1
|
Wakabayashi T, Iwata H. Association between Relative Bradycardia and Adult-onset Still Disease. JMA J 2024; 7:426-430. [PMID: 39114620 PMCID: PMC11301058 DOI: 10.31662/jmaj.2023-0189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 02/19/2024] [Indexed: 08/10/2024] Open
Affiliation(s)
- Takao Wakabayashi
- Department of General and Emergency Medicine, Japan Community Health-Care Organization Sapporo Hokushin Hospital, Sapporo, Japan
| | - Hiroyoshi Iwata
- Center for Environmental and Health Sciences, Hokkaido University, Sapporo, Japan
| |
Collapse
|
2
|
Nabarro LE, McCann N, Herdman MT, Dugan C, Ladhani S, Patel D, Morris-Jones S, Balasegaram S, Heyderman RS, Brown M, Parry CM, Godbole G. British Infection Association Guidelines for the Diagnosis and Management of Enteric Fever in England. J Infect 2022; 84:469-489. [PMID: 35038438 DOI: 10.1016/j.jinf.2022.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/10/2021] [Accepted: 01/05/2022] [Indexed: 11/25/2022]
Abstract
Enteric fever (EF) is an infection caused by the bacteria called Salmonella Typhi or Paratyphi. Infection is acquired through swallowing contaminated food or water. Most EF in England occurs in people returning from South Asia and other places where EF is common; catching EF in England is rare. The main symptom is fever, but stomach pain, diarrhoea, muscle aches, rash and other symptoms may occur. EF is diagnosed by culturing the bacteria from blood and/or stool in a microbiology laboratory. EF usually responds well to antibiotic treatment. Depending on how unwell the individual is, antibiotics may be administered by mouth or by injection. Over the past several years, there has been an overall increase in resistance to antibiotics used to treat enteric fever, in all endemic areas. Additionally, since 2016, there has been an ongoing outbreak of drug-resistant EF in Pakistan. This infection is called extensively drug-resistant, or XDR, EF and only responds to a limited number of antibiotics. Occasionally individuals develop complications of EF including confusion, bleeding, a hole in the gut or an infection of the bones or elsewhere. Some people may continue to carry the bacteria in their stool for a longtime following treatment for the initial illness. These people may need treatment with a longer course of antibiotics to eradicate infection. Travellers can reduce their risk of acquiring EF by following safe food and water practices and by receiving the vaccine at least a few weeks before travel. These guidelines aim to help doctors do the correct tests and treat patients for enteric fever in England but may also be useful to doctors and public health professionals in other similar countries.
Collapse
Affiliation(s)
- L E Nabarro
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; United Kingdom Health Security Agency, UK; St George's University Hospitals NHS Foundation Trust, London, UK; British Infection Association, UK
| | - N McCann
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - C Dugan
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | - S Ladhani
- United Kingdom Health Security Agency, UK; Paediatric Infectious Diseases Research Group, St George's University, London, UK
| | - D Patel
- National Travel Health Network and Centre (NaTHNaC), UK
| | - S Morris-Jones
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - R S Heyderman
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; Research Department of Infection, Division of Infection and Immunity, University College London, London, UK
| | - M Brown
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - C M Parry
- Liverpool School of Tropical Medicine, Liverpool, UK; Alder Hey Hospital and Liverpool University Hospitals, Liverpool, UK; Centre for Tropical Medicine and Global Health, University of Oxford, UK
| | - G Godbole
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; United Kingdom Health Security Agency, UK; British Infection Association, UK.
| |
Collapse
|
3
|
Chmel M, Bartoš O, Beran O, Pajer P, Dresler J, Čurdová M, Holub M. Salmonella Paratyphi Infection: Use of Nanopore Sequencing as a Vivid Alternative for the Identification of Invading Bacteria. Prague Med Rep 2021; 122:96-105. [PMID: 34137685 DOI: 10.14712/23362936.2021.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
In our study we present an overview of the use of Oxford Nanopore Technologies (ONT) sequencing technology on the background of Enteric fever. Unlike traditional methods (e.g., qPCR, serological tests), the nanopore sequencing technology enables virtually real-time data generation and highly accurate pathogen identification and characterization. Blood cultures were obtained from a 48-year-old female patient suffering from a high fever, headache and diarrhea. Nevertheless, both the initial serological tests and stool culture appeared to be negative. Therefore, the bacterial isolate from blood culture was used for nanopore sequencing (ONT). This technique in combination with subsequent bioinformatic analyses allowed for prompt identification of the disease-causative agent as Salmonella enterica subsp. enterica serovar Paratyphi A. The National Reference Laboratory for Salmonella (NIPH) independently reported this isolate also as serovar Paratyphi A on the basis of results of biochemical and agglutination tests. Therefore, our results are in concordance with certified standards. Furthermore, the data enabled us to assess some basic questions concerning the comparative genomics, i.e., to describe whether the isolated strain differs from the formerly published ones or not. Quite surprisingly, these results indicate that we have detected a novel and so far, unknown variety of this bacteria.
Collapse
Affiliation(s)
- Martin Chmel
- Department of Infectious Diseases, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, Czech Republic. .,Military Health Institute, Military Medical Agency, Prague, Czech Republic.
| | - Oldřich Bartoš
- Institute of Animal Physiology and Genetics, Laboratory of Fish Genetics, The Czech Academy of Sciences, Liběchov, Czech Republic.,Military Health Institute, Military Medical Agency, Prague, Czech Republic
| | - Ondřej Beran
- Department of Infectious Diseases, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, Czech Republic
| | - Petr Pajer
- Military Health Institute, Military Medical Agency, Prague, Czech Republic
| | - Jiří Dresler
- Military Health Institute, Military Medical Agency, Prague, Czech Republic
| | - Martina Čurdová
- Department of Clinical Microbiology, Military University Hospital Prague, Prague, Czech Republic
| | - Michal Holub
- Department of Infectious Diseases, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, Czech Republic
| |
Collapse
|
4
|
Buss I, Genton B, D'Acremont V. Aetiology of fever in returning travellers and migrants: a systematic review and meta-analysis. J Travel Med 2020; 27:5955503. [PMID: 33146395 PMCID: PMC7665639 DOI: 10.1093/jtm/taaa207] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/05/2020] [Accepted: 10/15/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Numerous publications focus on fever in returning travellers, but there is no known systematic review considering all diseases, or all tropical diseases causing fever. Such a review is necessary in order to develop appropriate practice guidelines. OBJECTIVES Primary objectives of this review were (i) to determine the aetiology of fever in travellers/migrants returning from (sub) tropical countries as well as the proportion of patients with specific diagnoses, and (ii) to assess the predictors for specific tropical diseases. METHOD Embase, MEDLINE and Cochrane Library were searched with terms combining fever and travel/migrants. All studies focusing on causes of fever in returning travellers and/or clinical and laboratory predictors of tropical diseases were included. Meta-analyses were performed on frequencies of etiological diagnoses. RESULTS 10 064 studies were identified; 541 underwent full-text review; 30 met criteria for data extraction. Tropical infections accounted for 33% of fever diagnoses, with malaria causing 22%, dengue 5% and enteric fever 2%. Non-tropical infections accounted for 36% of febrile cases, with acute gastroenteritis causing 14% and respiratory tract infections 13%. Positive likelihood ratios demonstrated that splenomegaly, thrombocytopenia and hyperbilirubinemia were respectively 5-14, 3-11 and 5-7 times more likely in malaria than non-malaria patients. High variability of results between studies reflects heterogeneity in study design, regions visited, participants' characteristics, setting, laboratory investigations performed and diseases included. CONCLUSION Malaria accounted for one-fifth of febrile cases, highlighting the importance of rapid malaria testing in febrile returning travellers, followed by other rapid tests for common tropical diseases. High variability between studies highlights the need to harmonize study designs and to promote multi-centre studies investigating predictors of diseases, including of lower incidence, which may help to develop evidence-based guidelines. The use of clinical decision support algorithms by health workers which incorporate clinical predictors, could help standardize studies as well as improve quality of recommendations.
Collapse
Affiliation(s)
- Imogen Buss
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Blaise Genton
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.,Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| | - Valérie D'Acremont
- Centre for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.,Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| |
Collapse
|
5
|
Ishaq U, Malik J, Asif M, Zaib H, Haider I, Zahid T, Abdul Sattar R, Ikram U. Eosinopenia in Patients With Typhoid Fever: A Case-Control Study. Cureus 2020; 12:e10359. [PMID: 33062482 PMCID: PMC7549842 DOI: 10.7759/cureus.10359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background and objectives Salmonella typhi is involved in one of the most prevalent infectious diseases of South East Asia, typhoid fever, but diagnostic tests cannot be performed regularly in developing countries. The objective of the study is to determine the association of eosinopenia with culture or serology-proven typhoid fever in patients, to determine the association of leukopenia with culture or serology-proven typhoid fever in patients and to determine independent predictors of eosinopenia. Methods This case-control study, done at Fauji Foundation Hospital, Pakistan, included patients with symptoms suggestive of typhoid fever, culture, or serology positive for typhoid fever and excluded patients who had been previously diagnosed with malaria and dengue hemorrhagic fever. After flagging cultures and serology, the records were viewed for leukocyte counts. Data, including age, gender, and clinical symptoms, were also recorded for analysis. Results Out of 200 participants, 59 participants with diagnosed typhoid fever had eosinopenia. There were 29 participants who had been diagnosed with typhoid fever via culture or serology and had leukopenia. Eosinopenia and leukopenia were more likely to be present in patients with a diagnosis of typhoid (OR: 9.60, 20.00). The independent predictors for eosinopenia were DOT enzyme immunoassay (DOT EIA) positive for Salmonella typhi, culture positive for Salmonella typhi and leukopenia (p<0.05). Conclusion The presence of eosinopenia and features or serology suggestive of typhoid would most likely be associated with cultures being positive and, therefore, might provide an efficient means to begin treatment.
Collapse
Affiliation(s)
- Uzma Ishaq
- Hematology and Medical Oncology, Fauji Foundation Hospital, Rawalpindi, PAK
| | - Jahanzeb Malik
- Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK
| | - Maliha Asif
- Pathology, Rahber Medical and Dental College, Lahore, PAK
| | - Hina Zaib
- Hematology, Ali Medical Center, Rawalpindi, PAK
| | - Iqbal Haider
- Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK
| | - Tayyaba Zahid
- Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK
| | | | - Umar Ikram
- Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, PAK
| |
Collapse
|
6
|
Islam MT, Im J, Ahmmed F, Kim DR, Khan AI, Zaman K, Ali M, Marks F, Qadri F, Kim JH, Clemens JD. Use of Typhoid Vi-Polysaccharide Vaccine as a Vaccine Probe to Delineate Clinical Criteria for Typhoid Fever. Am J Trop Med Hyg 2020; 103:665-671. [PMID: 32588803 PMCID: PMC7410438 DOI: 10.4269/ajtmh.19-0968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Blood cultures (BCs) detect an estimated 50% of typhoid fever cases. There is need for validated clinical criteria to define cases that are BC negative, both to help direct empiric antibiotic treatment and to better evaluate the magnitude of protection conferred by typhoid vaccines. To derive and validate a clinical rule for defining BC-negative typhoid fever, we assessed, in a cluster-randomized effectiveness trial of Vi-polysaccharide (ViPS) typhoid vaccine in Kolkata, India, 14,797 episodes of fever lasting at least 3 days during 4 years of comprehensive, BC-based surveillance of 70,865 persons. A recursive partitioning algorithm was used to develop a decision rule to predict BC-proven typhoid cases with a diagnostic specificity of 97–98%. To validate this rule as a definition for BC-negative typhoid fever, we assessed whether the rule defined culture-negative syndromes prevented by ViPS vaccine. In a training subset of individuals, we identified the following two rules: rule 1: patients aged < 15 years with prolonged fever accompanied by a measured body temperature ≥ 100°F, headache, and nausea; rule 2: patients aged ≥ 15 years with prolonged fever accompanied by nausea and palpable liver but without constipation. The adjusted protective efficacy of ViPS against clinical typhoid defined by these rules in persons aged ≥ 2 years in a separate validation subset was 33% (95% CI: 4–53%). We have defined and validated a clinical rule for predicting BC-negative typhoid fever using a novel vaccine probe approach. If validated in other settings, this rule may be useful to guide clinical care and to enhance typhoid vaccine evaluations.
Collapse
Affiliation(s)
- Md Taufiqul Islam
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Justin Im
- International Vaccine Institute, Seoul, Republic of Korea
| | - Faisal Ahmmed
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Deok Ryun Kim
- International Vaccine Institute, Seoul, Republic of Korea
| | - Ashraful Islam Khan
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Khalequ Zaman
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | | | - Florian Marks
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom.,International Vaccine Institute, Seoul, Republic of Korea
| | - Firdausi Qadri
- International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Jerome H Kim
- International Vaccine Institute, Seoul, Republic of Korea
| | - John D Clemens
- Korea University College of Medicine, Seoul, South Korea.,UCLA Fielding School of Public Health, Los Angeles, California.,International Centre for Diarrheal Disease Research, Bangladesh, Dhaka, Bangladesh
| |
Collapse
|
7
|
Travel-Related Typhoid Fever: Narrative Review of the Scientific Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17020615. [PMID: 31963643 PMCID: PMC7013505 DOI: 10.3390/ijerph17020615] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 01/11/2020] [Accepted: 01/13/2020] [Indexed: 12/13/2022]
Abstract
Enteric fever is a foodborne infectious disease caused by Salmonella enterica serotypes Typhi and Paratyphi A, B and C. The high incidence in low income countries can increase the risk of disease in travelers coming from high income countries. Pre-travel health advice on hygiene and sanitation practices and vaccines can significantly reduce the risk of acquiring infections. Although the majority of the cases are self-limiting, life-threatening complications can occur. Delayed diagnosis and cases of infections caused by multi-drug resistant strains can complicate the clinical management and affect the prognosis. More international efforts are needed to reduce the burden of disease in low income countries, indirectly reducing the risk of travelers in endemic settings. Surveillance activities can help monitor the epidemiology of cases caused by drug-susceptible and resistant strains.
Collapse
|
8
|
Fish-Low CY, Balami AD, Than LTL, Ling KH, Mohd Taib N, Md Shah A, Sekawi Z. Hypocalcemia, hypochloremia, and eosinopenia as clinical predictors of leptospirosis: A retrospective study. J Infect Public Health 2019; 13:216-220. [PMID: 31455598 DOI: 10.1016/j.jiph.2019.07.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 07/15/2019] [Accepted: 07/27/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Underestimation of leptospirosis cases is happening in many countries. The most common factor of underreporting is misdiagnosis. Considering the limitations of direct detection of pathogen and serological diagnosis for leptospirosis, clinical features and blood tests though non-specific are usually referred in making presumptive diagnosis to decide disease management. METHODS In this single-centre retrospective study, comparative analysis on clinical presentations and laboratory findings was performed between confirmed leptospirosis versus non-leptospirosis cases. RESULTS In multivariate logistic regression evidenced by a Hosmer-Lemeshow significance value of 0.979 and Nagelkerke R square of 0.426, the predictors of a leptospirosis case are hypocalcemia (calcium <2.10mmol/L), hypochloremia (chloride <98mmol/L), and eosinopenia (absolute eosinophil count <0.040×109/L). The proposed diagnostic scoring model has a discriminatory power with area under the curve (AUC) 0.761 (p<0.001). A score value of 6 reflected a sensitivity of 0.762, specificity of 0.655, a positive predictive value of 0.38, negative predictive value of 0.91, a positive likelihood ratios of 2.21, and a negative likelihood ratios of 0.36. CONCLUSION With further validation in clinical settings, implementation of this diagnostic scoring model is helpful to manage presumed leptospirosis especially in the absence of leptospirosis confirmatory tests.
Collapse
Affiliation(s)
- Cheng-Yee Fish-Low
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Ahmed D Balami
- Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Leslie T L Than
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - King-Hwa Ling
- Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Niazlin Mohd Taib
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Anim Md Shah
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia
| | - Zamberi Sekawi
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400 Serdang, Selangor, Malaysia.
| |
Collapse
|
9
|
Freeth P, Phuong LK, Osowicki J. Dissociative state: Returned traveller with a high fever and low heart rate. J Paediatr Child Health 2018; 54:1395-1396. [PMID: 30506781 DOI: 10.1111/jpc.2_14243] [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: 08/11/2018] [Revised: 08/24/2018] [Accepted: 09/07/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Pippin Freeth
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Linny K Phuong
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Joshua Osowicki
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.,Group A Streptococcal Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Department of Paediatric Infection and Immunity, Monash Children's Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
10
|
Karakonstantis S, Kalemaki D, Tzagkarakis E, Lydakis C. Pitfalls in studies of eosinopenia and neutrophil-to-lymphocyte count ratio. Infect Dis (Lond) 2017; 50:163-174. [PMID: 29070003 DOI: 10.1080/23744235.2017.1388537] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
There is a number of publications evaluating the eosinophil count and the neutrophil-to-lymphocyte count ratio for diagnosis, prognosis or monitoring of patients. Of special interest is the use of these parameters for discrimination between the different causes of fever (e.g. bacterial versus viral vs. non-infectious causes of fever) and for monitoring the efficacy of therapy and predict the course of the patient. However, pitfalls in previous study designs prevent applicability to clinical practice. Here, we provide a short review of the relevant literature and summarize important factors that should be taken into account when designing studies, with special attention to the selection of a proper and clinically meaningful study population and the effects of the stress response and of corticosteroids.
Collapse
Affiliation(s)
- Stamatis Karakonstantis
- a Resident of Internal Medicine, Second Department of Internal Medicine , General Hospital of Heraklion 'Venizeleio-Pananeio' , Heraklion , Greece
| | - Dimitra Kalemaki
- b Resident of General Medicine , University Hospital of Heraklion, Voutes , Heraklion , Greece
| | - Emmanouil Tzagkarakis
- c Consultant in Internal Medicine. Second Department of Internal Medicine , General Hospital of Heraklion 'Venizeleio-Pananeio' , Heraklion , Greece
| | - Charalampos Lydakis
- d Head of the Second Department of Internal Medicine , Second Department of Internal Medicine, General Hospital of Heraklion 'Venizeleio-Pananeio' , Heraklion , Greece
| |
Collapse
|