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Al-Hindi S, Khalaf Z, Al-Sousi AN. Presentation of Acute Pancreatitis in Sickle Cell Disease Patients: A Single Hospital Experience. Afr J Paediatr Surg 2024; 21:151-154. [PMID: 39162749 DOI: 10.4103/ajps.ajps_133_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/16/2023] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Sickle cell disease (SCD) is a haemoglobinopathy that leads to the formation of distorted sickle-shaped red blood cells that are prone to vaso-occlusion. This may lead to vaso-occlusive crises that may affect any organ. Acute pancreatitis (AP) in SCD patients may be mimicked by a vaso-occlusive crisis in the abdomen. The objective of this article is to analyse the clinical profiles of SCD patients with AP and understand the differences in the presentation of AP compared to an abdominal vaso-occlusive crisis and the difference between its presentation in SCD patients in comparison to other patients. MATERIALS AND METHODS Twenty-eight SCD patients who were diagnosed with AP during their admission to the paediatric department at a tertiary hospital between January 2012 and December 2020 were retrospectively studied. Patients aged older than 14 years were excluded. The data collected concerned: demographics, the clinical course and the hospital course. The diagnosis and severity protocols followed the revised Atlanta Criteria. RESULTS The patients were aged with a mean of 9.61 years. There were 15 males and 13 females. Demographics were not significantly correlated to complication rates (P > 0.05). The mean duration of hospitalisation was 6.43 days. The most common clinical presentations were abdominal pain, fever, then vomiting and nausea. Three patients experienced complications and they were all cases of cholangitis (10.71%). There were no cases of pseudocysts, acute necrotic collections, pancreatic or peripancreatic necrosis or walled-off necroses. All of the cases of AP in SCD children were mild according to the revised Atlanta classification. Leucocytosis was present in 29.29% of patients and 17.8% of patients had high C-reactive proteins (CRPs). There was no significant correlation between leucocyte counts, CRP levels, serum or urinary amylase levels and complications (P > 0.05). All patients had haemoglobin (Hb) levels above 7 g/dL. The levels of sickle Hb ranged from 40 to 70 g/dL and reticulocyte counts averaged at 3.57%. Haematologic parameters were not significantly correlated with complication rates (P > 0.05). There were no recurrences. CONCLUSION AP in SCD patients presented with classic signs and symptoms. There were no associations between demographics and complications. The levels of leucocytes, CRP counts and serum and urinary amylase were not correlated with complications. The level of Hb and sickle cell Hb was not associated with complication rates. Reticulocytes were slightly elevated in SCD patients with AP. More studies are needed to demarcate factors distinguishing AP in SCD from abdominal vaso-occlusive crises.
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Affiliation(s)
- Saeed Al-Hindi
- Department of Pediatric Surgery, Salmaniya Medical Complex, Manama, Kingdom of Bahrain
| | - Zahra Khalaf
- Department of Postgraduate Surgical Studies, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - AbdelSalam N Al-Sousi
- Department of Postgraduate Surgical Studies, Royal College of Surgeons in Ireland, Dublin, Ireland
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Dike CR, Fittro S, Oster RA, Morrow CD, Brandow A, Demark-Wahnefried W, Lebensburger J. Gastrointestinal symptoms, diagnostic evaluations, and abdominal pathology in children with sickle cell disease. Pediatr Blood Cancer 2023; 70:e30699. [PMID: 37787664 DOI: 10.1002/pbc.30699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND Children with sickle cell disease (SCD) frequently present with acute pain. The abdomen, a common site of acute SCD-related pain, may be present in a variety of gastrointestinal (GI) pathologies. Limited data exist on prevalence and workup of abdominal pain in patients with SCD during acute pain events. OBJECTIVES Determine prevalence of GI symptoms, GI-specific evaluation and risks of hospitalization in children with SCD presenting to the emergency department (ED) or hospitalized with abdominal pain. METHODS Retrospective study of children less than 21 years presenting to the ED or hospitalized with pain in our center over 2 years. Descriptive statistics were used to report clinical characteristics, frequency of GI symptoms, workup by age (<5 vs. ≥5 years), and genotype (sickle cell anemia [SCA] vs. non-SCA). Logistic regression models were used to identify risks associated with hospitalization. RESULTS A total of 1279 encounters in 378 patients were analyzed; 23% (n = 291) encounters were associated with abdominal pain. More abdominal pain-associated hospitalizations occurred in older children, SCA, children with lower mean hemoglobin (8.7 ± 1.9 vs. 9.6 ± 1.6 g/dL, p < .001) and higher mean white blood cell (WBC) count (14.9 ± 6.6 vs. 13.2 ± 5.3 × 103 /μL, p = .02). We identified that less than 50% of patients presenting to the ED with abdominal pain received a GI-specific evaluation. CONCLUSION Children with SCD frequently present with abdominal pain and other GI symptoms, with limited GI evaluations performed. GI-specific evaluation may increase diagnosis of GI pathologies, rule out GI pathologies, and contribute to the limited knowledge of the abdomen as a primary site of SCD pain.
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Affiliation(s)
- Chinenye R Dike
- Department of Pediatrics, Division of Pediatric Gastroenterology, Hepatology and Nutrition, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sarah Fittro
- University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Robert A Oster
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Casey D Morrow
- Department of Cell, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Amanda Brandow
- Department of Pediatrics, Section of Pediatric Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Wendy Demark-Wahnefried
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey Lebensburger
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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3
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Solomon N, Segaran N, Badawy M, Elsayes KM, Pellerito JS, Katz DS, Moshiri M, Revzin MV. Manifestations of Sickle Cell Disorder at Abdominal and Pelvic Imaging. Radiographics 2022; 42:1103-1122. [PMID: 35559660 DOI: 10.1148/rg.210154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Sickle cell disorder (SCD) refers to a spectrum of hematologic disorders that cause a characteristic clinical syndrome affecting the entire body. It is the most prevalent monogenetic hemoglobinopathy worldwide, with a wide range of focal and systemic expressions. Hemoglobin gene mutation leads to the formation of abnormal sickle-shaped red blood cells, which cause vascular occlusion and result in tissue and organ ischemia and infarction. Recurrent episodes of acute illness lead to progressive multisystem organ damage and dysfunction. Vaso-occlusion, hemolysis, and infection as a result of functional asplenia are at the core of the disease manifestations. Imaging plays an essential role in the diagnosis and management of SCD-related complications in the abdomen and pelvis. A thorough understanding of the key imaging findings of SCD complications involving hepatobiliary, gastrointestinal, genitourinary, and musculoskeletal systems is crucial to timely recognition and accurate diagnosis. The authors aim to familiarize the radiologist with the SCD spectrum, focusing on the detection and evaluation of manifestations that may appear at imaging of the abdomen and pelvis. The topics the authors address include (a) the pathophysiology of the disease, (b) the placement of SCD among hemoglobinopathies, (c) the clinical presentation of SCD, (d) the role of imaging in the evaluation and diagnosis of patients with SCD who present with abdominal and pelvic manifestations in addition to extraperitoneal manifestations detectable at abdominal or pelvic imaging, (e) imaging features associated with common and uncommon sequelae of SCD in abdominal and pelvic imaging studies, and (f) a brief overview of management and treatment of patients with SCD. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Nadia Solomon
- From the Department of Radiology and Biomedical Imaging, 333 Cedar Street, PO Box 208042 Room TE-2, New Haven, CT 06520 (N. Solomon, M.V.R.); Stanford University, Stanford, Calif (N. Segaran); Department of Imaging Physics (M.B.) and Department of Abdominal Imaging (K.M.E.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, N.Y. (J.S.P.); Department of Radiology, NYU Winthrop University Hospital, Mineola, N.Y. (D.S.K.); and Department of Radiology, University of Washington Medical Center, Seattle Wash. (M.M.)
| | - Nicole Segaran
- From the Department of Radiology and Biomedical Imaging, 333 Cedar Street, PO Box 208042 Room TE-2, New Haven, CT 06520 (N. Solomon, M.V.R.); Stanford University, Stanford, Calif (N. Segaran); Department of Imaging Physics (M.B.) and Department of Abdominal Imaging (K.M.E.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, N.Y. (J.S.P.); Department of Radiology, NYU Winthrop University Hospital, Mineola, N.Y. (D.S.K.); and Department of Radiology, University of Washington Medical Center, Seattle Wash. (M.M.)
| | - Mohamed Badawy
- From the Department of Radiology and Biomedical Imaging, 333 Cedar Street, PO Box 208042 Room TE-2, New Haven, CT 06520 (N. Solomon, M.V.R.); Stanford University, Stanford, Calif (N. Segaran); Department of Imaging Physics (M.B.) and Department of Abdominal Imaging (K.M.E.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, N.Y. (J.S.P.); Department of Radiology, NYU Winthrop University Hospital, Mineola, N.Y. (D.S.K.); and Department of Radiology, University of Washington Medical Center, Seattle Wash. (M.M.)
| | - Khaled M Elsayes
- From the Department of Radiology and Biomedical Imaging, 333 Cedar Street, PO Box 208042 Room TE-2, New Haven, CT 06520 (N. Solomon, M.V.R.); Stanford University, Stanford, Calif (N. Segaran); Department of Imaging Physics (M.B.) and Department of Abdominal Imaging (K.M.E.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, N.Y. (J.S.P.); Department of Radiology, NYU Winthrop University Hospital, Mineola, N.Y. (D.S.K.); and Department of Radiology, University of Washington Medical Center, Seattle Wash. (M.M.)
| | - John S Pellerito
- From the Department of Radiology and Biomedical Imaging, 333 Cedar Street, PO Box 208042 Room TE-2, New Haven, CT 06520 (N. Solomon, M.V.R.); Stanford University, Stanford, Calif (N. Segaran); Department of Imaging Physics (M.B.) and Department of Abdominal Imaging (K.M.E.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, N.Y. (J.S.P.); Department of Radiology, NYU Winthrop University Hospital, Mineola, N.Y. (D.S.K.); and Department of Radiology, University of Washington Medical Center, Seattle Wash. (M.M.)
| | - Douglas S Katz
- From the Department of Radiology and Biomedical Imaging, 333 Cedar Street, PO Box 208042 Room TE-2, New Haven, CT 06520 (N. Solomon, M.V.R.); Stanford University, Stanford, Calif (N. Segaran); Department of Imaging Physics (M.B.) and Department of Abdominal Imaging (K.M.E.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, N.Y. (J.S.P.); Department of Radiology, NYU Winthrop University Hospital, Mineola, N.Y. (D.S.K.); and Department of Radiology, University of Washington Medical Center, Seattle Wash. (M.M.)
| | - Mariam Moshiri
- From the Department of Radiology and Biomedical Imaging, 333 Cedar Street, PO Box 208042 Room TE-2, New Haven, CT 06520 (N. Solomon, M.V.R.); Stanford University, Stanford, Calif (N. Segaran); Department of Imaging Physics (M.B.) and Department of Abdominal Imaging (K.M.E.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, N.Y. (J.S.P.); Department of Radiology, NYU Winthrop University Hospital, Mineola, N.Y. (D.S.K.); and Department of Radiology, University of Washington Medical Center, Seattle Wash. (M.M.)
| | - Margarita V Revzin
- From the Department of Radiology and Biomedical Imaging, 333 Cedar Street, PO Box 208042 Room TE-2, New Haven, CT 06520 (N. Solomon, M.V.R.); Stanford University, Stanford, Calif (N. Segaran); Department of Imaging Physics (M.B.) and Department of Abdominal Imaging (K.M.E.), University of Texas MD Anderson Cancer Center, Houston, Tex; Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, N.Y. (J.S.P.); Department of Radiology, NYU Winthrop University Hospital, Mineola, N.Y. (D.S.K.); and Department of Radiology, University of Washington Medical Center, Seattle Wash. (M.M.)
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Wong V, Ali H, Amer K, Ahlawat S. A Rare Case of a Sickle Cell Patient With Post Endoscopic Retrograde Cholangiopancreatography (ERCP) Pancreatitis and Pseudoaneurysm Formation: An Association Worth Exploring. Cureus 2022; 14:e21780. [PMID: 35251850 PMCID: PMC8890677 DOI: 10.7759/cureus.21780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2022] [Indexed: 11/05/2022] Open
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5
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Sickle Cell Trait Presenting as Chronic Calcific Pancreatitis with Pseudocyst- A Case Report. Indian J Clin Biochem 2020; 36:239-241. [PMID: 33867717 DOI: 10.1007/s12291-020-00910-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
Abstract
Sickle cell disease is known to cause acute pancreatitis either due to gall stones obstructing the pancreatic duct or by vaso-occlusive mechanism. However chronic pancreatitis is a very rare complication in sickle cell anemia. We report a case of sickle cell trait presenting with chronic pancreatitis with pseudo cyst. USG abdomen and CT abdomen confirmed the diagnosis of chronic calcific pancreatitis with pseudocyst. Etiological work up for other causes did not reveal anything except sickle cell trait. This case represents a rare association between chronic calcific pancreatitis and sickle cell trait.
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Kinger NP, Moreno CC, Miller FH, Mittal PK. Abdominal Manifestations of Sickle Cell Disease. Curr Probl Diagn Radiol 2020; 50:241-251. [PMID: 32564896 DOI: 10.1067/j.cpradiol.2020.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/24/2020] [Accepted: 05/26/2020] [Indexed: 12/24/2022]
Abstract
Sickle cell disease is a debilitating hematologic process that affects the entire body. Disease manifestations in the abdomen most commonly result from vaso-occlusion, hemolysis, or infection due to functional asplenia. Organ specific manifestations include those involving the liver (eg, hepatopathy, iron deposition), gallbladder (eg, stone formation), spleen (eg, infarction, abscess formation, sequestration), kidneys (eg, papillary necrosis, infarction), pancreas (eg, pancreatitis), gastrointestinal tract (eg, infarction), reproductive organs (eg, priapism, testicular atrophy), bone (eg, marrow changes, avascular necrosis), vasculature (eg, vasculopathy), and lung bases (eg, acute chest syndrome, infarction). Imaging provides an important clinical tool for evaluation of acute and chronic disease manifestations and complications. In summary, there are multifold abdominal manifestations of sickle cell disease. Recognition of these sequela helps guide management and improves outcomes. The purpose of this article is to review abdominal manifestations of sickle cell disease and discuss common and rare complications of the disease within the abdomen.
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Affiliation(s)
- Nikhar P Kinger
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA.
| | - Courtney C Moreno
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA
| | - Frank H Miller
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Pardeep K Mittal
- Department of Radiology and Imaging, Medical College of Georgia, Augusta, GA
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7
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Manafa P, Okocha C, Nwogho B, Aneke J, Okpara PSD, lbeh N, Chukwuma G, Manafa V, Nwane E. comparative study of carbohydrate antigen 19-9 in sickle cell disease subjects and controls in Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria. Afr Health Sci 2018; 18:1003-1009. [PMID: 30766566 PMCID: PMC6354859 DOI: 10.4314/ahs.v18i4.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Sickle cell disease is characterized by chronic complications that affect almost all body organs. Pancreatic disease is rare in SCD. CA 19-9 is a non-specific surrogate marker for pancreatic disease especially carcinoma. CA 19-9 levels have not been evaluated in SCD patients in our environment. Objectives The study aimed to compare the levels of CA 19-9 in homozygous sickle cell disease subjects in steady state with those of (Hb AS) and normal healthy subjects (Hb AA) Method Seventy nine subjects including 39 Hb SS, 19 Hb AS and 21 Hb AA subjects were recruited in a cross-sectional study in Nnamdi Azikiwe University and Teaching Hospital. Haemoglobin genotype and CA 19-9 estimation were done using Hb electrophoresis and enzyme linked immunosorbent assay respectively. Data was analyzed with IBM SPSS 21. P value was set at 0.05. Result The mean CA 19-9 (U/ml) level in Hb SS, Hb AS and Hb AA were 13.6 ± 7.6, 15.3 ± 9.9, and 20.0 ± 15.9 respectively. [Reference value <37U/ml] CA 19-9 was significantly lower in Hb SS compared to Hb AA subjects (p = 0.035). Conclusion Low levels of CA 19-9 in Hb SS may suggest reduced pancreatic disorders in SCA.
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Affiliation(s)
- Patrick Manafa
- Medical laboratory Science department, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Anambra State Nigeria
| | - Chide Okocha
- Haematology Department, Nnamdi Azikiwe University Teaching Hospital, PMB 5025, Nnewi, Anambra State, Nigeria
| | - Benedict Nwogho
- Haematology Department , College of Medical Sciences, University of Benin, Edo State, Nigeria
| | - John Aneke
- Haematology Department, Nnamdi Azikiwe University Teaching Hospital, PMB 5025, Nnewi, Anambra State, Nigeria
| | - Paul Smith Davis Okpara
- Medical laboratory Science department, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Anambra State Nigeria
| | - Nancy lbeh
- Medical laboratory Science department, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Anambra State Nigeria
| | - George Chukwuma
- Medical laboratory Science department, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Anambra State Nigeria
| | - Vera Manafa
- Chemical Pathology department, Nnamdi Azikiwe University Teaching Hospital, PMB 5025, Nnewi, Anambra State, Nigeria
| | - Ejike Nwane
- Medical laboratory Science department, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Anambra State Nigeria
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Abstract
A common cause of abdominal pain is acute pancreatitis, with the majority of cases being attributed to gallstones and excess alcohol. Sickle cell anaemia (SCA) is an autosomal recessive disease causing the production of abnormal haemoglobin. Physiological changes can lead to vaso-occlusion in sickle cell anaemia. Cholelithiasis is frequently seen in patients with SCA and complications from this can increase patient morbidity. We present a rare case of acute pancreatitis inducing a vaso-occlusive crisis.
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9
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Turnbull TL, Houston PM, Batalis NI. A Fatal Case of Necrotizing Pancreatitis in Sickle Cell Beta Thalassemia Zero. Am Surg 2018. [DOI: 10.1177/000313481808400922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Taylor L. Turnbull
- Medical and Forensic Autopsy Section Department of Pathology Medical University of South Carolina Charleston, South Carolina
| | - Peter M. Houston
- Medical and Forensic Autopsy Section Department of Pathology Medical University of South Carolina Charleston, South Carolina
| | - Nicholas I. Batalis
- Medical and Forensic Autopsy Section Department of Pathology Medical University of South Carolina Charleston, South Carolina
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Hasan B, Asif T, Braun C, Bahaj W, Dosokey E, Pauly RR. Pancreatitis in the Setting of Vaso-occlusive Sickle Cell Crisis: A Rare Encounter. Cureus 2017; 9:e1193. [PMID: 28553571 PMCID: PMC5444912 DOI: 10.7759/cureus.1193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Acute pancreatitis is a common cause of acute abdominal pain. Gallstones and alcohol abuse account for the majority of the cases. Pancreatic ischemia is an uncommon but established cause of pancreatitis associated with connective tissue diseases, vasculitis, and shock. Our case highlights a rare case of vaso-occlusive crisis (VOC) in a patient with sickle cell (SC) disease leading to pancreatitis. Treatment remains largely conservative but exchange transfusion may be the therapy of choice in severely hypoxic patients or in patients with high pre-treatment hemoglobin S levels.
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Affiliation(s)
- Badar Hasan
- Department of Internal Medicine, University of Missouri Kansas City (UMKC)
| | - Talal Asif
- Department of Internal Medicine, University of Missouri Kansas City (UMKC)
| | - Cody Braun
- Department of Internal Medicine, University of Missouri Kansas City (UMKC)
| | - Waled Bahaj
- Department of Internal Medicine, University of Missouri Kansas City (UMKC)
| | - Eslam Dosokey
- Department of Internal Medicine, University of Missouri Kansas City (UMKC)
| | - Rebecca R Pauly
- Department of Internal Medicine, University of Missouri Kansas City (UMKC)
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11
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Yavropoulou MP, Pikilidou M, Pantelidou D, Tsalikakis DG, Mousiolis A, Chalkia P, Yovos JG, Zebekakis P. Insulin Secretion and Resistance in Normoglycemic Patients with Sickle Cell Disease. Hemoglobin 2017; 41:6-11. [PMID: 28372488 DOI: 10.1080/03630269.2017.1295983] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Diabetes mellitus has been described in chronic hemolytic anemias, but data are scarce regarding glucose metabolism in normoglycemic patients. To address this issue, we evaluated insulin sensitivity and secretion in patients with sickle cell disease (SCD) and normal oral glucose tolerance test (OGTT). Forty-five adult patients with homozygous sickle cell disease and Hb S/β-thalassemia (β-thal) (mean age 42.5 ± 9.5 years) and 45 healthy individuals matched for age and body mass index (BMI) were included in the study. All participants underwent an oral glucose tolerance test (OGTT) after an overnight fast. All patients had normal OGTT. Fasting glucose values did not differ significantly between groups, however, fasting insulin levels were significantly lower in the patient group compared to the control group (5.1 ± 2.7 μUI/mL vs. 11.3 ± 6.6 μUI/mL, p <0.005, respectively). Pancreatic β-cell insulin secretion index in the fasting state was significantly lower in patients with sickle cell disease compared with controls as assessed by calculations of the homeostatic model assessment for β-cell function (HOMA β%) (77.0 vs. 106.0%, respectively, p <0.001), while HOMA insulin resistance (HOMA IR), was lower in the sickle cell disease patients, albeit not statistically significant (0.8 vs. 1.1, respectively, p = 0.054). The HOMA β% was significantly correlated with ferritin levels (r = -526, p <0.001) (negative correlation) and with 25-hydroxy (OH)-vitamin D levels (r = 0.479, p <0.001) (positive correlation), even when adjusted for serum ferritin levels. Normoglycemic patients with sickle cell disease demonstrated impaired β-cell function with reduced insulin secretion even before OGTT was impaired.
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Affiliation(s)
- Maria P Yavropoulou
- a Division of Endocrinology and Metabolism, 1st Department of Internal Medicine , AHEPA University Hospital, Aristotle University of Thessaloniki (AUTH) , Thessaloniki , Greece
| | - Maria Pikilidou
- b Hypertention Excellence center, 1st Department of Internal Medicine , AHEPA University Hospital, Aristotle University of Thessaloniki (AUTH) , Thessaloniki , Greece
| | - Despoina Pantelidou
- c Division of Hematology and Thalassemia Unit, 1st Department of Internal Medicine , AHEPA University Hospital , Thessaloniki , Greece
| | - Dimitrios G Tsalikakis
- d Department of Informatics and Telecommunication Engineering , University of Western Macedonia , Kozani , Greece
| | - Athanasios Mousiolis
- a Division of Endocrinology and Metabolism, 1st Department of Internal Medicine , AHEPA University Hospital, Aristotle University of Thessaloniki (AUTH) , Thessaloniki , Greece
| | - Panagiota Chalkia
- c Division of Hematology and Thalassemia Unit, 1st Department of Internal Medicine , AHEPA University Hospital , Thessaloniki , Greece
| | - John G Yovos
- a Division of Endocrinology and Metabolism, 1st Department of Internal Medicine , AHEPA University Hospital, Aristotle University of Thessaloniki (AUTH) , Thessaloniki , Greece
| | - Pantelis Zebekakis
- b Hypertention Excellence center, 1st Department of Internal Medicine , AHEPA University Hospital, Aristotle University of Thessaloniki (AUTH) , Thessaloniki , Greece
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12
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CT abdominal imaging findings in patients with sickle cell disease: acute vaso-occlusive crisis, complications, and chronic sequelae. Abdom Radiol (NY) 2016; 41:2524-2532. [PMID: 27600384 DOI: 10.1007/s00261-016-0890-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Sickle cell disease (SCD) is the most prevalent hemoglobinopathy. Survival in patients with SCD has improved over the past few decades. These patients experience a lifetime of repeated acute pain crises, which are thought to result from sickling and microvascular occlusions; acute abdominal pain is common. Moreover, repeated crises often lead to organ dysfunction, such as asplenia, hepatic failure, and renal failure. The spleen, liver, biliary system, kidneys, and gastrointestinal tract can all be affected. Patients may undergo CT to further direct clinical management. We review the spectrum of CT imaging findings of abdominal manifestations in patients with SCD, from the acute microvascular occlusive pain crisis to the potential complications and chronic sequelae.
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13
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Structural Changes in the Pancreas and Its Blood Vessels at the Early Stages of Ischemia. BIONANOSCIENCE 2016. [DOI: 10.1007/s12668-016-0265-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gardner CS, Jaffe TA. Acute gastrointestinal vaso-occlusive ischemia in sickle cell disease: CT imaging features and clinical outcome. Abdom Radiol (NY) 2016; 41:466-75. [PMID: 27039317 DOI: 10.1007/s00261-015-0621-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE The purpose of this study was to determine the incidence, specific imaging features, and outcome of gastrointestinal vaso-occlusive ischemia (GVOI) in sickle cell patients undergoing CT for acute abdominal pain. METHODS This HIPAA-compliant, IRB-approved retrospective study evaluated sickle cell patients with an abdominal pain crisis and acute gastrointestinal abnormalities on CT from 1/2006 to 1/2014. CT findings were divided into those compatible and incompatible with bowel ischemia or clinical diagnosis of GVOI. Two abdominal radiologists (1, 13 years' experience) reviewed the CTs for specific imaging features of ischemia. Clinical laboratory values (lactate, WBC) and outcome were recorded. Descriptive statistics and Wilcoxon-Mann-Whitney two-sample rank-sum test were performed. RESULTS Of 217 CTs, 33 had acute gastrointestinal abnormalities: 75% (25/33) consistent with ischemia and clinical GVOI. Complications of ischemia occurred in 16% (4/25): ileus (50%), perforation (25%), and pneumatosis (25%). In uncomplicated cases, all had bowel wall thickening: segmental 52% (11/21) or diffuse 48% (10/21). The colon was commonly involved (76%, 16/21), particularly the ascending (57%, 12/21). Most abnormalities (52%, 11/21) were in the superior mesenteric artery distribution. Average lactate (4.3 ± 4.0 mmol/L, p = 0.02) and WBC count (20.1 ± 10.4, ×1000 cells/μL, p = 0.01) were significantly higher in GVOI. Overall mortality in patients with GVOI was 17% (3/18). CONCLUSION GVOI is an important feature of the acute abdominal crisis in patients with sickle cell disease and can be seen in up to 75% of patients with abnormal bowel findings on CT. The diagnosis should be strongly considered in sickle cell patients with CT findings of diffuse or segmental bowel wall thickening, particularly involving the colon.
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Affiliation(s)
- Carly S Gardner
- Baylor College of Medicine, One Baylor Plaza, BCM360, Houston, TX, 77030, USA.
| | - Tracy A Jaffe
- Duke University Medical Center, 2301 Erwin Road, Box 3808, Durham, NC, 27710, USA
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15
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Löhr JM, Haas S. Can a polymorphism in the thalassemia gene and a heterozygote CFTR mutation cause acute pancreatitis? World J Clin Cases 2014; 2:62-66. [PMID: 24653987 PMCID: PMC3955802 DOI: 10.12998/wjcc.v2.i3.62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 12/10/2013] [Accepted: 01/16/2014] [Indexed: 02/05/2023] Open
Abstract
The case of a 32-year-old black woman of African descent who suffered from repeated episodes of acute pancreatitis, initially triggered when flying on airplanes, is reported. She did not drink alcohol or smoke. Genetic analysis was negative for cationic trypsinogen, serine protease inhibitor Kazal type 1 and chymotrypsin C. However, hemoglobin F was elevated. Sequencing of the thalassemia gene revealed a novel alteration in the 5’ region indicative of a functional abnormality of the molecule. Sequencing the cystic fibrosis transmembrane conductance regulator (CFTR) gene revealed a heterozygote sequence variant. The combination of a hemoglobin gene mutation known for thalassemia in conjunction with the hitherto undescribed CFTR mutation is suggested to pave the road for initial and repetitive pancreatitis attacks. This will be discussed.
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16
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McGovern PC, Wible M, Korth-Bradley JM, Quintana A. Pancreatitis in tigecycline Phase 3 and 4 clinical studies. J Antimicrob Chemother 2013; 69:773-8. [PMID: 24216769 PMCID: PMC3922153 DOI: 10.1093/jac/dkt427] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objectives To examine the incidence of pancreatitis among subjects enrolled in the tigecycline clinical trial programme, summarize cases and examine concomitant use of other pancreatitis-causing medications. Methods Subject data from Phase 3 and 4 comparative tigecycline studies were included in the analysis; investigator-reported adverse events of ‘pancreatitis’, ‘necrotizing pancreatitis’ or ‘pancreas disorder’ were reviewed. Data were summarized and cases were reported. No statistical comparisons were made. The incidence of overall pancreatitis with 95% CIs was calculated. The Wilson score method was used to calculate CIs. Results Nineteen subjects with investigator-determined pancreatitis were identified from the programme database, which included 3788 subjects treated with tigecycline and 3646 subjects treated with a comparator. There were 9 cases identified among the tigecycline-treated subjects [9 of 3788 (0.24%; 95% CI, 0.11–0.45)] and 10 cases among the comparator-treated subjects [10 of 3646 (0.27%; 95% CI, 0.13–0.50)]. The demographic characteristics of the subjects with pancreatitis were similar between treatment groups. The median duration of tigecycline therapy was 8.0 days compared with 11.0 days of comparator treatment. Concomitant or prior exposure to a Badalov class I medication was evident in the majority of subjects who developed pancreatitis. A numerically higher number of tigecycline-treated subjects were exposed to furosemide prior to the onset of pancreatitis than comparator-treated subjects. Conclusions Pancreatitis was uncommon in subjects treated with tigecycline, with an occurrence of <1%. Concomitant medications known to cause pancreatitis should be considered when prescribing tigecycline, but may not identify those at risk of developing pancreatitis.
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Affiliation(s)
| | | | | | - Alvaro Quintana
- Medicines Development Group, Pfizer Inc., Collegeville, PA, USA
- Corresponding author. Tel: +1-484-865-2027; Fax: +1-484-865-6462; E-mail:
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17
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Agha M, Eid AF, Sallam M. Sickle cell anemia: Imaging from head to toe. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2013. [DOI: 10.1016/j.ejrnm.2013.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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18
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Singh S, Kumar R, Choudhuri G, Agarwal S. Chronic pancreatitis: A new pathophysiology. INDIAN JOURNAL OF HUMAN GENETICS 2013; 18:380-2. [PMID: 23716956 PMCID: PMC3656537 DOI: 10.4103/0971-6866.108056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Shweta Singh
- Department of Genetics, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Ballas SK, Kesen MR, Goldberg MF, Lutty GA, Dampier C, Osunkwo I, Wang WC, Hoppe C, Hagar W, Darbari DS, Malik P. Beyond the definitions of the phenotypic complications of sickle cell disease: an update on management. ScientificWorldJournal 2012; 2012:949535. [PMID: 22924029 PMCID: PMC3415156 DOI: 10.1100/2012/949535] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 04/01/2012] [Indexed: 12/25/2022] Open
Abstract
The sickle hemoglobin is an abnormal hemoglobin due to point mutation (GAG → GTG) in exon 1 of the β globin gene resulting in the substitution of glutamic acid by valine at position 6 of the β globin polypeptide chain. Although the molecular lesion is a single-point mutation, the sickle gene is pleiotropic in nature causing multiple phenotypic expressions that constitute the various complications of sickle cell disease in general and sickle cell anemia in particular. The disease itself is chronic in nature but many of its complications are acute such as the recurrent acute painful crises (its hallmark), acute chest syndrome, and priapism. These complications vary considerably among patients, in the same patient with time, among countries and with age and sex. To date, there is no well-established consensus among providers on the management of the complications of sickle cell disease due in part to lack of evidence and in part to differences in the experience of providers. It is the aim of this paper to review available current approaches to manage the major complications of sickle cell disease. We hope that this will establish another preliminary forum among providers that may eventually lead the way to better outcomes.
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Affiliation(s)
- Samir K Ballas
- Cardeza Foundation and Department of Medicine, Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107, USA.
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Hackert T, Werner J. Antioxidant therapy in acute pancreatitis: experimental and clinical evidence. Antioxid Redox Signal 2011; 15:2767-77. [PMID: 21834688 DOI: 10.1089/ars.2011.4076] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
SIGNIFICANCE Oxidative stress plays an important role in the pathogenesis of both acute and chronic pancreatitis. Although its impact is well investigated and has been studied clinically in chronic pancreatitis, it is less well defined for acute pancreatitis. RECENT ADVANCES Pathophysiological aspects of oxidative stress in acute pancreatitis have shown that reactive oxidative species (ROS) participate in the inflammatory cascade, and mediate inflammatory cell adhesion and consecutive tissue damage. Furthermore, ROS are involved in the generation of pain as another important clinical feature of patients suffering from acute pancreatitis. CRITICAL ISSUES Despite sufficient basic and experimental knowledge and evidence, the step from bench to bedside has not been successfully performed. Only a limited number of clinical studies are available that can give convincing evidence for the use of antioxidants in the clinical setting of acute pancreatitis. FUTURE DIRECTIONS Future studies are required to evaluate potential benefits of antioxidative substances to attenuate the severity of acute pancreatitis. Special focus should be put on the aspect of pain generation and the progression from mild to severe acute pancreatitis in the clinical setting.
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Affiliation(s)
- Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany
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Abstract
IMPORTANCE OF THE FIELD Acute pancreatitis (AP) is a multifactorial disorder not fully understood yet. In particular, the pathogenetic pathways promoting a severe life-threatening course of AP are the subject of ongoing investigations. P-selectin has been shown to play a central role in the complex pathophysiology in AP as well as various other inflammatory conditions. AREAS COVERED IN THIS REVIEW P-selectin function in AP is reviewed with focus on its dual function as a mediator of leukocyte recruitment and cell adhesion, which implies the unique effect of linking both inflammation and coagulation, especially in the progression from mild to severe necrotizing AP. Potential therapeutic aspects are discussed with regard to the clinical situation. WHAT THE READER WILL GAIN A better understanding of the pathogenic role of P-selectin in AP and of the rationale for a therapeutic blockade. TAKE HOME MESSAGE P-selectin is a glycoprotein that mediates the adhesion of activated platelets and leukocytes to the vessel wall in various inflammatory conditions. Both pathophysiological steps are closely linked and play a key role in the course of severe AP. A treatment approach by inhibition of P-selectin could be of distinct interest as a therapeutic option in severe AP.
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Affiliation(s)
- Thilo Hackert
- University of Heidelberg, Department of Surgery, Germany.
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Abstract
Sickle cell anemia is one of the common hemoglobinopathies around the world. It results from a single change of one amino acid valine instead of glutamic acid in the hemoglobin beta change. This change leads to polymerization of the hemoglobin when the oxygen saturation is lowered, resulting in deformity of the red blood cells and microvascular occlusion. Sickle cell anemia can affect any part of the body and one of the main organs to be affected is the hepatobiliary system either directly from the sicklening process or indirectly as a result of chronic hemolysis and multiple blood transfusions. This manifests in several clinical conditions which poses diagnostic and therapeutic dilemmas to the treating physicians. These hepatobiliary manifestations will be outlined in this review.
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Affiliation(s)
- Hussain Issa
- Department of Internal Medicine, Division of Gastroenterology, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ahmed H Al-Salem
- Department of Pediatric Surgery, Maternity and Children Hospital, Dammam, Saudi Arabia
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Thachil J. Lessons from acute pancreatitis-induced thrombotic thrombocytopenic purpura. Eur J Intern Med 2009; 20:739-43. [PMID: 19892300 DOI: 10.1016/j.ejim.2009.09.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 09/09/2009] [Accepted: 09/10/2009] [Indexed: 12/15/2022]
Abstract
Acute pancreatitis is an inflammatory disease characterized by local tissue injury which can trigger a systemic inflammatory response. There is increasing evidence that endothelial dysfunction is one of the critical pathophysiologic manifestations in patients with severe form of acute pancreatitis. In keeping with this, there have been recent reports of a haematological disorder, thrombotic thrombocytopenic purpura (TTP), as being precipitated by acute pancreatitis. However, the patients who develop TTP, secondary to acute pancreatitis, do not always have the characteristic low levels of VonWillebrand multimer cleaving enzyme, ADAMTS-13 suggesting the involvement of other pathophysiological factors. On the contrary, the occurrence of acute pancreatitis in haemolytic diseases may suggest TTP as being a precipitating factor for the pancreatic inflammatory state. This review focuses on the association of these two conditions which have given insights into the role players and the pathogenic mechanisms leading to the development of either of these conditions.
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Affiliation(s)
- Jecko Thachil
- University of Liverpool, Prescot Road, Liverpool, UK.
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Hackert T, Hartwig W, Fritz S, Schneider L, Strobel O, Werner J. Ischemic acute pancreatitis: clinical features of 11 patients and review of the literature. Am J Surg 2008; 197:450-4. [PMID: 18778810 DOI: 10.1016/j.amjsurg.2008.04.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 04/07/2008] [Accepted: 04/10/2008] [Indexed: 12/14/2022]
Abstract
BACKGROUND Besides alcohol and gallstones, pancreatic ischemia can cause acute pancreatitis (AP). This entity should be considered when no other reasons can be defined. The aim of the current study was to define ischemic AP with its pathophysiologic, radiologic, and clinical conditions. METHODS Eleven patients with ischemic AP of different origin were analyzed regarding course, severity, and outcome, as well as diagnostic and therapeutic measures. RESULTS Ischemic AP was caused by hemorrhage and hypotension (7 patients) or mesenteric macrovessel occlusion (4 patients). Therapy was conservative (4 patients) or operative with hemostasis, necrosectomy, and drainage (7 patients). Seven patients died within 38 days, and 4 patients recovered. CONCLUSION Pancreatic hypoperfusion is an important etiology of AP. Severity of the disease ranges from moderate reversible changes to severe courses with fatal outcome. The indication for surgical intervention in ischemic AP is more aggressive; diagnostic and conservative therapeutic procedures are similar to AP of other etiologies.
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Affiliation(s)
- Thilo Hackert
- Department of Surgery, University of Heidelberg, Heidelberg, Germany.
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Qureshi A, Lang N, Bevan DH. Sickle cell 'girdle syndrome' progressing to ischaemic colitis and colonic perforation. ACTA ACUST UNITED AC 2006; 28:60-2. [PMID: 16430462 DOI: 10.1111/j.1365-2257.2006.00739.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Abdominal pain of presumed vasocclusive origin, often termed 'girdle syndrome' because of the circumferential distribution of the pain, is common in sickle cell anaemia (SCA). Evidence of progression to bowel infarction is rare. A 27-year-old man with SCA developed chest and abdominal pain unresponsive to opiate analgesia. Abdominal X-ray showed dilated bowel loops because of partial obstruction. Despite reduction of HbS to 23% by automated red cell exchange, abdominal pain worsened. A CT scan was the most informative investigation and showed free peritoneal air. He underwent emergency hemicolectomy and reversible ileostomy formation. Histology of the resected colon was consistent with acute ischaemic colitis. Early surgical intervention remains essential in SCA when abdominal pain does not respond to maximal therapy including red cell exchange: as this case illustrates, sickle girdle syndrome has the capacity to progress to irreversible ischaemic colitis and necrotic perforation of the bowel wall.
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Affiliation(s)
- A Qureshi
- St George's Hospital - Haematology, Tooting, SW17 0QT, UK.
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Abstract
Sickle cell disease is characterized by chronic hemolytic anemia and vaso-occlusive painful crises. The vascular occlusion in sickle cell disease is a complex process and accounts for the majority of the clinical manifestation of the disease. Abdominal pain is an important component of vaso-occlusive painful crises. It often represents a substantial diagnostic challenge in this population of patients. These episodes are often attributed to micro-vessel occlusion and infarcts of mesentery and abdominal viscera. Abdominal pain due to sickle cell vaso-occlusive crisis is often indistinguishable from an acute intra-abdominal disease process such as acute cholecystitis, acute pancreatitis, hepatic infarction, ischemic colitis and acute appendicitis. In the majority of cases, however, no specific cause is identified and spontaneous resolution occurs. This chapter will focus on etiologies, pathophysiology and management of abdominal pain in patients with sickle cell disease.
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Affiliation(s)
- Shahid Ahmed
- Saskatoon Cancer Center, University of Saskatchewan, University of Saskatchewan Campus, 20 Campus Drive, Saskatoon, Sask., Canada S7N4H4.
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Nguyen H, Le C. Multi-organ Failure Associated with Acute Parvovirus Infection and Exercise in a Patient with Sickle Beta Thalassemia. South Med J 2004; 97:1139-40. [PMID: 15586616 DOI: 10.1097/01.smj.0000140829.91526.cd] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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