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Crisp J, Ahmad M, Crockett S, Mohamed A, Hamady M, Bernstein O, Shalhoub J. Spontaneous bilateral superficial femoral artery pseudoaneurysms and a unilateral posterior tibial artery aneurysm in an immunocompromised patient. Clin Case Rep 2024; 12:e8686. [PMID: 38515996 PMCID: PMC10954564 DOI: 10.1002/ccr3.8686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 01/28/2024] [Accepted: 02/07/2024] [Indexed: 03/23/2024] Open
Abstract
Key Clinical Message The presence of multiple pseudoaneurysms in a patient should prompt investigations for the underlying etiologies including autoimmune and immunosuppressive disease processes. Treatment options include open repair and endovascular stenting. Abstract Pseudoaneurysms (also known as false aneurysms) are atypical dilatations or outpouchings from a vessel which are not always contained by the three layers of a normal vessel wall, namely the intima, media, and adventitia. These are distinct from a true aneurysm which has a wall comprising all three layers. The underlying etiology for both true aneurysms and pseudoaneurysm can vary. We present the rare case of bilateral superficial femoral artery pseudoaneurysms, of unknown etiology and a concurrent posterior tibial artery saccular aneurysm in a patient with Human Immunodeficiency Virus (HIV) infection and multiple comorbidities. This was managed using a combination of endovascular covered stent grafts and open surgical repair technique. The patient is doing well on follow-up a year later with no post-operative infections. A literature review of the existing reports of superficial femoral artery pseudoaneurysms and posterior tibial artery aneurysms and their management is also reported.
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Affiliation(s)
- Jonathan Crisp
- Department of Vascular SurgeryImperial College Healthcare NHS TrustLondonUK
| | - Manal Ahmad
- Department of Vascular SurgeryImperial College Healthcare NHS TrustLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
| | - Stephen Crockett
- Department of Vascular SurgeryImperial College Healthcare NHS TrustLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
| | - Abdulla Mohamed
- Department of Vascular SurgeryImperial College Healthcare NHS TrustLondonUK
| | - Mohamad Hamady
- Department of Vascular SurgeryImperial College Healthcare NHS TrustLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
- Department of RadiologyImperial College Healthcare NHS TrustLondonUK
| | - Ondina Bernstein
- Department of Vascular SurgeryImperial College Healthcare NHS TrustLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
- Department of RadiologyImperial College Healthcare NHS TrustLondonUK
| | - Joseph Shalhoub
- Department of Vascular SurgeryImperial College Healthcare NHS TrustLondonUK
- Department of Surgery and CancerImperial College LondonLondonUK
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Palmier M, Monnot A, Tenière T, Cohen Q, Plissonnier D. Mycotic arterial aneurysm secondary to BCG intravesical instillation: A review. JOURNAL DE MEDECINE VASCULAIRE 2022; 47:94-105. [PMID: 35691669 DOI: 10.1016/j.jdmv.2022.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Mycotic aortic aneurysm is a rare and life-threatening pathology. The first case of mycotic aneurysm induced by immunotherapy with bacille Calmette-Guérin for malignancy was published in 1988. The main objective of this review is to characterize this rare pathology. MATERIALS AND METHODS Since then, 60 cases of arterial aneurysm following intra vesical BCG instillation have been described in the literature. All cases have been included, and characteristics have been collected retrospectively, with simple statistical analyses of the cases. RESULTS We present a brief review from 1988 to 2022 enhancing the contemporary understanding of this arterial infection. Mycotic aneurysm secondary to BCG instillation has a poor prognosis, up to 50% complication and 15% mortality at 1 month, whether managed by open repair or endovascular means. CONCLUSION BCG mycotic aneurysm is an extremely serious condition, the diagnosis of which must be considered at an early stage in order to adapt diagnostic and therapeutic strategies.
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Affiliation(s)
- M Palmier
- Department of vascular surgery, Rouen university hospital, 1, rue de Germont, 76031 Rouen cedex, France.
| | - A Monnot
- Department of vascular surgery, Rouen university hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - T Tenière
- Department of vascular surgery, Rouen university hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - Q Cohen
- Department of vascular surgery, Rouen university hospital, 1, rue de Germont, 76031 Rouen cedex, France
| | - D Plissonnier
- Department of vascular surgery, Rouen university hospital, 1, rue de Germont, 76031 Rouen cedex, France
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Systematic review of case reports of Bacillus Calmette-Guerin (BCG) vascular infections. Ann Vasc Surg 2022; 83:369-377. [DOI: 10.1016/j.avsg.2022.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/16/2022] [Accepted: 01/19/2022] [Indexed: 12/24/2022]
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Clinical Features of Tuberculosis Pseudoaneurysm and Risk Factors for Mortality. J Vasc Surg 2021; 75:1729-1738.e2. [PMID: 34788648 DOI: 10.1016/j.jvs.2021.10.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/24/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVES The objective of this study was to determine the clinical features of tuberculosis aneurysms and risk factors for mortality. MATERIALS AND METHOD We reviewed all case reports of tuberculous aneurysms in the English literature from January 2000 to December 2020. The clinical features and possible risk factors for mortality were recorded and analyzed. RESULT In total, 174 cases of tuberculosis aneurysms were identified. The morbidity of men was more than twice that of women. Male patients (51.47±20.67 years) were older than female patients (39.52±20.23 years), p<0.05. The rupture rate of women (69.2%) was higher than that of men (48.8%). TB-induced aneurysms often spontaneously ruptured 1.41-3.01 months after the onset of TB symptoms without any treatment, and Bacillus Calmette-Guerin (BCG)-induced aneurysms often spontaneously ruptured 10.51-26.49 months after BCG administration. The morbidity of large artery aneurysms was nearly twice that of middle artery aneurysms. However, middle artery aneurysms were more likely to rupture (75.4%) than large artery aneurysms (43.5%), p<0.05. The rupture rate of BCG-induced aneurysms (37.0%) was lower than that of TB-induced aneurysms, regardless of whether there was a TB history (56.7%) or not (57.7%). Symptoms of TB occurred in 63.2% of patients, but only 8.6% of patients had both symptoms of TB and aneurysmal mass effects. Pain was the most common atypical clinical manifestation (50.0%). The Cox proportional hazards regression analysis and Kaplan-Meier estimator showed that rupture and no combined therapy were risk factors for mortality. CONCLUSION Tuberculosis aneurysms seemingly shared the same demographic characteristics as common aneurysms. The clinical features of TB-induced aneurysms were different from those of BCG-induced aneurysms in terms of the aneurysm loactation and rupture rate. Tuberculosis aneurysms may occur at any site of the cardiovascular system with a preponderance for large arteries. The changeable clinical manifestations were an important index for diagnosis, but focusing only on clinical manifestations may lead to a missed diagnosis. The combination of anti-TB medications and surgery before aneurysm rupture may provide the best prognosis.
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Mukherjee N, Julián E, Torrelles JB, Svatek RS. Effects of Mycobacterium bovis Calmette et Guérin (BCG) in oncotherapy: Bladder cancer and beyond. Vaccine 2021; 39:7332-7340. [PMID: 34627626 DOI: 10.1016/j.vaccine.2021.09.053] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/28/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
The Mycobacterium bovis Bacillus Calmette et Guérin (BCG) vaccine was generated in 1921 with the efforts of a team of investigators, Albert Calmette and Camille Guérin, dedicated to the determination to develop a vaccine against active tuberculosis (TB) disease. Since then, BCG vaccination is used globally for protection against childhood and disseminated TB; however, its efficacy at protecting against pulmonary TB in adult and aging populations is highly variable. Due to the BCG generated immunity, this vaccine later proved to have an antitumor activity; though the standing mechanisms behind are still unclear. Recent studies indicate that both innate and adaptive cell responses may play an important role in BCG eradication and prevention of bladder cancer. Thus, cells such as natural killer (NK) cells, macrophages, dendritic cells, neutrophils but also MHC-restricted CD4 and CD8 T cells and γδ T cells may play an important role and can be one the main effectors in BCG therapy. Here, we discuss the role of BCG therapy in bladder cancer and other cancers, including current strategies and their impact on the generation and sustainability of protective antitumor immunity against bladder cancer.
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Affiliation(s)
- Neelam Mukherjee
- Department of Urology University of Texas Health San Antonio (UTHSA), San Antonio, TX, USA
| | - Esther Julián
- Departament de Genètica i de Microbiologia, Facultat de Biociències, Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Jordi B Torrelles
- Population Health Program, Texas Biomedical Research Institute, San Antonio, TX, USA.
| | - Robert S Svatek
- Department of Urology University of Texas Health San Antonio (UTHSA), San Antonio, TX, USA.
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Akabane K, Uchida T, Matsuo S, Hirooka S, Kim C, Uchino H, Shimanuki T. Hybrid operation for infectious thoracic and abdominal aortic aneurysms complicated with Bacillus Calmette-Guérin therapy for bladder cancer: A case report. Medicine (Baltimore) 2021; 100:e24796. [PMID: 33607839 PMCID: PMC7899839 DOI: 10.1097/md.0000000000024796] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/29/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONAL Bacillus Calmette-Guérin (BCG) intravesical instillation therapy is a widely used treatment for bladder cancer; however, an infectious aneurysm has been reported as a rare complication. PATIENT CONCERNS A 76-year-old man who underwent BCG intravesical instillation therapy for bladder cancer presented with prolonged dull back pain for 3 months. DIAGNOSIS Computed tomography (CT) revealed both thoracic and abdominal aortic aneurysms (AAAs). Follow-up CT at 4 weeks after the initial examination showed rapid enlargement of both aneurysms and typical findings of inflammation. Therefore, he was diagnosed with an impending rupture of infectious aneurysms. INTERVENTIONS Although open surgical resection of both aneurysms and vascular reconstruction were ideal, these operations were considered highly invasive for the patient. Therefore, a hybrid operation consisting of simultaneous endovascular repair of the thoracic aneurysm and open surgery of the abdominal lesion was performed. OUTCOMES BCG "Tokyo-172" strain was identified in the resected sample from the aneurysmal wall, and he continued to receive oral antituberculosis drugs for 6 months. No sign of recurrent infection was observed 1 year after the operation. LESSONS A hybrid operation might be justified as an alternative to the conventional open surgical procedure, especially for patients with infectious aneurysms caused by weak pathogenic bacteria such as, the BCG mycobacteria.
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MESH Headings
- Administration, Intravesical
- Aged
- Aneurysm, Infected/etiology
- Aneurysm, Infected/microbiology
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/microbiology
- Aortic Aneurysm, Abdominal/surgery
- Aortic Aneurysm, Thoracic/diagnostic imaging
- Aortic Aneurysm, Thoracic/microbiology
- Aortic Aneurysm, Thoracic/surgery
- BCG Vaccine/administration & dosage
- BCG Vaccine/adverse effects
- Humans
- Male
- Mycobacterium/isolation & purification
- Tomography, X-Ray Computed
- Urinary Bladder Neoplasms/drug therapy
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Affiliation(s)
- Kentaro Akabane
- Division of Cardiovascular Surgery, Nihonkai General Hospital, Sakata
| | - Tetsuro Uchida
- Second Department of Surgery, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Somei Matsuo
- Division of Cardiovascular Surgery, Nihonkai General Hospital, Sakata
| | - Shuto Hirooka
- Division of Cardiovascular Surgery, Nihonkai General Hospital, Sakata
| | - Cholus Kim
- Division of Cardiovascular Surgery, Nihonkai General Hospital, Sakata
| | - Hideaki Uchino
- Division of Cardiovascular Surgery, Nihonkai General Hospital, Sakata
| | - Takao Shimanuki
- Division of Cardiovascular Surgery, Nihonkai General Hospital, Sakata
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Joshi R, Krishna D, Khan MM. Use of Dorsal Ulnar Artery Flap for Coverage of Arterio-Cutaneous Fistula over Post-Electrical Burn Scar: A Case Report. World J Plast Surg 2020; 9:232-234. [PMID: 32934938 PMCID: PMC7482533 DOI: 10.29252/wjps.9.2.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
We reported a 38 year old male patient who suffered from electric burn 2 years ago, and came with complaints of recurrent profuse bleeding from post electric burn scar over left wrist area since last 6-8 months. We successfully used the dorsal ulnar artery flap to cover the arterio-cutaneous fistula over the post-electrical burn scar.
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Affiliation(s)
- Rishabh Joshi
- Department of Burns and Plastic Surgery, AIIMS, Bhopal (M.P.), India
| | - Deepak Krishna
- Department of Burns and Plastic Surgery, AIIMS, Bhopal (M.P.), India
| | - Manal M Khan
- Department of Burns and Plastic Surgery, AIIMS, Bhopal (M.P.), India
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Viviani E, Bracale UM. Re: "Ruptured Mycotic Aneurysm After Intravesical Instillation for Bladder Tumor". Ann Vasc Surg 2019; 65:e299. [PMID: 31336163 DOI: 10.1016/j.avsg.2019.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 04/27/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Emanuela Viviani
- Vascular Surgery Unit, Department of Public Health, University Federico II of Naples, Naples, Italy
| | - Umberto Marcello Bracale
- Vascular Surgery Unit, Department of Public Health, University Federico II of Naples, Naples, Italy.
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Karhof S, van Roeden SE, Oosterheert JJ, Bleeker-Rovers CP, Renders NHM, de Borst GJ, Kampschreur LM, Hoepelman AIM, Koning OHJ, Wever PC. Primary and secondary arterial fistulas during chronic Q fever. J Vasc Surg 2019; 68:1906-1913.e1. [PMID: 29685511 DOI: 10.1016/j.jvs.2018.01.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 01/18/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVE After primary infection with Coxiella burnetii, patients may develop acute Q fever, which is a relatively mild disease. A small proportion of patients (1%-5%) develop chronic Q fever, which is accompanied by high mortality and can be manifested as infected arterial or aortic aneurysms or infected vascular prostheses. The disease can be complicated by arterial fistulas, which are often fatal if they are left untreated. We aimed to assess the cumulative incidence of arterial fistulas and mortality in patients with proven chronic Q fever. METHODS In a retrospective, observational study, the cumulative incidence of arterial fistulas (aortoenteric, aortobronchial, aortovenous, or arteriocutaneous) in patients with proven chronic Q fever (according to the Dutch Chronic Q Fever Consensus Group criteria) was assessed. Proven chronic Q fever with a vascular focus of infection was defined as a confirmed mycotic aneurysm or infected prosthesis on imaging studies or positive result of serum polymerase chain reaction for C. burnetii in the presence of an arterial aneurysm or vascular prosthesis. RESULTS Of 253 patients with proven chronic Q fever, 169 patients (67%) were diagnosed with a vascular focus of infection (42 of whom had a combined vascular focus and endocarditis). In total, 26 arterial fistulas were diagnosed in 25 patients (15% of patients with a vascular focus): aortoenteric (15), aortobronchial (2), aortocaval (4), and arteriocutaneous (5) fistulas (1 patient presented with both an aortocaval and an arteriocutaneous fistula). Chronic Q fever-related mortality was 60% for patients with and 21% for patients without arterial fistula (P < .0001). Primary fistulas accounted for 42% and secondary fistulas for 58%. Of patients who underwent surgical intervention for chronic Q fever-related fistula (n = 17), nine died of chronic Q fever-related causes (53%). Of patients who did not undergo any surgical intervention (n = 8), six died of chronic Q fever-related causes (75%). CONCLUSIONS The proportion of patients with proven chronic Q fever developing primary or secondary arterial fistulas is high; 15% of patients with a vascular focus of infection develop an arterial fistula. This observation suggests that C. burnetii, the causative agent of Q fever, plays a role in the development of fistulas in these patients. Chronic Q fever-related mortality in patients with arterial fistula is very high, in both patients who undergo surgical intervention and patients who do not.
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Affiliation(s)
- Steffi Karhof
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sonja E van Roeden
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Jan J Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Chantal P Bleeker-Rovers
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center and Radboud Expertise Center for Q Fever, Nijmegen, The Netherlands
| | - Nicole H M Renders
- Department of Medical Microbiology and Infection Control, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Gert J de Borst
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Linda M Kampschreur
- Department of Internal Medicine and Infectious Diseases, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Andy I M Hoepelman
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier H J Koning
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Peter C Wever
- Department of Medical Microbiology and Infection Control, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
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Ruptured Iliac Pseudoaneurysm after Intravesical Bacillus Calmette-Guérin: Urgent Endovascular Treatment. Case Report and Literature Review. Ann Vasc Surg 2018; 53:269.e1-269.e9. [DOI: 10.1016/j.avsg.2018.05.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 04/27/2018] [Accepted: 05/01/2018] [Indexed: 12/29/2022]
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Lareyre F, Reverso-Meinietti J, Carboni J, Gaudart A, Hassen-Khodja R, Raffort J. Mycotic Aortic Aneurysm and Infected Aortic Graft After Intravesical Bacillus Calmette-Guérin Treatment for Bladder Cancer. Vasc Endovascular Surg 2018; 53:86-91. [DOI: 10.1177/1538574418800128] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although intravesical therapy with bacillus Calmette-Guérin (BCG) has proven its efficiency in the treatment of early-stage bladder cancer, infectious complications can occur and mycotic aneurysms represent a rare but life-threatening complication. Here, we report the case of an aortic graft infection in a patient with abdominal aortic aneurysm who received BCG instillations for the treatment of bladder cancer. Based on the current knowledge on this rare vascular complication, we discuss factors that may have contributed to its occurrence and review issues to optimize its management and early detection.
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Affiliation(s)
- Fabien Lareyre
- Department of Vascular Surgery, University Hospital of Nice, Nice, France
- Université Côte d’Azur, CHU, Inserm U1065, Nice, France
| | - Julie Reverso-Meinietti
- Université Côte d’Azur, CHU, Inserm U1065, Nice, France
- Department of Pathology (Laboratoire central d’Anatomopathologie), University Hospital of Nice, Nice, France
| | - Joseph Carboni
- Department of Vascular Surgery, University Hospital of Nice, Nice, France
| | - Alice Gaudart
- Department of Bacteriology, University Hospital of Nice, Nice, France
| | - Réda Hassen-Khodja
- Department of Vascular Surgery, University Hospital of Nice, Nice, France
- Université Côte d’Azur, CHU, Inserm U1065, Nice, France
| | - Juliette Raffort
- Université Côte d’Azur, CHU, Inserm U1065, Nice, France
- Clinical Chemistry Laboratory, University Hospital of Nice, Nice, France
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