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Maringhini A, Rossi M, Patti R, Maringhini M, Vassallo V. Acute Pancreatitis during and after Pregnancy: A Review. J Clin Med 2024; 13:2028. [PMID: 38610793 PMCID: PMC11012882 DOI: 10.3390/jcm13072028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/22/2024] [Accepted: 03/24/2024] [Indexed: 04/14/2024] Open
Abstract
During pregnancy and in the post-partum period, several diseases may arise or become exacerbated. Acute pancreatitis is an inflammatory disease with an increasing incidence in Western countries. The incidence of acute pancreatitis during pregnancy is not different with respect to the general population, but this incidence increases in the first 2 years after delivery. Biliary sludge and stones are the most frequent aetiologies, followed by hypertriglyceridemia. Taking care of the mother and foetus through a potentially severe disease requires a team consisting of an obstetrician, a gastroenterologist, an anaesthesiologist, and a surgeon. It is necessary to monitor the health of the foetus/child and the mother during pregnancy, childbirth, and puerperium. The management of this care depends on the systemic and local complications, the severity of the acute pancreatitis, and the trimester of pregnancy. Some diagnostic tools and many drugs are not safe for foetuses, while interventional endoscopy and surgery have limitations and can only be used after an accurate evaluation of benefit/risk ratios. Despite these limitations, maternal mortality due to acute pancreatitis is low during pregnancy, mainly thanks to multidisciplinary approaches for these patients. A careful diet to prevent obesity, alcohol abstinence, routine serum triglyceride control, and breastfeeding for at least three months may prevent acute pancreatitis during and after pregnancy.
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Affiliation(s)
- Alberto Maringhini
- Internal Medicine, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Civico, 90127 Palermo, Italy; (M.R.); (M.M.); (V.V.)
| | - Margherita Rossi
- Internal Medicine, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Civico, 90127 Palermo, Italy; (M.R.); (M.M.); (V.V.)
| | - Rosalia Patti
- Pancreas Unit, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Civico, 90127 Palermo, Italy;
| | - Marco Maringhini
- Internal Medicine, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Civico, 90127 Palermo, Italy; (M.R.); (M.M.); (V.V.)
| | - Valerio Vassallo
- Internal Medicine, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Civico, 90127 Palermo, Italy; (M.R.); (M.M.); (V.V.)
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Cao W, Ni X, Gan M, Xie B, Xie Y, Wang Q, Meng L, He C, Chen J, Wang X. Treatment and diagnosis of hyperlipidemia acute pancreatitis in pregnancy associated with pre‑pregnancy obesity and diabetes: A case report. Exp Ther Med 2023; 26:573. [PMID: 38023361 PMCID: PMC10652241 DOI: 10.3892/etm.2023.12272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 08/30/2023] [Indexed: 12/01/2023] Open
Abstract
Hyperlipidemia acute pancreatitis (HLAP) is a specific type of pancreatitis mainly caused by elevated serum triglyceride (TG) levels. Therefore, knowledge of patients' medical history is crucial to the identification of those at high risk of HLAP. Diabetes and obesity are associated with high levels of triglycerides, a risk factor for the development of HLAP, which should be controlled before pregnancy. Moreover, HLAP is associated with additional diagnostic and management challenges related to hyperlipidemia (HL) and pregnancy. HLAP during pregnancy has a rapid onset and rapid progression, and complications are more likely to damage the function of multiple organs. HLAP is more common after 28 weeks of pregnancy, the cause is mostly high TG and the serum TG of the patient is often >1,000 mg/d1. Clinicians should be alert to the occurrence of server acute pancreatitis (AP). Therefore, clinicians need to identify and implement effective treatment in a timely manner to control the progression of HLAP during pregnancy and improve pregnancy outcomes. The present study reported the case of a 26-year-old pregnant patient who was hospitalized for epigastric pain at 35 weeks and 2 days of gestation. Medical and family history reported previous diagnoses of diabetes and obesity (weight before pregnancy, 103 kg; BMI, 36.40 kg/m2). Laboratory tests demonstrated high levels of lipase and amylase, a notable systemic inflammatory response, HL, coagulopathy, hypoproteinemia and hyperglycemia. Abdominal ultrasonography demonstrated a hypoechoic pancreatic head. A clinical diagnosis of AP was confirmed using CT scanning. Initial interventions for HLAP included aggressive intravenous hydration, bowel rest, pain control and a combination of heparin and insulin. Lipid-lowering agents were administered to reduce serum lipid levels. Hemoperfusion and continuous renal replacement therapy were also used to rapidly counteract the elevated lipid levels. Antibiotics were administered in the present case because inflammatory markers such as leukocytes, neutrophils and C-reactive protein were elevated. The patient and newborn were discharged 11 days after hospitalization, with an improvement in maternal clinical health and the infant was healthy. When evaluating pregnant patients with pre-obesity and diabetes presenting with abdominal pain, obstetricians should consider HLAP. Timely diagnosis and multi-team precision treatment are effective for good outcomes for mother and baby.
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Affiliation(s)
- Weiping Cao
- Department of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Xia Ni
- Department of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Mengwen Gan
- Department of Nursing, School of Medicine, Jiangsu University, Zhenjiang, Jiangsu 212013, P.R. China
| | - Bing Xie
- Department of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Yurong Xie
- Department of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Qin Wang
- Department of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Lishi Meng
- Department of Computed Tomography, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Chao He
- Central Laboratory of Medicine, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
| | - Juan Chen
- Department of Obstetrics, Maternity and Child Health Hospital of Zhenjiang, Zhenjiang, Jiangsu 212001, P.R. China
- Department of Obstetrics, Shanghai Changning District Maternal and Children Health Hospital, Shanghai 200050, P.R. China
| | - Xinzhi Wang
- New Drug Screening Center, Jiangsu Center for Pharmacodynamics Research and Evaluation, China Pharmaceutical University, Nanjing, Jiangsu 210009, P.R. China
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Qiu M, Zhou X, Zippi M, Goyal H, Basharat Z, Jagielski M, Hong W. Comprehensive review on the pathogenesis of hypertriglyceridaemia-associated acute pancreatitis. Ann Med 2023; 55:2265939. [PMID: 37813108 PMCID: PMC10563627 DOI: 10.1080/07853890.2023.2265939] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 09/26/2023] [Indexed: 10/11/2023] Open
Abstract
It is well known, that the inflammatory process that characterizes acute pancreatitis (AP) can lead to both pancreatic damage and systemic inflammatory response syndrome (SIRS). During the last 20 years, there has been a growing incidence of episodes of acute pancreatitis associated with hypertriglyceridaemia (HTAP). This review provides an overview of triglyceride metabolism and the potential mechanisms that may contribute to developing or exacerbating HTAP. The article comprehensively discusses the various pathological roles of free fatty acid, inflammatory response mechanisms, the involvement of microcirculation, serum calcium overload, oxidative stress and the endoplasmic reticulum, genetic polymorphism, and gut microbiota, which are known to trigger or escalate this condition. Future perspectives on HTAP appear promising, with ongoing research focused on developing more specific and effective treatment strategies.
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Affiliation(s)
- Minhao Qiu
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Xiaoying Zhou
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
| | - Maddalena Zippi
- Unit of Gastroenterology and Digestive Endoscopy, Sandro Pertini Hospital, Rome, Italy
| | - Hemant Goyal
- Department of Surgery, University of TX Health Sciences Center, Houston, TX, United States
| | | | - Mateusz Jagielski
- Department of General, Gastroenterological and Oncological Surgery, Nicolaus Copernicus University in Toruń, Poland
| | - Wandong Hong
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, People’s Republic of China
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Alanzi A, Fouad A, Ghazzal S, Adeel S, Eldesokey A. Acute Pancreatitis (AP) in Pregnancy and Its Complications From an Anesthesia Perspective: A Case Report. Cureus 2023; 15:e38913. [PMID: 37313098 PMCID: PMC10259756 DOI: 10.7759/cureus.38913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/15/2023] Open
Abstract
Acute pancreatitis (AP) is a rare event in pregnancy that is characterized by a sudden and severe inflammation of the pancreas. The clinical manifestation of AP during pregnancy is highly variable ranging from a mild form to a severe and potentially life-threatening presentation. We share a case of a 29-year-old female (gravida II, para I) who presented in her 33rd gestational week. The patient complained of upper abdominal pain and nausea. Her previous history revealed that she had four episodes of vomiting (food-containing, non-projectile) at home. Her uterine tone was normal, and her cervix was closed. Her white blood cell count was 13,000/mm3, and her C-reactive protein (CRP) level was 65 mg/L. She underwent an emergency laparotomy due to suspected acute appendicitis; however, no peritonitis was found intraoperatively. Further blood tests showed high levels of triglyceride at 87.5 mmol/L. The electrophoretic pattern of lipoprotein was consistent with type V hyperlipoproteinemia. An abdominal computed tomography (CT) confirmed the diagnosis of acute pancreatitis. During follow-up after one month, the patient showed triglyceride levels at 4.75 mmol/L and cholesterol at 6.07 mmol/L. Acute pancreatitis due to hypertriglyceridemia is a rare finding; nonetheless, it should be considered as a potential etiology in pregnant patients with nonobstructive abdominal pain.
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Affiliation(s)
- Ahemd Alanzi
- Anesthesia and Critical Care, King Hamad University Hospital, Muharraq, BHR
| | - Amir Fouad
- Anesthesia and Critical Care, King Hamad University Hospital, Muharraq, BHR
| | - Samar Ghazzal
- Anesthesia and Critical Care, King Hamad University Hospital, Muharraq, BHR
| | - Shahid Adeel
- Anesthesia and Critical Care, King Hamad University Hospital, Muharraq, BHR
| | - Ahmed Eldesokey
- Anesthesia and Critical Care, King Hamad University Hospital, Muharraq, BHR
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Mądro A. Pancreatitis in Pregnancy-Comprehensive Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16179. [PMID: 36498253 PMCID: PMC9737239 DOI: 10.3390/ijerph192316179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/30/2022] [Accepted: 12/01/2022] [Indexed: 06/17/2023]
Abstract
Acute and chronic pancreatitis, until recently observed incidentally in pregnancy, has occurred much more frequently in the last 2-3 decades. Particularly severe complications for the mother and fetus may be a consequence of acute pancreatitis. Therefore, it is important to know more about the diagnostic and therapeutic possibilities of pancreatic diseases in the course of pregnancy. Epidemiology, causes, clinical characteristics, differential diagnosis, and complex management are presented in this review. Particular emphasis is on the prevention of acute pancreatitis (AP) through the proper diagnosis and treatment of cholelithiasis and hypertriglyceridemia, both before and during pregnancy. The most up-to-date reports and management strategies are presented. This publication contributes to a wide group of scientists and practitioners better understanding the discussed issues, and indicates the directions of research for the future.
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Affiliation(s)
- Agnieszka Mądro
- Department of Gastroenterology with Endoscopic Unit, Medical University, 20-059 Lublin, Poland
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Zhang X, Yang G, Chen Y, Mu Z, Zhou H, Zhang L. Resveratrol pre-treatment alleviated caerulein-induced acute pancreatitis in high-fat diet-feeding mice via suppressing the NF-κB proinflammatory signaling and improving the gut microbiota. BMC Complement Med Ther 2022; 22:189. [PMID: 35842665 PMCID: PMC9288014 DOI: 10.1186/s12906-022-03664-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 06/09/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND hyperlipidemia acute pancreatitis (HTG-AP) is a major hidden danger affecting human health, however, whether there is a protective effect of resveratrol on HTG-AP is unclear. Therefore our study was aimed to investigate the preventive effect and the underlying mechanism of resveratrol in the HTG-AP mice model. METHODS This research was divided into two parts. In the first part, mice were adaptively fed with normal chow or HFD for 6 weeks. From the second week, resveratrol-treated mice were in intragastric administration with resveratrol (45 mg/kg/d) for 4 weeks. In the second part, the procedures were the same as the first part. After the last intragastric administration with resveratrol, all mice were intraperitoneal injections of cerulean. RESULTS We found resveratrol effectively inhibited pancreatic pathological injury in the HFD, AP, and HTG-AP mice. Resveratrol reduced the LPS, IL-6, TNF-α, and MCP-1 expressions in the HFD mice. Resveratrol also reduced TNF-α, MDA, and MCP-1 expressions and increased SOD and T-AOC expressions in the AP and HTG-AP mice. Furthermore, resveratrol suppressed the NF-κB pro-inflammatory signaling pathway in pancreatic tissues in the AP and HTG-AP mice. Moreover, resveratrol improved the gut microbiota in the HFD mice. CONCLUSION The resveratrol pre-treatment could attenuate pancreas injury, inflammation, and oxidative stress in the HTG-AP mice, via restraining the NF-κB signaling pathway and regulating gut microbiota. Therefore, Our study proved that the resveratrol pre-treatment had a preventive effect on HTG-AP.
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Affiliation(s)
- Xiaoying Zhang
- School of Basic Medicine, North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Guodong Yang
- Department of Gastroenterology and Hepatology, Affiliated Hospital of North Sichuan Medical College, No.63, Cultural Rd., Shunqing Dist, Nanchong, 637000, Sichuan Province, China.
| | - Yulin Chen
- North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Zhao Mu
- North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Haiyue Zhou
- North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Luoyao Zhang
- North Sichuan Medical College, Nanchong, 637000, Sichuan, China
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Zheng CB, Zheng ZH, Zheng YP. Therapeutic plasma exchange for hyperlipidemic pancreatitis: Current evidence and unmet needs. World J Clin Cases 2021; 9:5794-5803. [PMID: 34368298 PMCID: PMC8316951 DOI: 10.12998/wjcc.v9.i21.5794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/24/2021] [Accepted: 05/26/2021] [Indexed: 02/06/2023] Open
Abstract
With changes in lifestyle and diet worldwide, the prevalence of hyperlipidemic acute pancreatitis (HLAP) has greatly increased, and it has become the most common cause of acute pancreatitis not due to gallstones or alcohol. There are many available therapies for HLAP, including oral lipid-lowering agents, intravenous insulin, heparin, and therapeutic plasmapheresis (TPE). It is believed that the risk and severity of HLAP increase with rising levels of serum triglycerides (TG), thus a rapid decrease in serum TG level is the key to the successful management of HLAP. TPE has emerged as an effective modality in rapidly reducing serum TG levels. However, due to its cost and accessibility, TPE remains poorly evaluated until now. Some studies revealed its efficacy in helping to treat and prevent the recurrence, while some studies suggested that TG levels were not correlated with disease severity, mortality, or length of hospital stay. Thus TPE might have no beneficial effect for the outcome. This article gives an overview of the published evidence of TPE in the treatment of HLAP and outlines current evidence regarding individual outcome predictors, adverse effects of the procedure, and TPE in special occasions such as for pregnant patients and patients with diabetic ketoacidosis. Future direction of TPE research for HLAP is also discussed in this review.
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Affiliation(s)
- Can-Bin Zheng
- Department of Endocrine and Metabolic Disease, Shantou Central Hospital, Shantou 515031, Guangdong Province, China
| | - Zi-Hui Zheng
- Nursing College, Guangdong Pharmaceutical University, Guangzhou 510000, Guangdong Province, China
| | - Yong-Ping Zheng
- Department of Gastroenterology, Shantou Central Hospital, Shantou 515031, Guangdong Province, China
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Management Considerations for Lipid Disorders During Pregnancy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00926-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Acar YA, Gunay G, Bilge S, Tezel O. Concomitant hypertriglyceridemia-induced pancreatitis in pregnant monozygotic twin siblings. Gynecol Endocrinol 2020; 36:654-656. [PMID: 32157928 DOI: 10.1080/09513590.2020.1737669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Hypertriglyceridemia-induced pancreatitis (HTIP) is the third most common cause of pancreatitis. Hypertriglyceridemia shows familial transition and pregnancy increases the risk of HTIP. The treatment of HTIP is initiated with supportive treatment and continues with specific treatments including plasmapheresis, insulin, heparin infusion, and hemofiltration. The current study reports monozygotic twins who are pregnant at the same time having concurrent HTIP attack.
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Affiliation(s)
- Yahya Ayhan Acar
- Department of Emergency Medicine, University of Health Sciences, Ankara, Turkey
| | - Gizem Gunay
- Department of Emergency Medicine, University of Health Sciences, Ankara, Turkey
| | - Sedat Bilge
- Department of Emergency Medicine, University of Health Sciences, Ankara, Turkey
| | - Onur Tezel
- Department of Emergency Medicine, University of Health Sciences, Ankara, Turkey
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Lin MH, Tian XH, Hao XL, Fei H, Yin JL, Yan DD, Li T. Management of a pregnant patient with chylomicronemia from a novel mutation in GPIHBP1: a case report. BMC Pregnancy Childbirth 2020; 20:272. [PMID: 32375710 PMCID: PMC7201967 DOI: 10.1186/s12884-020-02965-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/22/2020] [Indexed: 12/14/2022] Open
Abstract
Background Familial chylomicronemia syndrome (FCS) is a rare autosomal recessive lipid disorder often associated with recurrent episodes of pancreatitis. It is documented in most cases with FCS due to the mutations of key proteins in lipolysis, including LPL, APOC2, APOA5, LMF1 and GPIHBP1. Case presentation We report the successful management of a 35-year-old pregnant woman carrying a novel homozygous frameshift mutation c.48_49insGCGG (p.P17A fs*22) in the GPIHBP1 gene with previous severe episodes of acute pancreatitis triggered by pregnancy, resulting in adverse obstetrical outcomes. With careful monitoring, the patient underwent an uneventful pregnancy and delivered a baby with no anomalies. Conclusions The case report contributes to the understanding of GPIHBP1-deficient familial chylomicronemia syndrome (FCS) and highlights gestational management of FCS patient.
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Affiliation(s)
- Min-Huan Lin
- Department of Obstetrics & Gynecology, the Seventh Affiliated Hospital of Sun Yat-Sen University, 628 Zhenyuan Road, Guangming District, Shenzhen, China
| | - Xiao-Hui Tian
- Department of Obstetrics & Gynecology, the Seventh Affiliated Hospital of Sun Yat-Sen University, 628 Zhenyuan Road, Guangming District, Shenzhen, China
| | - Xiu-Lan Hao
- Department of Obstetrics & Gynecology, the Seventh Affiliated Hospital of Sun Yat-Sen University, 628 Zhenyuan Road, Guangming District, Shenzhen, China
| | - Hui Fei
- Department of Obstetrics & Gynecology, the Seventh Affiliated Hospital of Sun Yat-Sen University, 628 Zhenyuan Road, Guangming District, Shenzhen, China
| | - Jian-Lan Yin
- Department of Obstetrics & Gynecology, the Seventh Affiliated Hospital of Sun Yat-Sen University, 628 Zhenyuan Road, Guangming District, Shenzhen, China
| | - Dan-Dan Yan
- Department of Obstetrics & Gynecology, the Seventh Affiliated Hospital of Sun Yat-Sen University, 628 Zhenyuan Road, Guangming District, Shenzhen, China
| | - Tian Li
- Department of Obstetrics & Gynecology, the Seventh Affiliated Hospital of Sun Yat-Sen University, 628 Zhenyuan Road, Guangming District, Shenzhen, China.
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Saruç M, Ünal HÜ. Pitfalls in hypertriglyceridemia induced acute pancreatitis. TURKISH JOURNAL OF GASTROENTEROLOGY 2019; 30:217-219. [PMID: 30923032 DOI: 10.5152/tjg.2019.110319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Murat Saruç
- Department of Gastroenterology, Acibadem Mehmet Ali Aydınlar University School of Medicine, İstanbul, Turkey
| | - Hakan Ümit Ünal
- Department of Gastroenterology, Acibadem Mehmet Ali Aydınlar University School of Medicine, İstanbul, Turkey
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