1812:94–105
Liu HY, Cao SY, Hong T, Han J, Liu Z, Cao W (2009) Insulin is a stronger inducer of insulin resistance than hyperglycemia in mice with type 1 diabetes mellitus (T1DM). J Biol Chem 284:27090–27100
Ragheb R, Shanab GM, Medhat AM, Seoudi DM, Adeli K, Fantus IG (2009) Free fatty acid-induced muscle insulin resistance and glucose uptake dysfunction: evidence for PKC activation and oxidative stress-activated signaling pathways. Biochem Biophys Res Commun 389:211–216
Bonnard C, Durand A, Peyrol S, Chanseaume E, Chauvin MA, Morio B, Vidal H, Rieusset J (2008) Mitochondrial dysfunction results from oxidative stress in the skeletal muscle of dietinduced insulin-resistant mice. J Clin Invest 118:789–800
Anderson EJ, Lustig ME, Boyle KE, (2009) Mitochondrial H2O2 emission and cellular redox state link excess fat intake to insulin resistance in both rodents and humans. J Clin Invest 119:573–581
Nishikawa T, Edelstein D, Du XL, Yamagishi S, Matsumura T, Kaneda Y, Yorek MA, Beebe D, Oates PJ, Hammes HP, Giardino I, Brownlee M (2000) Normalizing mitochondrial superoxide production blocks three pathways of hyperglycaemic damage. Nature 404:787–790
Shoelson SE, Lee J, Goldfine AB (2006) Inflammation and insulin resistance. J Clin Invest 116:1793–1801
Supinski GS, Callahan LA (2007) Free radical-mediated skeletal muscle dysfunction in inflammatory conditions. J Appl Physiol 102:2056–2063
Wei Y, Sowers JR, Clark SE, Li W, Ferrario CM, Stump CS (2008) Angiotensin II-induced skeletal muscle insulin resistance mediated by NF-kappaB activation via NADPH oxidase. Am J Physiol Endocrinol Metab 294:E345–E351
Green CJ, Macrae K, Fogarty S, Hardie DG, Sakamoto K, Hundal HS (2011) Counter modulation of fatty acid-induced proinflammatory NFkB signalling in rat skeletal muscle cells by AMPK. Biochem J 435:463–474
Kim JK, Kim J, Fillmore JJ, Chen Y, Moore I, Lee J, Yuan M, Li ZW, Karin M, Perret P, Shoelson SE, Shulman GI (2001) Prevention of fat-induced insulin resistance by salicylate. J Clin Invest 108:437–446
Valerio A, Cardile A, Cozzi V, Bracale R, Tedesco L, Pisconti A, Palomba L, Cantoni O, Clementi E, Moncada S, Carruba MO, Nisoli E (2006) TNF-alpha downregulates eNOS expression and mitochondrial biogenesis in fat and muscle of obese rodents. J Clin Invest 116:2791–2798
Spriet LL, Heigenhauser GJ (2002) Regulation of pyruvate dehydrogenase (PDH) activity in human skeletal muscle during exercise. Exerc Sport Sci Rev 30:91–95
Pilegaard H, Saltin B, Neufer PD (2003) Exercise induces transient transcriptional activation of the PGC-1alpha gene in human skeletal muscle. J Physiol 546:851–858.
Gibala MJ, McGee SL, Garnham AP, Howlett KF, Snow RJ, Hargreaves M (2009) Brief intense interval exercise activates AMPK and p38 MAPK signaling and increases the expression of PGC-1alpha in human skeletal muscle. J Appl Physiol 106:929–934
Little JP, Safdar A, Cermak N, Tarnopolsky MA, Gibala MJ (2010) Acute endurance exercise increases the nuclear abundance of PGC-1alpha in trained human skeletal muscle. Am J Physiol Regul Integr Comp Physiol 298:R912–R917
Schrauwen P, Hesselink MK (2004) Oxidative capacity, lipotoxicity, and mitochondrial damage in type 2 diabetes. Diabetes 53:1412–1417
Summers SA (2010) Sphingolipids and insulin resistance: the five Ws. Curr Opin Lipidol 21:128–135
Muoio DM (2010) Intramuscular triacylglycerol and insulin resistance: guilty as charged or wrongly accused? Biochim Biophys Acta 1801:281–288
Morino K, Petersen KF, Shulman GI (2006) Molecular mechanisms of insulin resistance in humans and their potential links with mitochondrial dysfunction. Diabetes 55 Suppl 2:S9–S15
Kelley DE, He J, Menshikova EV, Ritov VB (2002) Dysfunction of mitochondria in human skeletal muscle in type 2 diabetes. Diabetes 51:2944–2950
Ritov VB, Menshikova EV, He J, Ferrell RE, Goodpaster BH, Kelley DE (2005) Deficiency of subsarcolemmal mitochondria in obesity and type 2 diabetes. Diabetes 54:8–14
Morino K, Petersen KF, Dufour S, Befroy D, Frattini J, Shatzkes N, Neschen S, White MF, Bilz S, Sono S, Pypaert M, Shulman GI (2005) Reduced mitochondrial density and increased IRS-1 serine phosphorylation in muscle of insulin-resistant offspring of type 2 diabetic parents. J Clin Invest 115:3587–3593
Mogensen M, Sahlin K, Fernström M, Glintborg D, Vind BF, Beck-Nielsen H, Højlund K (2007) Mitochondrial respiration is decreased in skeletal muscle of patients with type 2 diabetes. Diabetes 56:1592–1599
Heilbronn LK, Gan SK, Turner N, Campbell LV, Chisholm DJ (2007) Markers of mitochondrial biogenesis and metabolism are lower in overweight and obese insulin-resistant subjects. J Clin Endocrinol Metab 92:1467–1473
Boushel R, Gnaiger E, Schjerling P, Skovbro M, Kraunsøe R, Dela F (2007) Patients with type 2 diabetes have normal mitochondrial function in skeletal muscle. Diabetologia 50:790–796
Ritov VB, Menshikova EV, Azuma K, Wood R, Toledo FG, Goodpaster BH, Ruderman NB, Kelley DE (2010) Deficiency of electron transport chain in human skeletal muscle mitochondria in type 2 diabetes mellitus and obesity. Am J Physiol Endocrinol Metab 298:E49–E58
Mootha VK, Lindgren CM, Eriksson KF, Subramanian A, Sihag S, Lehar J, Puigserver P, Carlsson E, Ridderstråle M, Laurila E, Houstis N, Daly MJ, Patterson N, Mesirov JP, Golub TR, Tamayo P, Spiegelman B, Lander ES, Hirschhorn JN, Altshuler D, Groop LC (2003) PGC-1alpha-responsive genes involved in oxidative phosphorylation are coordinately downregulated in human diabetes. Nat Genet 34:267–273
Richardson DK, Kashyap S, Bajaj M, Cusi K, Mandarino SJ, Finlayson J, DeFronzo RA, Jenkinson CP, Mandarino LJ (2005) Lipid infusion decreases the expression of nuclear encoded mitochondrial genes and increases the expression of extracellular matrix genes in human skeletal muscle. J Biol Chem 280:10290–10297
Bajaj M, Medina-Navarro R, Suraamornkul S, Meyer C, DeFronzo RA, Mandarino LJ (2007) Paradoxical changes in muscle gene expression in insulin-resistant subjects after sustained reduction in plasma free fatty acid concentration. Diabetes 56:743–752
Chavez AO, Kamath S, Jani R, Sharma LK, Monroy A, Abdul-Ghani MA, Centonze VE, Sathyanarayana P, Coletta DK, Jenkinson CP, Bai Y, Folli F, DeFronzo RA, Tripathy D (2010) Effect of short-term free fatty acids elevation on mitochondrial function in skeletal muscle of healthy individuals. J Clin Endocrinol Metab 95:422–429
Rabøl R, Højberg PM, Almdal T, Boushel R, Haugaard SB, Madsbad S, Dela F (2009) Effect 8 Muscle Biopsy To Investigate Mitochondrial Turnover 83 of hyperglycemia on mitochondrial respiration in type 2 diabetes. J Clin Endocrinol Metab 94:1372–1378
Toledo FG, Menshikova EV, Azuma K, Radiková Z, Kelley CA, Ritov VB, Kelley DE (2008) Mitochondrial capacity in skeletal muscle is not stimulated by weight loss despite increases in insulin action and decreases in intramyocellular lipid content. Diabetes 57:987–994
Phielix E, Meex R, Moonen-Kornips E, Hesselink MK, Schrauwen P (2010) Exercise training increases mitochondrial content and ex vivo mitochondrial function similarly in patients with type 2 diabetes and in control individuals. Diabetologia 53:1714–1721
Bruce CR, Thrush AB, Mertz VA, Bezaire V, Chabowski A, Heigenhauser GJ, Dyck DJ (2006) Endurance training in obese humans improves glucose tolerance and mitochondrial fatty acid oxidation and alters muscle lipid content. Am J Physiol Endocrinol Metab 291:E99–E107
Bordenave S, Metz L, Flavier S, Lambert K, Ghanassia E, Dupuy AM, Michel F, Puech-Cathala AM, Raynaud E, Brun JF, Mercier J (2008) Training-induced improvement in lipid oxidation in type 2 diabetes mellitus is related to alterations in muscle mitochondrial activity. Effect of endurance training in type 2 diabetes. Diabetes Metab 34:162–168
Short KR, Vittone JL, Bigelow ML, Proctor DN, Rizza RA, Coenen-Schimke JM, Nair KS (2003) Impact of aerobic exercise training on age-related changes in insulin sensitivity and muscle oxidative capacity. Diabetes 52:1888–1896
Sartorio A, Fontana P, Trecate L, Lafortuna CL (2003) Short-term changes of fatigability and muscle performance in severe obese patients after an integrated body mass reduction program. Diabetes Nutr Metab 16:88–93
Sartorio A, Narici MV, Fumagalli E, Faglia G, Lafortuna CL (2001) Aerobic and anaerobic performance before and after a short-term body mass reduction program in obese subjects. Diabetes Nutr Metab 14:51–57
Stump CS, Short KR, Bigelow ML, Schimke JM, Nair KS (2003) Effect of insulin on human skeletal muscle mitochondrial ATP production, protein synthesis, and mRNA transcripts. Proc Natl Acad Sci U S A 100:7996–8001
Asmann YW, Stump CS, Short KR, Coenen-Schimke JM, Guo Z, Bigelow ML, Nair KS (2006) Skeletal muscle mitochondrial functions, mitochondrial DNA copy numbers, and gene transcript profiles in type 2 diabetic and nondiabetic subjects at equal levels of low or high insulin and euglycemia. Diabetes 55:3309–3319
Hoeks J, van Herpen NA, Mensink M, Moonen-Kornips E, van Beurden D, Hesselink MK, Schrauwen P (2010) Prolonged fasting identifies skeletal muscle mitochondrial dysfunction as consequence rather than cause of human insulin resistance. Diabetes 59:2117–2125
Østergård T, Andersen JL, Nyholm B, Lund S, Nair KS, Saltin B, Schmitz O (2006) Impact of exercise training on insulin sensitivity, physical fitness, and muscle oxidative capacity in firstdegree relatives of type 2 diabetic patients. Am J Physiol Endocrinol Metab 290:E998–E1005
Nair KS, Bigelow ML, Asmann YW, Chow LS, Coenen-Schimke JM, Klaus KA, Guo ZK, Sreekumar R, Irving BA (2008) Asian Indians have enhanced skeletal muscle mitochondrial capacity to produce ATP in association with severe insulin resistance. Diabetes 57:1166–1175
Choi CS, Befroy DE, Codella R, Kim S, Reznick RM, Hwang YJ, Liu ZX, Lee HY, Distefano A, Samuel VT, Zhang D, Cline GW, Handschin C, Lin J, Petersen KF, Spiegelman BM, Shulman GI (2008) Paradoxical effects of increased expression of PGC-1alpha on muscle mitochondrial function and insulin-stimulated muscle glucose metabolism. Proc Natl Acad Sci U S A 105:19926–19931
Furukawa S, Fujita T, Shimabukuro M, Iwaki M, Yamada Y, Nakajima Y, Nakayama O, Makishima M, Matsuda M, Shimomura I (2004) Increased oxidative stress in obesity and its impact on metabolic syndrome. J Clin Invest 114:1752–1761
Kern PA, Saghizadeh M, Ong JM, Bosch RJ, Deem R, Simsolo RB (1995) The expression of tumor necrosis factor in human adipose tissue. Regulation by obesity, weight loss, and relationship to lipoprotein lipase. J Clin Invest 95:2111–2119
Melov S, Shoffner JM, Kaufman A, Wallace DC (1995) Marked increase in the number and variety of mitochondrial DNA rearrangements in aging human skeletal muscle. Nucleic Acids Res 23:4122–4126 84 R. Barazzoni
Rooyackers OE, Adey DB, Ades PA, Nair KS (1996) Effect of age on in vivo rates of mitochondrial protein synthesis in human skeletal muscle. Proc Natl Acad Sci U S A 93:15364–15369
Short KR, Bigelow ML, Kahl J, Singh R, Coenen-Schimke J, Raghavakaimal S, Nair KS (2005) Decline in skeletal muscle mitochondrial function with aging in humans. Proc Natl Acad Sci U S A 102:5618–5623
Kouidi E, Albani M, Natsis K, Megalopoulos A, Gigis P, Guiba-Tziampiri O, Tourkantonis A, Deligiannis A (1998) The effects of exercise training on muscle atrophy in haemodialysis patients. Nephrol Dial Transplant 13:685–699
Gosker HR, Schrauwen P, Broekhuizen R, Hesselink MK, Moonen-Kornips E, Ward KA, Franssen FM, Wouters EF, Schols AM (2006) Exercise training restores uncoupling protein-3 content in limb muscles of patients with chronic obstructive pulmonary disease. Am J Physiol Endocrinol Metab 290:E976–E981
Tyni-Lenné R, Gordon A, Jansson E, Bermann G, Sylvén C (1997) Skeletal muscle endurance training improves peripheral oxidative capacity, exercise tolerance, and health-related quality of life in women with chronic congestive heart failure secondary to either ischemic cardiomyopathy or idiopathic dilated cardiomyopathy. Am J Cardiol 80:1025–1029
Gielen S, Adams V, Linke A, Erbs S, Möbius-Winkler S, Schubert A, Schuler G, Hambrecht R (2005) Exercise training in chronic heart failure: correlation between reduced local inflammation and improved oxidative capacity in the skeletal muscle. Eur J Cardiovasc Prev Rehabil 12:393–400
Fredriksson K, Tjäder I, Keller P, Petrovic N, Ahlman B, Schéele C, Wernerman J, Timmons JA, Rooyackers O (2008) Dysregulation of mitochondrial dynamics and the muscle transcriptome in ICU patients suffering from sepsis induced multiple organ failure. PLoS One 3:e3686
Adey D, Kumar R, McCarthy JT, Nair KS (2000) Reduced synthesis of muscle proteins in chronic renal failure. Am J Physiol Endocrinol Metab 278:E219–E225
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2012 Springer-Verlag Italia
About this chapter
Cite this chapter
Barazzoni, R. (2012). Muscle Biopsy To Investigate Mitochondrial Turnover. In: Luzi, L. (eds) Cellular Physiology and Metabolism of Physical Exercise. Springer, Milano. https://doi.org/10.1007/978-88-470-2418-2_8
Download citation
DOI: https://doi.org/10.1007/978-88-470-2418-2_8
Publisher Name: Springer, Milano
Print ISBN: 978-88-470-2417-5
Online ISBN: 978-88-470-2418-2
eBook Packages: Biomedical and Life SciencesBiomedical and Life Sciences (R0)