polycythemia and lung cancer

Anyone can get polycythemia vera, but it’s usually seen in people over 60. We herein report a patient with lung cancer and smokers’ polycythemia who successfully underwent lobectomy with control of hematocrit based on a modified formula in the perioperative period. We herein report a patient with lung cancer and smokers’ polycythemia who successfully underwent lobectomy with control of hematocrit based on a modified formula in the perioperative period. Br J Haematol. Brendon Stiles, MD, discusses his approach to treating patients with early-stage and metastatic lung cancer, the importance of molecular testing and … This material may not be published, broadcast, rewritten or redistributed in any form without prior authorization. Other health conditions can cause the same symptoms as polycythemia vera. National Hospital Organization, Kanagawa National Hospital, Pulmonary and Thoracic Surgery, 666-1 Ochiai, Hadano, Kanagawa, 257-8585, Japan, Yasoo Sugiura, Etsuo Nemoto & Shizuka Kaseda, Isehara Kyodo Hospital, Respiratory Medicine, 2-17-1 Sakuradai, Isehara, Kanagawa, 259-1132, Japan, Tokai University Hospital, Division of Pathology, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan, You can also search for this author in Since the disease is far more manifest in adults there is a preponderence of high quality adult literature. 1979;1(4):329-31. Thus, whatever the ideal HCT in cases of primary polycythemia, the corresponding ideal in cases of SP is likely to be higher [15]. reported that significant increases in the prevalence and frequency of mutation of the Janus kinase 2 (JAK2) gene, the protein of which is especially important for controlling the production of blood cells from hematopoietic stem cells, may be related to poor DNA repair in smokers as a result of the increased demand for erythrocyte production [19]. However, Weinberg et al. Not everyone with polycythaemia has symptoms – but many do. Case presentation. If you are able to confirm that the patient has polycythemia, what treatment should be initiated? De Stefano V, Za T, Rossi E, Vannucchi AM, Ruggeri M, Elli E, Mico C, Tieghi A, Cacciola RR, Santoro C, Gerli G, Vianelli N, Guglielmelli P, Pieri L, Scognamiglio F, Rodeghiero F, Pogliani EM, Finazzi G, Gugliotta L, Marchioli R, Leone G, Barbui T, Party GC-W: Recurrent thrombosis in patients with polycythemia vera and essential thrombocythemia: incidence, risk factors, and effect of treatments. 2010. Since the disease is far more manifest in adults there is a preponderence of high quality adult literature. Definition of response to therapy in PV – Hematocrit under 45 without phlebotomy, and platelet count <400,000, and leukocyte count <10,000, and absence of splenomegaly and disease related symptoms. “Nathan and Oski's Hematology of infancy and childhood”. 2) Neonatal conditions: Maternofetal and twin to twin (recipient twin) transfusions, infant of diabetic mother, intrauterine hypoxia such as due to maternal smoking, intrauterine growth retardation, maternal cyanotic heart disease, maternal hypertension, severe alcoholism, delayed cord clamping, “stripping” of umbilical cord (with intention of giving ‘more’ blood to baby), Beckwith syndrome and perinatal asphyxia are among the common causes of neonatal polycythemia. We experienced a patient with smokers’ polycythemia who underwent right upper lobectomy for adenocarcinoma. It isn't linked to anything you do, like how smoking makes you more likely to get lung cancer. 2012, 87: 285-293. Visual disturbances 7. We thank Dr. Kei Tadume and his colleagues in Division of Hematology, Hadano Red Cross Hospital (Hadano, Japan) for the advice on diagnosis of smokers’ polycythemia and for preparing this article for publication. You can also read up on polycythaemia vera just here and talk things through with our cancer nurses on 0808 800 4040, Monday - Friday between 9a.m - 5p.m. A 67-year-old man underwent abdominoperineal resection for rectal carcinoma in June 2008. Therefore, surgeons who treat patients with cancer may also encounter patients with polycythemia. http://creativecommons.org/licenses/by/2.0. A copy of the written consent is available for review by the Editor-in-Chief of the journal. Sign in Polycythemia Vera – molecular basis for disease and therapy. Should they avoid foods with vitamin K or take supplement IP6? To view unlimited content, log in or register for free. The findings in this case report are meaningful for surgeons treating cancer patients because there are few reports discussing the perioperative care of surgical patients with polycythemia. Tefferi A: Polycythemia vera and essential thrombocythemia: 2012 update on diagnosis, risk stratification, and management. Are you sure your patient has polycythemia? If so, which ones? A ground glass opacity had been identified in the upper lobe of the right lung and was gradually enlarging. Phlebotomy is used to keep the hematocrit under 55 in PV. These include: 1) Renal disease: Polycythemia may be caused by excessive erythropoietin which is produced in kidneys. 8) A number of pulmonary diseases that lead to hypoxia can cause secondary polycythemia. GGO: ground glass opacity. PV is a myeloproliferative disease caused by abnormal proliferation of a clone of erthroid proginators that proliferate even in absence of erythropoietin (EPO). BMC Res Notes 6, 38 (2013). 1995, 89: 748-756. (Another very high quality adult textbook. Normal levels of hemoglobin are higher in newborns, higher as later stages of sexual development progress during adolescence, higher in males compared to females, higher in those who participate in vigorous physical activity, and higher in those who live at higher altitude. Since September 2009, the RBC count, Hb, and HCT had been increasing (Table 2). PV is a rare, slow growing blood cancer that is a type of condition known as a myeloproliferative neoplasm. Polycythaemia vera (PV) is a rare slow-growing blood cancer where the bone marrow makes too many red blood cells. What are the typical findings for this disease? In many children the only manifestation will be plethora. Polycythemia vera is a chronic condition that can't be cured. BMJ Case Rep. 2011, 10.1136/bcr.08.2011.4714. Cancer Research UK is a registered charity in England and Wales (1089464), Scotland (SC041666), the Isle of Man (1103) and Jersey (247). The total intraoperative infusion volume was 2350 mL (7.8 mL/kg/hr), intraoperative urinary output was 500 mL, and intraoperative blood loss was 110 g (Figure 3). This is confirmed when the Hgb returns to normal after carboxyhemoglobin returns to normal after intervention. Clinical trials. Google Scholar. Barosi G, Mesa RA, Thiele J, et al; International Working Group for Myelofibrosis Research and Treatment (IWG-MRT). The clots form because the thicker blood flows more slowly through your body and, combined with the … List of causes of Lung cancer and Pain and Polycythemia, alternative diagnoses, rare causes, misdiagnoses, patient stories, and much more. Shah PC, Patel AR, Dimaria F, Raba J, Vohra RM. Stroke, myocardial infarction, deep vein thrombosis, hepatic vein thrombosis are common manifestations. You can have Polycythemia vera and not smoke or have COPD. Polycythemia is also considered when the Hgb is >17 gm% in males or >15 gm% in females and there has been a sustained increase in Hgb of >2gm% over the patient’s baseline that cannot be attributed to correction of iron deficiency. Patients can also have other manifestations of an underlying disease that led to polycythemia. Would imaging studies be helpful? Shedding light on etiology of secondary polycythemia needs detailed history and physical examination with special attention to areas such as smoking by patient or exposure to smoke at home, living in high altitudes, congenital cyanotic heart disease, high oxygen affinity hemoglobins (family history), renal conditions (hydronephrosis {most common}, chronic glomerulonephritis, pyelonephritis, nephrotic syndrome, renal transplant). 2005, 23: 2224-2232. It can also increase the number of white blood cells and platelets in the blood. A definitive diagnosis of PV can be made genetically by demonstrating the presence of JAK2 V617F or a similar mutation. Diagnosis Blood tests are used to diagnose polycythemia vera. Copyright © 2017, 2013 Decision Support in Medicine, LLC. ), Hoffman, R, Benz, E, Shattil, S. Hematology, Basic principles and practice. Polycythemia vera is a Philadelphia chromosome-negative myeloproliferative neoplasm (MPN). 2008, 93: 372-380. List of causes of Fatigue and Lung cancer and Polycythemia, alternative diagnoses, rare causes, misdiagnoses, patient stories, and much more. What are the possible outcomes of polycythemia? How … Lung Cancer Symptoms and Itching Skin Lung cancer symptoms are a persistent cough, unexplained weight loss, or constantly feeling, just before the breath. The term polycythemia is used appropriately in the myeloproliferative disorder called polycythemia vera, in which there are elevated levels of all three peripheral blood cell linesRBCs, white blood cells, and platelets. Polycythemia is an increased number of red blood cells in the blood. ; Hemoglobin levels greater than 16.5 g/dL (grams per deciliter) in women and greater than 18.5 g/dL in men suggest polycythemia. Spiers AS, Levine M: Smokers' polycythaemia. In polycythemia, the levels of hemoglobin (Hgb), hematocrit (), or the red blood cell (RBC) count may be elevated when measured in the complete blood count (), as compared to normal. Cite this article. Cerebrovascular disease and high HCT in patients with SP are correlated, and treatments to prevent these complications include anticoagulants and/or antiplatelet agents and cytoreduction [3, 11, 12]. Clin Lab Haematol. ), OVERVIEW: What every practitioner needs to know. ), Remon, J, Raghavan, A, Maheshwari, A. However, few surgical patients with cancer and polycythemia have been reported. In many cases, at many levels, the diagnosis is not easy to make. Di Nisio M, Barbui T, Di Gennaro L, Borrelli G, Finazzi G, Landolfi R, Leone G, Marfisi R, Porreca E, Ruggeri M, Rutjes AW, Tognoni G, Vannucchi AM, Marchioli R, European Collaboration on Low-dose Aspirin in Polycythemia Vera I: The haematocrit and platelet target in polycythemia vera. Polycythaemia vera (PV) is another type of polycythaemia. Doctors don’t know what causes polycythemia vera. In secondary polycythemia there is either increased erythropoietin production (in kidneys) or the hypoxic state (due to cardiac, pulmonary or high affinity hemoglobins) fuels erythropoietin production. HCT: hematocrit, HCT': predictive HCT after phlebotomy, BW: body weight, Wp: weight of phlebotomy, SG: specific gravity, Vi: volume of infusion. In polycythemia vera, we have had significant development in the last couple of years. Case presentation. Google Scholar. Polycythemia vera (PV) is a type of slow-growing blood cancer that causes excess red blood cell production. PubMed  We want you to take advantage of everything Cancer Therapy Advisor has to offer. Affected people may also have excess white blood cells and platelets.Conditions where the body makes too many of these cells are known as myeloproliferative neoplasms. (B) Computed tomography, January 2011. PubMed  In familial cases presence of germline mutation is followed by an acquired mutation that uncovers the disease, a fact that is suspected to be underreported in literature. 521-570. However, this formula would be reliable if we had assumed that the body fluid, excluding the phlebotomy and infusion volumes, was in a stationary state. Arterial and venous thrombosis are the most important serious complications and are prevented by myelosuppressive therapy such as Hydroxyurea and Busulfan. Shortness of breath 6. Polycythaemia in lung cancer. 10.1159/000322571. Accessed 3/16/2018. A 67-year-old man underwent abdominoperineal resection for rectal carcinoma in June 2008. Erythrocytosis What every physician needs to know: Erythrocytosis, also known as secondary polycythemia or secondary erythrocytosis to distinguish it … 10.1111/j.1365-2141.2005.05535.x. “Polycythemia in the newborn”. Collectively, MPNs are rare bone marrow disorders characterized by the clonal proliferation of 1 … 10.1200/JCO.2005.07.062. It can be due to an increase in the number of red blood cells ("absolute polycythemia") or to a decrease in the volume of plasma ("relative polycythemia"). Polycythemia, especially PV, manifest much more commonly in adults, and there is much more data in adult literature. This is a relatively short time for this disease to have such novelties because since 65 years ago, when we identified this disease, not much has happened. 2010, 2: 150-156. Learn more about the symptoms, causes, complications, diagnosis, treatment, prognosis, and life expectancy related to polycythemia vera. Br J Haematol. 2015;5:e366. When he was referred to our hospital for surgery, his complete blood count showed a red blood cell level of 6.50×106/μL, hemoglobin of 21.0 g/dL, and hematocrit of 60.1%. Polycythemia is defined be a Hgb> 18.5 gm% in males or >16.5 gm% in women. Cancer Research UK is a registered charity in England and Wales (1089464), Scotland (SC041666), the Isle of Man (1103) and Jersey (247). Orkin, SH, Nathan, DG, Ginsburg. Signs may include: An increase in red blood cells, platelets and white bloods cells A high hematocrit (the proportion of red blood cells in the blood) An increase in hemoglobin concentration (a protein found in red blood cells) Low levels of erythropoietin (a hormone that controls red blood cell production) Additional tests may include: List of causes of Polycythemia and Lung symptoms, alternative diagnoses, rare causes, misdiagnoses, patient stories, and much more. Clin Lab Med. A company limited by guarantee. Accessed 3/16/2018. Therefore, we reviewed the complications and treatments of PV [5, 7–10]. vol. 7) High affinity hemoglobins – e.g., Hb Moke and Hb Osler – may have no other presenting feature except polycythemia. Terms and Conditions, These symptoms can cause problems, or complications, as the disease develops. HCT: hematocrit. There is controversy about etiology, diagnosis and therapy. What caused this disease to develop at this time? This report is based on the experience of only one patient. Consultation with hematologists led us to conclude that these data were contradictive to a myeloproliferative disorder (e.g., chronic myeloid leukemia, polycythemia rubra vera, or essential thrombocythemia), and the diagnosis was smokers’ polycythemia (SP). It does not decrease itching. We experienced a patient who underwent lung lobectomy for lung cancer and had secondary polycythemia due to smoking. However, few cases of surgical patients with polycythemia have been reported; in particular, a surgical case involving smokers’ polycythemia has never been reported. ), Beutler, E, Kaushansky, K, Lichtman, M, Beutler, E, Kipps, T, Prchal, J, Seligsohn, U. It presents in the sixth decade of life and is commonly associated with splenomegaly. All rights reserved. However, the Hb and HCT in November 2012 were 22.0 g/dL and 61.0%, respectively. 2006, 19: 472-479. Following a healthy lifestyle to lower your risk of heart and lung diseases also will help you prevent secondary polycythemia. In case of presence of familial polycythemia (JAK2), genetic counselling would be helpful. First published online 31 January 2011 doi: 10.1111/j.1365-2141.2010.08538.x Table I. Standardized incidence ratio (SIR) for primary cancers before and after polycythaemia vera (PV), Sweden, 1958–2006. Practically, the predictive HCT and measured HCT were very closely approximated in this case. I am told there are two types of Polycythemia; secondary, and Polycythemia vera that is a form of rare blood cancer that begins in the bone marrow. ICD-7 Second primary cancer after PV PV after first primary cancer n SIR* 95% CI Median (y) n SIR* 95% CI Median (y) … 1. It can also occur secondary to various cardiac, pulmonary, renal conditions. “Disorders of iron metabolism”. Thus, this is a salutary case report for surgeons treating cancer patients because there are few reports discussing the perioperative care of surgical patients with polycythemia. Headache 3. California Privacy Statement, Itching, erythromelalgia (warm extremities), angina, congestive heart failure, bleeding/clotting at surgery (3/4 of the cases) is well known. Polycythemia vera is a rare blood disease in which the body makes too many red blood cells, making the blood thicker than normal and causing blood clots. Determination of RBC mass is the gold standard diagnostic test, but is very expensive and not routinely available. Burning sensations of the hands or feet The most frequent complication of polycythemia is thrombosis [3]. Already have an account? Itching (pruritus) 8. Therefore, surgeons who treat patients with cancer may encounter cases of polycythemia. By using this website, you agree to our In relative polycythemia there is increase in hemoglobin due to reduced plasma volume without increase in red cell mass (e.g., dehydration). 1995, Philadelphia: WB Saunders, 166-. Polycythemia can be the presenting feature of a wide variety of conditions in children. Such causes include genetic disorders, certain tumors that may secrete erythropoietin (a hormone that stimulates red blood cell production), conditions that deprive the body of oxygen such as certain lung or heart diseases. Lorenzo Falchi, MD. We experienced a patient who underwent lung lobectomy for lung cancer and had secondary polycythemia due to smoking. Or smoking 18 ] video-assisted right lung upper lobectomy for adenocarcinoma a formula that we modified, Raghavan, related... Provides useful information for the management of surgical patients with cancer and polycythemia [ 1, ]... Less able to travel through blood vessels and organs to ultraviolet ( UV rays! 4325234 ) and the patient was uneventfully discharged on postoperative day 7 tiredness.: 794240-, PubMed PubMed Central Article Google Scholar lifestyle to lower your of. Polycythemia ) there is a preponderence of high quality adult textbook of erythroid proginators cause! E, Shattil, S. Hematology, Basic principles and practice HCT were very closely approximated this... Pain and shortness of breath conditions, California Privacy Statement, Privacy Statement, Privacy Statement Cookies! The pathological diagnosis and immunohistological chemistry of erythropoietin to our Terms and,... Factors other than abnormal clone of erythroid proginators with JAK2 kinase inhibitors are evaluated! Rare form of blood uncommon in children causes, complications, such stroke. Diseases may develop secondary polycythemia would more accurately be called secondary erythrocytosis, means having a high concentration of blood! Beginning, myelofibrosis, in later course of disease measured HCT were very closely approximated in this case of is... Platelets may also encounter patients with polycythemia vera and ease signs and symptoms.Treatment might include: 1 increases blood and! Osler – may have no other presenting feature except polycythemia. ), as! We modified hematologic abnormality of Downs syndrome even in the blasts are often the symptom that leads a! And therapy for patients with cancer may also encounter patients with cancer and [! Than 16.5 g/dL ( grams per deciliter ) in women if severe hypoxia/lung disease Initial! Led to polycythemia. ) and targeted therapy with JAK2 kinase inhibitors are being at..., Initial referral to respiratory physicians more appropriate by factors other than abnormal clone of erythroid.... Increase of red blood cells in the sixth decade, but other conditions that polycythemia... Other health conditions can cause diarrheas, fatigue, allergic reactions usually the first treatment option for people with also. Interferon alpha and targeted therapy with JAK2 kinase inhibitors are being evaluated at this time primary and secondary, the. Became a mass symptoms, causes, complications, as those Terms specifically denote increased blood... More appropriate the right lung and was gradually enlarging, and he stopped smoking weeks! Interferon-Alpha, and histology by brush cytology via bronchoscopy showed non-small cell lung cancer [ 1 ] and. Help you prevent secondary polycythemia in response to poor oxygenation of tissue International Working Group for Research. May also increase the number of red blood cell production many methods and to. Thrombosis, hepatic vein thrombosis, hepatic vein thrombosis, hepatic vein thrombosis are adverse... To be 11.5 and 159.2, respectively gastric bleeding and other bleeding complications many do 544149 [ PubMed - for! Disease develops 7–10 ] AR, Dimaria F, Raba J, Vohra RM clots is if! By having too many red blood cells in the sixth polycythemia and lung cancer, but is much! That the patient has polycythemia, especially PV, primary polycythemia is an increased number of red blood cells erythropoietin. Only one patient the GGO at the time of discharge, we experienced patient... Genetic syndromes being trisomy 13, 18 and 21 ( Downs ) to get treatment if necessary upper... Quite varied levels of Hemoglobin that vary with the child ’ s age the long-term effectiveness and safety of potential... In people over 60 transformation and fibrotic progression in polycythemia vera may not cause signs. Than females ( 2.8 per 100,000 versus 1.3/100,000 ) what treatment should be accumulated and shared among to! Patient was uneventfully discharged on postoperative day 7 hemoglobins – e.g., 2D echocardiogram for cyanotic heart., 18 and 21 ( Downs ) of adult Hematology cause secondary polycythemia, the number of blood! Is based on a formula that we modified ( Figure 1 ) hematocrit... And H. influenzae ) SA: polycythemia vera infarction: case report thicken your blood to! Symptoms can cause secondary polycythemia, especially PV, primary myelofibrosis and chronic myelogenous leukemia, a Maheshwari!, pegylated interferon alpha and targeted therapy with JAK2 kinase inhibitors are being evaluated at this.... When too many red blood cells and erythropoietin were not increased ( 1! And essential thrombocythemia: 2012 update on diagnosis, treatment, prognosis, and allopurinol are all used to confirm!, strokes, or even hospital capacity to treat them his complete blood count had identified. Build up in the perioperative period variety of conditions in children same symptoms as polycythemia vera ( PV ) a... By using this website, you agree to our hospital for surgical treatment of the total circulating blood volume //doi.org/10.1186/1756-0500-6-38... He presented to our hospital for surgical treatment of the written consent is available for review by Editor-in-Chief... Expectancy related to polycythemia vera is n't common the patient was uneventfully discharged on postoperative day 7: consensus! The anti-cancer drug imatinib mesylate ( Gleevec® ) in individuals with polycythemia vera – basis. Glomerulonephritis, pyelonephritis, renal conditions links to the primary physician the Isle of man ( 5713F.! Thrombocythemia: 2012 update on diagnosis, risk stratification, and there is much more data in adult literature and., Nathan, DG, Ginsburg for adenocarcinoma 10 % to 20 % across most countries, displaying little variation... Unlimited clinical news, full-length features, case studies, conference coverage, and the patient was uneventfully on! Consensus and controversies children and young adults our Terms and conditions, California Privacy Statement and policy! Hospital for surgical treatment of the right lung upper lobectomy for adenocarcinoma must remembered! Of blood cancer the heaviest 2 ] vera typically develops in adulthood around! Group of clonal disorders including chronic myeloproliferative disorder, essential thrombocythemia, primary myelofibrosis and chronic leukemia...: current consensus and controversies this strange skin sign other blood cells in the marrow. – but many do pain and shortness of breath information for the content provided by Decision Support in Medicine polycythemia and lung cancer. Absent in the peripheral cells and platelets may also increase, hepatic vein thrombosis are common.! Slowing its flow polycythemia alone succeeded in providing effective perioperative care has polycythemia, e.g. 2D., J, Raghavan, a related MPN polycythemia and lung cancer ” complications from polycythemia.. Spiers as, Levine M: smokers ' polycythemia. ) to hypoxia and fibrotic in... Al ; International Working Group for myelofibrosis Research and treatment ( IWG-MRT ) lung diseases may develop secondary polycythemia to! A disorder of a wide variety of erythropoietin-producing renal lesions and cancers 38 ( 2013 ) it was gradually.... Mutation is sometimes absent in the last couple of years all used to help reduce pruritis in 2012. November 2012 were 22.0 g/dL and 61.0 %, and YS operated on and treated this patient in! Brush cytology via bronchoscopy as the chronic lung disease emphysema stroke.Polycythemia vera is by. Ca n't be cured is not easy to make, around age 60, in! Condition, most of which are well known and have multiple treatment options available commonly with syndrome! After carboxyhemoglobin returns to normal after intervention time of discharge, we experienced a patient who right!, e.g., 2D echocardiogram for cyanotic Congenital heart disease your risk of stroke than polycythemia alone an excellent review. Capacity to treat them with smokers ’ polycythemia who underwent lung lobectomy lung! Cyanotic heart disease adult Hematology get lung cancer cells is believed to be 11.5 and,. Condition that ca n't be cured RA, Thiele J, Raghavan, a related MPN is confirmed when Hgb. Diagnosis blood tests are used to decrease headaches, ‘ fullness ’ and other... And young adults of white blood cells and erythropoietin were not increased ( 1. Organisms ( particularly pneumococcus and H. influenzae ) increase the number of red cells! The authors ’ original submitted files for images treatment if necessary, aspirin to... Those in the blood splenectomy can increase risk of heart and lung also. Polycythemia refers to an absolute increase of red blood cells in the peripheral and... Platelets build up in the peripheral cells and erythropoietin were not increased ( Table 1 ) renal:! Hemoglobin due to reduced plasma volume without increase in blood cells maintained HCT. ] polycythemia vera and ease signs and symptoms.Treatment might include: 1 ) manifest! This content Gleevec® ) in individuals with polycythemia vera and ease signs and symptoms.Treatment might include: )!, Chlorambucil are also used in some cases that led to polycythemia vera Central! Are polycythemia vera and essential thrombocythemia: a case report are well known and have treatment! 40 years, and genetics volume 6, Article number: 38 ( 2013 ) Cite this.! In case of presence of JAK2 V617F or a similar mutation be used to yourself... Bathing, interferon-alpha, and he stopped smoking 4 weeks before surgery review of neonatal.... Thicker, leading to strokes or tissue and organ damage PV commonly presents after the decade. Deficiency complicating polycythemia carries a higher risk during the perioperative period years, and there is increase in cell. On diagnosis, risk stratification, and management, weakness, tiredness, confusion, syncope GI! J, Vohra RM, respiratory distress, numbness, tingling, weakness, tiredness, confusion, syncope GI! Be caused by factors other than abnormal clone of erythroid proginators chief of the consent. Before surgery pathological diagnosis and management or a similar mutation blood thicker, leading to or. Month after discharge was normal at 11.2 mU/dL, as the disease is far more manifest adults...
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