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Thavonlun S, Houngngam N, Kingpetch K, Numkarunarunrote N, Santisitthanon P, Buranasupkajorn P, Pongchaiyakul C, Sutcharitchan P, Wattanachanya L. Association of osteoporosis and sarcopenia with fracture risk in transfusion-dependent thalassemia. Sci Rep 2023; 13:16413. [PMID: 37775530 PMCID: PMC10541420 DOI: 10.1038/s41598-023-43633-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/26/2023] [Indexed: 10/01/2023] Open
Abstract
Patients with transfusion-dependent thalassemia (TDT) have an increased risk of osteoporosis and fractures. They also have several potential factors associated with sarcopenia. There has been currently no study on sarcopenia and its association with falls and fractures in TDT. This study aims to determine the prevalence of and factors associated with osteoporosis, fragility fractures, and sarcopenia in adults with TDT. A cross-sectional study was conducted at the hematologic clinic at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Clinical data and laboratory testing were collected. Bone mineral density and morphometric vertebral fracture were assessed. Sarcopenia was defined using the 2014 and 2019 Asian Working Group for Sarcopenia (AWGS) criteria. We included 112 TDT patients aged 35.1 ± 12.5 years. The prevalence of osteoporosis was 38.4%. Fragility fractures were found in 20.5% of patients. Lower BMI (OR 0.29; 95% CI 0.12-0.72, P = 0.007) and hypogonadal state (OR 3.72; 95% CI 1.09-12.74, P = 0.036) were independently associated with osteoporosis. According to the 2014 AWGS criteria, the prevalence of overall sarcopenia and severe sarcopenia was 44.6% and 13.4%, respectively. Severe sarcopenia was strongly associated with fragility fractures (OR 4.59, 95% CI 1.21-17.46, P = 0.025). In conclusion, osteoporosis, fragility fractures, and sarcopenia were prevalent in adults with TDT. Severe sarcopenia was associated with fragility fractures. Early osteoporosis and sarcopenia screening and prevention may reduce fracture risk and its complications in these patients.
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Affiliation(s)
- Suttana Thavonlun
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Natnicha Houngngam
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Kanaungnit Kingpetch
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Numphung Numkarunarunrote
- Division of Diagnostic Radiology, Department of Radiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Prangareeya Santisitthanon
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Patinut Buranasupkajorn
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
- Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Chatlert Pongchaiyakul
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
| | - Pranee Sutcharitchan
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Lalita Wattanachanya
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.
- Excellence Center for Diabetes, Hormone, and Metabolism, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand.
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Charoenngam N, Pongchaiyakul C. Current issues in evaluation and management of osteoporosis in Thailand. Osteoporos Sarcopenia 2023; 9:53-59. [PMID: 37496986 PMCID: PMC10366423 DOI: 10.1016/j.afos.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/27/2023] [Accepted: 05/19/2023] [Indexed: 07/28/2023] Open
Abstract
Osteoporosis is a major public health issue in Thailand, which increased morbidity, mortality, and health-care utilization. The objective of this review is to provide current perspectives on epidemiology, evaluation and management of osteoporosis in Thailand. According to epidemiologic data, the prevalence of osteoporosis and the incidence of hip fracture were comparable to the rest of the world. However, among Thai postmenopausal women, the prevalence of asymptomatic vertebral fracture was disproportionately high. In addition to established risk factors, conditions that may affect the risk of osteoporosis in the Thai population include certain genetic variants, thalassemia, vitamin D deficiency, and low dietary calcium intake, which requires further investigations to draw conclusions. In 2021, the Thai Osteoporosis Foundation released a new Clinical Practice Guideline that provides up-to-date evidence-based recommendations for evaluation and management of osteoporosis. Nonetheless, more research is required to provide local evidence in a variety of areas to guide management of osteoporosis in Thailand. These include epidemiology of distal radial fracture, the optimal intervention threshold of the Thai-specific Fracture Risk Assessment Tool model, screening for asymptomatic vertebral fracture, and the economic evaluation of osteoporosis management options, including fracture liaison service.
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Affiliation(s)
- Nipith Charoenngam
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, USA
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chatlert Pongchaiyakul
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand
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Carnevale A, Pellegrino F, Bravi B, Gamberini MR, Gagliardi I, Reverberi R, Zatelli MC, Giganti M, Ambrosio MR. The role of opportunistic quantitative computed tomography in the evaluation of bone disease and risk of fracture in thalassemia major. Eur J Haematol 2022; 109:648-655. [PMID: 36000276 PMCID: PMC9826074 DOI: 10.1111/ejh.13847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Dual-energy X-ray absorptiometry (DXA) remains the cornerstone for osteoporosis evaluation in Thalassemia major. However, several drawbacks have been observed in this unique setting. We sought to determine the correlation between quantitative CT (QCT) and DXA-derived parameters; secondarily, we aimed to investigate the role of the two techniques in predicting the risk of fracture. METHODS We retrospectively included patients with β-thalassemia major who had undergone both lumbar and femoral DXA examinations, and CT scans including the lumbar spine, performed for disparate diagnostic issues, within 4 months from the DXA. CT data were examined employing a phantom-less QCT method for bone mineral density (BMD) assessment. We also retrieved any spontaneous or fragility fractures occurring from 1 year before up to 5 years after the date of DXA scans. RESULTS The 43 patients were included. QCT measures were significantly higher than those determined by DXA. The gap between QCT and DXA values was strongly associated with patient age. The most powerful predictive variable for risk of fracture was the ACR classification based on volumetric BMD obtained by QCT. CONCLUSIONS DXA provided more negative measures than those determined by QCT. However, QCT seemed to evaluate thalassaemic osteopathy better than DXA, since volumetric BMD was a stronger predictor of fracture.
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Affiliation(s)
- Aldo Carnevale
- Department of Translational Medicine, Section of RadiologyUniversity of FerraraFerraraItaly
| | - Fabio Pellegrino
- Department of Translational Medicine, Section of RadiologyUniversity of FerraraFerraraItaly
| | - Beatrice Bravi
- Department of Translational Medicine, Section of RadiologyUniversity of FerraraFerraraItaly
| | - Maria Rita Gamberini
- Unit of Thalassaemia and Haemoglobinopathies Day Hospital, Regional HUB Centre, Department of MedicineAzienda Ospedaliero‐Universitaria Sant'AnnaFerraraItaly
| | - Irene Gagliardi
- Department of Medical Sciences, Section of Endocrinology and Internal MedicineUniversity of FerraraFerraraItaly
| | - Roberto Reverberi
- Blood Transfusion ServiceAzienda Ospedaliero‐Universitaria Sant'AnnaFerraraItaly
| | - Maria Chiara Zatelli
- Department of Medical Sciences, Section of Endocrinology and Internal MedicineUniversity of FerraraFerraraItaly
| | - Melchiore Giganti
- Department of Translational Medicine, Section of RadiologyUniversity of FerraraFerraraItaly
| | - Maria Rosaria Ambrosio
- Department of Medical Sciences, Section of Endocrinology and Internal MedicineUniversity of FerraraFerraraItaly
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Shash H. Non-Transfusion-Dependent Thalassemia: A Panoramic Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58101496. [PMID: 36295656 PMCID: PMC9608723 DOI: 10.3390/medicina58101496] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/08/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022]
Abstract
Non-transfusion-dependent thalassemia (NTDT) has been considered less severe than its transfusion-dependent variants. The most common forms of NTDT include β-thalassemia intermedia, hemoglobin E/beta thalassemia, and hemoglobin H disease. Patients with NTDT develop several clinical complications, despite their regular transfusion independence. Ineffective erythropoiesis, iron overload, and hypercoagulability are pathophysiological factors that lead to morbidities in these patients. Therefore, an early and accurate diagnosis of NTDT is essential to ascertaining early interventions. Currently, several conventional management options are available, with guidelines suggested by the Thalassemia International Federation, and novel therapies are being developed in light of the advancement of the understanding of this disease. This review aimed to increase clinicians’ awareness of NTDT, from its basic medical definition and genetics to its pathophysiology. Specific complications to NTDT were reviewed, along with the risk factors for its development. The indications of different therapeutic options were outlined, and recent advancements were reviewed.
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Affiliation(s)
- Hwazen Shash
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia;
- Department of Pediatrics, King Fahad Hospital of the University, Al-Khobar 31952, Saudi Arabia
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Carsote M, Vasiliu C, Trandafir AI, Albu SE, Dumitrascu MC, Popa A, Mehedintu C, Petca RC, Petca A, Sandru F. New Entity-Thalassemic Endocrine Disease: Major Beta-Thalassemia and Endocrine Involvement. Diagnostics (Basel) 2022; 12:diagnostics12081921. [PMID: 36010271 PMCID: PMC9406368 DOI: 10.3390/diagnostics12081921] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/30/2022] [Accepted: 08/03/2022] [Indexed: 11/28/2022] Open
Abstract
Beta-thalassemia (BTH), a recessively inherited haemoglobin (Hb) disorder, causes iron overload (IO), extra-medullary haematopoiesis and bone marrow expansion with major clinical impact. The main objective of this review is to address endocrine components (including aspects of reproductive health as fertility potential and pregnancy outcome) in major beta-thalassemia patients, a complex panel known as thalassemic endocrine disease (TED). We included English, full-text articles based on PubMed research (January 2017–June 2022). TED includes hypogonadism (hypoGn), anomalies of GH/IGF1 axes with growth retardation, hypothyroidism (hypoT), hypoparathyroidism (hypoPT), glucose profile anomalies, adrenal insufficiency, reduced bone mineral density (BMD), and deterioration of microarchitecture with increased fracture risk (FR). The prevalence of each ED varies with population, criteria of definition, etc. At least one out of every three to four children below the age of 12 y have one ED. ED correlates with ferritin and poor compliance to therapy, but not all studies agree. Up to 86% of the adult population is affected by an ED. Age is a positive linear predictor for ED. Low IGF1 is found in 95% of the population with GH deficiency (GHD), but also in 93.6% of persons without GHD. HypoT is mostly pituitary-related; it is not clinically manifested in the majority of cases, hence the importance of TSH/FT4 screening. HypoT is found at any age, with the prevalence varying between 8.3% and 30%. Non-compliance to chelation increases the risk of hypoT, yet not all studies confirmed the correlation with chelation history (reversible hypoT under chelation is reported). The pitfalls of TSH interpretation due to hypophyseal IO should be taken into consideration. HypoPT prevalence varies from 6.66% (below the age of 12) to a maximum of 40% (depending on the study). Serum ferritin might act as a stimulator of FGF23. Associated hypocalcaemia transitions from asymptomatic to severe manifestations. HypoPT is mostly found in association with growth retardation and hypoGn. TED-associated adrenal dysfunction is typically mild; an index of suspicion should be considered due to potential life-threatening complications. Periodic check-up by ACTH stimulation test is advised. Adrenal insufficiency/hypocortisolism status is the rarest ED (but some reported a prevalence of up to one third of patients). Significantly, many studies did not routinely perform a dynamic test. Atypical EM sites might be found in adrenals, mimicking an incidentaloma. Between 7.5–10% of children with major BTH have DM; screening starts by the age of 10, and ferritin correlated with glycaemia. Larger studies found DM in up to 34%of cases. Many studies do not take into consideration IGF, IGT, or do not routinely include OGTT. Glucose anomalies are time dependent. Emerging new markers represent promising alternatives, such as insulin secretion-sensitivity index-2. The pitfalls of glucose profile interpretation include the levels of HbA1c and the particular risk of gestational DM. Thalassemia bone disease (TBD) is related to hypoGn-related osteoporosis, renal function anomalies, DM, GHD, malnutrition, chronic hypoxia-induced calcium malabsorption, and transplant-associated protocols. Low BMD was identified in both paediatric and adult population; the prevalence of osteoporosis/TBD in major BTH patients varies; the highest rate is 40–72% depending on age, studied parameters, DXA evaluation and corrections, and screening thoracic–lumbar spine X-ray. Lower TBS and abnormal dynamics of bone turnover markers are reported. The largest cohorts on transfusion-dependent BTH identified the prevalence of hypoGn to be between 44.5% and 82%. Ferritin positively correlates with pubertal delay, and negatively with pituitary volume. Some authors appreciate hypoGn as the most frequent ED below the age of 15. Long-term untreated hypoGn induces a high cardiovascular risk and increased FR. Hormonal replacement therapy is necessary in addition to specific BTH therapy. Infertility underlines TED-related hormonal elements (primary and secondary hypoGn) and IO-induced gonadal toxicity. Males with BTH are at risk of infertility due to germ cell loss. IO induces an excessive amount of free radicals which impair the quality of sperm, iron being a local catalyser of ROS. Adequate chelation might improve fertility issues. Due to the advances in current therapies, the reproductive health of females with major BTH is improving; a low level of statistical significance reflects the pregnancy status in major BTH (limited data on spontaneous pregnancies and growing evidence of the induction of ovulation/assisted reproductive techniques). Pregnancy outcome also depends on TED approach, including factors such as DM control, adequate replacement of hypoT and hypoPT, and vitamin D supplementation for bone health. Asymptomatic TED elements such as subclinical hypothyroidism or IFG/IGT might become overt during pregnancy. Endocrine glands are particularly sensitive to iron deposits, hence TED includes a complicated puzzle of EDs which massively impacts on the overall picture, including the quality of life in major BTH. The BTH prognostic has registered progress in the last decades due to modern therapy, but the medical and social burden remains elevated. Genetic counselling represents a major step in approaching TH individuals, including as part of the pre-conception assessment. A multidisciplinary surveillance team is mandatory.
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Affiliation(s)
- Mara Carsote
- Department of Endocrinology, C. Davila University of Medicine and Pharmacy & C.I. Parhon National Institute of Endocrinology, 011684 Bucharest, Romania
- Correspondence: (M.C.); (M.-C.D.)
| | - Cristina Vasiliu
- Department of Obstetrics and Gynaecology, C. Davila University of Medicine and Pharmacy & University Emergency Hospital, 011684 Bucharest, Romania
| | - Alexandra Ioana Trandafir
- Department of Endocrinology, C.I. Parhon National Institute of Endocrinology, 011684 Bucharest, Romania
| | - Simona Elena Albu
- Department of Obstetrics and Gynaecology, C. Davila University of Medicine and Pharmacy & University Emergency Hospital, 011684 Bucharest, Romania
| | - Mihai-Cristian Dumitrascu
- Department of Obstetrics and Gynaecology, C. Davila University of Medicine and Pharmacy & University Emergency Hospital, 011684 Bucharest, Romania
- Correspondence: (M.C.); (M.-C.D.)
| | - Adelina Popa
- Department of Dermatovenerology, C. Davila University of Medicine and Pharmacy & “Elias” University Emergency Hospital, 011684 Bucharest, Romania
| | - Claudia Mehedintu
- Department of Obstetrics and Gynaecology, C. Davila University of Medicine and Pharmacy & “Filantropia” Clinical Hospital, 011684 Bucharest, Romania
| | - Razvan-Cosmin Petca
- Department of Urology, C. Davila University of Medicine and Pharmacy & “Prof. Dr. Theodor Burghele” Clinical Hospital, 011684 Bucharest, Romania
| | - Aida Petca
- Department of Obstetrics and Gynaecology, C. Davila University of Medicine and Pharmacy & University Emergency Hospital, 011684 Bucharest, Romania
| | - Florica Sandru
- Department of Dermatovenerology, C. Davila University of Medicine and Pharmacy & “Elias” University Emergency Hospital, 011684 Bucharest, Romania
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Yang F, Ruan H, Li S, Hou W, Qiu Y, Deng L, Su S, Chen P, Pang L, Lai K. Analysis of circRNAs and circRNA-associated competing endogenous RNA networks in β-thalassemia. Sci Rep 2022; 12:8071. [PMID: 35577924 PMCID: PMC9110710 DOI: 10.1038/s41598-022-12002-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/04/2022] [Indexed: 11/24/2022] Open
Abstract
The involvement of circRNAs in β-thalassemia and their actions on fetal hemoglobin (HbF) is unclear. Here, the circRNAs in β-thalassemia carriers with high HbF levels were comprehensively analyzed and compared with those of healthy individuals. Differential expression of 2183 circRNAs was observed and their correlations with hematological parameters were investigated. Down-regulated hsa-circRNA-100466 had a strong negative correlation with HbF and HbA2. Bioinformatics was employed to construct a hsa-circRNA-100466‑associated competing endogenous RNA (ceRNA) network to identify hub genes and associated miRNAs. The hsa-circRNA-100466▁miR-19b-3p▁SOX6 pathway was identified using both present and previously published data. The ceRNA network was verified by qRT-PCR analysis of β-thalassemia samples, RNA immunoprecipitation of K562 cell lysates, and dual-luciferase reporter analysis. qRT-PCR confirmed that hsa-circRNA-100466 and SOX6 were significantly down-regulated, while miR-19b-3p was up-regulated. Hsa-circRNA-100466, miR-19b-3p, and SOX6 were co-immunoprecipitated by anti-argonaute antibodies, indicating involvement with HbF induction. A further dual-luciferase reporter assay verified that miR-19b-3p interacted directly with hsa-circRNA-100466 and SOX6. Furthermore, spearman correlation coefficients revealed their significant correlations with HbF. In conclusion, a novel hsa-circRNA-100466▁miR-19b-3p▁SOX6 pathway was identified, providing insight into HbF induction and suggesting targets β-thalassemia treatment.
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Affiliation(s)
- Fang Yang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Heyun Ruan
- Department of Obstetrics and Gynecology, Minzu Hospital of Guangxi, Zhuang Autonomous Region, Affiliated Minzu Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Shuquan Li
- NHC Key Laboratory of Thalassemia Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.,Key Laboratory of Thalassemia Medicine, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.,Guangxi Key Laboratory of Thalassemia Research, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Wei Hou
- NHC Key Laboratory of Thalassemia Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.,Key Laboratory of Thalassemia Medicine, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.,Guangxi Key Laboratory of Thalassemia Research, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Yuling Qiu
- NHC Key Laboratory of Thalassemia Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.,Key Laboratory of Thalassemia Medicine, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.,Guangxi Key Laboratory of Thalassemia Research, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Lingjie Deng
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Sha Su
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ping Chen
- NHC Key Laboratory of Thalassemia Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China. .,Key Laboratory of Thalassemia Medicine, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China. .,Guangxi Key Laboratory of Thalassemia Research, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
| | - Lihong Pang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
| | - Ketong Lai
- NHC Key Laboratory of Thalassemia Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China. .,Key Laboratory of Thalassemia Medicine, Chinese Academy of Medical Sciences, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China. .,Guangxi Key Laboratory of Thalassemia Research, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China.
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