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Buech J, Radner C, Fabry T, Rutkowski S, Hagl C, Peterss S, Pichlmaier MA. Case Report: Incidental finding of an atresia of the inferior vena cava-a challenge for cardiac surgery. Front Cardiovasc Med 2024; 11:1321685. [PMID: 38380181 PMCID: PMC10876821 DOI: 10.3389/fcvm.2024.1321685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 01/22/2024] [Indexed: 02/22/2024] Open
Abstract
Inferior vena cava atresia is a rare and usually asymptomatic condition. However, when these patients undergo cardiac surgery, it can present an unexpected and challenging situation for the surgeon. Specifically, adequate venous drainage during cardiopulmonary bypass (CPB) is a critical issue here and may require an extension of cannulation strategies. Adequate preoperative diagnostics, ideally with imaging modalities such as CT angiography or MRI, are required for optimal surgical planning. Here, we describe a rare case of thoracic ascending aortic aneurysm with concomitant inferior vena cava atresia that was successfully operated on. With adequate preoperative planning, we were able to perform an operation without unforeseen complications with standard initialization of CPB.
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Affiliation(s)
- Joscha Buech
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
- University Aortic Center Munich (LMU), LMU University Hospital, Munich, Germany
| | - Caroline Radner
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
- University Aortic Center Munich (LMU), LMU University Hospital, Munich, Germany
| | - Thomas Fabry
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- University Aortic Center Munich (LMU), LMU University Hospital, Munich, Germany
| | - Simon Rutkowski
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- University Aortic Center Munich (LMU), LMU University Hospital, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
- University Aortic Center Munich (LMU), LMU University Hospital, Munich, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- University Aortic Center Munich (LMU), LMU University Hospital, Munich, Germany
| | - Maximilian A. Pichlmaier
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- University Aortic Center Munich (LMU), LMU University Hospital, Munich, Germany
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Marco-Rico A, Marco-Vera P. Antithrombin Deficiency and Thrombosis: A Wide Clinical Scenario Reported in a Single Institution. J Blood Med 2023; 14:499-506. [PMID: 37674759 PMCID: PMC10478923 DOI: 10.2147/jbm.s416355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/11/2023] [Indexed: 09/08/2023] Open
Abstract
Congenital antithrombin (AT) deficiency represents the form of thrombophilia with the highest thrombotic risk. It is characterized by a heterogeneous clinical presentation, depending mostly on the family history of thrombosis and type of genetic mutation. Inherited AT deficiency promotes idiopathic thrombosis at an early age (even in the pediatric population) and at atypical sites. Therefore, a positive family background necessitates ruling out this high-risk thrombophilia at a young age. Studying first-degree relatives, even if they are asymptomatic, is essential to establish thromboprophylaxis and a proper therapeutic approach in case of thrombosis. Patients with congenital AT deficiency require indefinite anticoagulation owing to the high thrombotic recurrence rate. Here, we present four unrelated cases reported in our institution who were diagnosed with hereditary AT deficiency, with a contrasting clinical evolution.
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Affiliation(s)
- Ana Marco-Rico
- Hemostasis and Thrombosis Department, Hematology Service, University General Hospital Dr. Balmis, Alicante, Spain
- Biomedical Research Institute (ISABIAL), Alicante, Spain
| | - Pascual Marco-Vera
- Biomedical Research Institute (ISABIAL), Alicante, Spain
- Clinical Medicine Department, Miguel Hernández University, Alicante, Spain
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Kumar R, Bakeer N, Dawson J, Al-Mughairy A, Stanek J, Dunn A, Male C, Chan A, Williams S. Impact of SERPINC1 mutation on thrombotic phenotype in children with congenital antithrombin deficiency-first analysis of the International Society on Thrombosis and Haemostasis pediatric antithrombin deficiency database and biorepository. J Thromb Haemost 2023; 21:1248-1257. [PMID: 36764659 DOI: 10.1016/j.jtha.2023.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND The natural history and genotype-phenotype correlation of congenital antithrombin (AT) deficiency in children are unknown. OBJECTIVES To describe the clinical presentation of congenital AT deficiency in children and evaluate its correlation to specific mutations in SERPINC1. METHODS In 2017, a prospective pediatric database and DNA biorepository for congenital AT deficiency was established. During the pilot phase, the database was opened at 4 tertiary care centers in Canada and US. Approval from research ethics board was obtained at each participating center. Written consent/assent was obtained from guardians/subjects who met eligibility. Demographic/clinical data were uploaded into a database. DNA extraction and SERPINC1 sequencing were centralized for US centers. Standard statistical methods were used to summarize parameters. Probability of VTE-free survival was assessed using the Kaplan-Meier method. RESULTS Overall, 43 participants (25 females) from 31 unique kindreds were enrolled. Median age (range) at enrollment was 14.8 years (1-21 years). Median AT activity was 52% (24%-87%), and median AT antigen (n = 20) was 55% (38%-110%). Nineteen (44%) participants had a history of venous thromboembolism (VTE). Median age at VTE diagnosis was 12.8 years (0.1-19.2 years). SERPINC1 sequencing was completed for 31 participants and 21 unique mutations were identified, including 5 novel variants. Probability of 5-year VTE-free survival (95% CI) for carriers of missense mutations (92.0% [95% CI: 71.6%-97.9%]) was significantly higher compared with carriers of null mutations (66.7% [95% CI: 19.5%-90.4%]); p = .0012. CONCLUSION To our knowledge, this is the first pediatric study to document a severe thrombotic phenotype in carriers of null mutations in SERPINC1, when compared with carriers of missense mutations; underscoring the importance of genetic testing.
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Affiliation(s)
- Riten Kumar
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA.
| | - Nihal Bakeer
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indianapolis, USA
| | - Jennifer Dawson
- Genomic Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alyaa Al-Mughairy
- Division of Pediatric Hematology/Oncology, The Royal Hospital, Muscat, Oman
| | - Joseph Stanek
- Division of Pediatric Hematology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Amy Dunn
- Division of Pediatric Hematology, Nationwide Children's Hospital, Columbus, Ohio, USA; Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Christoph Male
- Department of Pediatrics, Medical University of Vienne, Vienna, Austria
| | - Anthony Chan
- Division of Pediatric Hematology, McMaster Children's Hospital, Hamilton, Ontario, Canada; Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Suzan Williams
- Division of Pediatric Hematology, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Tang LV, Tao Y, Feng Y, Ma J, Lin W, Zhang Y, Zhang Y, Wu T, Cai Y, Lu H, Wei J, Corral J, Hu Y. Gene editing of human iPSCs rescues thrombophilia in hereditary antithrombin deficiency in mice. Sci Transl Med 2022; 14:eabq3202. [PMID: 36449603 DOI: 10.1126/scitranslmed.abq3202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Hereditary antithrombin deficiency is caused by SERPINC1 gene mutations and predisposes to recurrent venous thromboembolism that can be life-threatening. Therefore, lifelong anticoagulation is required, which has side effects and may not be effective. In this study, peripheral blood mononuclear cells from a patient with severe antithrombin deficiency were reprogrammed into induced pluripotent stem cells (iPSCs). The mutation was corrected using CRISPR-Cas9 and Cre/LoxP genome editing. iPSCs were differentiated into hepatocytes, which were injected into the spleen of antithrombin knockout mice to restore the activity of antithrombin and reduce the thrombophilic state. Human iPSC-differentiated hepatocytes colonized mice and secreted antithrombin stably, normalizing antithrombin in plasma (activity: from 46.8 ± 5.7% to 88.6 ± 7.6%, P < 0.0001; antigen: from 146.9 ± 19.5 nanograms per milliliter to 390.7 ± 16.1 nanograms per milliliter, P < 0.0001). In venous thrombosis model, the rate of thrombosis in mice treated with edited hepatocytes, parental hepatocytes, and wild-type mice were 60, 90, and 70%, respectively. The thrombus weight was much lighter in mice treated with edited hepatocytes compared with parental hepatocytes (7.25 ± 2.00 milligrams versus 15.32 ± 2.87 milligrams, P = 0.0025) and showed no notable difference compared with that in wild-type mice (10.41 ± 2.91 milligrams). The activity and concentration of antithrombin remained high for 3 weeks after injection. The liver and kidney function markers showed no obvious abnormality during the observation period. This study provides a proof of principle for correction of mutations in patient-derived iPSCs and potential therapeutic applications for hereditary thrombophilia.
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Affiliation(s)
- Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yanyi Tao
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yuanzheng Feng
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jiewen Ma
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Wenyi Lin
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yuyang Zhang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yi Zhang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Tingting Wu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yaohua Cai
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Hui Lu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jun Wei
- iRegene Therapeutics Co. Ltd., Wuhan 430070, PR China
| | - Javier Corral
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER, Ronda de Garay S/N, 30003 Murcia, Spain
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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Kim S, Lee WJ, Moon J, Jung KH. Utility of the SERPINC1 Gene Test in Ischemic Stroke Patients With Antithrombin Deficiency. Front Neurol 2022; 13:841934. [PMID: 35720094 PMCID: PMC9203840 DOI: 10.3389/fneur.2022.841934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveAntithrombin (AT) plays a critical role in the coagulation system, and its deficiency induces hypercoagulability. AT deficiency is caused not only by inherited variants in the SERPINC1 gene but also by acquired conditions. Therefore, AT deficiency alone could not ensure the presence of the SERPINC1 mutation. We evaluated the utility of the SERPINC1 gene test in ischemic stroke, an important clinical type of arterial thrombosis.MethodsThis retrospective, observational study investigated symptomatic patients who underwent the SERPINC1 gene test because of decreased AT activity (<80%) during 2009-2021 at a tertiary hospital. For the detection of sequence variants in the SERPINC1 gene, direct Sanger sequencing and multiplex ligation-dependent probe amplification were performed. The phenotypes of patients with SERPINC1 gene mutations were examined, and the conditions associated with the pathogenic variants were analyzed.ResultsIn our cohort (n = 19), 13 of 19 patients (68.4%) had the pathogenic variant of the SERPINC1 gene. Ischemic stroke (n = 7) was significantly associated with the pathogenic variants (p = 0.044), and the pathogenicity detection rate was 100%. For any kind of arterial thrombosis (n = 8), the detection rate of the pathogenic variant was 87.5%, but was not statistically significant (p = 0.177). The detection rates of the pathogenic variant in ischemic stroke or arterial thrombosis groups were both higher than those in the venous thrombosis-only group (54.5%).ConclusionThe SERPINC1 gene test was useful in determining the cause of AT deficiency-related arterial thrombosis, especially ischemic stroke. We propose the diagnostic flow of SERPINC1-related ischemic stroke.
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Affiliation(s)
- Seondeuk Kim
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Woo-Jin Lee
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
| | - Jangsup Moon
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
- Department of Genomic Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Keun-Hwa Jung
- Department of Neurology, Seoul National University Hospital, Seoul, South Korea
- Program in Neuroscience, Seoul National University College of Medicine, Seoul, South Korea
- *Correspondence: Keun-Hwa Jung
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Weronska A, Potaczek DP, Oto J, Medina P, Undas A, Wypasek E. A Series of 14 Polish Patients with Thrombotic Events and PC Deficiency-Novel c.401-1G>A PROC Gene Splice Site Mutation in a Patient with Aneurysms. Genes (Basel) 2022; 13:genes13050733. [PMID: 35627118 PMCID: PMC9141864 DOI: 10.3390/genes13050733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/16/2022] [Accepted: 04/18/2022] [Indexed: 12/04/2022] Open
Abstract
Objectives: Protein C (PC) deficiency is an inherited thrombophilia with a prevalence of 0.5% in the general population and 3% in subjects with a first-time deep vein thrombosis (DVT). Here we report a series of 14 PC-deficient Polish patients with comprehensive clinical and molecular characteristics, including long-term follow-up data and a deep mutational analysis of the PROC gene. Patients and Methods: Fourteen unrelated probands (mean ± SD age 43.8 ± 13.0 years) with suspicion of PC deficiency, who experienced thromboembolic events and a majority of whom received anticoagulants (92.8%), were screened for PROC mutations by sequencing the nine PROC exons and their flanking intron regions. Results: Ten probands (71.4%) had missense mutations, two patients (14.3%) carried nonsense variants, and the other two subjects (14.3%) had splice-site mutations, the latter including the c.401-1G>A variant, reported here for the very first time. The proband carrying the c.401-1A allele had a hepatic artery aneurysm with a highly positive family history of aneurysms and the absence of any mutations known to predispose to this vascular anomaly. Conclusion: A novel detrimental PROC mutation was identified in a family with aneurysms, which might suggest yet unclear links of thrombophilia to vascular anomalies, including aneurysms at atypical locations in women. The present case series also supports data indicating that novel oral anticoagulants (NOACs) are effective in PC deficient patients.
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Affiliation(s)
- Anna Weronska
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland;
| | - Daniel P. Potaczek
- Translational Inflammation Research Division & Core Facility for Single Cell Multiomics, Medical Faculty, Biochemical Pharmacological Center (BPC), Philipps University of Marburg, 35043 Marburg, Germany;
| | - Julia Oto
- Haemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe, 46026 Valencia, Spain; (J.O.); (P.M.)
| | - Pilar Medina
- Haemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe, 46026 Valencia, Spain; (J.O.); (P.M.)
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University School of Medicine, 31-202 Krakow, Poland;
- John Paul II Hospital, 80 Prądnicka Street, 31-202 Krakow, Poland
| | - Ewa Wypasek
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland;
- John Paul II Hospital, 80 Prądnicka Street, 31-202 Krakow, Poland
- Correspondence: ; Tel./Fax: +48-12-6143145
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Müller-Knapp M, Classen CF, Knöfler R, Spang C, Hauenstein C, Heinrich T, Gabriel FLP, Däbritz J, Reuter DA, Ehler J. Coexistence of antithrombin deficiency and suspected inferior vena cava atresia in an adolescent and his mother - case report and clinical implications. Thromb J 2021; 19:105. [PMID: 34937572 PMCID: PMC8693492 DOI: 10.1186/s12959-021-00360-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 12/14/2021] [Indexed: 12/04/2022] Open
Abstract
Background Antithrombin deficiency (ATD) is an autosomal dominant thrombophilia presenting with varying phenotypes. In pediatric patients with ATD, thrombosis typically develops during the neonatal period or adolescence. However, to date there are no consistent recommendations on the therapeutic management of children with ATD. Inferior vena cava atresia (IVCA) belongs to a range of congenital or acquired vena cava malformations and is described as an independent risk factor for thrombosis. The present case report explores two cases of combined ATD and IVCA in an adolescent and his mother. Case presentation A 14-year-old male presented with extensive deep venous thromboses (DVTs) of both lower extremities as well as an IVCA. The patient had previously been diagnosed with an asymptomatic ATD without therapeutic consequences at that time. His mother was suffering from an ATD and had herself just been diagnosed with IVCA, too. The DVTs in the adolescent were treated by systemic anticoagulation and catheter-directed local thrombolysis causing favourable results. Yet, despite adequate oral anticoagulation the DVTs in both lower extremities reoccurred within 1 week after the patient was discharged from hospital. This time, thrombolysis could not be fully achieved. Surprisingly, probing and stenting of the IVCA was achieved, indicating an acquired IVCA which could have occurred after undetected thrombosis in early childhood. Genetic analyses showed the same mutation causing ATD in both son and mother: heterozygote missense mutation c.248 T > C, p.(Leu83Pro), within the heparin binding domain of antithrombin. This mutation was never reported in mutation databases before. Conclusions To our knowledge this is the first case report discussing combined ATD and IVCA in two family members. Since ATDs present with clinical heterogeneity, taking a thorough family history is crucial for the anticipation of possible complications in affected children and decisions on targeted diagnostics and therapeutic interventions. Affected families must be educated on risk factors and clinical signs of thrombosis and need an immediate diagnostic workup in case of clinical symptoms. IVCA in patients with ATD could occur due to thrombotic occlusion at a very early age. Therefore, in case of family members with IVCA and ATD ultrasound screening in newborns should be considered.
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Affiliation(s)
- M Müller-Knapp
- Department of Pediatrics, Interdisciplinary Pediatric Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany
| | - C F Classen
- Department of Pediatrics, Oncology and Hematology Unit, University Medical Center Rostock, Rostock, Germany
| | - R Knöfler
- Department of Pediatrics, Division of Pediatric Hemostaseology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - C Spang
- Department of Pediatrics, Interdisciplinary Pediatric Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany.,Department of Anesthesiology and Intensive Care Medicine, Interdisciplinary Pediatric Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany
| | - C Hauenstein
- Institute of Diagnostic and Interventional Radiology, Paediatric Radiology and Neuroradiology, University Medical Center Rostock, Rostock, Germany
| | - T Heinrich
- MVZ für Humangenetik und Molekularpathologie GmbH, Rostock, Germany
| | - F L P Gabriel
- Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center Rostock, Rostock, Germany
| | - J Däbritz
- Department of Pediatrics, University Medical Center Rostock, Rostock, Germany
| | - D A Reuter
- Department of Anesthesiology and Intensive Care Medicine, Interdisciplinary Pediatric Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany
| | - J Ehler
- Department of Pediatrics, Interdisciplinary Pediatric Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany. .,Department of Anesthesiology and Intensive Care Medicine, Interdisciplinary Pediatric Intensive Care Medicine, University Medical Center Rostock, Rostock, Germany.
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