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Sarjare S, Nedunchelian M, Ravichandran S, Rajaiah B, Karupanan R, Abiramalatha T, Gunasekaran K, Ramakrishnan S, Varadharajan S. Role of advanced (magnetic resonance) neuroimaging and clinical outcomes in neonatal strokes: Experience from tertiary care center. Neuroradiol J 2023; 36:297-304. [PMID: 36170618 PMCID: PMC10268086 DOI: 10.1177/19714009221130488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Neonatal strokes constitute a major cause of pediatric mortality and morbidity. Neuroimaging helps in its diagnosis as well as prognostication. However, advanced imaging, including magnetic resonance imaging (MRI), carries multiple challenges. Limited data exists in the literature on imaging-based predictors of neurological outcomes in neonatal stroke in the Indian population. In this study, we reviewed our available data on neonatal stroke patients between 2015 and 2020 for clinico-radiological patterns. During this period, 17 neonatal strokes were admitted and the majority were term births with a slight male preponderance. Seizures and encephalopathy were the most common presentation. Multiple maternal risk factors such as gestational diabetes, meconium-stained liquor, APLA syndrome, fever, deranged coagulation profile, oligohydramnios, cord prolapse, and non-progressive labor were seen. Cardiac abnormalities were seen in only less than half of these patients with the most common finding being atrial septal defects (ASD). Transcranial ultrasound was performed in eight neonates and the pick-up rate of ultrasound was poor. MR imaging showed large infarcts in 11 patients. The MCA territory was most commonly involved. Interestingly, five neonates had venous thrombosis with three showing it in addition to arterial thrombosis. Associated ictal, as well as Wallerian changes, were noted in 10. Although large territorial infarcts were the most common pattern, non-contrast MR angiography did not show major vessel occlusion in these cases. Outcomes were fairly good and only three patients had a residual motor deficit at 1 year. No recurrence of stroke was seen in any of the neonates.
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Affiliation(s)
- Sandhya Sarjare
- Department of Imaging Sciences and Interventional Radiology, Kovai medical center and Hospital, India
| | - Meena Nedunchelian
- Department of Imaging Sciences and Interventional Radiology, Kovai medical center and Hospital, India
| | | | | | | | | | - Kannan Gunasekaran
- Department of Imaging Sciences and Interventional Radiology, Kovai medical center and Hospital, India
| | | | - Shriram Varadharajan
- Department of Imaging Sciences and Interventional Radiology, Kovai medical center and Hospital, India
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Shevell M. The evolution of our understanding of the conceptualization and genetics of cerebral palsy: Implications for genetic testing. Mol Genet Metab 2022; 137:449-453. [PMID: 33423928 DOI: 10.1016/j.ymgme.2020.12.294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Michael Shevell
- Department of Pediatrics, McGill University, Montreal Children's Hospital-McGill University Health Centre, Room B.RC. 6354, 1001 Decarie Blvd, Montreal, Quebec H4A 3J1, Canada.
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Gordeeva OB, Vashakmadze ND, Karaseva MS, Babaykina MA, Zhurkova NV, Soloshenko MA, Kretova EV. Modern Aspects of Anticoagulation System Disorders Diagnosis in Children with Different Polymorphisms in Coagulation Genes. Initial Results. PEDIATRIC PHARMACOLOGY 2022. [DOI: 10.15690/pf.v19i4.2444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background. Hemostatic system pathology is topical and poorly studied issue in pediatrics. One of the main causes of coagulation pathway disorders associated with thrombotic events is abnormality in various parts of the hemostatic system. Vascular accidents are commonly caused by anticoagulation system factors deficiency. Conventionally, thrombosis is a common event in adult patients, and there is no adequate attention to disorders of primary physiological anticoagulants system in children. More often acquired anticoagulant proteins deficiency develops in presence of various pathological conditions, especially after the past infectious diseases. All these diseases (thrombophilia, trombotic events, cardiovascular pathology, nervous system diseases, genetic diseases) can occur separately and in association with each other, plus clinical picture of coagulation events may be similar. Objective. The aim of the study is to evaluate changes in the physiological anticoagulants system in children with different pathologies who have polymorphic variants in coagulation genes and who had new coronavirus infection. Methods. The study included 33 children who had severe coronavirus infection in family clusters and had severe chronic pathology potentially associated with disorders of the coagulation system (nervous system damage, hypertrophic cardiomyopathy, hereditary monogenic syndromes, hemato-mesenchymal dysplasia syndrome). All children underwent complete examination including clinical examination, laboratory, and instrumental diagnostics. Results. Preliminary study results indicate significant incidence of polymorphic variants in coagulation genes (one third of children with various diseases from the study). Some children had decreased activity of anticoagulation system glycoproteins (from 6% to 36%) that confirmed the topicality of the examination of anticoagulation system factors deficiency and the need for further dynamic follow-up, as well as revealing of trombophilia predictors in children in selected target groups. Study on revealing anticoagulation system disorders and mutations in coagulation genes will predict the risk of thrombotic disorders. Conclusion. The obtained results have confirmed the significant role of the ongoing study for comprehensive assessment of hemostatic system disorders in children. That will allow us to optimize the approach to diagnosis and personalize the management strategy for patients with different chronic pathologies and disorders of the natural anticoagulants system. The study is currently ongoing.
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Affiliation(s)
- Olga B. Gordeeva
- Pediatrics and Child Health Research Institute in Petrovsky National Research Centre of Surgery; Pirogov Russian National Research Medical University
| | - Nato D. Vashakmadze
- Pediatrics and Child Health Research Institute in Petrovsky National Research Centre of Surgery; Pirogov Russian National Research Medical University
| | - Maria S. Karaseva
- Pediatrics and Child Health Research Institute in Petrovsky National Research Centre of Surgery
| | - Marina A. Babaykina
- Pediatrics and Child Health Research Institute in Petrovsky National Research Centre of Surgery
| | - Natalia V. Zhurkova
- Pediatrics and Child Health Research Institute in Petrovsky National Research Centre of Surgery
| | - Margarita A. Soloshenko
- Pediatrics and Child Health Research Institute in Petrovsky National Research Centre of Surgery
| | - Elena V. Kretova
- Pediatrics and Child Health Research Institute in Petrovsky National Research Centre of Surgery
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Incidence of Deep Vein Thrombosis in Cerebral Palsy Following an Orthopaedic Surgical Event. J Pediatr Orthop 2022; 42:285-288. [PMID: 35180727 DOI: 10.1097/bpo.0000000000002113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to identify the incidence of venous thromboembolism (VTE) and characterize the demographics, comorbidities, and risk factors for patients with cerebral palsy (CP) having orthopaedic surgery. METHODS All patients diagnosed with CP who underwent an orthopaedic surgical procedure at one institution between 2008 and 2017 were identified. Diagnosis codes and associated patient events were recovered from the electronic medical record. Each VTE event was reviewed to ascertain an actual VTE episode related to a surgical event. RESULTS The review included 2583 orthopaedic surgical events in 1371 patients. Of the initial 88 cases identified, 28 cases had a deep thrombosis documented. Six cases of VTE occurred within 3 months following the surgical event. Three of these cases had thigh thrombosis, and 2 patients had upper arm thrombosis, and 1 patient had a superior vena cava thrombosis. On further workup, 5 of these 6 patients were identified as having a congenital hypercoagulable condition. CONCLUSIONS VTE is a relatively rare occurrence after orthopaedic surgery in pediatric patients with CP, but when it occurs, a full hematologic workup for a congenital hypercoagulable condition is indicated. Based on the low incidence of thigh thrombosis, routine pharmacological or intermittent mechanical calf compression is not recommended. A careful clinical and family history should be performed to identify patients with possible genetic hypercoagulable conditions who would merit prophylaxis. LEVEL OF EVIDENCE Level IV.
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Penn AA, Wintermark P, Chalak LF, Armstrong J, Redline R, Scher MS, Nelson KB. Placental contribution to neonatal encephalopathy. Semin Fetal Neonatal Med 2021; 26:101276. [PMID: 34420894 DOI: 10.1016/j.siny.2021.101276] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Placental assessment, although currently underused, can inform our understanding of the etiology and timing of Neonatal Encephalopathy (NE). We review our current understanding of the links between placental dysfunction and NE and how this information may inform clinical decisions, now and in the future, emphasizing the four major placental lesions associated with NE. In addition, we discuss maternal and fetal factors that are hypothesized to contribute to specific placental pathologies, especially innate or acquired thrombophilias. We outline the importance of assessing placenta across trimesters and after delivery. As this field continues to evolve, currently available placental histopathological examination methods may need to be combined with advanced prenatal molecular and imaging assessments of placenta and be applied in well-designed studies in large representative populations to better define the links between placental dysfunction and NE.
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Affiliation(s)
- A A Penn
- Division of Neonatology, Department of Pediatrics, Columbia University, New York, NY, USA.
| | - P Wintermark
- Division of Newborn Medicine, Montreal Children's Hospital, Montreal, Canada
| | - L F Chalak
- Neonatal-Perinatal Medicine, Department of Pediatrics, UT Southwestern Medical Center, Dallas, USA
| | - J Armstrong
- Department of Pediatrics (Section of Child Neurology, Neurology, and OB/GYN), University of Colorado Anschutz Medical Campus, Hemophilia and Thrombosis Center, Aurora, CO, USA
| | - R Redline
- Department of Pathology, UH Cleveland Medical Center, Cleveland, OH, USA
| | - M S Scher
- Case Western Reserve University School of Medicine, Department of Pediatrics, Department of Neurology, Rainbow Babies and Children's Hospital/MacDonald Hospital for Women, UH Cleveland Medical Center, Cleveland, OH, USA
| | - K B Nelson
- National Institutes of Health, National Institute of Neurological Diseases and Stroke, Bethesda, MD, USA
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Horber V, Grasshoff U, Sellier E, Arnaud C, Krägeloh-Mann I, Himmelmann K. The Role of Neuroimaging and Genetic Analysis in the Diagnosis of Children With Cerebral Palsy. Front Neurol 2021; 11:628075. [PMID: 33633660 PMCID: PMC7900404 DOI: 10.3389/fneur.2020.628075] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 12/30/2020] [Indexed: 11/13/2022] Open
Abstract
Cerebral magnetic resonance imaging (MRI) is considered an important tool in the assessment of a child with cerebral palsy (CP), as it is abnormal in more than 80% of children with CP, disclosing the pathogenic pattern responsible for the neurological condition. MRI, therefore, is recommended as the first diagnostic step after medical history taking and neurological examination. With the advances in genetic diagnostics, the genetic contribution to CP is increasingly discussed, and the question arises about the role of genetic testing in the diagnosis of cerebral palsy. The paper gives an overview on genetic findings reported in CP, which are discussed with respect to the underlying brain pathology according to neuroimaging findings. Surveillance of Cerebral Palsy in Europe (SCPE) classifies neuroimaging findings in CP into five categories, which help to stratify decisions concerning genetic testing. Predominant white and gray matter injuries are by far predominant (accounting for around 50 and 20% of the findings). They are considered to be acquired. Here, predisposing genetic factors may play a role to increase vulnerability (and should especially be considered, when family history is positive and/or causative external factors are missing). In maldevelopments and normal findings (around 11% each), monogenic causes are more likely, and thus, genetic testing is clearly recommended. In the miscellaneous category, the precise nature of the MRI finding has to be considered as it could indicate a genetic origin.
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Affiliation(s)
- Veronka Horber
- Department of Paediatric Neurology, University Children's Hospital, Tübingen, Germany
| | - Ute Grasshoff
- Institute of Medical Genetics and Applied Genomics, University Hospital, Tübingen, Germany
| | - Elodie Sellier
- Grenoble Alpes University, CNRS, Grenoble INP, CHU Grenoble Alpes, TIMC-IMAG, Grenoble, France.,Registre des Handicaps de l'Enfant et Observatoire Périnatal, Grenoble, France
| | - Catherine Arnaud
- CERPOP, SPHERE Team, University of Toulouse, Inserm, UPS, Toulouse, France.,Clinical Epidemiology Unit, Toulouse University Hospital, Toulouse, France
| | | | - Kate Himmelmann
- Department of Pediatrics, Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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8
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Torres-Martel JM, Bautista-Hernández KM. Trombofilia hereditaria y trombo intracardíaco. REVISTA COLOMBIANA DE CARDIOLOGÍA 2018. [DOI: 10.1016/j.rccar.2017.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Sarecka-Hujar B, Kopyta I, Skrzypek M. Is the 1298A>C polymorphism in the MTHFR gene a risk factor for arterial ischaemic stroke in children? The results of meta-analysis. Clin Exp Med 2018; 18:337-345. [PMID: 29396624 DOI: 10.1007/s10238-018-0489-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/22/2018] [Indexed: 01/03/2023]
Abstract
An elevated level of homocysteine is a risk factor for vascular diseases, brain atrophy and several other disorders. The 1298A>C polymorphism (rs1801131) leads to mildly decreased MTHFR activity. Previously, it was observed that the MTHFR 1298A>C polymorphism in combined analysis with the MTHFR 677C>T polymorphism increases homocysteine levels. However, conflicting results on its relation to ischaemic stroke in children can be found. We conducted a meta-analysis to analyse possible connections between the MTHFR 1298A>C polymorphism and ischaemic stroke in paediatric patients. We identified available data published before December 2016 using appropriate keywords and searching PubMed as well as the references cited in the found articles. Eight case-control studies were included in the meta-analysis (426 children with stroke and 778 controls). Statistical analyses were made using R and Comprehensive Meta-Analysis softwares to investigate the impact of polymorphism in four models: dominant, recessive, additive and allelic. No publication bias was observed in the meta-analysis. We demonstrated no relationship between the 1298A>C polymorphism and ischaemic stroke in children in the case of recessive, additive and allelic models. However, the results of the dominant model analysis should be treated with caution due to the sensitivity analysis results. After omitting one of the included study, we observed a significant association between the carriers of the MTHFR C allele (cases with AC + CC genotypes) and ischaemic stroke in children (OR 1.35 95% CI 1.02-1.79, p = 0.035 in a fixed effects model). In conclusion, the 1298A>C polymorphism in the MTHFR gene is not a risk factor for ischaemic stroke in paediatric patients.
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Affiliation(s)
- Beata Sarecka-Hujar
- Department of Pharmaceutical Technology, School of Pharmacy with the Division of Laboratory Medicine in Sosnowiec, Medical University of Silesia in Katowice, Kasztanowa Str 3, 41-200, Sosnowiec, Poland.
| | - Ilona Kopyta
- Department of Paediatric Neurology, School of Medicine in Katowice, Medical University of Silesia in Katowice, Medykow str 16, 40-072, Katowice, Poland
| | - Michal Skrzypek
- Department of Biostatistics, School of Public Health in Bytom, Medical University of Silesia in Katowice, Piekarska str 18, 41-902, Bytom, Poland
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van Eyk C, Corbett M, Maclennan A. The emerging genetic landscape of cerebral palsy. HANDBOOK OF CLINICAL NEUROLOGY 2018; 147:331-342. [DOI: 10.1016/b978-0-444-63233-3.00022-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Fahey MC, Maclennan AH, Kretzschmar D, Gecz J, Kruer MC. The genetic basis of cerebral palsy. Dev Med Child Neurol 2017; 59:462-469. [PMID: 28042670 DOI: 10.1111/dmcn.13363] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2016] [Indexed: 12/23/2022]
Abstract
Although prematurity and hypoxic-ischaemic injury are well-recognized contributors to the pathogenesis of cerebral palsy (CP), as many as one-third of children with CP may lack traditional risk factors. For many of these children, a genetic basis to their condition is suspected. Recent findings have implicated copy number variants and mutations in single genes in children with CP. Current studies are limited by relatively small patient numbers, the underlying genetic heterogeneity identified, and the paucity of validation studies that have been performed. However, several genes mapping to intersecting pathways controlling neurodevelopment and neuronal connectivity have been identified. Analogous to other neurodevelopmental disorders such as autism and intellectual disability, the genomic architecture of CP is likely to be highly complex. Although we are just beginning to understand genetic contributions to CP, new insights are anticipated to serve as a unique window into the neurobiology of CP and suggest new targets for intervention.
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Affiliation(s)
- Michael C Fahey
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia
| | - Alastair H Maclennan
- The Robinson Research Institute, The University of Adelaide, Adelaide, SA, Australia
| | - Doris Kretzschmar
- Oregon Institute of Occupational Health Sciences, Oregon Health and Science University, Portland, OR, USA
| | - Jozef Gecz
- The Robinson Research Institute, The University of Adelaide, Adelaide, SA, Australia.,South Australian Health & Medical Research Institute, Adelaide, SA, Australia
| | - Michael C Kruer
- Departments of Child Health, Neurology and Genetics, University of Arizona, College of Medicine, Phoenix, AZ, USA.,Programs in Neuroscience and Molecular & Cellular Biology, Arizona State University, Tempe, AZ, USA.,Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, USA
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TNF-α and MTHFR Polymorphisms Associated with Cerebral Palsy in Chinese Infants. Mol Neurobiol 2015; 53:6653-6658. [PMID: 26646537 DOI: 10.1007/s12035-015-9566-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 11/29/2015] [Indexed: 10/22/2022]
Abstract
This study aims to examine whether the presence of polymorphisms in TNF-α (rs361525 and rs1799724) and MTHFR (rs1476413 and rs9651118) genes is associated with the pathogenesis of cerebral palsy (CP). A total of 105 CP patients and 114 age-, gender-, and ethnicity-matched healthy controls were genotyped for the selected polymorphisms, using TaqMan allelic discrimination assay. Odds ratios (OR) and 95 % confidence intervals (CI) were determined to measure the strength of associations of TNF-α and MTHFR polymorphisms with CP. The proportion of subjects with the gestational age more than 37 weeks or asphyxia was much larger in cases compared with controls (gestational age 63.8 vs. 34.2 %; asphyxia 25.7 vs. 7.9 %). The genotype frequencies of TNF-α rs1799724 were similar between groups (P > 0.05), yet the allele distributions were significantly different (P < 0.05). Both the allele and genotype distributions of MTHFR rs9651118 polymorphism varied significantly between the groups (P < 0.05). Subgroup analysis based on gestational age indicated a significant association between rs361525 and rs9651118 and CP with or without premature. TNF-α protein concentrations were significantly increased among patients with rs361525 GG genotype compared with controls. Also, a significant increase in the risk of CP was observed to be associated with the interactions of TNF-α rs1799724 and MTHFR rs9651118 (OR 2.75, 95 % CI 1.23-6.13). These data suggest that polymorphisms in TNF-α and MTHFR genes might be involved in the pathogenesis of CP in Chinese infants.
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Rosa M, De Lucia S, Rinaldi VE, Le Gal J, Desmarest M, Veropalumbo C, Romanello S, Titomanlio L. Paediatric arterial ischemic stroke: acute management, recent advances and remaining issues. Ital J Pediatr 2015; 41:95. [PMID: 26631262 PMCID: PMC4668709 DOI: 10.1186/s13052-015-0174-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 09/21/2015] [Indexed: 01/06/2023] Open
Abstract
Stroke is a rare disease in childhood with an estimated incidence of 1-6/100.000. It has an increasingly recognised impact on child mortality along with its outcomes and effects on quality of life of patients and their families. Clinical presentation and risk factors of paediatric stroke are different to those of adults therefore it can be considered as an independent nosological entity. The relative rarity, the age-related peculiarities and the variety of manifested symptoms makes the diagnosis of paediatric stroke extremely difficult and often delayed. History and clinical examination should investigate underlying diseases or predisposing factors and should take into account the potential territoriality of neurological deficits and the spectrum of differential diagnosis of acute neurological accidents in childhood. Neuroimaging (in particular diffusion weighted magnetic resonance) is the keystone for diagnosis of paediatric stroke and other investigations might be considered according to the clinical condition. Despite substantial advances in paediatric stroke research and clinical care, many unanswered questions remain concerning both its acute treatment and its secondary prevention and rehabilitation so that treatment recommendations are mainly extrapolated from studies on adult population. We have tried to summarize the pathophysiological and clinical characteristics of arterial ischemic stroke in children and the most recent international guidelines and practical directions on how to recognise and manage it in paediatric emergency.
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Affiliation(s)
- Margherita Rosa
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Naples, Italy.
| | - Silvana De Lucia
- Department of Paediatrics, Aldo Moro University of Bari, Bari, Italy.
| | | | - Julie Le Gal
- Paediatric Migraine & Neurovascular diseases Unit, Department of Paediatrics, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
| | - Marie Desmarest
- Paediatric Migraine & Neurovascular diseases Unit, Department of Paediatrics, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
| | - Claudio Veropalumbo
- Department of Translational Medicine-Section of Pediatrics, Federico II University, Naples, Italy.
| | - Silvia Romanello
- Paediatric Emergency Department, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
| | - Luigi Titomanlio
- Paediatric Migraine & Neurovascular diseases Unit, Department of Paediatrics, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
- Paediatric Emergency Department, Robert Debré Hospital, Paris Diderot University, Sorbonne Paris Cité, Paris, France.
- Pediatric Emergency Department, INSERM U-1141 AP-HP Robert Debré University Hospital, 48, Bld Sérurier, 75019, Paris, France.
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