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Hwang JY, Yoon HK, Kim KM. Characteristics of Pediatric Pancreatitis on Magnetic Resonance Cholangiopancreatography. Pediatr Gastroenterol Hepatol Nutr 2015; 18:73-84. [PMID: 26157692 PMCID: PMC4493250 DOI: 10.5223/pghn.2015.18.2.73] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 06/02/2015] [Indexed: 02/07/2023] Open
Abstract
Pediatric pancreatitis is not uncommon and results in considerable morbidity and mortality in the affected children. Unlike adults, pediatric pancreatitis is more frequently associated with underlying structural abnormalities, trauma, and drugs rather than an idiopathic etiology. Magnetic resonance cholangiopancreatography (MRCP) is a good imaging modality for evaluating pancreatitis and determining etiology without exposure to radiation. This article focuses on MRCP findings associated with various causes of pancreatitis in children, particularly structural abnormalities of the pancreaticobiliary system, as well as describing the feasibility, limitations, and solutions associated with pediatric MRCP.
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Affiliation(s)
- Jae-Yeon Hwang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Radiology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hye-Kyung Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Radiology, Kangwon National University Hospital, Chuncheon, Korea
| | - Kyung Mo Kim
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
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Terui K, Yoshida H, Kouchi K, Hishiki T, Saito T, Mitsunaga T, Takenouchi A, Tsuyuguchi T, Yamaguchi T, Ohnuma N. Endoscopic sphincterotomy is a useful preoperative management for refractory pancreatitis associated with pancreaticobiliary maljunction. J Pediatr Surg 2008; 43:495-9. [PMID: 18358288 DOI: 10.1016/j.jpedsurg.2007.10.071] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Pancreatitis associated with pancreaticobiliary maljunction (PBM) is commonly treated nonoperatively before surgery. It is, however, sometimes uncontrollable, and little has been reported about the management. METHODS Focusing on the preoperative management, we reviewed clinical courses of 4 PBM cases (ages 1 to 7 years old). Each had pancreatitis that was totally resistant to medical treatment and was applied endoscopic sphincterotomy (ES). RESULTS The first case underwent percutaneous transhepatic catheter drainage (PTCD) primarily. In spite of daily lavage using the drainage tube for a week, plugs located in the common channel were not removed, and clinical findings were not improved. Therefore, ES followed by removal of protein plugs was performed to improve pancreatitis dramatically. Through this experience, 3 subsequent cases with refractory pancreatitis all underwent successful ES primarily soon after the medical treatments turned out to be ineffective. In all 4 cases, protein plugs were impacted in common channels, and ES could successfully remove the plugs that were impossible to remove by using PTCD. Improved preoperative pancreaticobiliary decompression by ES shortens the duration of recalcitrant acute pancreatitis associated with PBM allowing for a subsequent safe operation. CONCLUSIONS Endoscopic sphincterotomy is one of the useful preoperative managements for refractory pancreatitis associated with PBM.
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Affiliation(s)
- Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan.
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Kim SR, Ikawa H, Ando K, Mita K, Fuki S, Imoto S, Shimizu K, Kanbara Y, Sugimoto K, Fujii M, Kudo M, Matsuoka T, Hayashi Y. Small hepatocellular carcinoma presenting with massive metastasis in the peritoneum, mimicking sarcomatous tumor. Hepatol Res 2007; 37:885-9. [PMID: 17573942 DOI: 10.1111/j.1872-034x.2007.00134.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The case of a 51-year-old man with hepatitis C virus (HCV)-related hepatocellular carcinoma metastasizing to the peritoneal cavity and mimicking a sarcomatous tumor is presented. A 12 x 12 cm mass, disclosed by computed tomography (CT), in the peritoneal cavity was predominantly isodense to muscle but had hypodense areas that suggested necrosis. T1-weighted magnetic resonance imaging (MRI) showed a large mass, slightly hyperintense to muscle, with local hyperintense areas of suspected hemorrhagic necrosis.T2-weighted MRI of the same region revealed a markedly non-homogeneous and hyperintense mass with inner high signals and peripheral brush-like linear striations. From such imaging studies, sarcomatous tumors, such as fibrosarcoma, leiomyosarcoma, and gastrointestinal stromal tumors, can be distinguished. Pathological findings at autopsy revealed necrotic tissue with a small portion of moderately differentiated HCC. Further studies may provide insights into the metastatic modes of HCC.
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Affiliation(s)
- Soo Ryang Kim
- Department of Gastroenterology, Kobe Asahi Hospital, Kobe, Japan
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Han SJ, Han A, Kim MJ, Kim H. The role of sphincteroplasty in adverse effect of anomalous pancreaticobiliary duct union in an animal model. Pediatr Surg Int 2007; 23:225-31. [PMID: 17021737 DOI: 10.1007/s00383-006-1787-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/13/2006] [Indexed: 02/07/2023]
Abstract
Anomalous union between the pancreatic and biliary systems (APBDU) has been reported to produce choledochal cyst. The aim of this experiment was to evaluate the role of sphincteroplasty to adverse effect of APBDU in an animal model. Twelve mongrel puppies were randomly divided into a control group (n = 5) and an experimental group (n = 7). A well-established model of APBDU was produced in both groups. Transduodenal sphincteroplasty was performed only on the experimental group. For all animals, serial chemical analyses of serum were performed, and biliary tree sizes were measured by magnetic resonance cholangiography 2.5 months after the experimental surgery. At the time of animal sacrifice, 3 months after the experimental surgery, operative cholangiography was performed, and bile juice and tissues were obtained for chemical analysis and histologic examination. Dilatation of the bile duct and thickening of the wall of the bile duct were observed less frequently in the experimental group than in the control group. There were no significant differences found in pancreatic enzyme activity in the bile juice between the two groups. Denudation of the mucosa was the predominant mucosal change seen in the experimental group, while epithelial hyperplasia was the predominant mucosal change found in the control group. Our experiment shows that sphincteroplasty is not effective to prevent the pancreaticobiliary reflux, but may be effective to reduce the degree of both bile duct dilatation and mural thickening in the APBDU puppy model.
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Affiliation(s)
- Seok Joo Han
- Department of Surgery, Yonsei University College of Medicine, Yongdong Severance Hospital, Dogok-dong 146-92, Kangnam-gu, Seoul, 135-720, South Korea.
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Abstract
BACKGROUND Anomalous pancreaticobiliary duct junction is associated with bile duct strictures, pancreatitis, choledochal cysts, and biliary carcinoma. Limited data are available for outcomes of endoscopic therapy. METHODS Review of 7537 patients undergoing endoscopic retrograde cholangiopancreatography from 1988 to 1997 yielded 18 patients with anomalous pancreaticobiliary duct junction. Therapeutic responses were tallied by chart review and phone calls. RESULTS There were 13 women and 5 men, with a mean age of 36 years. Twelve patients had no ductographic evidence of pancreatitis and 6 had chronic pancreatitis. Seven had choledochal cysts. Fifteen patients (83%) underwent endoscopic biliary sphincterotomy, two of whom underwent repeat endoscopic biliary sphincterotomy for recurrence of symptoms. The other therapies included stent placement for benign biliary strictures in 5 patients, lithotripsy of pancreatic stones in 1 patient, and choledochal cyst removal in 4 patients. Three cases with malignant biliary strictures are excluded from endoscopic outcome studies. The 12 patients with pancreatitis had a mean of 2.0 episodes per year before any treatment. After endoscopic therapy 7 patients had no further episodes of pancreatitis, whereas 5 patients had further episodes, with a mean of one additional attack per year, over 3 years mean follow-up. CONCLUSIONS Patients with anomalous pancreaticobiliary duct junction have complex pathology associated with strictures, choledochal cysts, pancreatitis, and malignancies. Endoscopic therapy appeared to benefit 13 of 15 patients without malignant disease with elimination of or decreased frequency of pancreatitis. Endoscopic therapy appears to be a logical first step in the management of most symptomatic patients with anomalous pancreaticobiliary duct junction.
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Affiliation(s)
- R Samavedy
- Division of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis 46202-5000, Indiana, USA
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Guelrud M, Morera C, Rodriguez M, Prados JG, Jaén D. Normal and anomalous pancreaticobiliary union in children and adolescents. Gastrointest Endosc 1999; 50:189-93. [PMID: 10425411 DOI: 10.1016/s0016-5107(99)70223-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The normal length of the pancreaticobiliary union (common channel) in the pediatric population is not known, nor is the frequency of anomalous pancreaticobiliary union and the extent to which it is associated with pancreaticobiliary disease. METHODS ERCP was performed on 136 patients younger than 1 year (group 1) and 128 older than 1 year (group 2). RESULTS In group 1 the average length of the common channel was 1.8 +/- 0.61 mm with a maximal length of 3 mm (mean plus 2 standard deviations). In group 2 the average length and maximal length of the common channel increased with age. In the 1 to 3 year age range the average length was 2.2 +/- 0.47 mm with a maximal length of 2.7 mm, in the 4 to 6 year range it was 2.8 +/- 0.40 mm (3.6 mm maximal), in the 7 to 9 year range it was 3.2 +/- 0.43 mm (4.1 mm maximal), in the 10 to 12 year range it was 3.9 +/- 0.5 mm (4.4 mm maximal), and in the 13 to 15 year range it was 4.0 +/- 0.51 mm (5 mm maximal). The prevalence of the anomalous pancreaticobiliary union was 25% (66/264). In group 1 the anomaly was present in 4.4% (6 of 136) of patients, 1.3% (1/76) with neonatal hepatitis, 4.6% (3/44) with biliary atresia, and 100% (2/2) with choledochal cyst. In group 2 the anomaly was present in 46.9% (60/128) of patients, 100% (57/57) with choledochal cyst and 15.7% (3/19) with idiopathic recurrent pancreatitis without bile duct dilatation. CONCLUSIONS The mean length of the common channel increases with age. The maximum normal length of the common channel in neonates and infants younger than 1 year is 3 mm. It increases with age to a maximum of 5 mm in children and adolescents between 13 and 15 years of age. Anomalous pancreaticobiliary union is relatively common among children and adolescents undergoing ERCP in our center, including those with idiopathic recurrent pancreatitis (15.7%). ERCP is valuable in the diagnosis of this anomaly.
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Affiliation(s)
- M Guelrud
- Gastroenterology Department and Pediatric Gastroenterology Unit, Hospital General del Oeste, Caracas, Venezuela
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Guelrud M, Morera C, Rodriguez M, Jaen D, Pierre R. Sphincter of Oddi dysfunction in children with recurrent pancreatitis and anomalous pancreaticobiliary union: an etiologic concept. Gastrointest Endosc 1999; 50:194-9. [PMID: 10425412 DOI: 10.1016/s0016-5107(99)70224-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The exact cause of recurrent pancreatitis among patients with anomalous pancreaticobiliary union is not known. Sphincter of Oddi dysfunction has been implicated as a mechanism. This study evaluated sphincter of Oddi function in children with anomalous pancreaticobiliary union and recurrent pancreatitis and assessed the results of endoscopic sphincterotomy in the management of this condition. METHODS We retrospectively reviewed 128 endoscopic retrograde cholangiopancreatographic (ERCP) studies performed on children older than 1 year and adolescents with pancreaticobiliary disease. In 64 instances, ERCP was performed because of recurrent pancreatitis. Nine patients underwent sphincter of Oddi manometry followed by endoscopic sphincterotomy, and these patients were included in this study. A basal pressure greater than 35 mm Hg was considered diagnostic for sphincter of Oddi dysfunction. Follow-up data were obtained retrospectively from the patients' relatives and referring physicians. RESULTS An anomalous pancreaticobiliary union was found in 18 of 64 (28%) patients with recurrent pancreatitis. The 9 patients who underwent sphincter manometry and endoscopic sphincterotomy were 5 girls and 4 boys 2.9 to 17 years of age (mean 7.8 years). A choledochal cyst was found in 7 of these 9 patients. Two patients had anomalous pancreaticobiliary union without common bile duct dilatation. All 9 patients had sphincter of Oddi dysfunction (mean basal pressure 96 +/- 37.8 mm Hg, range 48 to 156 mm Hg). The length of the common channel was 22.8 +/- 5.5 mm, and the length of the sphincter of Oddi segment was 12.1 +/- 1.9 mm (p < 0.001). In all patients the sphincter of Oddi segment was located within the duodenal wall. The mean follow-up period after endoscopic sphincterotomy was 26.4 months (range 18 to 38 months). Eight patients had excellent results defined as absence of symptoms and no subsequent episodes of acute pancreatitis. Treatment of 1 patient was considered moderately successful because the patient still had occasional pain without pancreatic enzyme elevation but no subsequent episodes of acute pancreatitis. One patient had mild postprocedural pancreatitis. CONCLUSIONS Recurrent pancreatitis and anomalous pancreaticobiliary union are associated with sphincter of Oddi dysfunction in children and adolescents. Endoscopic sphincterotomy is beneficial to these patients.
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Affiliation(s)
- M Guelrud
- Gastroenterology Department adn Pediatric Gastroenterology Unit, Hospital del Oeste, Caracas, Venezuela
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Wang HP, Wu MS, Lin CC, Chang LY, Kao AW, Wang HH, Lin JT. Pancreaticobiliary diseases associated with anomalous pancreaticobiliary ductal union. Gastrointest Endosc 1998; 48:184-9. [PMID: 9717785 DOI: 10.1016/s0016-5107(98)70161-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anomalous pancreaticobiliary ductal union (APBDU) is associated with different pancreaticobiliary diseases. The aim of this study is to clarify the frequency with which it occurs and its several subtypes in various pancreaticobiliary diseases. METHODS Radiograms of 1752 subjects who underwent endoscopic retrograde cholangiopancreatography were reviewed independently by two endoscopists. APBDU was diagnosed using recently accepted criteria and divided into B-P and P-B subtypes according to the insertion of biliary and pancreatic ducts. RESULTS Fifty-nine (8.7%) of 680 subjects with clearly visualized pancreaticobiliary radiograms had APBDU. APBDU was present in 93.8% of patients (15 of 16) with choledochal cyst, 62.5% (5 of 8) with gallbladder cancer, 33.3% (9 of 27) with common bile duct cancer, 50.0% (6 of 12) with gallbladder adenomyomatosis, 13.2% (7 of 53) with biliary pancreatitis, 3.4% (10 of 293) with cholelithiasis, 2.2% (2 of 89) with non-biliary pancreatitis, 2.1% (1 of 47) with hilar cholangiocarcinoma, 1.9% (1 of 54) with pancreatic cancer, and 10.2% (9 of 88) with other miscellaneous disorders. There were 25 patients (42.4%) with the B-P type and 34 patients (57.6%) with the P-B type of APBDU. Patients with choledochal cyst frequently had the B-P type, whereas gallbladder cancer, adenomyomatosis, or biliary pancreatitis frequently coexisted with the P-B type. CONCLUSION APBDU is relatively common in patients undergoing endoscopic retrograde cholangiopancreatography at our center. There are a variety of pancreaticobiliary diseases that are associated with APBDU. Its role in these conditions is uncertain and needs to be further delineated.
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Affiliation(s)
- H P Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei
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Abstract
Magnetic resonance cholangiopancreatography (MRCP) has replaced direct cholangiography and pancreatography in many instances. Its complete noninvasiveness and flexibility are less onerous for patients. For the use of screening as well as scrutiny, MRCP has played an important role in diagnosing various pathologies in this field. The usefulness of MRCP is not limited to anatomical evaluations; it can also yield physiologic and functional information. From a cost-performance basis, MRCP is undoubtedly superior to direct methods. Coupled with a cutting-edge MR system, MRCP has the potential to limit the use of invasive transpapillary and percutaneous methods merely to interventional purposes. In the near future, the emergence of interventional MR scanners will make MRCP even more competitive, and the replacement will be accelerated.
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Affiliation(s)
- Y Takehara
- Department of Radiology, Hamamatsu University School of Medicine, Handa, Japan.
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Tuncel M, Erbil M, Bayramoglu A, Abbasoglu O. A case of intraperitoneal pancreas. Surg Radiol Anat 1995; 17:343-6. [PMID: 8896156 DOI: 10.1007/bf01795195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A case of anomalous location of the pancreas is presented. In this case, head and a part of the body of the pancreas were found intraperitoneal. The pancreas was covered by the peritoneum within the omental bursa except its tail. Additionally, the anterior layer of the hepatogastric ligament turned over the hepatoduodenal ligament and continued behind the head of the pancreas together with the peritoneum which formed the posterior wall of the epiploic foramen (Winslow). The peritoneum also covered a part of the posterior surface of the body and directed to the right, forming a recessus just behind the pancreas.
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Affiliation(s)
- M Tuncel
- Department of Anatomy, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Guelrud M, Mujica C, Jaen D, Plaz J, Arias J. The role of ERCP in the diagnosis and treatment of idiopathic recurrent pancreatitis in children and adolescents. Gastrointest Endosc 1994; 40:428-36. [PMID: 7926532 DOI: 10.1016/s0016-5107(94)70205-5] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
ERCP was performed in 51 patients, aged 1 to 18 years, as part of diagnostic evaluation for recurrent pancreatitis without obvious cause or as therapeutic intervention. ERCP was successful in 50 patients (98%). Thirty-four patients (68%) had anatomic findings indicating a possible cause of recurrent pancreatitis. Three patients (6%) had findings suggestive of sphincter of Oddi dysfunction. Eighteen of the 37 patients (49%) with ductal abnormalities underwent endoscopic therapy, with a favorable outcome in 15 (83%). Eleven patients were treated surgically, and 8 of these patients (73%) improved symptomatically. Eight patients received no treatment, and 6 of them (67%) had recurrent bouts of clinical pancreatitis. One mild case of pancreatitis (1.9%) occurred after ERCP, and 3 mild cases followed endoscopic therapy. In conclusion, ERCP is a relatively safe technique that produces opacification of the desired ductal system with a high degree of accuracy and provides useful information in the evaluation of children with idiopathic recurrent pancreatitis. These data suggest that endoscopic pancreatic therapy may result in symptomatic improvement, eliminating the need for surgery in selected children. Furthermore, the study demonstrates that manipulation of the pancreatic duct is comparatively safe and less hazardous than formerly believed.
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Affiliation(s)
- M Guelrud
- Department of Medicine, Hospital General del Oeste, Caracas, Venezuela
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Abstract
We report three cases of intraperitoneal seeding from hepatoma. Manifestation of intraperitoneal seeding from hepatoma were intraperitoneal masses (N = 2) and peritoneal thickening (N = 1). Main vascular feeder to intraperitoneal masses was omental branches of the gastroduodenal artery and/or the superior mesenteric artery.
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Affiliation(s)
- P N Kim
- Department of Radiology, Soonchunhyang University Hospital, Choongnam, Korea
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Cangiarella J, Thomas PA, Genieser NB, Greco MA. Pancreatitis due to anomalous junction of the pancreaticobiliary ductal system. PEDIATRIC PATHOLOGY 1993; 13:853-61. [PMID: 8108302 DOI: 10.3109/15513819309048272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- J Cangiarella
- Department of Pathology, New York University, New York 10016
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