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Ashraf M, Naseeruddin G, Zahra SG, Sultan KA, Kamboh UA, Manzoor M, Farooq M, Ahmad M, Ashraf N. Intracerebral hemorrhage as the first symptomatic manifestation of chronic myeloid leukemia (chronic phase): A case report and literature review. Surg Neurol Int 2023; 14:5. [PMID: 36751457 PMCID: PMC9899481 DOI: 10.25259/sni_897_2022] [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: 09/27/2022] [Accepted: 12/27/2022] [Indexed: 01/08/2023] Open
Abstract
Background Chronic myeloid leukemia (CML) is mostly asymptomatic at diagnosis. Intracerebral hemorrhage (ICH), as the first presentation of CML in its chronic phase (CP) has only once been reported in the literature. In addition, CML (CP) patients developing ICH are equally rare, with only eight cases reported. ICH is more commonly associated with CML progressing to its end stage (accelerated phase [AP] and blast crisis [BC]). The pathophysiology of ICH in CML-CP is postulated to be due to leukostasis, unlike in the CML-AP/BC, where thrombocytopenia and coagulopathy are the underlying mechanisms. This case adds to the scarce literature on a rare and challenging complication of ICH in CML-CP, especially as these patients tend to rebleed and management is uncertain. Case Description A 22-year-old male presented with a 2-week history of headaches and vomiting, associated with a 1-week history of the left-sided weakness. Initial blood work revealed hyperleukocytosis. The patient was investigated for CML with intracranial involvement. During his stay, his Glasgow coma score (GCS) dropped (from 14 to 11), prompting an urgent CT scan which revealed a large resolving ICH with perifocal edema and midline shift. A decompressive hemicraniectomy with expansion duraplasty was performed to alleviate the mass effect and reduce intracranial pressure. Three hours postoperatively, the patient developed an extradural hematoma which needed prompt evacuation. A postoperative CT revealed an improved midline shift, and after 7 days, his GCS improved to 15, and he began oncological treatment. Neurological symptoms were experienced by our patient at presentation with hyperleukocytosis on full blood count, which may implicate leukostasis as an underlying mechanism. Conclusion Even in the CP, CML patients presenting with mild neurological symptoms should be investigated to exclude intracranial bleeds. As these patients tend to rebleed, they should be conservatively managed unless there is a need to alleviate intracranial pressure.
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Affiliation(s)
- Mohammad Ashraf
- Wolfson School of Medicine, University of Glasgow, Scotland, United Kingdom,,Corresponding author: Mohammad Ashraf, Wolfson School of Medicine, University of Glasgow, Scotland, United Kingdom.
| | - Ghulam Naseeruddin
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Shah Gul Zahra
- School of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Kashif Ali Sultan
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Usman Ahmad Kamboh
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Mehwish Manzoor
- Department of Oncology, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Minaam Farooq
- School of Medicine, King Edward Medical University, Lahore, Pakistan
| | - Manzoor Ahmad
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
| | - Naveed Ashraf
- Department of Neurosurgery, Allama Iqbal Medical College, Jinnah Hospital, Lahore, Pakistan
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Wade CI, Couperus-Mashewske CJ, Geurts ME, Derfler N, Ngo J, Couperus KS. Respiratory Failure Due to a Large Mediastinal Mass in a 4-year-old Female with Blast Cell Crisis: A Case Report. Clin Pract Cases Emerg Med 2020; 4:400-403. [PMID: 32926696 PMCID: PMC7434292 DOI: 10.5811/cpcem.2020.5.47016] [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: 02/19/2020] [Revised: 04/27/2020] [Accepted: 05/05/2020] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Symptomatic leukostasis is an exceptionally atypical presentation of blast crisis; and when coupled with an enlarged neoplastic mediastinal mass in a four-year-old female, an extremely rare and challenging pediatric emergency arises. CASE REPORT We present a unique case of a four-year-old female who arrived via emergency medical services in cardiopulmonary arrest with clinical and radiographic evidence suggestive of bilateral pneumothoraces, prompting bilateral chest tube placement. Further evaluation revealed a large mediastinal mass and a concurrent white blood cell count of 428,400 per milliliter (/mL) (4,400-12,900/mL), with a 96% blast differential, consistent with complications of T-cell acute lymphoblastic leukemia. CONCLUSION This case highlights how pulmonary capillary hypoperfusion secondary to leukostasis, coupled with a ventilation/perfusion mismatch due to compression atelectasis by an enlarged thymus, resulted in this patient's respiratory arrest. Furthermore, the case highlights how mediastinal masses in pediatric patients present potential diagnostic challenges for which ultrasound may prove beneficial.
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Affiliation(s)
- Christian I. Wade
- Uniformed Services University of the Health Sciences, School of Medicine, Department of Emergency Medicine, Bethesda, Maryland
| | | | - Mia E. Geurts
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
| | - Nicholas Derfler
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
| | - John Ngo
- Providence St. Peter Hospital Olympia, Department of Emergency Medicine, Olympia, Washington
| | - Kyle S. Couperus
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
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Sharma SR, Dey B. Blast crisis of chronic myeloid leukemia initially presenting as severe acute intracerebral hemorrhage. J Family Med Prim Care 2020; 9:1266-1269. [PMID: 32318512 PMCID: PMC7114033 DOI: 10.4103/jfmpc.jfmpc_940_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 12/19/2019] [Accepted: 12/27/2019] [Indexed: 12/21/2022] Open
Abstract
Intracerebral hemorrhage (ICH) is frequent pathology in emergency department. Coagulopathy leading to ICH are rare. Intracerebral hemorrhage is a leading cause of mortality among patients diagnosed with chronic myelogenous leukemia (CML). In this report we discussed the case of a previously healthy male patient, who presented with fatal ICH, newly diagnosed with blast crisis in CML.
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Affiliation(s)
- Shri Ram Sharma
- Department of Neurology, NEIGRIHMS, North Eastern Indira Gandhi Regional Institute of Medical Sciences, Shillong, Meghalaya, India (An Autonomous Institute, Ministry of Health and Family Welfare, Govt of India), India
| | - Biswajit Dey
- Department of Pathology, NEIGRIHMS, Shillong, Meghalaya, India
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Lim WK, Fong CY, Li L, Foo JC, Yap TY. Extensive intracranial haemorrhage as a complication of acute lymphoblastic leukaemia with hyperleukocytosis. J Clin Neurosci 2019; 64:11-14. [DOI: 10.1016/j.jocn.2019.03.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 03/25/2019] [Indexed: 10/27/2022]
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Dardiotis E, Aloizou AM, Markoula S, Siokas V, Tsarouhas K, Tzanakakis G, Libra M, Kyritsis AP, Brotis AG, Aschner M, Gozes I, Bogdanos DP, Spandidos DA, Mitsias PD, Tsatsakis A. Cancer-associated stroke: Pathophysiology, detection and management (Review). Int J Oncol 2019; 54:779-796. [PMID: 30628661 PMCID: PMC6365034 DOI: 10.3892/ijo.2019.4669] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 12/28/2018] [Indexed: 12/15/2022] Open
Abstract
Numerous types of cancer have been shown to be associated with either ischemic or hemorrhagic stroke. In this review, the epidemiology and pathophysiology of stroke in cancer patients is discussed, while providing vital information on the diagnosis and management of patients with cancer and stroke. Cancer may mediate stroke pathophysiology either directly or via coagulation disorders that establish a state of hypercoagulation, as well as via infections. Cancer treatment options, such as chemotherapy, radiotherapy and surgery have all been shown to aggravate the risk of stroke as well. The clinical manifestation varies greatly depending upon the underlying cause; however, in general, cancer‑associated strokes tend to appear as multifocal in neuroimaging. Furthermore, several serum markers have been identified, such as high D‑Dimer levels and fibrin degradation products. Managing cancer patients with stroke is a delicate matter. The cancer should not be considered a contraindication in applying thrombolysis and recombinant tissue plasminogen activator (rTPA) administration, since the risk of hemorrhage in cancer patients has not been reported to be higher than that in the general population. Anticoagulation, on the contrary, should be carefully examined. Clinicians should weigh the benefits and risks of anticoagulation treatment for each patient individually; the new oral anticoagulants appear promising; however, low‑molecular‑weight heparin remains the first choice. On the whole, stroke is a serious and not a rare complication of malignancy. Clinicians should be adequately trained to handle these patients efficiently.
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Affiliation(s)
- Efthimios Dardiotis
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | - Athina-Maria Aloizou
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | - Sofia Markoula
- Department of Neurology, University Hospital of Ioannina, 45110 Ioannina
| | - Vasileios Siokas
- Department of Neurology, Laboratory of Neurogenetics, University of Thessaly, University Hospital of Larissa, 41100 Larissa
| | | | - Georgios Tzanakakis
- Laboratory of Anatomy-Histology-Embryology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Massimo Libra
- Department of Biomedical and Biotechnological Sciences, Pathology and Oncology Section, University of Catania, 95124 Catania, Italy
| | | | - Alexandros G. Brotis
- Department of Neurosurgery, University of Thessaly, University Hospital of Larissa, 41100 Larissa, Greece
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Illana Gozes
- The Lily and Avraham Gildor Chair for the Investigation of Growth Factors, The Elton Laboratory for Molecular Neuroendocrinology, Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Sagol School of Neuroscience and Adams Super Center for Brain Studies, Tel Aviv University, Tel Aviv 69978, Israel
| | - Dimitrios P. Bogdanos
- Department of Rheumatology and Clinical Immunology, University General Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, 40500 Larissa
- Cellular Immunotherapy and Molecular Immunodiagnostics, Biomedical Section, Centre for Research and Technology-Hellas (CERTH) - Institute for Research and Technology-Thessaly (IRETETH), 41222 Larissa
| | | | - Panayiotis D. Mitsias
- Department of Neurology, School of Medicine, University of Crete, 71003 Heraklion, Greece
- Comprehensive Stroke Center and Department of Neurology, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Aristidis Tsatsakis
- Laboratory of Toxicology, School of Medicine, University of Crete, 71003 Heraklion, Greece
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Blackburn LM, Brown S, Munyon A, Orovets M. Leukostasis: Management to Prevent Crisis in Acute Leukemia
. Clin J Oncol Nurs 2018; 21:E267-E271. [PMID: 29149122 DOI: 10.1188/17.cjon.e267-e271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hyperleukocytosis, a peripheral white blood cell count greater than 100,000/mm3,is most commonly seen in patients with newly diagnosed or relapsed acute lymphoblastic leukemia and acute myeloid leukemia. Leukostasis is a reduction in blood flow related to hyperviscosity. Hyperleukocytosis, causing leukostasis, is an oncologic emergency and requires an exacting assessment and rapid response with appropriate intervention to prevent morbidity and mortality in the first week after diagnosis. OBJECTIVES The objectives of this article are to equip oncology nurse to identify patients with hyperleukocytosis and to provide nursing interventions that will ensure safe, quality care. METHODS A case study is used to demonstrate key concepts that are critical in early assessment, identification, and treatment of patients with leukostasis.
. FINDINGS Oncology nurses well versed in the pathophysiology, clinical presentation, and management of leukostasis can make a significant contribution to the safe management of patients with cancer.
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Affiliation(s)
- Lisa M Blackburn
- Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
| | - Shelly Brown
- Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
| | - Aimee Munyon
- Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
| | - Michelle Orovets
- Ohio State University Comprehensive Cancer Center-Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
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Olfa CW, Imen R, Leila K, Hichem K, Adnane A, Mourad C, Adel C, Choumous K, Noureddine R. Diagnosis of chronic myeloid leukemia from acute intracerebral hemorrhage: A case report. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/j.joad.2015.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Gong J, Wu B, Guo T, Zhou S, He B, Peng X. Hyperleukocytosis: A report of five cases and review of the literature. Oncol Lett 2014; 8:1825-1827. [PMID: 25202418 PMCID: PMC4156199 DOI: 10.3892/ol.2014.2326] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 06/12/2014] [Indexed: 11/06/2022] Open
Abstract
Hyperleukocytosis (white blood cell count, >100×109/l), an uncommon presentation of leukemia, is associated with an increased risk of early mortality. It may present with a variety of symptoms secondary to leukostasis, a syndrome caused by the sludging of circulating leukemic blasts in the microvasculature. Adequate measures for managing this medical emergency include hydration, cytoreduction, prevention of tumor lysis and, rarely, leukapheresis in cases complicated by leukostasis and hyperviscosity syndrome. The present study reports a case series of five patients with hyperleukocytic leukemia. In addition, a review of the literature with regard to the incidence, pathophysiology, clinical manifestations and management of this laboratory abnormality is included. This study demonstrated that the central nervous system and lungs are the most common sites for leukostasis, and that emergency cases require aggressive treatment.
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Affiliation(s)
- Junmei Gong
- Department of Haematology, Chinese People's Liberation Army No. 421 Hospital, Guangzhou, Guangdong 510310, P.R. China
| | - Bijia Wu
- Department of Haematology, Chinese People's Liberation Army No. 421 Hospital, Guangzhou, Guangdong 510310, P.R. China
| | - Tianjian Guo
- Department of Haematology, Chinese People's Liberation Army No. 421 Hospital, Guangzhou, Guangdong 510310, P.R. China
| | - Silang Zhou
- Department of Haematology, Chinese People's Liberation Army No. 421 Hospital, Guangzhou, Guangdong 510310, P.R. China
| | - Benfu He
- Department of Haematology, Chinese People's Liberation Army No. 421 Hospital, Guangzhou, Guangdong 510310, P.R. China
| | - Xinzhao Peng
- Department of Haematology, Chinese People's Liberation Army No. 421 Hospital, Guangzhou, Guangdong 510310, P.R. China
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Colquitt JL, D'Orazio JA. Intracranial hemorrhage and a white blood cell count of almost 1 million cells/μL. J Pediatr 2013; 162:214-214.e1. [PMID: 22947653 DOI: 10.1016/j.jpeds.2012.07.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 07/13/2012] [Indexed: 11/19/2022]
Affiliation(s)
- John L Colquitt
- Department of Pediatrics, University of Kentucky College of Medicine, Lexington, Kentucky, USA
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Chen CY, Tai CH, Cheng A, Wu HC, Tsay W, Liu JH, Chen PY, Huang SY, Yao M, Tang JL, Tien HF. Intracranial hemorrhage in adult patients with hematological malignancies. BMC Med 2012; 10:97. [PMID: 22931433 PMCID: PMC3482556 DOI: 10.1186/1741-7015-10-97] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 08/29/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical characteristics and outcomes of intracranial hemorrhage (ICH) among adult patients with various hematological malignancies are limited. METHODS A total of 2,574 adult patients diagnosed with hematological malignancies admitted to a single university hospital were enrolled into this study between 2001 and 2010. The clinical characteristics, image reports and outcomes were retrospectively analyzed. RESULTS A total of 72 patients (48 men and 24 women) with a median age of 56 (range 18 to 86) had an ICH. The overall ICH incidence was 2.8% among adult patients with hematological malignancies. The incidence of ICH was higher in acute myeloid leukemia (AML) patients than in patients with other hematological malignancies (6.3% vs 1.1%, P = 0.001). ICH was more common among patients with central nervous system (CNS) involvement of lymphoma than among patients with CNS involved acute leukemia (P <0.001). Sites of ICH occurrence included the cerebral cortex (60 patients, 83%), basal ganglia (13 patients, 18%), cerebellum (10 patients, 14%), and brainstem (5 patients, 7%). A total of 33 patients (46%) had multifocal hemorrhages. In all, 56 patients (77%) had intraparenchymal hemorrhage, 22 patients (31%) had subdural hemorrhage, 15 patients (21%) had subarachnoid hemorrhage (SAH), and 3 patients (4%) had epidural hemorrhage. A total of 22 patients had 2 or more types of ICH. In all, 46 (64%) patients died of ICH within 30 days of diagnosis, irrespective of the type of hematological malignancy. Multivariate analysis revealed three independent prognostic factors: prolonged prothrombin time (P = 0.008), SAH (P = 0.021), and multifocal cerebral hemorrhage (P = 0.026). CONCLUSIONS The incidence of ICH in patients with AML is higher than patients with other hematological malignancies. But in those with intracranial malignant disease, patients with CNS involved lymphoma were more prone to ICH than patients with CNS involved acute leukemia. Mortality was similar regardless of the type of hematological malignancy. Neuroimaging studies of the location and type of ICH could assist with prognosis prediction for patients with hematological malignancies.
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Affiliation(s)
- Chien-Yuan Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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ZHOU ZHUOL, TANG BIN, NGAN ALFONSOHW. THE BIOMECHANICS OF DRUG-TREATED LEUKEMIA CELLS INVESTIGATED USING OPTICAL TWEEZERS. ACTA ACUST UNITED AC 2012. [DOI: 10.1142/s179398441100044x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Leukemia is a very common cancer worldwide, and different drugs have been applied to treat the disease. However, the influence of the drugs on the biomechanical properties of leukemia cells, which are related to the risk of leukostasis, is still unknown. Moreover, accurate measurement of biomechanical properties of leukemia cells is still a challenging task because of their non-adherent nature and high sensitivity to the surrounding physiological conditions. In this study, a protocol to measure the biomechanical properties of leukemia cells by performing indentation tests using optical tweezers is proposed. The biomechanical properties of normal leukemia cells and cells treated with various cancer drugs, including phorbol 12-myristate 13-acetate (PMA), all-trans retinoic acid (ATRa), Cytoxan (CTX), and Dexamethasone (DEX), were measured. The adhesion between the cells and certain proteins existing in the extracellular matrix, i.e., fibronetin and collagen I, was also characterized with the help of a static adhesion assay. It was found that after treatment by ATRa, CTX, and DEX, the cells became softer, and the adhesion between the cells and the proteins became weaker. PMA treatment caused no change in the stiffness of the HL60 cells, but increased the stiffness of the K562 cells, and increased the cell–protein adhesion of both K562 cells and HL60 cells.
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Affiliation(s)
- ZHUO L. ZHOU
- Department of Mechanical Engineering, The University of Hong Kong, Pokfulam Road, Hong Kong, P. R. China
| | - BIN TANG
- Department of Mechanical Engineering, The University of Hong Kong, Pokfulam Road, Hong Kong, P. R. China
- Department of Mechanical Engineering, King Abdullah University of Science and Technology, Thuwal, Saudi Arabia
| | - ALFONSO H. W. NGAN
- Department of Mechanical Engineering, The University of Hong Kong, Pokfulam Road, Hong Kong, P. R. China
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