Physical factors determining mitral regurgitation jet area.
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Blood Flow Velocity↗
Biomedical subjects
J M Rivera
Publications and source records attributed to J M Rivera.
Quantification of tricuspid regurgitation by means of the proximal flow convergence method: a clinical study.
Quantitation of valvular regurgitation remains an important goal in clinical cardiology. It has been described previously that with the use of color Doppler flow mapping, simple measurements of apparent jet size do not correlate closely with quantitative regurgitant indices. Recently the proximal flow convergence method has been proposed to quantify valvular regurgitation by analysis of the converging flow field proximal to a regurgitant lesion. Assuming hemispherical convergence, flow rate Q can be calculated as Q = 2 pi r2va, where va is the aliasing velocity at a distance r from the orifice. For maximal accuracy, previously validated correction factors must be used to account for the flattening effect of the isovelocity contours close to the orifice and for the actual sector angle subtended by the valve leaflets (alpha), to yield a flow rate formula Q = 2 pi r2va.(vp/vp - va).(alpha/180), where vp is the orifice velocity obtained by continuous wave Doppler. In 45 patients (35 in sinus rhythm, 10 with atrial fibrillation) with tricuspid regurgitation, regurgitant stroke volume, regurgitant flow rate, and regurgitant fraction were calculated using the proximal flow convergence method and were compared with values obtained by the Doppler two-dimensional echocardiographic method. Regurgitant stroke volumes (SV) calculated by the proximal flow convergence method correlated very closely with values obtained by the Doppler two-dimensional method with r = 0.95 (y = 0.94x + 0.99) and delta SV = -0.3 +/- 5.2 cm3. Regurgitant flow rates (Q) calculated by both methods showed a similar correlation: r = 0.96 (y = 0.97x + 45) and delta Q = 1.6 +/- 429 cm3/min.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Effective regurgitant orifice area in tricuspid regurgitation: clinical implementation and follow-up study.
Analysis of the flow-convergence zone proximal to a regurgitant orifice permits the noninvasive, quantitative measurement of clinically useful parameters of valvular insufficiency. However, many indexes such as flow rate reflect not only the size of the regurgitant lesion but are also highly dependent on the hemodynamic loading conditions. The effective regurgitant orifice area (ROA) in contrast is a more fundamental parameter, less dependent on hemodynamics and more reflective of real changes in the geometry of the valve, making it a promising index for serial assessment of patients. In this study, the measurement of regurgitant orifice area by the flow-convergence method was tested in tricuspid regurgitation and then used to monitor patients noninvasively over time. The effective ROA was calculated in 45 patients with tricuspid regurgitation by means of the flow-convergence method and compared with the ROA obtained with pulsed Doppler echocardiographic methods. An excellent correlation was obtained between the two assessments of ROA (r = 0.96, delta ROA = -0.09 +/- 6.5 mm2). ROA also showed an excellent correlation with other indexes of valvular insufficiency such as regurgitant stroke volume (r = 0.89) and regurgitant fraction (r = 0.88). In a subgroup of 22 patients thought to be clinically stable, ROA was calculated serially over a mean follow-up period of 2 months and its variability compared with that of other flow-based parameters obtainable from proximal acceleration. The variation between the two studies in regurgitant stroke volume and regurgitant flow rate was 5% +/- 20.6% and 5.2% +/- 35.7%, respectively. The effective ROA showed significantly less variability at 1.8% +/- 15%.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Three-dimensional reconstruction of ventricular septal defects: validation studies and in vivo feasibility.
OBJECTIVES: The purpose of this study was to demonstrate the feasibility of in vivo three-dimensional reconstruction of ventricular septal defects and to validate its quantitative accuracy for defect localization in excised hearts (used to permit comparison of three-dimensional and direct measurements without cardiac contraction). BACKGROUND: Appreciating the three-dimensional spatial relations of ventricular septal defects could be useful in planning surgical and catheter approaches. Currently, however, echocardiography provides only two-dimensional views, requiring mental integration. A recently developed system automatically combines two-dimensional echocardiographic images with their spatial locations to produce a three-dimensional construct. METHODS: Surgically created ventricular septal defects of varying size and location were imaged and reconstructed, along with the left and right ventricles, in the beating heart of six dogs to demonstrate the in vivo feasibility of producing a coherent image of the defect that portrays its relation to surrounding structures. Two additional gel-filled excised hearts with defects were completely reconstructed. Quantitative localization of the defects relative to other structures (ventricular apexes and valve insertions) was then validated for seven defects in excised hearts. The right septal margins of the exposed defects were also traced and compared with their reconstructed areas and circumferences. RESULTS: The three-dimensional images provided coherent images and correct spatial appreciation of the defects (two inlet, two trabecular, one outlet and one membranous Gerbode in vivo; one inlet and one apical in excised hearts). The distances between defects and other structures in the excised hearts agreed well with direct measures (y = 1.05x-0.18, r = 0.98, SEE = 0.30 cm), as did reconstructed areas (y = 1.0x-0.23, r = 0.98, SEE = 0.21 cm2) and circumferences (y = 0.97x + 0.13, r = 0.97, SEE = 0.3 cm). CONCLUSIONS: Three-dimensional reconstruction of ventricular septal defects can be achieved in the beating heart and provides an accurate appreciation of defect size and location that could be of value in planning interventions.
Animals↗
Quantification of pericardial effusions by three-dimensional echocardiography.
OBJECTIVES: The purpose of this study was to examine the accuracy of three-dimensional echocardiography for the quantification of asymmetric pericardial effusion volume and to compare this new technique with two-dimensional echocardiography. BACKGROUND: Quantification of pericardial effusion by two-dimensional echocardiography relies on a symmetric distribution of the fluid. Three-dimensional echocardiography can quantitate volume without these limitations, but its accuracy for pericardial effusion volume has not yet been assessed. METHODS: In six open chest dogs, 41 different asymmetrically distributed pericardial effusions of known volume were created by serial infusions of fluid through a pericardial catheter. The hearts were imaged using an automated echocardiographic method that integrates three-dimensional spatial and imaging data. The surfaces of the pericardial sac and heart were then reconstructed, and the volumes of pericardial effusions were calculated. Two-dimensional echocardiography was performed simultaneously, and volumes were calculated using the prolate ellipsoid method. Asymmetric distribution of the fluid was obtained by applying localized hydrostatic pressure to the pericardium. RESULTS: The volumes of pericardial effusion quantified using three-dimensional echocardiography correlated well with actual volumes (y = 1.0x - 1.4, SEE = 7.7 ml, r = 0.98). Two-dimensional echocardiography had an acceptable correlation (y = 1.0x + 2.3, SEE = 23 ml, r = 0.84), but a marked degree of variation from the true value was observed for any individual measurement. CONCLUSIONS: Three-dimensional echocardiography accurately quantifies pericardial effusion volume in vivo, even when the fluid is distributed asymmetrically, whereas two-dimensional echocardiography is less reliable. This new technique may be of clinical value in quantitating pericardial effusion, especially in the serial evaluation of asymmetric or loculated effusions.
Algorithms↗
Is nitric oxide involved in cutaneous vasodilation during body heating in humans?
The neurotransmitter responsible for neurogenic vasodilation in human skin during body heating is unknown. We sought to determine whether the vasodilating substance nitric oxide (NO) is involved in this phenomenon. Six subjects were heated for 50 min by use of a water-perfused suit while forearm blood flow (FBF) was measured with plethysmography and skin blood flow (SkBF) was measured by the laser-Doppler method in both arms. In one forearm, NG-monomethyl-L-arginine (L-NMMA), an NO synthase blocker, was infused into the brachial artery. Bolus doses of L-NMMA (< or = 4 mg/min) for 5 min were given to blunt NO-mediated vasodilator responses to acetylcholine (ACh, 64 micrograms/min). A continuous infusion of L-NMMA (< or = 1.0 mg/min) was used during body heating to maintain NO synthase blockade. In the forearm receiving L-NMMA, FBF was 1.8 +/- 0.3 ml.100 ml-1.min-1 before drug infusion and rose to 9.5 +/- 1.3 ml.100 ml-1.min-1 with ACh. After L-NMMA infusion, FBF was 1.3 +/- 0.2 ml.100 ml-1.min-1 and rose to 2.6 +/- 0.4 ml.100 ml-1.min-1 with ACh (both P < 0.05 vs. pre-L-NMMA). Similar changes in SkBF were seen with ACh and L-NMMA, confirming that the drugs reached cutaneous vessels. With body heating, oral temperature increased by 1.2 degrees C, heart rate increased by 34 beats/min, and mean arterial pressure remained constant at approximately 75 mmHg. FBF in the treated forearm rose to 11.5 +/- 2.1 vs. 12.6 +/- 1.7 ml.100 ml-1.min-1 in the control forearm (P > 0.05, control vs. treated response).(ABSTRACT TRUNCATED AT 250 WORDS)
Acetylcholine↗
[The use of the proximal acceleration method in cases of incompetence of the right atrioventricular valve].
BACKGROUND: Quantitation of valvular regurgitation remains an important goal in cardiology. It has been described previously that using color Doppler flow mapping, measurements of apparent jet size do not correlate always closely with quantitative regurgitant indexes. Recently the proximal flow convergence method has been proposed to quantify valvular regurgitation by analysis of the converging flow field proximal to a regurgitant lesion. Assuming hemispherical convergence, peak flow rate Qp can be calculated as Qp = 2 pi r2Va, where Va is the aliasing velocity at a distance r from the orifice. For maximal accuracy, previously validated correction factors must be used to account for the flattening effect of the isovelocity contours close to the orifice and for the actual sector angle subtended by the valve leaflets (alpha) to yield a flow rate formula Qp = 2 pi r2Va (Vp/Vp-Va) (alpha/180), where Vp is the orifice velocity obtained by continuous wave Doppler. METHODS: In 45 patients (35 in sinus rhythm, 10 with atrial fibrillation) with tricuspid regurgitation, regurgitant stroke volume, regurgitant flow rate were calculated using the proximal flow convergence method and compared with values obtained by the Doppler two-dimensional echocardiographic method. RESULTS: Regurgitant stroke volumes (SV) calculated by the proximal flow convergence method correlated very closely with values obtained by the Doppler two-dimensional method with r = 0.95 (y = 0.94x + 0.99) and delta SV = -0.3 +/- 5.2 cm3. Regurgitant flow rates (Q) calculated by both methods showed a similar correlation: r = 0.96 (y = 0.97x + 45) and delta Q = 1.6 +/- 4.29 cm3/min. All correlations were slightly better for the group of patients in sinus rhythm. CONCLUSION: This study demonstrates that the proximal flow convergence method is an accurate and reproducible technique for quantifying tricuspid regurgitation. While improvements of this method are to be expected, flow calculations based on the proximal flow field show excellent results and appear appropriate for clinical use.
Adult↗
[A description of a new method of quantifying the regurgitant flow in patients with an incompetent mitral valve].
BACKGROUND: It has been shown previously that using color Doppler flow mapping, simple measurements of apparent jet size do not correlate closely with regurgitant flow rate and regurgitant fraction. Recently the proximal flow convergence method has been proposed to quantify valvular regurgitation by analysis of the converging flow field proximal to a regurgitant lesion. Flow rate Q can be calculated as Q = 2 pi r2va where va is the aliasing velocity at a distance r from the orifice. PATIENTS AND METHODS: In 54 patients (43 in sinus rhythm, 11 with atrial fibrillation) with at least mild mitral regurgitation by semi-quantitative assessment, regurgitant stroke volume, regurgitant flow rate, and regurgitant fraction were calculated using the proximal flow convergence method and compared with values obtained by the Doppler/two-dimensional echocardiographic method. RESULTS: Regurgitant stroke volumes (VL) calculated by the proximal flow convergence method correlated very closely with values obtained by the Doppler-2D method with r = 0.93 (y = 0.95x + 0.55) and delta VL = -0.3 +/- 4.0 cm3. Regurgitant flow rates (Q) calculated by both methods showed a similar correlation: r = 0.93 (y = 0.95x + 54) and delta Q = -34 +/- 284 cm3/min. The correlation for regurgitant fraction (RF) calculated by both techniques showed r = 0.89 (y = 0.98x + 0.006) and delta RF = -0.005 +/- 0.06. All correlations were slightly better for the group of patients in sinus rhythm compared with the study group in atrial fibrillation. CONCLUSION: This study demonstrates that the proximal flow convergence method is an accurate and reproducible technique to quantify mitral regurgitation. This approach is easy and less time-consuming than the Doppler-echocardiographic method. While future improvements of this method are to be expected, flow calculations based on the assumption of simple hemispheric symmetry of the proximal flow field appear suitable for clinical application at the present time.
Adult↗
Which physical factors determine tricuspid regurgitation jet area in the clinical setting?
The visual assessment of jet area has become the most common method used in daily clinic practice to evaluate valvular regurgitation. Despite the high prevalence of tricuspid regurgitation, however, few studies have systematically compared TR jet areas with a quantitative standard. To evaluate this, 40 patients in sinus rhythm with tricuspid regurgitation were analyzed: 16 with centrally directed free jets and 24 with impinging wall jets. The size of the maximal planimetered color jet area (cm2) was compared with parameters derived using the pulsed Doppler 2-dimensional echocardiographic method: regurgitant fraction and the flow convergence method (peak flow rate, effective regurgitant orifice area and momentum). Mean tricuspid regurgitant fraction averaged 33 +/- 15%, peak flow rate 76 +/- 54 cm3/s, effective regurgitant orifice area 27 +/- 21 mm2 and momentum 21,717 +/- 15,014 cm4/s2. An average of 4-chamber, and long- and short-axis areas in free jets correlated well with regurgitant fraction (r = 0.81, p < 0.001), better with peak flow rate (r = 0.94, p < 0.001), effective regurgitant orifice (r = 0.92, p < 0.001) and momentum (r = 0.94, p < 0.001). The correlation was worse, but still significant, in wall jets. For the same peak flow rate, wall jets were 75% of the size of a corresponding free jet. Jet area measurement is a good semiquantitative tool to measure tricuspid regurgitation in free jets, which correlates well with regurgitant fraction and better with new parameters available from analysis of the proximal acceleration field. In patients with eccentrically directed wall jets the correlation with planimetered jet area was worse, but still significant.
Adult↗
A new integrated system for three-dimensional echocardiographic reconstruction: development and validation for ventricular volume with application in human subjects.
OBJECTIVES: The purpose of this study was to improve three-dimensional echocardiographic reconstruction by developing an automated mechanism for integrating spark gap locating data with corresponding images in real time and to validate use of this mechanism for the measurement of left ventricular volume. BACKGROUND: Initial approaches to three-dimensional echocardiographic reconstruction were often limited by inefficient reconstructive processes requiring manual coordination of two-dimensional images and corresponding spatial locating data. METHODS: In this system, a single computer overlays the binary-encoded positional data on the two-dimensional echocardiographic image, which is then recorded on videotape. The same system allows images to be digitized, traced, analyzed and displayed in three dimensions. This system was validated by using it to reconstruct 11 ventricular phantoms (19 to 271 ml) and 11 gel-filled excised ventricles (21 to 236 ml) imaged in intersecting long- and short-axis views and by apical rotation. To measure cavity volume, a surface was generated by an algorithm that takes advantage of the full three-dimensional data set. RESULTS: Reconstructed cavity volumes agreed well with actual values: y = 0.96x + 2.2 for the ventricular phantoms in long- and short-axis views (r = 0.99, SEE = 2.7 ml); y = 0.95x + 2.9 for the phantoms, reconstructed by apical rotation (r = 0.99, SEE = 2.7 ml); and y = 0.99x + 0.11 ml for the excised ventricles (reconstructed in long- and short-axis views; r = 0.99, SEE = 5.9 ml). The mean difference between three-dimensional and actual volumes was 3% of the mean (3.0 ml) for the phantoms and 6% (4.6 ml) for the excised ventricles. Observer variability was 2.3% for the phantoms and 5.6% for the excised ventricles. Application to 14 normal subjects demonstrated feasibility of left ventricular reconstruction, which provided values for stroke volume that agreed well with an independent Doppler measure (y = 0.97x + 0.94; r = 0.95, SEE = 3.2 ml), with an observer variability of 4.9% (2.4 ml). CONCLUSIONS: A system has therefore been developed that automatically integrates locating and imaging data in no more time than the component two-dimensional echocardiographic scans. This system can accurately reconstruct ventricular volumes in vitro over a wide range and is feasible in vivo, thus laying the foundation for further applications. It has increased the efficiency of three-dimensional reconstruction and enhanced our ability to address clinical and research questions with this technique.
Adult↗
Automated flow rate calculations based on digital analysis of flow convergence proximal to regurgitant orifices.
OBJECTIVES: The purpose of the study was to develop and validate an automated method for calculating regurgitant flow rate using color Doppler echocardiography. BACKGROUND: The proximal flow convergence method is a promising approach to quantitate valvular regurgitation noninvasively because it allows one to calculate regurgitant flow rate and regurgitant orifice area; however, defining the location of the regurgitant orifice is often difficult and can lead to significant error in the calculated flow rates. To overcome this problem we developed an automated algorithm to locate the orifice and calculate flow rate based on the digital Doppler velocity map. METHODS: This algorithm compares the observed velocities with the anticipated relative velocities, cos psi/2 pi r2. The orifice is localized as the point with maximal correlation between predicted and observed velocity, whereas flow rate is specified as the slope of the regression line. We validated this algorithm in an in vitro model for flow through circular orifices with planar surroundings and a porcine bioprosthesis. RESULTS: For flow through circular orifices, flow rates calculated on individual Doppler maps and on an average of eight velocity maps showed excellent agreement with true flow, with r = 0.977 and delta Q = -3.7 +/- 15.8 cm3/s and r = 0.991 and delta Q = -4.3 +/- 8.5 cm3/s, respectively. Calculated flow rates through the bioprosthesis correlated well but underestimated true flow, with r = 0.97, delta Q = -10.9 +/- 12.5 cm3/s, suggesting flow convergence over an angle > 2 pi. This systematic underestimation was corrected by assuming an effective convergence angle of 212 degrees. CONCLUSIONS: This algorithm accurately locates the regurgitant orifice and calculates regurgitant flow rate for circular orifices with planar surroundings. Automated analysis of the proximal flow field is also applicable to more physiologic surfaces surrounding the regurgitant orifice; however, the convergence angle should be adjusted. This automated algorithm should make quantification of regurgitant flow rate and regurgitant orifice area more reproducible and readily available in clinical cardiology practice.
Algorithms↗
Application of color Doppler flow mapping to calculate effective regurgitant orifice area. An in vitro study and initial clinical observations.
BACKGROUND: Analogous to stenotic valve area in the assessment of valvular stenosis, regurgitant orifice area (ROA) represents a fundamental parameter to assess valvular insufficiency. However, this parameter has not been routinely available up to now. In this study, we introduce the concept and provide the methodology to calculate regurgitant orifice area noninvasively, based on the analysis of the proximal flow convergence zone. METHODS AND RESULTS: In an in vitro study, we showed the feasibility and the accuracy of calculating effective ROA by the proximal flow convergence method throughout a range of driving pressures. The calculated and true ROA showed an excellent correlation with r = .992, delta ROA = -1.4 +/- 2.9 mm2. We then applied this concept clinically in 77 patients with mitral regurgitation and showed a very good correlation between effective ROA calculated by the proximal flow convergence method and calculated by the Doppler echocardiographic method: r = .95, delta ROA = -0.2 +/- 3.9 mm2. The ROA also correlated very well with Doppler echocardiographic-derived regurgitant stroke volume (r = .93) and regurgitant fraction (r = .82). In a subgroup of 20 patients who underwent invasive evaluation, the calculated effective ROA also correlated well with the angiographic grade of mitral regurgitation (rho = .81). CONCLUSIONS: We conclude that effective ROA represents unique information on the severity of a regurgitant lesion and can easily be calculated by the proximal flow convergence method. This new parameter should enhance our understanding and improve the serial assessment of valvular regurgitation.
Blood Flow Velocity↗
Three-dimensional echocardiography. In vivo validation for left ventricular volume and function.
BACKGROUND: Current two-dimensional quantitative echocardiographic methods of volume assessment require image acquisition from standardized scanning planes. Left ventricular volume and ejection fraction are then calculated by assuming ventricular symmetry and geometry. These assumptions may not be valid in distorted ventricles. Three-dimensional echocardiography can quantify left ventricular volume without the limitations imposed by the assumptions of two-dimensional methods. We have developed a three-dimensional system that automatically integrates two-dimensional echocardiographic images and their positions in real time and calculates left ventricular volume directly from traced endocardial contours without geometric assumptions. METHODS AND RESULTS: To study the accuracy of this method in quantifying left ventricular volume and performance in vivo, a canine model was developed in which instantaneous left ventricular volume can be measured directly with an intracavitary balloon connected to an external column. Ten dogs were studied at 84 different cavity volumes (4 to 85 cm3) and in conditions of altered left ventricular shape produced by either coronary occlusion or right ventricular volume overload. To demonstrate clinical feasibility, 19 adult human subjects were then studied by this method for quantification of stroke volume. Left ventricular volume, stroke volume, and ejection fraction calculated by three-dimensional echocardiography correlated well with directly measured values (r = .98, .96, .96 for volume, stroke volume, and ejection fraction, respectively) and agreed closely with them (mean difference, -0.78 cm3, -0.60 cm3, -0.32%). In humans, there was a good correlation (r = .94, SEE = 4.29 cm3) and agreement (mean difference, -0.98 +/- 4.2 cm3) between three-dimensional echocardiography and Doppler-derived stroke volumes. CONCLUSIONS: Three-dimensional echocardiography allows accurate assessment of left ventricular volume and systolic function.
Adult↗
[The toxic shock syndrome versus the adult Kawasaki syndrome. The diagnostic difficulties].
The case of a 18-year-old woman with the toxic shock syndrome (TSS) associated to a staphylococcal infection in the maxillary sinus is presented. The initial course of the disease was clinically superposed to a Kawasaki syndrome (KS). Both entities, of purely clinical diagnosis, possess many common elements occasionally making differentiation extremely difficult. The clinical data that may orient diagnosis to one of the processes was analyzed. Finally, it is emphasized that the paranasal sinus must be considered as an occult foci in those cases of TSS in which there is no apparent foci of infection.
Adolescent↗
Quantification of mitral regurgitation with the proximal flow convergence method: a clinical study.
Accurate quantitation of valvular incompetence remains an important goal in clinical cardiology. It has been shown previously that when color flow Doppler mapping is used, simple measurements of apparent jet size do not correlate closely with regurgitant flow rate and regurgitant fraction. Recently the proximal flow convergence method has been proposed to quantify valvular regurgitation by analysis of the converging flow field proximal to a regurgitant lesion. Flow rate Q can be calculated as Q = 2 pi r2v(a), where v(a) is the aliasing velocity at a distance r from the orifice. In 54 patients (43 with sinus rhythm and 11 with atrial fibrillation) who had at least mild mitral regurgitation according to semiquantitative assessment, regurgitant stroke volume, regurgitant flow rate, and regurgitant fraction were calculated with the proximal flow convergence method and compared with values that were obtained by the Doppler two-dimensional echocardiographic method. Regurgitant stroke volumes (Vr) as calculated by the proximal flow convergence method correlated very closely with values that were obtained by the Doppler two-dimensional method, with r = 0.93 (y = 0.95x + 0.55) and delta Vr = -0.3 +/- 4.0 cm3. Regurgitant flow rates (Q) as calculated by both methods showed a similar correlation: r = 0.93 (y = 0.95x + 54) and delta Q = -34 +/- 284 cm3/min. The correlation for regurgitant fraction (RF) as calculated by both techniques showed r = 0.89 (y = 0.98x + 0.006) and delta RF = -0.005 +/- 0.06. All correlations were slightly better for the group of patients with sinus rhythm than for the study group of patients with atrial fibrillation.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Painful ophthalmoplegia associated with infectious mononucleosis].
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Adult↗
[Multi-infarct dementia in giant cell arteritis (temporal arteritis)].
Dementia is an infrequent and little known manifestation of giant cell arteritis or temporal arteritis (GCA-TA). The cases of 2 women with histologically proven GCA-TA are presented in which, together with the most classical symptoms, they presented a brusque mental deterioration on initiation of the disease. One patient developed a severe irreversible dementia which coincided with a rapid reduction in the doses of corticoids; while the other patient demonstrated improvement in cognitive function with steroid treatment and control of the disease. Magnetic resonance studies revealed multiple areas of infarction in both hemispheres in the two patients. The importance of treating multi-infarct dementia is underlined in the context of GCA-TA with high doses of corticoids. It is also emphasized that GCA-TA should be considered in the evaluation of older patients with mental alterations.
Aged↗
[Leukemoid reaction and thrombocytosis in sarcoidosis].
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Humans↗