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Sugano K, Spechler SJ, El-Omar EM, McColl KEL, Takubo K, Gotoda T, Fujishiro M, Iijima K, Inoue H, Kawai T, Kinoshita Y, Miwa H, Mukaisho KI, Murakami K, Seto Y, Tajiri H, Bhatia S, Choi MG, Fitzgerald RC, Fock KM, Goh KL, Ho KY, Mahachai V, O'Donovan M, Odze R, Peek R, Rugge M, Sharma P, Sollano JD, Vieth M, Wu J, Wu MS, Zou D, Kaminishi M, Malfertheiner P. Kyoto international consensus report on anatomy, pathophysiology and clinical significance of the gastro-oesophageal junction. Gut 2022; 71:1488-1514. [PMID: 35725291 PMCID: PMC9279854 DOI: 10.1136/gutjnl-2022-327281] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/03/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE An international meeting was organised to develop consensus on (1) the landmarks to define the gastro-oesophageal junction (GOJ), (2) the occurrence and pathophysiological significance of the cardiac gland, (3) the definition of the gastro-oesophageal junctional zone (GOJZ) and (4) the causes of inflammation, metaplasia and neoplasia occurring in the GOJZ. DESIGN Clinical questions relevant to the afore-mentioned major issues were drafted for which expert panels formulated relevant statements and textural explanations.A Delphi method using an anonymous system was employed to develop the consensus, the level of which was predefined as ≥80% of agreement. Two rounds of voting and amendments were completed before the meeting at which clinical questions and consensus were finalised. RESULTS Twenty eight clinical questions and statements were finalised after extensive amendments. Critical consensus was achieved: (1) definition for the GOJ, (2) definition of the GOJZ spanning 1 cm proximal and distal to the GOJ as defined by the end of palisade vessels was accepted based on the anatomical distribution of cardiac type gland, (3) chemical and bacterial (Helicobacter pylori) factors as the primary causes of inflammation, metaplasia and neoplasia occurring in the GOJZ, (4) a new definition of Barrett's oesophagus (BO). CONCLUSIONS This international consensus on the new definitions of BO, GOJ and the GOJZ will be instrumental in future studies aiming to resolve many issues on this important anatomic area and hopefully will lead to better classification and management of the diseases surrounding the GOJ.
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Affiliation(s)
- Kentaro Sugano
- Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Stuart Jon Spechler
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center, Dallas, Texas, USA
| | - Emad M El-Omar
- Microbiome Research Centre, St George & Sutherland Clinical Campuses, School of Clinical Medicine, Faculty of Medicine & Health, Sydney, New South Wales, Australia
| | - Kenneth E L McColl
- Division of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Kaiyo Takubo
- Research Team for Geriatric Pathology, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsunori Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Takashi Kawai
- Department of Gastroenterological Endoscopy, Tokyo Medical University, Tokyo, Japan
| | | | - Hiroto Miwa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hyogo College of Medicine, Kobe, Japan
| | - Ken-Ichi Mukaisho
- Education Center for Medicine and Nursing, Shiga University of Medical Science, Otsu, Japan
| | - Kazunari Murakami
- Department of Gastroenterology, Oita University Faculty of Medicine, Yuhu, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hisao Tajiri
- Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | | | - Myung-Gyu Choi
- Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, The Republic of Korea
| | - Rebecca C Fitzgerald
- Medical Research Council Cancer Unit, Hutchison/Medical Research Council Research Centre, University of Cambridge, Cambridge, UK
| | - Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Duke NUS School of Medicine, National University of Singapore, Singapore
| | | | - Khek Yu Ho
- Department of Medicine, National University of Singapore, Singapore
| | - Varocha Mahachai
- Center of Excellence in Digestive Diseases, Thammasat University and Science Resarch and Innovation, Bangkok, Thailand
| | - Maria O'Donovan
- Department of Histopathology, Cambridge University Hospital NHS Trust UK, Cambridge, UK
| | - Robert Odze
- Department of Pathology, Tuft University School of Medicine, Boston, Massachusetts, USA
| | - Richard Peek
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Massimo Rugge
- Department of Medicine DIMED, Surgical Pathology and Cytopathology Unit, University of Padova, Padova, Italy
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Jose D Sollano
- Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Michael Vieth
- Institute of Pathology, Klinikum Bayreuth, Friedrich-Alexander University Erlangen, Nurenberg, Germany
| | - Justin Wu
- Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Duowu Zou
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Peter Malfertheiner
- Medizinixhe Klinik und Poliklinik II, Ludwig Maximillian University Klinikum, Munich, Germany
- Klinik und Poliklinik für Radiologie, Ludwig Maximillian University Klinikum, Munich, Germany
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Pinto D, Plieschnegger W, Schneider NI, Geppert M, Bordel H, Höss GM, Eherer A, Wolf EM, Vieth M, Langner C. Carditis: a relevant marker of gastroesophageal reflux disease. Data from a prospective central European multicenter study on histological and endoscopic diagnosis of esophagitis (histoGERD trial). Dis Esophagus 2019; 32:5078141. [PMID: 30137321 DOI: 10.1093/dote/doy073] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The columnar-lined mucosa at the gastroesophageal junction may contain an inflammatory infiltrate, commonly referred to as carditis (or cardia gastritis). The etiology of carditis is not entirely clear since published data are conflicting. Some authors believe it to be secondary to gastroesophageal reflux disease (GERD) and others to Helicobacter pylori gastritis. This prospective study aims at clarifying the relationship between carditis and the histological, clinical, and endoscopic findings of GERD, in a large cohort of individuals negative for H. pylori infection. Eight hundred and seventy-three individuals (477 females and 396 males, median age 53 years) participated in this study. Biopsy material was systematically sampled from above and below the gastroesophageal junction. Reflux-associated changes of the esophageal squamous epithelium were assessed according to the Esohisto consensus guidelines. Grading of carditis was performed according to the Updated Sydney System, known from the histological evaluation of gastritis. In total, 590 individuals (67.5%) had chronic carditis. Of these, 468 (53.6%) had mild chronic inflammation, with 321 individuals (68.6%) showing no or minimal changes on endoscopic examination (Los Angeles Categories N and M). The presence of chronic carditis was associated with several GERD-related parameters of the esophageal squamous epithelium (P < 0.0001), and data retained statistical significance even when analysis was restricted to individuals with mild chronic carditis and/or endoscopically normal mucosa. Chronic carditis was also associated with the presence of intestinal metaplasia (P < 0.0001). In addition, chronic carditis had a statistically significant association with patients' symptoms of GERD (P = 0.0107). This observation remained valid for mild chronic carditis in all patients (P = 0.0038) and in those with mild chronic carditis and normal endoscopic mucosa (P = 0.0217). In conclusion, chronic carditis appears to be the immediate consequence of GERD, correlating with patients' symptoms and endoscopic diagnosis. These results are valid in individuals with nonerosive reflux disease, which indicates a higher sensitivity of histological diagnosis. Our findings may impact the routine assessment of reflux patients.
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Affiliation(s)
- D Pinto
- Centro Hospitalar de Lisboa Ocidental, EPE, Lisboa, Portugal.,Diagnostic & Research Centre for Molecular BioMedicine, Institute of Pathology, Medical University of Graz, Graz, Austria
| | - W Plieschnegger
- Department of Internal Medicine, Krankenhaus der Barmherzigen Brüder, St. Veit/Glan, Austria
| | - N I Schneider
- Diagnostic & Research Centre for Molecular BioMedicine, Institute of Pathology, Medical University of Graz, Graz, Austria
| | - M Geppert
- Private Practice of Gastroenterology, Bayreuth, Germany
| | - H Bordel
- Private Practice of Gastroenterology, Osnabrück, Germany
| | - G M Höss
- Department of Surgery, Division of General Surgery, Medical University of Graz, Graz, Austria
| | - A Eherer
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - E-M Wolf
- Diagnostic & Research Centre for Molecular BioMedicine, Institute of Pathology, Medical University of Graz, Graz, Austria
| | - M Vieth
- Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany
| | - C Langner
- Diagnostic & Research Centre for Molecular BioMedicine, Institute of Pathology, Medical University of Graz, Graz, Austria
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Yucel O. Interactions between Helicobacter pylori and gastroesophageal reflux disease. Esophagus 2019; 16:52-62. [PMID: 30151653 DOI: 10.1007/s10388-018-0637-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/17/2018] [Indexed: 02/07/2023]
Abstract
Interactions between Helicobacter Pylori (HP) and gastroesophageal reflux disease (GERD) are a complex issue. Several pathophysiological factors influence the development and the course of GERD, HP infection might be only one of these. Many studies emphasize the co-existence of these diseases. HP infection could contribute to GERD through both a protective and an aggressive role. Gastric acid secretion is a key factor in the pathophysiology of reflux esophagitis. Depending on the type of gastritis related to HP, acid secretion may either increase or decrease. Gastritis in corpus leads to hypoacidity, while antrum gastritis leads to hyperacidity. In cases of antral gastritis and duodenal ulcers which have hyperacidity, the expectation is an improvement in pre-existing reflux esophagitis after eradication of HP. In adults, HP infection is often associated with atrophic gastritis in the corpus. Atrophic gastritis may protect against GERD. Pangastritis which leads to gastric atrophy is commonly associated with CagA strains of HP and it causes more severe gastric inflammation. In case of HP-positive corpus gastritis in the stomach, pangastritis, and atrophic gastritis, reflux esophagitis occurs frequently after eradication of HP. Nonetheless, as a predisposing disease of gastric cancer, HP should be treated. In conclusion, as the determinative factors affecting GERD involving in HP, detailed data on the location of gastric inflammation and CagA positivity should be obtained by the studies at future.
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Affiliation(s)
- Oya Yucel
- Pediatric Department, Baskent University, Istanbul Education and Research Hospital, Cemil Topuzlu Cad. Yuvam Apt. N0:32/12 Ciftehavuzlar, Kadıkoy, 34726, Istanbul, Turkey.
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Kim A, Park WY, Shin N, Lee HJ, Kim YK, Lee SJ, Hwang CS, Park DY, Kim GH, Lee BE, Jo HJ. Cardiac mucosa at the gastroesophageal junction: An Eastern perspective. World J Gastroenterol 2015; 21:9126-9133. [PMID: 26290639 PMCID: PMC4533044 DOI: 10.3748/wjg.v21.i30.9126] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/08/2015] [Accepted: 05/27/2015] [Indexed: 02/07/2023] Open
Abstract
AIM: To investigate the nature and origin of cardiac mucosa (CM).
METHODS: Biopsy samples from sixty-one individuals were included in this study. The specimens were taken “at”, “just below”, or “just above” the gastroesophageal junction, including the histologic squamocolumnar junction. Clinical data were obtained by reviewing electronic medical records for each patient. Patients with a history of stomach adenoma or carcinoma and esophageal carcinoma were excluded, and cases that were endoscopically suspicious of Barrett’s esophagus or a polyp were also ruled out. Histologic and endoscopic reviews were performed blinded to the patient’s clinical data. Histologic evaluation was conducted by two pathologists, and endoscopic review was performed by a endoscopist with wide experience in the field. Histologically, the columnar epithelium of squamocolumnar junction, presence and severity of acute and chronic inflammation, atrophy, intestinal metaplasia, and presence of carditis were evaluated. Endoscopically, reflux esophagitis was evaluated by Los Angeles (LA) classification, hiatal hernias were classified by Hill grade, and gastroesophageal flap valves were assessed.
RESULTS: Fifty-nine of the 61 (96.7%) patients were Korean; 65.6% (40/61) of the patients underwent endoscopy according to the schedule of the National Health Insurance Program as a screening inspection. Of these, only 20.0% (8/40) of cases had reflux symptoms. CM was present in 41/61 (67.2%) individuals, and its presence was associated with older age compared to oxyntocardiac mucosa/oxyntic mucosa (60.59 ± 2.02 years vs 51.55 ± 3.35 years; P = 0.018). The presence of CM was associated with endoscopic diagnosis of esophagitis according to the LA classification (P = 0.022). CM was associated with mononuclear cell infiltration and neutrophilic infiltration, which were statistically significant (P = 0.001, and P = 0.004, respectively). The inflammation of CM, “carditis”, showed a statistically significant association with endoscopic diagnosis of reflux esophagitis according to the LA classification (P = 0.008).
CONCLUSION: CM at the gastroesophageal junction is a common histologic finding in biopsy specimens, though not always present, and associated with gastroesophageal reflux disease and carditis severity.
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Piqué N, Ponce M, Garrigues V, Rodrigo L, Calvo F, de Argila CM, Borda F, Naranjo A, Alcedo J, José Soria M, Rey E, Bujanda L, Gisbert JP, Suarez D, Calvet X, Ponce J. Prevalence of severe esophagitis in Spain. Results of the PRESS study (Prevalence and Risk factors for Esophagitis in Spain: A cross-sectional study). United European Gastroenterol J 2015; 4:229-35. [PMID: 27087951 DOI: 10.1177/2050640615595916] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 06/21/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND *N.P. and M.P. contributed equally to this study.The current prevalence of esophagitis in southern Europe is unknown. In addition, the risk factors for reflux esophagitis are not fully understood. OBJECTIVE The objective of this article is to assess the prevalence and risk factors for esophagitis in Spain. METHODS A prospective, observational, cross-sectional, multicenter study (PRESS study) was conducted among 31 gastrointestinal endoscopy units throughout Spain. A total of 1361 patients undergoing upper gastrointestinal endoscopy were enrolled. Sociodemographic, clinical and treatment data were recorded. RESULTS A total of 95% of patients were Caucasian and 52% were male (mean age: 53 ± 17 years). The most frequent symptoms prompting endoscopy were heartburn (40%), regurgitation (26%) and dysphagia (15%). Fifty-four percent of patients undergoing endoscopy were receiving proton pump inhibitor (PPI) treatment. Esophagitis (mainly mild-moderate) was present in 154 (12.4%) patients. The severe form was recorded in only 11 (0.8%) patients. Multivariate analysis results indicated that the likelihood of esophagitis was higher in men (OR = 1.91, 95% CI = 1.31-2.78), in patients with high GERD-Q scores (OR = 1.256, 95% CI = 1.176-1.343), weight increase (OR = 1.014, 95% CI = 1.003-1.025) and high alcohol consumption (OR = 2.49, 95% CI = 1.16-5.36). CONCLUSION Severe esophagitis is a rare finding in the Spanish population. Male gender, high GERD-Q score, weight increase and high alcohol consumption are main risk factors for its appearance.
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Affiliation(s)
- Núria Piqué
- Department of Microbiology and Parasitology, Pharmacy Faculty, Universitat de Barcelona, Spain
| | - Marta Ponce
- Department of Gastroenterology, Hospital Universitario La Fe, Valencia, Spain
| | - Vicente Garrigues
- Department of Gastroenterology, Hospital Universitario La Fe, Valencia, Spain
| | - Luis Rodrigo
- Digestive Tract Department, Hospital Central de Asturias, Oviedo, Spain
| | - Félix Calvo
- Department of Gastroenterology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | - Fernando Borda
- Service of Digestive Tract, Hospital de Navarra, Pamplona, Spain
| | - Antonio Naranjo
- Gastroenterology and Hepatology Department, University Hospital Reina Sofia, Córdoba, Spain
| | - Javier Alcedo
- Gastroenterology and Hepatology, Hospital San Jorge, Huesca, Spain
| | - María José Soria
- Department of Digestive Tract, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Enrique Rey
- Department of Digestive Tract, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - Luis Bujanda
- Department of Gastroenterology Hospital de Donostia, San Sebastian, Spain; Instituto Biodonostia (Universidad del País Vasco UPV/EHU), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Javier P Gisbert
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - David Suarez
- Unitat d'Epidemiologia i Avaluació-Fundació Parc Taulí, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autónoma de Barcelona, Sabadell, Spain
| | - Xavier Calvet
- Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Department of Gastroenterology, Corporació Sanitaria Universitària Parc Taulí, Sabadell (Barcelona), Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Julio Ponce
- Department of Gastroenterology, Hospital Universitario La Fe, Valencia, Spain
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Zayachkivska O, Havryluk O, Hrycevych N, Bula N, Grushka O, Wallace JL. Cytoprotective effects of hydrogen sulfide in novel rat models of non-erosive esophagitis. PLoS One 2014; 9:e110688. [PMID: 25333941 PMCID: PMC4204999 DOI: 10.1371/journal.pone.0110688] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 09/14/2014] [Indexed: 02/06/2023] Open
Abstract
Non-erosive esophagitis is a chronic inflammatory condition of the esophagus and is a form of gastroesophageal reflux disease. There are limited treatment options for non-erosive esophagitis, and it often progresses to Barrett's esophagus and esophageal carcinoma. Hydrogen sulfide has been demonstrated to be a critical mediator of gastric and intestinal mucosal protection and repair. However, roles for H2S in esophageal mucosal defence, inflammation and responses to injury have not been reported. We therefore examined the effects of endogenous and exogenous H2S in rat models of non-erosive esophagitis. Mild- and moderate-severity non-erosive esophagitis was induced in rats through supplementation of drinking water with fructose, plus or minus exposure to water-immersion stress. The effects of inhibitors of H2S synthesis or of an H2S donor on severity of esophagitis was then examined, along with changes in serum levels of a pro- and an anti-inflammatory cytokine (IL-17 and IL-10, respectively). Exposure to water-immersion stress after consumption of the fructose-supplemented water for 28 days resulted in submucosal esophageal edema and neutrophil infiltration and the development of lesions in the muscular lamina and basal cell hyperplasia. Inhibition of H2S synthesis resulted in significant exacerbation of inflammation and injury. Serum levels of IL-17 were significantly elevated, while serum IL-10 levels were reduced. Treatment with an H2S donor significantly reduced the severity of esophageal injury and inflammation and normalized the serum cytokine levels. The rat models used in this study provide novel tools for studying non-erosive esophagitis with a range of severity. H2S contributes significantly to mucosal defence in the esophagus, and H2S donors may have therapeutic value in treating esophageal inflammation and injury.
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Affiliation(s)
- Oksana Zayachkivska
- Physiology Department, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Olena Havryluk
- Department of Pathology, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Nazar Hrycevych
- Physiology Department, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Nazar Bula
- Physiology Department, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Oksana Grushka
- Central Scientific Research Laboratory, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - John L. Wallace
- Department of Physiology & Pharmacology, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
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Esophageal biopsies in the management of GERD: complementary tool for many but not for all-reply. Hum Pathol 2014; 45:2513-4. [PMID: 25267510 DOI: 10.1016/j.humpath.2014.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 06/30/2014] [Indexed: 11/21/2022]
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