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Fiske HW, Ward C, Shah SA, Holubar SD, Al-Bawardy B, Barnes EL, Binion D, Bohm M, Brand M, Clarke K, Cohen BL, Cross RK, Dueker J, Engels M, Farraye FA, Fine S, Forster E, Gaidos J, Ginsburg P, Goyal A, Hanson J, Herfath H, Hull T, Kelly CR, Lazarev M, Levy LC, Melia J, Philpott J, Qazi T, Siegel CA, Watson A, Wexner SD, Williams ED, Regueiro M. Clinical Decision Making in Inflammatory Bowel Disease Mimics: Practice Management from Inflammatory Bowel Disease LIVE. CROHN'S & COLITIS 360 2024; 6:otae022. [PMID: 38720935 PMCID: PMC11078036 DOI: 10.1093/crocol/otae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Indexed: 05/12/2024] Open
Abstract
Background Since 2009, inflammatory bowel disease (IBD) specialists have utilized "IBD LIVE," a weekly live video conference with a global audience, to discuss the multidisciplinary management of their most challenging cases. While most cases presented were confirmed IBD, a substantial number were diseases that mimic IBD. We have categorized all IBD LIVE cases and identified "IBD-mimics" with consequent clinical management implications. Methods Cases have been recorded/archived since May 2018; we reviewed all 371 cases from May 2018-February 2023. IBD-mimics were analyzed/categorized according to their diagnostic and therapeutic workup. Results Confirmed IBD cases made up 82.5% (306/371; 193 Crohn's disease, 107 ulcerative colitis, and 6 IBD-unclassified). Sixty-five (17.5%) cases were found to be mimics, most commonly medication-induced (n = 8) or vasculitis (n = 7). The evaluations that ultimately resulted in correct diagnosis included additional endoscopic biopsies (n = 13, 21%), surgical exploration/pathology (n = 10, 16.5%), biopsies from outside the GI tract (n = 10, 16.5%), genetic/laboratory testing (n = 8, 13%), extensive review of patient history (n = 8, 13%), imaging (n = 5, 8%), balloon enteroscopy (n = 5, 8%), and capsule endoscopy (n = 2, 3%). Twenty-five patients (25/65, 38%) were treated with biologics for presumed IBD, 5 of whom subsequently experienced adverse events requiring discontinuation of the biologic. Many patients were prescribed steroids, azathioprine, mercaptopurine, or methotrexate, and 3 were trialed on tofacitinib. Conclusions The diverse presentation of IBD and IBD-mimics necessitates periodic consideration of the differential diagnosis, and reassessment of treatment in presumed IBD patients without appropriate clinical response. The substantial differences and often conflicting treatment approaches to IBD versus IBD-mimics directly impact the quality and cost of patient care.
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Affiliation(s)
- Hannah W Fiske
- Department of Internal Medicine, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Christopher Ward
- Division of Gastroenterology, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Samir A Shah
- Gastroenterology Associates Inc., The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Stefan D Holubar
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Badr Al-Bawardy
- Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA
- Division of Gastroenterology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Edward L Barnes
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - David Binion
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Matthew Bohm
- Division of Gastroenterology, Indiana University School of Medicine, Carmel, IN, USA
| | - Myron Brand
- Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA
| | - Kofi Clarke
- Division of Gastroenterology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Benjamin L Cohen
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Raymond K Cross
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jeffrey Dueker
- Division of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael Engels
- Division of Gastroenterology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Sean Fine
- Division of Gastroenterology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Erin Forster
- Division of Gastroenterology, Medical University of South Carolina, Charleston, SC, USA
| | - Jill Gaidos
- Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA
| | - Philip Ginsburg
- Division of Gastroenterology, Yale School of Medicine, New Haven, CT, USA
| | - Alka Goyal
- Department of Pediatric Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
| | - John Hanson
- Division of Gastroenterology and Hepatology, Atrium Health, Charlotte, NC, USA
| | - Hans Herfath
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Tracy Hull
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Colleen R Kelly
- Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Mark Lazarev
- Division of Gastroenterology, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - L Campbell Levy
- Center for Digestive Health, Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Joanna Melia
- Division of Gastroenterology, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Jessica Philpott
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Taha Qazi
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Corey A Siegel
- Center for Digestive Health, Section of Gastroenterology and Hepatology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Andrew Watson
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Emmanuelle D Williams
- Division of Gastroenterology, Penn State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Miguel Regueiro
- Department of Gastroenterology, Hepatology, & Nutrition, Cleveland Clinic, Cleveland, OH, USA
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Kim SH, Buhle A, Roberts A, Singh N, Mir A, Kesar V, Lozano A, Ji W, Hanlon A, Grider D. Multidisciplinary Inflammatory Bowel Disease Conference: The Impact of the Expert Pathologist on Patient Care. Inflamm Bowel Dis 2023:izad192. [PMID: 37672726 DOI: 10.1093/ibd/izad192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Multidisciplinary teams (MDT) aid the diagnosis and management of patients with inflammatory bowel disease (IBD) and improve patient outcomes. The direct impact of a gastrointestinal expert pathologist on MDT care of IBD patients is unknown. METHODS A retrospective chart review was conducted evaluating all cases (N = 289) discussed at the IBD MDT conference at Carilion Roanoke Memorial Hospital from June 1, 2013, through December 31, 2019. Cases were discussed between 1 and 6 times at the conference. Data collected included demographics, diagnosis before and after conference, reason for diagnostic change, endoscopy findings, medications, surgeries, and clinical follow-up. RESULTS Approximately 15% to 42% of patients had a change in diagnosis after the first 3 conferences. The majority of diagnostic changes after the first (84%), second (73%), and third (67%) conferences were due to expert pathologist interpretation. Indeterminate colitis was the most frequently changed diagnosis, and Crohn's disease was the most common new diagnosis after conference. Among patients with a diagnostic change, 28.6% to 38.5% of patients had a change in their IBD medication regimen, and 7.7% to 10.9% had a surgical intervention after the first 2 conferences. Approximately 54.2% to 60% of patients reported clinical improvement or remission within 6 months of the first 3 conferences. CONCLUSION The majority of diagnostic changes made at the multidisciplinary IBD conference were due to histopathologic re-interpretation. A change in diagnosis at times led to significant modifications in medical or surgical management. An expert gastrointestinal pathologist is an essential MDT member for IBD management.
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Affiliation(s)
- Seo Hyun Kim
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Anna Buhle
- Carolinas Medical Center, Charlotte, NC, USA
| | - Abra Roberts
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Neha Singh
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Adil Mir
- Division of Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Varun Kesar
- Division of Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
| | - Alicia Lozano
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, VA, USA
| | - Wenyan Ji
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, VA, USA
| | - Alexandra Hanlon
- Center for Biostatistics and Health Data Science, Department of Statistics, Virginia Tech, Roanoke, VA, USA
| | - Douglas Grider
- Dermatology Section, Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Dominion Pathology Associates, Roanoke VA, USA
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Tan Z, Zhu S, Liu C, Meng Y, Li J, Zhang J, Dong W. Causal Link between Inflammatory Bowel Disease and Fistula: Evidence from Mendelian Randomization Study. J Clin Med 2023; 12:jcm12072482. [PMID: 37048564 PMCID: PMC10095427 DOI: 10.3390/jcm12072482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/05/2023] [Accepted: 03/20/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Previous observational studies have found that fistulas are common in Crohn's disease (CD) and less common in ulcerative colitis (UC). However, some patients have a fistula before diagnosis. Based on retrospective analysis, it was not possible to determine whether there was a bi-directional causal relationship between inflammatory bowel disease (IBD) and fistulas. METHODS Data were extracted from the open GWAS database; 25,042 cases and 34,915 controls were included for IBD, and 6926 cases and 30,228 controls were included for fistula. Two-sample Mendelian randomization and multivariable Mendelian randomization were used in combination to determine the causal relationship between IBD and fistula. RESULTS Forward MR showed that IBD increased the risk of colonic or urogenital fistula (FISTULA) (OR: 1.09, 95% CI: 1.05 to 1.13, p = 1.22 × 10-6), mainly associated with fissure and fistula of the anal and rectal regions (FISSANAL) (OR:1.10, 95% CI:1.06 to 1.14, p = 6.12 × 10-8), but not with fistulas involving the female genital tract (FEMGENFISTUL) (OR:0.97, 95% CI: 0.85 to 1.11, p = 0.669). Furthermore, both UC and CD increased the risk of FISTULA. However, after adjusting by MVMR, only CD increased the risk of FISTULA (OR: 1.06, 95% CI: 1.02 to 1.11, p = 0.004), and UC did not increase the risk of FISTULA (OR: 1.01, 95% CI: 0.95 to 1.06, p = 0.838). Reverse MR showed that fistulas did not increase the risk of IBD. CONCLUSION Our study confirms it is CD, rather than UC, that casually leads to an increased risk of fistula, but fistulas do not increase the risk of IBD.
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Affiliation(s)
- Zongbiao Tan
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan 430060, China
| | - Shijie Zhu
- Department of Occupational and Environmental Health, School of Public Health, Wuhan University, Wuhan 430071, China
| | - Chuan Liu
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan 430060, China
| | - Yang Meng
- Department of Ophthalmology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan 430060, China
| | - Jiao Li
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan 430060, China
| | - Jixiang Zhang
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan 430060, China
| | - Weiguo Dong
- Department of Gastroenterology, Renmin Hospital of Wuhan University, 238 Jiefang Road, Wuhan 430060, China
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Abdemalek E, Bose M, Phillips R, Feakins R, Forbes A, Papadia C. The role of biopsy protocol in inflammatory bowel disease: getting the diagnosis right first time. Intern Emerg Med 2023; 18:673-676. [PMID: 36539603 DOI: 10.1007/s11739-022-03175-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Ehab Abdemalek
- Department of Gastroenterology, Princess Alexandra Hospital, Hamstel Rd, Harlow, UK
| | - Monica Bose
- Department of Gastroenterology, Princess Alexandra Hospital, Hamstel Rd, Harlow, UK
| | - Rosemary Phillips
- Department of Gastroenterology, Princess Alexandra Hospital, Hamstel Rd, Harlow, UK
| | - Roger Feakins
- Department of Pathology, University College London, London, UK
| | - Alastair Forbes
- Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Cinzia Papadia
- Department of Gastroenterology, Whipps Cross University Hospital-Barts Health Trust, Queen Mary University of London, Whipps Cross Road, London, E11 1NR, UK.
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Zeineldin M, Larman TC. SATB2 loss in inflammatory bowel disease-associated small intestinal metaplasia of the distal colon. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.01.526729. [PMID: 36778374 PMCID: PMC9915658 DOI: 10.1101/2023.02.01.526729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Epithelial metaplasia is a common adaptation to chronic inflammatory processes and can be associated with increased risk of dysplasia and cancer. The distal colon of patients with inflammatory bowel disease (IBD) commonly shows crypt architectural distortion and Paneth cell metaplasia (PCM), and IBD patients also carry increased risk of colitis-associated dysplasia and cancer (CAC). Loss of SATB2 expression (Special AT-rich binding 2 protein, a colon-restricted chromatin remodeler) has recently been shown to distinguish colitis-associated dysplasia and CAC from sporadic disease. Here we report non-diffuse heterogeneous patterns of SATB2 loss across non-dysplastic distal colon biopsies from IBD patients (n=20). This cohort was specifically curated to include biopsies with well-developed histologic features of villiform growth and PCM. Notably, CDX2 was strongly expressed and P53 showed a wild-type immunolabeling pattern across our non-dysplastic cohort, regardless of SATB2 immunolabeling pattern. Our findings fit with recent murine studies in which colon-specific Satb2 deletion resulted in histologic conversion of colonic mucosa to small intestinal-like mucosa, including emergence of villi and Paneth cells. Taken together, we show that SATB2 loss is associated with a pre-neoplastic metaplastic response to chronic injury in human IBD and chronic colitis, reframing PCM more broadly as small intestinal metaplasia. We propose that inflammation-associated SATB2 loss mediates a remodeled chromatin landscape permissive for dysplasia and CAC.
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Affiliation(s)
- Maged Zeineldin
- Department of Pathology, Division of Gastrointestinal/Liver Pathology, and Center for Cell Dynamics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tatianna C Larman
- Department of Pathology, Division of Gastrointestinal/Liver Pathology, and Center for Cell Dynamics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Indolent T-cell lymphoproliferative disorder of gastrointestinal tract with unusual clinical courses: report of 6 cases and literature review. Virchows Arch 2022; 482:729-743. [PMID: 36472661 DOI: 10.1007/s00428-022-03467-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 11/20/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022]
Abstract
Indolent T-cell lymphoproliferative disorder of the gastrointestinal tract (iTLPD-GI) is a rare neoplasm usually having an indolent clinical course and easily misdiagnosed as inflammatory bowel disease or other T-cell lymphomas. A subset of the disorders that progressed to overt peripheral T-cell lymphoma have been reported, and the etiology and pathogenesis are poorly understood. The current study retrospectively examined the pathological, molecular, and clinical features of 6 cases of iTLPD-GI. Hematoxylin and eosin staining, immunohistochemistry, in situ hybridization, T-cell receptor gene rearrangement, and next-generation sequencing (NGS) were performed with the diseased tissues. All the 6 patients were immunocompetent Chinese men, who presented with recurrent abdominal pain and diarrhea for 4 to 13 years. Histologically, the intestinal tissue was expanded by lymphoid infiltration, composed of small-to-medium-sized lymphocytes with gland intact. The neoplastic cells were CD4 - /CD8 + with expression of TIA1 and variable granzyme B in five cases, and the other one was CD4 + /CD8 - . Two of the 5 patients progressed to more aggressive T-cell lymphoma and died of disease with complications. NGS identified TET2 and DDX3X mutations in patient 1, and BIRC6 and REV3L mutations in patient 2. Literature review indicated that iTLPD-GI with CD4 - /CD8 + immunophenotype was more commonly reported in Chinese cases. Our limited data indicated CD4-/CD8 + iTLPD-GI have similar potential to progress to more aggressive T-cell lymphoma as that of CD4 + /CD8 - , and gradually increased expression of granzyme B and Ki-67 may be early signs of the disease progression. Gain of novel gene mutations may be indicators of the pathogenesis.
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Villanacci V, Reggiani-Bonetti L, Leoncini G, Parente P, Cadei M, Albarello L, Mandelli G, Caputo A. Histopathology of Non-IBD Colitis. A practical approach from the Italian Group for the study of the gastrointestinal tract (GIPAD). Pathologica 2021; 113:54-65. [PMID: 33686310 PMCID: PMC8138693 DOI: 10.32074/1591-951x-234] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 12/12/2022] Open
Abstract
Non-IBD colitides (NIBDC) are intestinal diseases clinically and endoscopically overlapping with Inflammatory Bowel Diseases (IBD), sometimes with a similar histological picture. NIBDC include entities such as infectious colitis, ischemic colitis, pseudomembranous colitis, eosinophilic colitis, autoimmune enterocolitis, segmental colitis associated with diverticulosis, drug-induced colitis, radiation-induced colitis, diversion colitis, and microscopic colitis, this last including two entities: collagenous and lymphocytic colitis. The knowledge of the most useful histological features and the main clinical data for each entity is mandatory in daily clinical practice, for correct pathological diagnosis and clinical management.
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Affiliation(s)
| | - Luca Reggiani-Bonetti
- Department of Diagnostic, Clinic and Public Health Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Paola Parente
- Unit of Pathology, Fondazione IRCCS Ospedale Casa Sollievo Della Sofferenza, San Giovanni Rotondo (FG), Italy
| | - Moris Cadei
- Institute of Pathology, Spedali Civili, Brescia, Italy
| | - Luca Albarello
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milano, Italy
| | | | - Alessandro Caputo
- University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, Salerno, Italy
- Correspondence Alessandro Caputo University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, via San Leonardo 1, 84131 Salerno, Italy E-mail:
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Hokama A, Omija H, Kishimoto K, Kinjo T, Kinjo T, Fujita J. Response to "Histopathological Mimics of Inflammatory Bowel Disease". Inflamm Bowel Dis 2021; 27:e5-e6. [PMID: 32793979 DOI: 10.1093/ibd/izaa222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Akira Hokama
- Department of Endoscopy, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hidenao Omija
- Department of Medicine, Yonabaru Chuo Hospital, Okinawa, Japan
| | | | - Tatsuya Kinjo
- Department of Digestive and General Surgery, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tetsu Kinjo
- Department of Endoscopy, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Jiro Fujita
- Department of Infectious Diseases, Respiratory, and Digestive Medicine, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
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