You are here

Vascularites

BONE MINERAL DENSITY AND THE PREVALENCE OF ITS DISORDERS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND SYNTROPIC COMORBID LESIONS

lun, 05/04/2021 - 12:00

Georgian Med News. 2021 Feb;(311):103-108.

ABSTRACT

The state of bone mineral density has not been properly examined yet in patients with systemic lupus erythematosus (SLE) and the pathogenetically associated syntropic comorbid lesions of organs and systems. In a randomized manner, after stratification by the presence of SLE, we enrolled 123 premenopausal women aged 21 to 51 years into the study. Patients with SLE, depending on the diagnosed pathogenetically associated syntropic comorbid lesions of organs and systems, were stratified into twenty groups (with hemorrhagic vasculitis, capillaritis, Raynaud syndrome, atherosclerosis, livedo reticularis, venous thrombosis, myocarditis, secondary hypertension, stable angina, pneumonitis, pneumosclerosis, autoimmune hepatitis, steatohepatitis, chronic pancreatitis, aseptic bone necrosis, arthralgia, myalgia, autoimmune thyroiditis, obesity, and alopecia). The bone mineral density (BMD) was determined for patients in each group through dual-energy X-ray absorptiometry (DXA) scans of the lumbar spine and proximal femur, taking into account the worst T-score result. Having analyzed the data from densitometric examinations of 20 patient groups, we arrived at the following conclusions: a) all patients from seven groups (with hemorrhagic vasculitis, capillaritis, stable angina, autoimmune hepatitis, steatohepatitis, aseptic bone necrosis, autoimmune thyroiditis) had reduced BMD disorders, and the largest proportion of patients with normal BMD were from the group with syntropic venous thrombosis; b) there was only one group of patients (with stable angina) without the cases of the first degree osteopenia, and the largest proportion of such patients was in the group with syntropic venous thrombosis; c) there was only one group of patients (with aseptic bone necrosis) without the cases of the second degree osteopenia, and the largest proportion of such patients was in the group with stable angina; d) there were patients with the third degree osteopenia in all groups, and the largest proportion of the third degree osteopenia cases was in the group with stable angina; e) there were no cases of osteoporosis in groups with syntropic venous thrombosis and stable angina, and the largest proportion of osteoporosis cases was in the groups with syntropic autoimmune hepatitis; the prevalence of osteoporosis is significantly higher than the prevalence of normal BMD and the first degree osteopenia in patients with atherosclerosis and chronic pancreatitis; the prevalence of osteoporosis is also significantly higher that the prevalence of normal BMD and all degrees of osteopenia in patients with autoimmune hepatitis.

PMID:33814401

Autoimmune and Rheumatic Manifestations Associated With COVID-19 in Adults: An Updated Systematic Review

lun, 29/03/2021 - 12:00

Front Immunol. 2021 Mar 12;12:645013. doi: 10.3389/fimmu.2021.645013. eCollection 2021.

ABSTRACT

Background: Numerous cases of the coronavirus disease 2019 (COVID-19) with autoimmune and rheumatic manifestations have been reported. Despite the available reviews that summarized its autoimmune/rheumatic manifestations, a systematic approach is still lacking. Therefore, we conducted a comprehensive systematic review in order to give an overview upon these rare but clinically significant manifestations. Methods: We performed a literature search of PubMed and EMBASE as of October 9, 2020. All articles relevant to either systemic or organ-specific autoimmune and rheumatic manifestations potentially associated with COVID-19 were collected. The reviewed literature were limited to adults ≥18 years. Results: Although most of the existing evidence was based on case reports or case series without a long-term follow-up, a variety of autoimmune/rheumatic manifestations were associated with COVID-19. The manifestations that have a consistent association with COVID-19 include autoimmune cytopenia, cutaneous vasculitis, encephalitis, and Guillain-Barre syndrome. Such association is conflicting as regards to antiphospholipid syndrome, hemophagocytic lymphohistiocytosis, and myasthenia gravis. Conclusion: Our systematic review indicated the potential of the COVID-19 virus to trigger a myriad of autoimmune and rheumatic manifestations, which should be considered amid global efforts to combat COVID-19.

PMID:33777042 | PMC:PMC7994612 | DOI:10.3389/fimmu.2021.645013

Prosthetic valve detachment complicated with intervalvular fibrous body destruction in Behcet's disease: a case report

ven, 26/03/2021 - 11:00

BMC Surg. 2021 Mar 25;21(1):164. doi: 10.1186/s12893-021-01164-9.

ABSTRACT

BACKGROUND: Prosthetic valve detachment is not rare after aortic valve replacement in Behcet's disease. However, destruction of the intervalvular fibrous body (IFB) due to Behcet's disease was rarely reported.

CASE PRESENTATION: We report a case of 30 year-old woman, with valve detachment and IFB separation. The patient received aortic valve replacement three months ago. Her medical history included recurrent oral ulcers and cutaneous lesions. Finally, reoperation was performed and peri-operative steroid therapy was carried out.

CONCLUSIONS: The case presented a rare complication of valve detachment in Behcet's disease.

PMID:33765960 | PMC:PMC7993506 | DOI:10.1186/s12893-021-01164-9

COVID-19 Recovery Without B Cells or Antibodies in Patients Receiving Rituximab for Autoimmune Disease

jeu, 25/03/2021 - 11:00

Iran J Kidney Dis. 2021 Mar;1(2):159-160.

ABSTRACT

No Abstract.

PMID:33764328

18F-Fluorodeoxyglucose positron emission tomography computed tomography detection of single organ vasculitis of the breast: A case report

jeu, 25/03/2021 - 11:00

Medicine (Baltimore). 2021 Mar 26;100(12):e25259. doi: 10.1097/MD.0000000000025259.

ABSTRACT

RATIONALE: Although single organ vasculitis (SOV) is a rare occurrence and it is difficult to diagnose, its possibility as a cause of fever of unknown origin (FUO) must be considered. Recently, the usefulness of 18F-fluorodeoxyglucose positron emission tomography computed tomography (FDG PET/CT) in the diagnosis of unknown fevers due to vasculitis, especially in cases of small and medium-sized vasculitis, has begun to be pointed out.

PATIENT CONCERNS: We report the case of an 84-year-old woman with persisting fever for more than 2 weeks. She had no accompanying symptoms, other than fever, and the physical examination, echocardiography, and contrast-enhanced CT did not reveal any diagnostic clue.

DIAGNOSES: The FDG PET/CT revealed positive uptakes of FDG in the left breast, with a standardized uptake value (SUV) of 2.9. The biopsy specimen of the left breast lesion revealed rupture of the elastic plate and evidence of fibrinoid necrosis of arteries, leading to the diagnosis of polyarteritis (PAN). Further angiographic examination and additional imaging did not reveal the presence of other lesions. Therefore, the diagnosis was established as a PAN-SOV of the left breast.

INTERVENTIONS: This patient has improved with follow-up only.

OUTCOMES: There has been no evidence of a relapse of PAN over a 5-year follow-up period.

LESSONS: SOV presenting with unspecific local symptoms is difficult to diagnose based on the medical history and clinical examination. Our findings show that early "Combination of PET-CT and biopsy" can be a powerful diagnostic tool in patients with FUO for whom diagnosis of the underlying cause is difficult despite appropriate clinical examination.

PMID:33761723 | DOI:10.1097/MD.0000000000025259

COVID-19-induced granulomatosis with polyangiitis

ven, 19/03/2021 - 11:00

BMJ Case Rep. 2021 Mar 18;14(3):e242142. doi: 10.1136/bcr-2021-242142.

ABSTRACT

COVID-19 and granulomatosis with polyangiitis share many clinical and radiological features, making it challenging for clinicians to distinguish between the two. In this case report, we describe a patient who was diagnosed with COVID-19 in October 2020. One month later, she presented with persistent fatigue, shortness of breath and anaemia with worsening renal functions, found to have elevated antineutrophil cytoplasmic antibodies and antiproteinase 3 antibodies, and diagnosed with granulomatosis with polyangiitis.

PMID:33737283 | PMC:PMC7978249 | DOI:10.1136/bcr-2021-242142

Case 7-2021: A 19-Year-Old Man with Shock, Multiple Organ Failure, and Rash

jeu, 11/03/2021 - 12:00

N Engl J Med. 2021 Mar 11;384(10):953-963. doi: 10.1056/NEJMcpc2027093.

NO ABSTRACT

PMID:33704941 | DOI:10.1056/NEJMcpc2027093

Description of symptom course in a telemedicine monitoring clinic for acute symptomatic COVID-19: a retrospective cohort study

sam, 06/03/2021 - 12:00

BMJ Open. 2021 Mar 5;11(3):e044154. doi: 10.1136/bmjopen-2020-044154.

ABSTRACT

OBJECTIVE: Describe the disease course in a cohort of outpatients with COVID-19 and evaluate factors predicting duration of symptoms.

DESIGN: Retrospective cohort study.

SETTING: Telemedicine clinic at a large medical system in Atlanta, Georgia.

PARTICIPANTS: 337 patients with acute COVID-19. Exclusion criteria included intake visit more than 10 days after symptom onset and hospitalisation prior to intake visit.

MAIN OUTCOME MEASURES: Symptom duration in days.

RESULTS: Common symptoms at intake visit are upper respiratory (73% cough, 55% loss of smell or taste, 57% sinus congestion, 32% sore throat) and systemic (66% headache, 64% body aches, 53% chills, 30% dizziness, 36% fever). Day of symptom onset was earliest for systemic and upper respiratory symptoms (median onset day 1 for both), followed by lower respiratory symptoms (day 3, 95% CI 2 to 4), with later onset of gastrointestinal symptoms (day 4, 95% CI 3 to 5), when present. Cough had the longest duration when present with median 17 days (95% CI 15 to 21), with 42% not resolved at final visit. Loss of smell or taste had the second longest duration with 14 days (95% CI 12 to 17), with 38% not resolved at final visit. Initial symptom severity is a significant predictor of symptom duration (p<0.01 for multiple symptoms).

CONCLUSIONS: COVID-19 illness in outpatients follows a pattern of progression from systemic symptoms to lower respiratory symptoms and persistent symptoms are common across categories. Initial symptom severity is a significant predictor of disease duration for most considered symptoms.

PMID:33674374 | PMC:PMC7938467 | DOI:10.1136/bmjopen-2020-044154

Postpartum ovarian vein thrombophlebitis presenting as vaginal bleeding: A case report

ven, 05/03/2021 - 12:00

Medicine (Baltimore). 2021 Feb 26;100(8):e24632. doi: 10.1097/MD.0000000000024632.

ABSTRACT

RATIONALE: Postpartum ovarian vein thrombophlebitis (POVT) is a rare condition, and it can lead to severe complications and mortality. Here we report a patient who presented with vaginal bleeding and the diagnosis of POVT was confirmed by imaging.

PATIENT CONCERNS: A 38-year-old postpartum woman without remarkable medical history presented with vaginal bleeding and lower abdominal pain.

DIAGNOSES: The diagnosis was confirmed by computed tomography scan marked by a thrombus mass involving the right ovarian vein and inferior vena cava.

INTERVENTIONS: The patient was treated with intravenous antibiotics and low-molecular-weight heparin.

OUTCOMES: The patient recovered smoothly without complications.

LESSONS: We should pay high attention to the recognition and management of POVT to prevent morbidity and mortality.

PMID:33663072 | PMC:PMC7909098 | DOI:10.1097/MD.0000000000024632

Begelomab for severe refractory dermatomyositis: A case report

mer, 03/03/2021 - 12:00

Medicine (Baltimore). 2021 Mar 5;100(9):e24372. doi: 10.1097/MD.0000000000024372.

ABSTRACT

RATIONALE: Severe refractory idiopathic inflammatory myopathy (IIM) represents a challenge for the clinician. The lack of efficacy of available tools reflects our incomplete insight into the molecular events sustaining the inflammatory tissue damage in these patients. We present the first case of refractory IIM treated with anti-dipeptidyl peptidase-4 (DPP-4)/cluster of differentiation 26 (CD26) monoclonal antibody.

PATIENT CONCERNS: A 55-year old man presented with proximal muscle weakness, diffuse erythematous skin lesions which rapidly evolved into ulcerations, dysphagia and dysphonia.

DIAGNOSIS: Increased serum creatine kinase levels and histological findings at muscle and skin biopsies were compatible with the diagnosis of dermatomyositis (DM). Several lines of treatment failed to control the disease including steroids, mycophenolate mofetil, tacrolimus, intravenous immunoglobulins and rituximab. Despite therapy, the patient also had recurrent intestinal vasculitis causing bowel perforation. Concurrently, DPP-4/CD26 expression in the patient's skin and skeletal muscle was observed.

INTERVENTIONS: The patient was treated with begelomab, a murine immunoglobulin G2b monoclonal antibody against DPP-4/CD26.

OUTCOMES: Dysphagia, skin lesions and intestinal vasculitis resolved and the patient experienced a significant improvement of his quality of life.

CONCLUSION: Blockade of DPP-4/CD26, which is expressed on T cells and mediates T cell activation and function, is safe and might be effective in patients with refractory DM.

PMID:33655912 | PMC:PMC7939186 | DOI:10.1097/MD.0000000000024372

Paraneoplastic polyarteritis nodosa in a patient with cutaneous T-cell lymphoma

ven, 26/02/2021 - 12:00

Lancet Haematol. 2021 Mar;8(3):e240. doi: 10.1016/S2352-3026(20)30393-8.

NO ABSTRACT

PMID:33636144 | DOI:10.1016/S2352-3026(20)30393-8

Worsening skin lesions but no diagnosis.

lun, 22/02/2021 - 20:37
Related Articles

Worsening skin lesions but no diagnosis.

J Fam Pract. 2020 12;69(10):E11-E13

Authors: Lubsen J

Abstract
A diagnosis was arrived at by doing something that the patient's other doctors hadn't: perform a biopsy.

PMID: 33348351 [PubMed - indexed for MEDLINE]

Endovascular Treatment of Critical Limb Ischemia in Buerger Disease (Thromboangiitis Obliterans) With Midterm Follow-Up: A Viable Option When Bypass Surgery Is Not Feasible.

lun, 22/02/2021 - 20:37
Related Articles

Endovascular Treatment of Critical Limb Ischemia in Buerger Disease (Thromboangiitis Obliterans) With Midterm Follow-Up: A Viable Option When Bypass Surgery Is Not Feasible.

AJR Am J Roentgenol. 2021 02;216(2):421-427

Authors: Uyanık SA, Öğüşlü U, Aminu IS, Yılmaz B, Çevik H, Atlı E, Gümüş B

Abstract
OBJECTIVE. Thromboangiitis obliterans (TAO) is an occlusive inflammatory disease affecting small- and medium-sized vessels that causes decrease in life quality and eventually limb loss. The only proven treatment method is smoking cessation, but it may be insufficient for limb salvage in patients with critical limb ischemia. In this single-center retrospective study, the feasibility and efficiency of endovascular treatment in TAO were evaluated. MATERIALS AND METHODS. After approval of the local institutional review board, 41 patients who underwent endovascular treatment of TAO between January 2014 and June 2019 were evaluated retrospectively. Technical success and procedure-related complications were recorded. Decrease in Rutherford classification score, relief of pain, and wound healing were evaluated to determine clinical success. Primary patency, limb salvage rate, and amputation-free survival were also evaluated. RESULTS. A total of 45 limbs were treated during the study period. Technical success was achieved in 82.2% of procedures. Mean follow-up was 29.8 months. Clinical improvement was achieved in 35 limbs. Three patients underwent major amputation and 12 patients underwent minor amputation. Amputation-free survival and limb salvage were both 93.3% at both 1 and 2 years. Reintervention was performed in 14 patients because of occlusion and clinical relapsing of the symptoms. CONCLUSION. Endovascular treatment of TAO is feasible, has a potential to prevent limb amputation in patients with critical limb ischemia, and has acceptable technical success and limb salvage rates. Because there is no consensus in treatment of TAO, prospective comparative studies are needed to determine the effectiveness of an endovascular approach.

PMID: 33325735 [PubMed - indexed for MEDLINE]

Craniectomy with microvascular flap reconstruction in a patient taking infliximab for vasculitis.

lun, 22/02/2021 - 20:37
Related Articles

Craniectomy with microvascular flap reconstruction in a patient taking infliximab for vasculitis.

BMJ Case Rep. 2020 Dec 09;13(12):

Authors: Nnamani Silva ON, Nguyen AB, Hoffman WY

Abstract
For patients whose vasculitis is managed with biologic medications, no reports or evidence-based guidance exists regarding the perioperative management of microvascular flaps. We present a case of a 78-year-old patient with Takayasu's arteritis (TA) and diabetes mellitus who was taking infliximab and underwent wide local excision of squamous cell carcinoma, craniectomy and reconstruction with a latissimus dorsi flap. TA, an immune-mediated large cell vasculitis characterised by granuloma formation, tends to affect larger vessels and aortic branches. The typical localisation of this condition raises concerns about potentially compromised pedicle and recipient vessels (ie, superficial temporal arteries), which could hinder postoperative flap success. Discontinuation of infliximab 4 weeks before surgery and resumption 6 weeks after led to favourable results. This case addresses the gap in the literature concerning stopping and restarting biologic drugs in the perioperative setting and documents a successful course of a microvascular procedure in a patient with vasculitis.

PMID: 33298502 [PubMed - indexed for MEDLINE]

Common and external iliac artery occlusion in Behçet's disease: a case of anchoring bias.

lun, 22/02/2021 - 20:37
Related Articles

Common and external iliac artery occlusion in Behçet's disease: a case of anchoring bias.

BMJ Case Rep. 2020 Dec 09;13(12):

Authors: Khawaja H, Font C

Abstract
This report describes the case of a 45-year-old woman with a history of Behçet's disease and complex regional pain syndrome of her legs who presented with severe pain and swelling in her left lower extremity. The patient was initially diagnosed with exacerbation of complex regional pain syndrome, which fit the symptom complex of hyperalgesia, oedema and skin temperature changes. However, after unsuccessful attempts at significant pain relief during admission, CT angiography demonstrated occlusion of the left common and external iliac arteries, a limb-threatening emergency. This case describes an example of anchoring bias, a type of cognitive bias in which there is a tendency to rely too heavily on an initial piece of information, the 'anchor', when making decisions. This report emphasises that clinicians should be aware of biases when making decisions and avoid anchoring bias by asking themselves if their diagnosis is influenced by any leading pieces of information.

PMID: 33298479 [PubMed - indexed for MEDLINE]

Recovery of Kidney Function Among Patients With Glomerular Disease Starting Maintenance Dialysis.

lun, 22/02/2021 - 20:37
Related Articles

Recovery of Kidney Function Among Patients With Glomerular Disease Starting Maintenance Dialysis.

Am J Kidney Dis. 2021 02;77(2):303-305

Authors: Kwong YD, Liu KD, Hsu RK, Johansen KL, McCulloch CE, Seth D, Fallahzadeh MK, Grimes BA, Ku E

PMID: 32771649 [PubMed - indexed for MEDLINE]

Optical coherence tomography angiography for the diagnosis of granulomatosis with polyangiitis with serous retinal detachment: A case report

sam, 20/02/2021 - 12:00

Medicine (Baltimore). 2021 Feb 19;100(7):e24789. doi: 10.1097/MD.0000000000024789.

ABSTRACT

RATIONALE: Granulomatosis with polyangiitis (GPA) is a rare systemic autoimmune disease of unknown etiology. GPA affects multiple ocular tissues, most commonly the orbit, conjunctiva, cornea, and sclera. Retinal and choroidal manifestations are rare in GPA, but they often include choroidal neovascularization (CNV).

PATIENT CONCERNS: A 36-year-old man was diagnosed with GPA. He had been taking oral steroid treatment for 8 years. He experienced disease recurrence and the dose of oral prednisolone was increased after steroid pulse therapy. Fundus examination showed small retinal pigment epithelial detachment and serous retinal detachment (SRD). Optical coherence tomography (OCT) revealed a protruded lesion inside the SRD. Fluorescein angiography (FA) showed a small, dot-shaped fluorescein leakage in the SRD, and indocyanine green fluorescein fundus angiography showed choroidal vascular hyperpermeability that was consistent with the hyperfluorescence seen with FA. We had to determine whether the protruded lesion inside the SRD was CNV secondary to the inflammation due to GPA or whether it was central serous chorioretinopathy (CSC)-like condition caused by high-dose steroid treatment.

DIAGNOSES: We confirmed that the SRD was due to CSC but not CNV because the protruded lesion examined by B-scan OCT angiography (OCTA) showed no blood flow.

INTERVENTIONS: We decided to reduce the dose of steroid.

OUTCOMES: Since the reduction of steroids, no sign of worsening in the protruded lesions with SRD has been observed.

LESSONS: We therefore propose the effectiveness of this advanced function of OCTA for the examination of blood flow signal images to detect CNV.

PMID:33607834 | PMC:PMC7899876 | DOI:10.1097/MD.0000000000024789

Granulomatosis with polyangiitis with obstructive pneumonia progressing to hypertrophic pachymeningitis: A case report.

ven, 19/02/2021 - 17:33
Related Articles

Granulomatosis with polyangiitis with obstructive pneumonia progressing to hypertrophic pachymeningitis: A case report.

Medicine (Baltimore). 2021 Jan 22;100(3):e24028

Authors: Hayashi K, Watanabe H, Yamamura Y, Asano Y, Katayama Y, Hiramatsu-Asano S, Ohashi K, Morishita M, Narazaki M, Matsumoto Y, Sada KE, Wada J

Abstract
RATIONALE: Bronchial involvement alone is a rare initial manifestation of granulomatosis with polyangiitis (GPA). Herein, we report a case of refractory GPA with obstructive pneumonia caused by bronchial involvement.
PATIENT CONCERNS: A 65-year-old man complained of a 2-week cough and fever.
DIAGNOSES: Considering the presence of opacities and multiple consolidations in both lungs due to obstruction or stenosis on the bronchus, which did not respond to antibiotics, and proteinase-3-antineutrophil cytoplasmic autoantibody positivity, he was diagnosed with GPA. Positron emission tomography- computed tomography scan revealed no abnormal findings in the upper respiratory tract.
INTERVENTIONS: He was treated with prednisolone (PSL, 50 mg/d) and intravenous cyclophosphamide.
OUTCOMES: His general and respiratory symptoms improved. However, 8 weeks after PSL treatment at 20 mg/d, he developed a relapse of vasculitis along with sinusitis and hypertrophic pachymeningitis. Hence, PSL treatment was resumed to 50 mg/d, and weekly administration of rituximab was initiated. Consequently, the symptoms gradually mitigated.
LESSONS: GPA with bronchial involvement is often intractable and requires careful follow-up, which should include upper respiratory tract and hypertrophic pachymeningitis assessment.

PMID: 33546000 [PubMed - indexed for MEDLINE]

Lemierre's syndrome involving milleri group streptococci: further insight into age and aetiology.

ven, 19/02/2021 - 17:33
Related Articles

Lemierre's syndrome involving milleri group streptococci: further insight into age and aetiology.

BMJ Case Rep. 2020 Nov 23;13(11):

Authors: Linares CA, Ryan F, Hajat I, Glass S

Abstract
Lemierre's syndrome (LS) is a suppurative thrombophlebitis of the internal jugular vein secondary to otorhinolaryngologic infection. It is classically associated with the Gram-negative anaerobe Fusobacterium necrophorum (FN) and is thought to be a disease of young people. Here, we describe the case of a 56-year-old woman with LS involving milleri group streptococci (MGS), which has been reported only 13 times since it was first observed in 2003. Subgroup analysis of all published cases of LS involving MGS demonstrated these patients were significantly older than those involving FN (median age 49 years versus 18 years, p = 0.007, IQR 36-58 years), although this finding is limited by publication bias. This report clarifies a 2014 hypothesis regarding the relationship between age and aetiology in this rare disease. While FN remains the most common cause of LS overall, empiric antibiotic therapy should also cover oral streptococci such as MGS, even in younger adults.

PMID: 33229487 [PubMed - indexed for MEDLINE]

Coronavirus Disease 2019 Acute Myocarditis and Multisystem Inflammatory Syndrome in Adult Intensive and Cardiac Care Units.

ven, 19/02/2021 - 17:33
Related Articles

Coronavirus Disease 2019 Acute Myocarditis and Multisystem Inflammatory Syndrome in Adult Intensive and Cardiac Care Units.

Chest. 2021 02;159(2):657-662

Authors: Hékimian G, Kerneis M, Zeitouni M, Cohen-Aubart F, Chommeloux J, Bréchot N, Mathian A, Lebreton G, Schmidt M, Hié M, Silvain J, Pineton de Chambrun M, Haroche J, Burrel S, Marot S, Luyt CE, Leprince P, Amoura Z, Montalescot G, Redheuil A, Combes A

PMID: 32910974 [PubMed - indexed for MEDLINE]

Pages