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Arora A, Rajesh S, Mukund A, Patidar Y, Thapar S, Arora A, Bhatia V. Clinicoradiological appraisal of 'paraduodenal pancreatitis': Pancreatitis outside the pancreas! Indian J Radiol Imaging 2015; 25:303-14. [PMID: 26288527 PMCID: PMC4531457 DOI: 10.4103/0971-3026.161467] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Purpose: Paraduodenal pancreatitis (PP) is a unique form of focal chronic pancreatitis that selectively involves the duodenum and aberrant pancreatic tissue located near the minor papilla (beyond the pancreas proper). The pseudotumoral nature of the disease often generates considerable clinical quandary and patient apprehension, and therefore merits a better understanding. The present study appraises the clinicoradiological manifestations of PP in 33 patients. Materials and Methods: Clinical, laboratory, and radiological manifestations of 33 patients of PP treated in gastroenterology/hepatology and hepato-pancreatico-biliary surgery units during June 2010-August 2014 were retrospectively reviewed. Results: All patients were young to middle-aged men (100%) with history of alcohol abuse (93.9%) and/or smoking (42.4%), who presented either with acute or gradually worsening abdominal pain (90.9%). Pancreatic enzymes and serum tumor markers remained normal or were mildly/transiently elevated. Cystic variant was detected in 57.6% (solid in 42.4%); the disease remained confined to the groove/duodenum (pure form) in 45.4%. Medial duodenal wall thickening with increased enhancement was seen in 87.87 and 81.81%, respectively, and duodenal/paraduodenal cysts were seen in 78.78%. Pancreatic calcifications and biliary stricture were seen 27.3% patients. Peripancreatic arteries were neither infiltrated nor encased. Conclusion: PP has a discrete predilection for middle-aged men with history of longstanding alcohol abuse and/or smoking. Distinguishing imaging findings include thickening of the pancreatic side of duodenum exhibiting increased enhancement with intramural/paraduodenal cysts. This may be accompanied by plate-like scar tissue in the groove region, which may simulate groove pancreatic carcinoma. However, as opposed to carcinoma, the peripancreatic arteries are neither infiltrated nor encased, rather are medially displaced.
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Affiliation(s)
- Ankur Arora
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - S Rajesh
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Amar Mukund
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Yashwant Patidar
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shalini Thapar
- Department of Radiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Asit Arora
- Department of Hepato-pancreatico-biliary surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Abstract
The duodenum is a unique segment of intestine, occupying both intra and extra-peritoneal locations. There is a wide spectrum of abnormalities of the duodenum that range from congenital anomalies to traumatic, inflammatory, and neoplastic entities. The duodenum may be overlooked on cross-sectional imaging due to its location and small size. Duodenal pathologies may, therefore, be missed or wrongly diagnosed. Knowledge about duodenal pathologies and optimal imaging techniques can increase diagnostic yield and permit optimal patient management. Conventionally, the duodenum was evaluated with upper GI studies on fluoroscopy; however, endoluminal evaluation is better performed with endoscopy. Additionally, a broad array of cross-sectional imaging modalities permits comprehensive assessment of the duodenum and surrounding viscera. While endoscopic sonography is increasingly used to locally stage duodenal malignancies, MDCT remains the primary modality widely used in the detection and characterization of duodenal abnormalities. MRI is used as a "problem solving" modality in select conditions. We present a comprehensive review of duodenal abnormalities with an emphasis on accurate diagnosis and management.
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Hwang JY, Yoon HK, Kim KM. Characteristics of Pediatric Pancreatitis on Magnetic Resonance Cholangiopancreatography. Pediatr Gastroenterol Hepatol Nutr 2015; 18:73-84. [PMID: 26157692 PMCID: PMC4493250 DOI: 10.5223/pghn.2015.18.2.73] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 06/02/2015] [Indexed: 02/07/2023] Open
Abstract
Pediatric pancreatitis is not uncommon and results in considerable morbidity and mortality in the affected children. Unlike adults, pediatric pancreatitis is more frequently associated with underlying structural abnormalities, trauma, and drugs rather than an idiopathic etiology. Magnetic resonance cholangiopancreatography (MRCP) is a good imaging modality for evaluating pancreatitis and determining etiology without exposure to radiation. This article focuses on MRCP findings associated with various causes of pancreatitis in children, particularly structural abnormalities of the pancreaticobiliary system, as well as describing the feasibility, limitations, and solutions associated with pediatric MRCP.
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Affiliation(s)
- Jae-Yeon Hwang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hye-Kyung Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Radiology, Kangwon National University Hospital, Chuncheon, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Lavelle LP, McEvoy SH, Ni Mhurchu E, Gibney RG, McMahon CJ, Heffernan EJ, Malone DE. Cystic Fibrosis below the Diaphragm: Abdominal Findings in Adult Patients. Radiographics 2015; 35:680-695. [PMID: 25910185 DOI: 10.1148/rg.2015140110] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Cystic fibrosis (CF) is the most common lethal autosomal recessive disease in the white population. Mutation of the CF transmembrane conductance regulator gene on chromosome 7 results in production of abnormally viscous mucus and secretions in the lungs of patients with CF. A similar pathologic process occurs in the gastrointestinal tract, pancreas, and hepatobiliary system. Inspissated mucus causes luminal obstruction and resultant clinical and radiologic complications associated with the disease process. Pancreatic involvement can result in exocrine and endocrine insufficiency, pancreatic atrophy, fatty replacement, or lipomatous pseudohypertrophy. Acute and chronic pancreatitis, pancreatic calcification, cysts, and cystosis also occur. Hepatic manifestations include hepatic steatosis, focal biliary and multilobular cirrhosis, and portal hypertension. Biliary complications include cholelithiasis, microgallbladder, and sclerosing cholangitis. The entire digestive tract can be involved. Distal ileal obstruction syndrome, intussusception, appendicitis, chronic constipation, colonic wall thickening, fibrosing colonopathy, pneumatosis intestinalis, gastroesophageal reflux, and peptic ulcer disease have been described. Renal manifestations include nephrolithiasis and secondary amyloidosis. The educational objectives of this review are to reveal the abdominal manifestations of CF to facilitate focused analysis of cross-sectional imaging in adult patients. Life expectancy in patients with CF continues to improve because of a combination of aggressive antibiotic treatment, improved emphasis on nutrition and physiotherapy, and development of promising new CF transmembrane conductance regulator modulators. As lung function and survival improve, extrapulmonary conditions, including hepatic and gastrointestinal malignancy, will be an increasing cause of morbidity and mortality. Awareness of the expected abdominal manifestations of CF may assist radiologists in identifying acute inflammatory or neoplastic conditions. (©)RSNA, 2015.
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Affiliation(s)
- Lisa P Lavelle
- From the Department of Radiology, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Hungerford JP, Neill Magarik MA, Hardie AD. The breadth of imaging findings of groove pancreatitis. Clin Imaging 2015; 39:363-6. [DOI: 10.1016/j.clinimag.2015.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 12/22/2014] [Accepted: 01/30/2015] [Indexed: 01/13/2023]
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Manikkavasakar S, AlObaidy M, Busireddy KK, Ramalho M, Nilmini V, Alagiyawanna M, Semelka RC. Magnetic resonance imaging of pancreatitis: An update. World J Gastroenterol 2014; 20:14760-14777. [PMID: 25356038 PMCID: PMC4209541 DOI: 10.3748/wjg.v20.i40.14760] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Revised: 06/02/2014] [Accepted: 06/17/2014] [Indexed: 02/06/2023] Open
Abstract
Magnetic resonance (MR) imaging plays an important role in the diagnosis and staging of acute and chronic pancreatitis and may represent the best imaging technique in the setting of pancreatitis due to its unmatched soft tissue contrast resolution as well as non-ionizing nature and higher safety profile of intravascular contrast media, making it particularly valuable in radiosensitive populations such as pregnant patients, and patients with recurrent pancreatitis requiring multiple follow-up examinations. Additional advantages include the ability to detect early forms of chronic pancreatitis and to better differentiate adenocarcinoma from focal chronic pancreatitis. This review addresses new trends in clinical pancreatic MR imaging emphasizing its role in imaging all types of acute and chronic pancreatitis, pancreatitis complications and other important differential diagnoses that mimic pancreatitis.
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Busireddy KK, AlObaidy M, Ramalho M, Kalubowila J, Baodong L, Santagostino I, Semelka RC. Pancreatitis-imaging approach. World J Gastrointest Pathophysiol 2014; 5:252-270. [PMID: 25133027 PMCID: PMC4133524 DOI: 10.4291/wjgp.v5.i3.252] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 02/13/2014] [Accepted: 05/16/2014] [Indexed: 02/06/2023] Open
Abstract
Pancreatitis is defined as the inflammation of the pancreas and considered the most common pancreatic disease in children and adults. Imaging plays a significant role in the diagnosis, severity assessment, recognition of complications and guiding therapeutic interventions. In the setting of pancreatitis, wider availability and good image quality make multi-detector contrast-enhanced computed tomography (MD-CECT) the most used imaging technique. However, magnetic resonance imaging (MRI) offers diagnostic capabilities similar to those of CT, with additional intrinsic advantages including lack of ionizing radiation and exquisite soft tissue characterization. This article reviews the proposed definitions of revised Atlanta classification for acute pancreatitis, illustrates a wide range of morphologic pancreatic parenchymal and associated peripancreatic changes for different types of acute pancreatitis. It also describes the spectrum of early and late chronic pancreatitis imaging findings and illustrates some of the less common types of chronic pancreatitis, with special emphasis on the role of CT and MRI.
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Rana SS, Bhasin DK, Sharma V, Rao C, Singh K. Role of endoscopic ultrasound in the diagnosis of pancreas divisum. Endosc Ultrasound 2014; 2:7-10. [PMID: 24949360 PMCID: PMC4062234 DOI: 10.7178/eus.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 01/03/2013] [Indexed: 12/24/2022] Open
Abstract
Objective: The published data on the accuracy of the detection of pancreas divisum by endoscopic ultrasound (EUS) is limited. In this study, we evaluate the accuracy of detection of pancreas divisum by radial EUS in patients with chronic pancreatitis. Methods: We retrospectively evaluated patients with chronic pancreatitis who underwent EUS followed by endoscopic retrograde cholangiopancreatography (ERCP) in the last four years to identify patients with complete pancreas divisum. Results: One hundred and forty six patients with chronic pancreatitis underwent EUS examination and 20 patients (13.6%) had pancreas divisum. The overall sensitivity, specificity, positive predictive value, negative predictive value and accuracy of absence of stack sign on EUS for the diagnosis of pancreas divisum were 50%, 97%, 73%, 93% and 91%, respectively and for the inability to trace pancreatic duct from the head to the body were 100%, 96%, 80%, 100% and 96%, respectively. Conclusion: EUS can diagnose pancreas divisum in a majority of patients. Pancreas divisum can be reliably excluded if pancreatic duct could be tracked backwards from the head to the body around the genu.
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Affiliation(s)
- Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Deepak Kumar Bhasin
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Chalapathi Rao
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
| | - Kartar Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh 160012, India
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Pezzilli R, Morselli-Labate AM. The concept of autoimmune pancreatitis and its immunological backgrounds. Expert Rev Clin Immunol 2014; 6:125-36. [DOI: 10.1586/eci.09.68] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Groove pancreatitis: spectrum of imaging findings and radiology-pathology correlation. AJR Am J Roentgenol 2013; 201:W29-39. [PMID: 23789694 DOI: 10.2214/ajr.12.9956] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Groove pancreatitis is a rare form of chronic pancreatitis affecting the "groove" between the pancreatic head, duodenum, and common bile duct. The exact cause is unknown, although there are strong associations with long-term alcohol abuse, functional obstruction of the duct of Santorini, and Brunner gland hyperplasia. CONCLUSION Unfortunately, differentiating groove pancreatitis from malignancy on the basis of imaging features, clinical presentation, or laboratory markers can be extraordinarily difficult, and the vast majority of these patients ultimately undergo a pancreaticoduodenectomy (Whipple procedure) because of an inability to completely exclude malignancy. In certain cases, however, the imaging features on CT and MRI can allow the radiologist to prospectively suggest the correct diagnosis.
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Abstract
OBJECTIVE IgG4-related disease was not recognized as a specific clinical entity until 2003 when extrapancreatic lesions were reported in patients with autoimmune pancreatitis. IgG4-related disease is characterized by elevated serum IgG4 levels and infiltration of the target organ by IgG4-positive plasma cells. The complete gamut of visceral involvement is still being outlined. The purpose of this article is to highlight the plethora of lesions under the spectrum of IgG4-related disease of the abdomen and pelvis, describe their imaging appearances on multimodality cross-sectional imaging, and discuss the differential diagnoses. CONCLUSION It is important for radiologists to recognize the multiorgan involvement and few classic features of IgG4-related disease that often tend to simulate malignancy.
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Abstract
Several uncommon primary pancreatic tumors, inflammatory conditions, metastasis to the pancreas and peripancreatic masses can mimic the appearance of pancreatic ductal adenocarcinoma (PDA). Differentiation between these lesions and PDA can be challenging, due to the overlap in imaging features; however, familiarity with their typical imaging features and clinical presentation may be helpful in their differentiation, as in some cases, invasive diagnostic tests or unnecessary surgery can be avoided. The different pathologies that can mimic PDA include inflammatory conditions such as the various forms of pancreatitis (chronic-focal mass-forming, autoimmune and groove pancreatitis), pancreatic neuroendocrine tumors, solid pseudopapillary tumors, metastasis (solid non-lymphomatous and hematologic), congenital variants (annular pancreas), as well as peripancreatic lesions (accessory spleen, adrenal masses, duodenal masses, lymph nodes and vascular lesions), and certain rare pancreatic tumors (e.g., acinar cell tumors, solid serous tumors, hamartoma and solitary fibrous tumors). The clinical presentation and imaging features of the most commonly encountered mimics of PDA are discussed in this presentation with representative illustrations.
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Affiliation(s)
- Mahmoud M Al-Hawary
- Department of Radiology, University of Michigan Health Services, Ann Arbor, MI, USA
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Sathyanarayana SA, Deutsch GB, Bajaj J, Friedman B, Bansal R, Molmenti E, Nicastro JM, Coppa GF. Ectopic pancreas: a diagnostic dilemma. Int J Angiol 2013; 21:177-80. [PMID: 23997566 DOI: 10.1055/s-0032-1325119] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
An ectopic pancreas is defined as pancreatic tissue lacking vascular or anatomic communication with the normal body of the pancreas. It is rarely symptomatic as it is found incidentally at laparotomy most of the time. Despite advances in diagnostic modalities, it still remains a challenge to the clinician to differentiate it from a neoplasm. It is prudent to differentiate it from neoplastic etiologies, as simple surgical excision can potentially be curative. We discuss the presentation, diagnosis, and treatment of an interesting case of ectopic pancreas presenting as a gastric antral tumor.
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65
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O'Malley RB, Maturen KE, Al-Hawary MM, Mathur AK. Case of the Season: Ectopic Pancreas. Semin Roentgenol 2013; 48:188-91. [DOI: 10.1053/j.ro.2013.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Olivetti L, Giardini A, Grassia R. An unusual case of epigastric pain: two causes for one disease. Gastroenterology 2013; 144:885, 1158-9. [PMID: 23523685 DOI: 10.1053/j.gastro.2013.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Revised: 12/20/2012] [Accepted: 01/07/2013] [Indexed: 12/02/2022]
Affiliation(s)
- Lucio Olivetti
- Department of Radiology, Istituti Ospitalieri di Cremona, Cremona, Italy
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67
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Imaging of Acute Pancreas. Emerg Radiol 2013. [DOI: 10.1007/978-1-4419-9592-6_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Ginsburg M, Ahmed O, Rana KA, Boumendjel R, Dachman AH, Zaritzky M. Ectopic pancreas presenting with pancreatitis and a mesenteric mass. J Pediatr Surg 2013; 48:e29-32. [PMID: 23331836 DOI: 10.1016/j.jpedsurg.2012.10.062] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 10/31/2012] [Accepted: 10/31/2012] [Indexed: 12/18/2022]
Abstract
Ectopic pancreas is defined by the presence of abnormally situated pancreatic tissue that lacks contact with normal pancreas and possesses its own duct system and vascular supply. Ectopic pancreas in the gastrointestinal tract is not uncommon. Moreover, there are several reported cases of adult ectopic pancreatitis in the literature, but to date, only two cases of pediatric ectopic pancreatitis have been reported. We describe a 15-year-old female with acute right upper quadrant pain and elevated serum lipase and amylase, in whom the radiological diagnosis was mesenteric soft tissue mass with adjacent inflammatory changes. The surgical pathology diagnosis, however, was mesenteric ectopic pancreas complicated by pancreatitis. We advocate for ectopic pancreatitis to be considered in a pediatric patient with acute abdominal pain, laboratory findings consistent with pancreatitis, and imaging findings of a mesenteric mass and normal orthotopic pancreas.
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Affiliation(s)
- Michael Ginsburg
- Department of Radiology, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA.
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Frequency and significance of calcification in IPMN. Pancreatology 2012; 13:43-7. [PMID: 23395569 DOI: 10.1016/j.pan.2012.11.306] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2012] [Revised: 11/11/2012] [Accepted: 11/12/2012] [Indexed: 02/08/2023]
Abstract
UNLABELLED The frequency and significance of calcification in intraductal papillary mucinous neoplasms (IPMN) are unknown. We examined calcifications by computed tomography (CT) in a large cohort of IPMNs and correlated them with clinicopathologic characteristics. METHODS Preoperative contrast-enhanced CT imaging studies of 164 patients with surgically resected IPMN were retrospectively reviewed. Morphologic characteristics of IPMN, presence and type of calcifications, their location, the degree of dysplasia and the epithelial subtype were recorded. Symptoms at the time of diagnosis, history of smoking, and alcohol consumption were obtained from medical records. RESULTS Of the 164 IPMNs, 68 were branch duct type (Br-IPMN) and 96 main duct (MD-IPMN) or combined type (CT-IPMN); 78 (48%) had a malignant component (CIS and Invasive). Calcifications were present in 33 cases (20%). By type, 16 calcifications were punctate, 11 coarse and 9 eggshell, and by location, 15 were mural, 3 septal, 2 ductal, 1 in the solid component, and 13 in multiple locations. Calcifications were seen more frequently in larger lesions (44 mm vs 32 mm p = 0.002), and when MPD dilation was noted (70% vs 45%, p = 0.023). There was no association between presence of calcification and malignancy, epithelial subtype, or other clinical data. However, malignancy was present in 9/11 IPMN with coarse calcification (p = 0.04), suggesting this may be a worrisome feature. CONCLUSION Calcification is found in 20% of IPMNs, and is more common in larger lesions. Although its overall presence has no correlation with malignancy, coarse calcification, when combined with other morphologic features, may be a radiologic sign of malignancy.
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Proctor RD, Rofe CJ, Bryant TJC, Hacking CN, Stedman B. Autoimmune pancreatitis: an illustrated guide to diagnosis. Clin Radiol 2012. [PMID: 23177083 DOI: 10.1016/j.crad.2012.08.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Autoimmune pancreatitis (AIP) remains one of the rarer forms of pancreatitis but has become increasingly well recognized and widely diagnosed as it is an important differential, particularly due to the dramatic response to appropriate therapy. It is now best considered as part of a multisystem disease and the notion of "IgG4-related systemic sclerosing disease" has become widely recognized as the number of extra-pancreatic associations of AIP grows. More recently AIP has been classified into two subtypes: lymphoplasmacytic sclerosing pancreatitis (LPSP) and idiopathic duct-centric pancreatitis (IDCP) with distinct geographical, age and sex distributions for the two subtypes, in addition to different pathological characteristics. The role of imaging is crucial in AIP and should be considered in conjunction with clinical, serological, and histopathological findings to make the diagnosis. Radiologists are uniquely placed to raise the possibility of AIP and aid the exclusion of significant differentials to allow the initiation of appropriate management and avoidance of unnecessary intervention. Radiological investigation may reveal a number of characteristic imaging findings in AIP but appearances can vary considerably and the focal form of AIP may appear as a pancreatic mass, imitating pancreatic carcinoma. This review will illustrate typical and atypical appearances of AIP on all imaging modes. Emphasis will be placed on the imaging features that are likely to prove useful in discriminating AIP from other causes prior to histopathological confirmation. In addition, examples of relevant differential diagnoses are discussed and illustrated.
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Affiliation(s)
- R D Proctor
- Department of Clinical Radiology, Royal Cornwall Hospitals NHS Trust, Truro, UK
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Ashish K, Vivek V, Adnan S. Recurrent Abdominal Pain in a Young Adult. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2012. [DOI: 10.47102/annals-acadmedsg.v41n6p277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Gonoi W, Akai H, Hagiwara K, Akahane M, Hayashi N, Maeda E, Yoshikawa T, Kiryu S, Tada M, Uno K, Ohtsu H, Okura N, Koike K, Ohtomo K. Meandering main pancreatic duct as a relevant factor to the onset of idiopathic recurrent acute pancreatitis. PLoS One 2012; 7:e37652. [PMID: 22655061 PMCID: PMC3360061 DOI: 10.1371/journal.pone.0037652] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 04/23/2012] [Indexed: 12/15/2022] Open
Abstract
Background Meandering main pancreatic duct (MMPD), which comprises loop type and reverse-Z type main pancreatic duct (MPD), has long been discussed its relation to pancreatitis. However, no previous study has investigated its clinical significance. We aimed to determine the non-biased prevalence and the effect of MMPD on idiopathic pancreatitis using non-invasive magnetic resonance (MR) technique. Methods and Findings A cross-sectional study performed in a tertiary referral center. The study enrolled 504 subjects from the community and 30 patients with idiopathic pancreatitis (7 acute, 13 chronic, and 10 recurrent acute). All subjects underwent MR scanning and medical examination. MMPD was diagnosed when the MPD in the head of pancreas formed two or more extrema in the horizontal direction on coronal images of MR cholangiopancreatography, making a loop or a reverse-Z shaped hairpin curves and not accompanied by other pancreatic ductal anomaly. Statistical comparison was made among groups on the rate of MMPD including loop and reverse-Z subtypes, MR findings, and clinical features. The rate of MMPD was significantly higher for all idiopathic pancreatitis/idiopathic recurrent acute pancreatitis (RAP) (20%/40%; P<0.001/0.0001; odds ratio (OR), 11.1/29.0) than in the community (2.2%) but was not higher for acute/chronic pancreatitis (14%/8%; P = 0.154/0.266). Multiple logistic regression analysis revealed MMPD to be a significant factor that induces pancreatitis/RAP (P<0.0001/0.0001; OR, 4.01/26.2). Loop/reverse-Z subtypes were found more frequently in idiopathic RAP subgroup (20%/20%; P = 0.009/0.007; OR, 20.2/24.2) than in the community (1.2%/1.0%). The other clinical and radiographic features were shown not associated with the onset of pancreatitis. Conclusions MMPD is a common anatomical variant and might be a relevant factor to the onset of idiopathic RAP.
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Affiliation(s)
- Wataru Gonoi
- Department of Radiology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan.
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Autoimmune pancreatitis: assessment of the enhanced duct sign on multiphase contrast-enhanced computed tomography. Eur J Radiol 2012; 81:3055-60. [PMID: 22613506 DOI: 10.1016/j.ejrad.2012.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 04/15/2012] [Accepted: 04/25/2012] [Indexed: 01/06/2023]
Abstract
PURPOSE To assess the usefulness of the computed tomography (CT) finding of main pancreatic duct (MPD) wall enhancement, termed the "enhanced duct sign", for diagnosis of autoimmune pancreatitis (AIP) in comparison with diagnosis of pancreatic carcinoma and chronic pancreatitis. MATERIALS AND METHODS Two radiologists independently evaluated the presence or absence of the enhanced duct sign on multiphase contrast-enhanced CT in patients with AIP (n=55), pancreatic carcinoma (n=50), and chronic pancreatitis (n=50). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of AIP were calculated. In patients demonstrating the enhanced duct sign, additional findings were evaluated by consensus. RESULTS The enhanced duct sign was more frequently observed in patients with AIP (37/55, 67%) than in patients with pancreatic carcinoma (5/50, 10%) or chronic pancreatitis (0/50, 0%) (P<0.05). The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of the finding were 0.67, 0.95, 0.85, 0.88, and 0.84, respectively. In AIP, the lumen within the enhanced duct was completely or partially invisible in 29 of 37 (78%) patients, and the enhanced duct was observed within the affected pancreatic parenchyma in 35 of 37 (95%) patients. In pancreatic carcinoma, the lumen within the enhanced duct was visible in all patients (5/5, 100%), and the enhanced duct was observed downstream of the tumor (5/5, 100%). CONCLUSION The enhanced duct sign is highly specific of AIP.
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Perez-Johnston R, Sainani NI, Sahani DV. Imaging of Chronic Pancreatitis (Including Groove and Autoimmune Pancreatitis). Radiol Clin North Am 2012; 50:447-66. [DOI: 10.1016/j.rcl.2012.03.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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75
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Abstract
Acute pancreatitis is one of the most common surgical disease, and thus cause of hospitalization. Incidence and etiology of this condition demonstrates large regional differences. This situation is a substantial financial burden forhospital district, and changes in organization structure and funding medical service should be taken under consideration.The aim of the study was to record the epidemiology with etiology, diagnosis and treatment of acute pancreatitis in large district (77 000 inhabitants).Material and methods. A meta-analysis study of all 298 patients admitted to Hospital St Hedwig in Trzebnica, in the six-year period from 2005 to 2010, with acute pancreatitis was performed.Results. Acute pancreatitis was diagnosed in 298 patients in the six - year period, giving an estimated incidence of 64.4 per 100 000. Among the group of 441 admissions for acute pancreatitis in 298 patients was confirmed. Severe acute pancreatitis developed in 22.5% (67/298) of patients, more often in males 56/208 (27%) than in females 11/90 (12%). Gallstones were found as an etiological factor in 27% (80/298), and alcohol intake in 49% of patients. 211/298 (70%) patients had only one attack, whereas 29% (87/298) were readmitted with 230 relapses. The risk of recurrent pancreatitis was 48% in alcohol induced and 6,25% in gallstone induced pancreatitis. 53/298 patients (17%) were operated, ERCP procedures were performed in 24.Performed operations: necrosectomy in 25/53 (47%), elective cholecystectomy in 16/53 (30%), open drainage of abdominal abscess in 5/53 (9%), open drainage of cysts in 5/53 (9%), Jurasz's operation in 2/53 (3%). Majority surgical treatment was carried out in 68% cases with severe acute pancreatitis. Mortality due to acute pancreatitis was 3% (10/298); 15% in severe pancreatitis.Conclusions. 1. Acute pancreatitis continues to be an important clinical problem. 2. Severe, necrotic acute pancreatitis is associated with high mortality rates. 3. The ethanol-intake-related episodes of acute pancreatitits are much more prevalent than the gall-stone-related ones. 4. After the exclusion of ethanol- and gall-stones-related etiologies, the subsequent diagnostic process should aim at excluding neoplastic process of the head of pancreas.
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Abstract
With novel genetic technologies available, there is a paradigm shift in the way that risk assessments, diagnoses,and therapies for genetic susceptibility syndromes are addressed. Hereditary pancreatitis is among these conditions, for which genetic counseling and next generation sequencing, help families better understand, cope with and live healthier lives. Identifying a genetic etiology to a condition formally believed to be solely environmentally induced can alter the path for treatment for many patients. This finding introduces the concept of gene-environment interactions in human disease and the relationship between genetic predisposition and exposure risk in disease development. The genetic counseling process is complex with medical explanations, psychosocial issues relating to coping with diagnosis, potential future health problems, recurrence risks and family planning. These sometimes difficult conversations can be facilitated by a genetic counselor as a member of the multidisciplinary team. This chapter addresses the intricate medical and psychosocial issues that can arise in the setting of treating patients with hereditary pancreatitis.
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Affiliation(s)
- Sheila Solomon
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, 15213
| | - David C Whitcomb
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, 15213
- Department of Cell Biology and Molecular Physiology, University of Pittsburgh, Pittsburgh, PA, 15213
- Department of Human Genetics, University of Pittsburgh, Pittsburgh, PA, 15213
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Low G, Panu A, Millo N, Leen E. Multimodality imaging of neoplastic and nonneoplastic solid lesions of the pancreas. Radiographics 2012; 31:993-1015. [PMID: 21768235 DOI: 10.1148/rg.314105731] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Solid lesions of the pancreas represent a heterogeneous group of entities that can be broadly classified as either neoplastic or nonneoplastic. Neoplastic lesions include pancreatic adenocarcinoma, pancreatic neuroendocrine tumor, solid pseudopapillary tumor, pancreatoblastoma, pancreatic lymphoma, metastases to the pancreas, and rare miscellaneous neoplasms. Nonneoplastic lesions include focal pancreatitis, fatty infiltration-replacement, intrapancreatic accessory spleen, congenital anomalies such as prominent pancreatic lobulation and bifid pancreatic tail (pancreatic bifidum), and rare miscellaneous lesions (eg, pancreatic sarcoidosis, Castleman disease of the pancreas). A variety of imaging modalities are available for assessing these solid lesions, including ultrasonography (US), computed tomography (CT), magnetic resonance imaging, endoscopic US, and hybrid nuclear imaging techniques such as single photon emission computed tomography-CT and positron emission tomography-CT, each of which has its own strengths and limitations. Accurate diagnosis can be challenging, and use of a multimodality imaging approach is often helpful in equivocal or complex cases. Knowledge of relevant clinical information and key radiologic features is essential for confident lesion characterization and differentiation.
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Affiliation(s)
- Gavin Low
- Department of Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, AB, Canada.
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Vlachou PA, Khalili K, Jang HJ, Fischer S, Hirschfield GM, Kim TK. IgG4-related sclerosing disease: autoimmune pancreatitis and extrapancreatic manifestations. Radiographics 2012; 31:1379-402. [PMID: 21918050 DOI: 10.1148/rg.315105735] [Citation(s) in RCA: 132] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Autoimmune pancreatitis is the pancreatic manifestation of IgG4-related sclerosing disease, which recently was recognized as a distinct disease entity. Numerous extrapancreatic organs, such as the bile ducts, gallbladder, kidneys, retroperitoneum, thyroid, salivary glands, lung, mediastinum, lymph nodes, and prostate may be involved, either synchronously or metachronously. Most cases of autoimmune pancreatitis are associated with elevated serum IgG4 levels; extensive IgG4-positive plasma cells; and infiltration of lymphocytes into various organs, which leads to fibrosis. There are several established diagnostic criteria systems that are used to diagnose autoimmune pancreatitis and that rely on a combination of imaging findings of the pancreas and other organs, serologic findings, pancreatic histologic findings, and response to corticosteroid therapy. It is important to recognize multiorgan involvement of IgG4-related sclerosing disease and be familiar with its clinical and imaging features because it demonstrates a favorable response to treatment.
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Affiliation(s)
- Paraskevi A Vlachou
- Department of Medical Imaging and Pathology, University of Toronto, Toronto, Canada
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Pezzilli R, Santini D, Calculli L, Casadei R, Morselli-Labate AM, Imbrogno A, Fabbri D, Taffurelli G, Ricci C, Corinaldesi R. Cystic dystrophy of the duodenal wall is not always associated with chronic pancreatitis. World J Gastroenterol 2011; 17:4349-64. [PMID: 22110260 PMCID: PMC3218148 DOI: 10.3748/wjg.v17.i39.4349] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Revised: 03/31/2011] [Accepted: 04/07/2011] [Indexed: 02/06/2023] Open
Abstract
Cystic dystrophy of the duodenal wall is a rare form of the disease which was described in 1970 by French authors who reported the presence of focal pancreatic disease localized in an area comprising the C-loop of the duodenum and the head of the pancreas. German authors have defined this area as a “groove”. We report our recent experience on cystic dystrophy of the paraduodenal space and systematically review the data in the literature regarding the alterations of this space. A MEDLINE search of papers published between 1966 and 2010 was carried out and 59 papers were considered for the present study; there were 19 cohort studies and 40 case reports. The majority of patients having groove pancreatitis were middle aged. Mean age was significantly higher in patients having groove carcinoma. The diagnosis of cystic dystrophy of the duodenal wall can now be assessed by multidetector computer tomography, magnetic resonance imaging and endoscopic ultrasonography. These latter two techniques may also add more information on the involvement of the remaining pancreatic gland not involved by the duodenal malformation and they may help in differentiating “groove pancreatitis” from “groove adenocarcinoma”. In conclusion, chronic pancreatitis involving the entire pancreatic gland was present in half of the patients with cystic dystrophy of the duodenal wall and, in the majority of them, the pancreatitis had calcifications.
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Segmental groove pancreatitis and duodenal gangliocytic paraganglioma with lymph node metastasis: a newly described association. Pancreas 2011; 40:1145-7. [PMID: 21926554 DOI: 10.1097/mpa.0b013e31821f54d6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Lee NK, Kim S, Jeon TY, Kim HS, Kim DH, Seo HI, Park DY, Jang HJ. Complications of congenital and developmental abnormalities of the gastrointestinal tract in adolescents and adults: evaluation with multimodality imaging. Radiographics 2011; 30:1489-507. [PMID: 21071371 DOI: 10.1148/rg.306105504] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
There is a wide variety of congenital anomalies that may affect the gastrointestinal tract. Most symptomatic congenital anomalies are found in newborns and infants. Such anomalies are relatively rare in adolescents and adults, and they may be difficult to identify because clinical symptoms often are nonspecific and insidious, causing them to be mistaken for other common abdominal conditions. Multimodality imaging is useful in evaluating congenital anomalies of the gastrointestinal tract in adults. The imaging features at radiography, fluoroscopy, ultrasonography, computed tomography, and magnetic resonance imaging may help identify congenital gastrointestinal anomalies such as congenital esophageal stenosis, gastric volvulus, duodenal web, annular pancreas, heterotopic pancreas, cecal volvulus, anomalies of the omphalomesenteric duct, Hirschsprung disease, and gastrointestinal duplication cyst. Familiarity with the imaging features of the various congenital anomalies of the gastrointestinal tract and their complications is important to establish the correct diagnosis and determine appropriate treatment, which is critical to avoid life-threatening complications.
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Affiliation(s)
- Nam Kyung Lee
- Department of Radiology, Pusan National University Hospital, Pusan National University School of Medicine, Pusan National University, Seo-Gu, Busan, Korea
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Ferreira A, Ramalho M, Herédia V, de Campos R, Marques P. Groove pancreatitis: A Case Report and Review of the Literature. J Radiol Case Rep 2010; 4:9-17. [PMID: 22470697 DOI: 10.3941/jrcr.v4i11.588] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Groove pancreatitis is a rare form of segmental chronic pancreatitis. It involves the anatomic space between the head of the pancreas, the duodenum and the common bile duct. It was first described in the early 1970s, but it remains largely unfamiliar to most physicians. Radiological diagnosis can be challenging, as it is often difficult to differentiate it from other entities. The differential diagnosis from pancreatic head carcinoma may be difficult and recognition of subtle differences between these two entities is extremely important as the management differs significantly. Groove pancreatitis can be managed by conservative medical treatment, and surgery is reserved only for patients with persistent and severe clinical symptoms. We present a case of a 27 year-old male with groove pancreatitis and discuss the Magnetic Resonance Imaging (MRI) appearance of this entity as well as the differential diagnosis.
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Affiliation(s)
- Ana Ferreira
- Department of Radiology, Hospital Pulido Valente, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
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Prasad Shanbhogue AK, Prasad SR, Jagirdar J, Takahashi N, Sandrasegaran K, Fazzio RT, Fidler JL. Comprehensive Update on Select Immune-Mediated Gastroenterocolitis Syndromes: Implications for Diagnosis and Management. Radiographics 2010; 30:1465-87. [DOI: 10.1148/rg.306105520] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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