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Ankylosing spondylitis

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ESPONDILOARTROPATIAS SERONEGATIVAS/ ESPONDILITIS ANQUILOSANTE

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Ankylosing spondylitis

  1. 1. MD OLMOS TUFIÑO ROSA R2 PG MI
  2. 2. Ankylosing spondylitis Reiter's syndrome (reactive or arthritis) Arthropathy of inflammatory bowel disease (Crohn's disease, ulcerative colitis) Psoriatic arthritis Undifferentiated spondyloarthropathies Juvenile chronic arthritis and ankylosing spondylitis of juvenile onset Spondyloarthropathies
  3. 3. Angkylos and spondylos Is a chronic inflammatory disease associated with the human leukocyte antigen (HLA-B27) Extra-articular Manifestations DEFINITION
  4. 4. In 1666-1698 Bernard Corner By Waters : 1693- 1824 1824 -1885 1897 -1931 1936 - 1950 In 1850, Brodie In 1896, Roentgen had discovered the radiographic technique; but 1930 History
  5. 5. BEFORE Y AFTER 1950 LUMPERS SPLITTERS 1963 SAR SA- ES-AP, SR NOT KNOWN ETIOLOGY History
  6. 6. 1968 BERNAR AMOR SPA- S. REITER , COMMON GENETIC BASIS 1970: spondyloarthropathy Moll et al: seronegative spondyloarthropathy History
  7. 7. Servicio de Rhumatologie, universitaire hopital Reina Sofía, departamento de Médecine, Université de Cordoue, Córdoba, España. Joint Bone Spine (factor de impacto: 2,75). 02/2000; 67 (6): 516-20.Fuente: PubMed Recomendación 12. No se recomiendan los criterios de ESSG ni los de Amor para la clasificación de las EsA [2b, B, 74,3%].
  8. 8. Spondyloarthropathies seronegative
  9. 9. Predisposition in certain population groups, such as American Indians or tribes near the Arctic Europe 0.3 or 1.8% of the population In Japan 0.3 to 6.9 in Finland and 7.3 in USA per people 100,000 / year Mexico is 0.9% among general Caucasian 0.05% prevalence of HLA-B27, around 2.5% Epidemiology
  10. 10. Males (3 to 5 times more) Onset after 50 years is exceptional Epidemilogy
  11. 11. Multifactorial Genetic factors : CMH HLA-B27 16% Immune Hypothesis FNT & HLA BW22-B40-B42- B16 Environmental factors: K. pneumonia, Shiguella,Y. enterocolitica Hypothesis arthritogenic Etiology
  12. 12. HLA B- 27 ------- CMH CLASE I ETIOLOGY
  13. 13. ETIOLOGY
  14. 14. Hypothesis I: molecular mimicry between arthritogenic bacteria and HLA-B27------ A Hypothesis b: Arthritogenic Etiology
  15. 15. THE ROLE OF T CELLS Etiology
  16. 16. FOLDING INSUFFICIENT HLA B-27 Formation of a misfolded form of HLA-B27 within the endoplasmic reticulum of an antigen-presenting cell and the elicitation of stress and proinflammatory responses ETIOLOGY
  17. 17. Homodimers on the cell surface and noncanonical recognition of HLA-B27 Generation of additional forms of HLA-B27, such as free heavy chains and dimers on the cell surface, and their interactions with T cells, natural killer cells and antigen-presenting cells. ETIOLOGY
  18. 18. - L T CD8 AND PRESENTATION OF THE SURFACE ANTIGENS OF HLA B27 A DECREASEDTHE AMOUNT DUE EXPLANATION OF PATHOPHYSIOLOGY A NEW KNOWLEDGE - ANY OTHERTHEORY EXCLUDES AND CAN NOT EVEN EXPLAINTHE PATHOGENESIS Conclusions
  19. 19. PATHOLOGICAL ANATOMY
  20. 20. ENTHESITIS EVOLVES A FIBROSIS AND OSSIFICATION JOINT INJURIES EARLYTHRUST: DISCITIS - sacroiliitis LATE THRUST: SYNDESMOPHYTES INJURY AP EXTRAARTICULAR ENTESOPATICAS EYE CARDIOVASCULAR PULMONARY SKIN MUCOUS PATHOLOGICAL ANATOMY
  21. 21. ENTHESITIS SYNDESMOPHYTES SQUARING VERTEBRAL BODIES PLATFORMSVERTEBRAL DESTRUCTION ACHILLESTENDINITIS PATHOLOGICAL ANATOMY
  22. 22. PATHOLOGICAL ANATOMY
  23. 23. PATHOLOGICAL ANATOMY
  24. 24. Clinical manifestations skeletal Clinical manifestations extraskeletal Diagnostic criteria Physical examination CLINICAL MANIFESTATIONS
  25. 25. INFLAMMATORY BACK PAIN CHEST PAIN SENSITIVITYTENDERTO PALPACION JOINT MANIFESTATIONS EXTRAAXIALIES CLINICAL MANIFESTATIONS SKELETAL
  26. 26. Clinical history as a screening test for ankylosing spondylitis A controlled study of 138 subjects demonstrated that the clinical history may be sensitive (95%) and specific (85%) in the differential diagnosis of ankylosing spondylitis when reliance of five specific historic features is made. Back pain that is insidious in onset, in a patient younger than 40 years, persisting for at least three months, associated with morning stiffness and improving with exercise is characteristic of inflammatory spinal disease INFLAMMATORY BACK PAIN
  27. 27. Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria We assessed the clinical history of 213 patients (101 with AS and 112 with MLBP) younger than 50 years who had chronic back pain. Single clinical parameters and combinations of parameters were compared between the AS and MLBP patient groups. ASAS IBP criteria mnemonic for criteria “Ipain S: 77% E 91.7% CB: > E < S CC: > S < E Ozgocmen S, Akgul O, Khan MA. Mnemotécnico para la evaluación de los criterios de la sociedad internacional espondiloartritis. J Rheumatol. 2010; 37 :. 1978 CRITERIA BERLIN
  28. 28. DIFFERENTIAL DIAGNOSIS
  29. 29. PLEURITIC PAIN TENDERNESS IN FAMILIES WITH HLA B.27 (+) IN ABSENCE OF SACROILETITIS CHEST PAIN
  30. 30. FREQUENTLY COSTOSTERNAL UNIONS SPINOUS PROCESSES ILIAC CRESTS GREATERTROCHANTERS ISCHIALTUBEROSITIES TIBIALTUBERCLES AND HEELS SENSITIVITYTENDERTO PALPACION
  31. 31. HIPS KNEES FEET JOINT MANIFESTATIONS EXTRAAXIALIES
  32. 32. EYE CARDIAC INTESTINAL PULMONARY NEUROLOGICAL RENAL SECONDARY OSTEOPOROSIS Extra-articular Manifestations
  33. 33. PULMONARY DISEASE: PULMONARY FUNCTION DISORDERS: LIMITED PULMONARY FIBROSIS INJURY PLEUROPULMONARY PATHOLOGYVAVULAR LOCK A-V CARDIOVASCULAR RISK NSAID NEPHROPATHY, IGA, AMILOISE DEPOSIT (RENAL AMYLOIDOSIS) INTESTINAL ULCERATIVECOLITIS DISEASE CROHN 2-6% RECURRENT UNILATERAL UVEITIS 95% HLA B27+ NEUROLOGICAL MANIFESTATIONS: HORSETAIL SYNDROME SPINE FRACTURES ROOT INJURYSECONDARY OSTEOPOROSIS
  34. 34. PHYSICAL EXAMINATION
  35. 35. PHYSICAL EXAMINATION
  36. 36. LATERAL BENDINGTHE COLUMN
  37. 37. PHYSICAL EXAMINATION TEST SCHOBER
  38. 38. INTERMALLEOLAR DISTANCE
  39. 39. PHYSICAL EXAMINATION
  40. 40. PHYSICAL EXAMINATION
  41. 41. PHYSICAL EXAMINATION sacroiliitis
  42. 42. PCR VSG ALKALINE PHOSPHATASE NORMOCHROMIC NORMOCYTIC ANEMIA LABORATORYTESTS
  43. 43. RADIOLOGICAL IMAGES
  44. 44. RADIOLOGICAL IMAGES
  45. 45. RADIOLOGICAL IMAGES
  46. 46. RADIOLOGICAL IMAGES: ARTHRITIS PERIFERICA
  47. 47. RADIOLOGICAL IMAGES: ENTHESITIS I-M
  48. 48. RADIOLOGICAL IMAGES
  49. 49. RADIOLOGICAL IMAGES SACROILIITIS ASAS ACUTE INFLAMMATORY INJURY EDEMA OSEO - OSTEITIS SYNOVITIS ENTHESITIS CAPSULITIS STRUCTURAL DAMAGE SUBCHONDRAL SCLEROSIS EROSION BONE MARROW FAT DEPOSITS PERIARTICULAR BRIDGES AND BONE ANCHYLOSIS
  50. 50. SACROILIITIS ASAS - EDEMA OSEO - OSTEITIS
  51. 51. SACROILIITIS ASAS. EDEMA OSEO - OSTEITIS
  52. 52. SACROILIITIS ASAS. SYNOVITIS
  53. 53. SACROILIITIS ASAS - ENTHESITIS
  54. 54. SACROILIITIS ASAS - CAPSULITIS
  55. 55. STRUCTURAL DAMAGE SUBCHONDRAL SCLEROSIS
  56. 56. EROSION
  57. 57. BONE MARROW FAT DEPOSITS PERIARTICULAR
  58. 58. BRIDGES AND BONE ANCHYLOSIS
  59. 59. DIAGNOSIS
  60. 60. DIAGNOSIS Recomendación 12. No se recomiendan los criterios de ESSG ni los de Amor para la clasificación de las EsA [2b, B, 74,3%].
  61. 61. 1. SUSPECT DIAGNOSED 2. EARLY DIAGNOSIS: 2. PROGRAM ESPERANZA ( ESPAÑA) 3. ESPIDEP ( GERMANY) DIAGNOSIS
  62. 62. DIAGNOSIS
  63. 63. DIAGNOSIS
  64. 64. DIAGNOSIS . CRITERIA ASAS M Rudwaleit1 D van der Heijde2 R Landewé3 N Akkoc4 J Brandt5 C T Chou6 M Dougados7 F Huang8 J Gu9 Y Kirazli10 F Van den Bosch11 I Olivieri12 E Roussou13 S Scarpato14 I J Sørensen15 R Valle-Oñate16 U Weber17 J Wei18 J Sieper
  65. 65. Area Domain Measurement / Instrument ACTIVITY (General and nightly) spinal pain Horizontal scale with numerical descriptors (1-10) Patient global assessment Horizontal scale with numerical descriptors (1-10) BASDAI Overall rating of health Horizontal scale with numerical descriptors (1-10) fatigue Horizontal scale with numerical descriptors (1-10) joint count Count of 44, 78/76 or 68/66 or 28 joints enthesitis Validated index (MASES, San Francisco, Berlin, etc) dactylitis Present / absent and acute / chronic Acute phase reactants ESR,CRP spinal Stiffness Horizontal scale with numerical descriptors (1-10)
  66. 66. Area Domain Measurement / Instrument Function spinal mobility chest expansion Test Schöber Occiput-wall distance cervical rotation Lateral flexion of the spine BASMI General function BASFI HAQ structural Damage X-ray Based on the criteria of NewYork Scale (sacroiliac joints) mSASSS (column) or BASRI (spine and hip) ASspiMRI
  67. 67. EVALUATION ACTIVITY
  68. 68. EVALUATION ACTIVITY
  69. 69. EVALUATION ACTIVITY Patient global assessment
  70. 70. joint count
  71. 71. enthesitis
  72. 72. EVALUATION OF ACTIVITY- BASDAI
  73. 73. ACTIVITY CRITERIA AND REFERRAL ASDAS Lukas et al. Ann RheumDis 2009;68:18-24 van derHeiijdeD et al. Ann Rheum Dis. 2008 Dec 5. [Epubahead of print]
  74. 74. ASDAS Lukas et al. Ann RheumDis 2009;68:18-24 van derHeiijdeD et al. Ann Rheum Dis. 2008 Dec 5. [Epubahead of print]
  75. 75. BASFI
  76. 76. BASMI
  77. 77. BASMI
  78. 78. BASMI
  79. 79. IDF
  80. 80. Simple radiology
  81. 81. BASRI
  82. 82. MSASSS
  83. 83. EVALUATION OF ACTIVITY AS-sspiRMI
  84. 84. 1. PHYSICAL REHABILITATION 2. PHARMACOLOGICAL THERAPY DMARD NSAIDs BIOLOGICAL NEW DRUGS 3. MEASURING INSTRUMENTSTREATMENT RESPONSE 1. BASDAI 2. ASA 20 3. ASS40 4. ASAS BETTER PART 5. ASDAS TREATMENT
  85. 85. ASAS20 AINES
  86. 86. BIOLOGICOS ASAS40
  87. 87. 1. FRONTLINE NSAIDS COX-2 INHIBITORS 2. SECOND LINE METHOTREXATE: NO EVIDENCE STEROIDS SULFASALAZINE 3. BIOLOGICAL: TNF INHIBITORS 4. ALTERNATIVETHERAPIES ABATACEPT INHIBITINGT CELL COSTIMULATION (CTLA-4Ig) THE IL-1 RECEPTOR ANTAGONIST ANAKINRA HAS BEEN STUDIED IN PATIENTS WITH AS APREMILAST IS A PHOSPHODIESTERASE-4 TALIDOMIDA INHIBITING DE FNT RITUXIMAB INHIBITING C20 TOCILIZUMAB MONOCLONAL ANTIBODY DESIGNEDTO INHIBIT BOTH SIGNALS THROUGHTHE MEMBRANE AND SOLUBLE IL-6R TREATMENT
  88. 88. EFFICIENCY SHORT AND LONG TERM INFLIXIMAB 5 mg/kg 0-2-6 y 8 RESPONSE VARIABLE 37-67% ADALIMUMAB 40 mg c/ 2 s ASAS 40 IMPROVEMENT CRITERIA OF 54% VS 12.5 PLACEBO GROUP ETANERCEP 25 MG SC 2 V X S BASDAI 66.1% IMPROVEMENT IN RELATION TO PLACEBO GROUP 50% GOLIMUMAB 50-100 mg 1 v/ moth IMPROVEMENT CRITERIA ASAS 40% IN RELATION TO 12% OF PLACEBO BIOLOGICAL: TNF INHIBITORS
  89. 89. A historical perspective of the spondyloarthritis Henning Zeidlera, Andrei Calinb and Bernard Amorc Current Opinion in Rheumatology 2011, 23:327–333 Hospital Clinicoquirúrgico Intermunicipal "Mártires del 9 de Abril «www.ncbi.nlm.nih.gov/pubmed/21519270 PATOGENIA DE LAS ESPONDILOARTROPATÍAS SERONEGATIVAS Dr. Modesto González Cortiñas Rev Cubana Med 1998;37(1):28-35 Genetic aspects of susceptibility, severity, and clinical expression in ankylosing spondylitis Matthew A. Brown, MB, BS, MD, FRACP, Alison M. Crane, PhD, and B. Paul Wordsworth, MRCP Current Opinion in Rheumatology 2002, 14:354–360 Pathogenesis of ankylosing spondylitis and reactive arthritis Tae-Hwan Kima, Wan-Sik Uhma and Robert D. Inman Curr Opin Rheumatol 17:400—405. ª 2005 Lippincott Williams & Wilkins. Classification criteria for spondyloarthropathies Published online: December 18, 2012. www.wjgnet.com REFERENCES
  90. 90. http://www.asas-group.org/mission-statement.php http://www.ser.es/practicaClinica/espoguia/espondilitis_anquilosante_6/evaluacion.php Servicio de Rhumatologie, universitaire hopital Reina Sofía, departamento de Médecine, Université de Cordoue, Córdoba, España. Joint Bone Spine (factor de impacto: 2,75). 02/2000; 67 (6): 516-20.Fuente: PubMed HLA-B27, arthritis and spondylitis in an isolated community in Papua New Guinea. Br J Rheumatol. 1990 Apr;29(2):97-100. González-Rodríguez M y cols. 2013 mexico Sociedad Española de Reumatologia Guias Espondiloartritis 2009 Ariza-Ariza R, Hernandez-Cruz B, Navarro-Sarabia F. Physical function and health-related quality of life of Spanish patients with ankylosing spondylitis. Arthritis Rheum. 2003 Aug 15;49(4):483-7. REFERENCES
  91. 91. Manifestaciones extraarticulares y complicaciones de la espondiloartritis anquilosante J. Gratacós Unidad de Reumatología. Hospital de Sabadell. Institut Universitari ParcTaulí. Universidad Autónoma de Barcelona. Sabadell. Barcelona España. 2009. Mecanismos de la enfermedad: la inmunopatogénesis de espondiloartropatías Colina Gaston Naturaleza de Práctica Clínica de Reumatología (2006) 2 , 383-392 doi : 10.1038 / ncprheum0219 Las espondiloartropatias seronegativas: interacción entre la genética y el entorno (entrevista). Documento Ciba-Geigy 1990;(4):5-7 .-The contribution of genes outside the major histocompatibility complex to susceptibility to ankylosing spondylit KELLEY REUMATOLOGIA CLINICA VII EDICION Inflammatory back pain in ankylosing spondylitis: a reassessment of the clinical history for application as classification and diagnostic criteria. Ozgocmen S, Akgul O, Khan MA. Mnemotécnico para la evaluación de los criterios de la sociedad internacional espondiloartritis. J Rheumatol. 2010; 37 :. 1978 Osteoporosis and vertebral fractures in ankylosing spondylitis Piet Geusensa,b, Debby Vossea and Sjef van der Lindena Current Opinion in Rheumatology 2007, 19:335–339 Cardiovascular risks in spondyloarthritides Sylvia Heeneman and Mat J.A.P. Daemen Current Opinion in Rheumatology 2007, 19:358– 362 REFERENCES
  92. 92. Classification criteria for spondyloarthropathies Ozgur Akgul, Salih Ozgocmen, Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Erciyes University, Gevher Nesibe Hospital, 38039 Kayseri,Turkey Author contributions: Akgul O and Ozgocmen S collectively reviewed the literature and drafted the manuscript. 2011 December 18; 2(12): 107-115 Online Submissions: http://www.wjgnet.com/2218-5836office Diagnóstico precoz de espondiloartritis Juan Mulero Mendoza Servicio de Reumatología. Hospital Puerta de Hierro. Madrid. España. Reumatol Clin. 2007;3 Supl 2:S15-8 15 Diagnostico precoz de las espondiloartropatı´as en Espan˜a: el programa ESPeranza Cristina Ferna´ndez Carballido, en nombre del Grupo ESPeranza Hospital General de Elda, Alicante, Espan˜a 1699-258X/$ - see front matter & 2009 Elsevier Espan˜ a, S.L.Todos los derechos reservados. doi:10.1016/j.reuma.2009.12.005 www.reumatologiaclinica.org REFERENCES
  93. 93. How to measure disease activity in axial spondyloarthritis? Pedro Machadoa,b and De´sire´e van der Heijdea Current Opinion in Rheumatology 2011, 23:339–345 How should we diagnose spondyloarthritis according to the ASAS classification criteria A guide for practicing physicians Rosaline van den Berg, Désirée M.F.M. van der Heijde University Medical Centre, Leiden, The Netherlands Pol Arch Med Wewn. 2010; 120 (11): 452-458 Copyright by Medycyna Praktyczna, Kraków 2010 How to diagnose axial spondyloarthritis early M Rudwaleit 1 ,Van der Heijde D 2 ,MA Khan 3 ,J Braun 4 , J Sieper 1 Afiliaciones de los autores 1 Reumatología, Departamento de Medicina I, Charité-Campus Benjamin Franklin, Berlín, Alemania 2 Reumatología, Instituto de Investigación CAPHRI, Universidad de Maastricht, Países Bajos 3 Universidad Case Western Reserve, MetroHealth Medical Center, Cleveland, Ohio, EE.UU. 4 Rheumazentrum Cuenca del Ruhr, Herne, Alemania Correspondencia a: Dr. M Rudwaleit Medizinische Klinik I, Charité-Campus Benjamin Franklin, Hindenburgdamm 30, 12200 Berlín, Alemania; martin.rudwaleit@charite.de Aceptado 17 de octubre 2003 Comparison of statistically derived ASAS improvement criteria for ankylosing spondylitis with clinically relevant improvement according to an expert panel A van Tubergen, D van der Heijde, J Anderson, R Landewé, M Dougados, J Braun, N Bellamy, G Udrea, Sj van der Linden, for the ASAS Working Group Ann Rheum Dis 2003;62:215–221 Nuevos criterios ASAS para el diagnóstico de espondiloartritis.Diagnóstico de sacroileítis por resonancia magnéticaM.E. Banegas Illescas∗, C. López Menéndez, M.L. Rozas Rodríguez yR.M. Fernández Quintero Servicio 0033-8338/$ – see front matter © 2013 SERAM. Publicado por Elsevier España, S.L. Todos los derechos reservados. http://dx.doi.org/10.1016/j.rx.2013.05.004 http://www.airemb.es/es/profesionales/investigacion/herramientas/calculadoras/item/72-calculadora-asdas.html The Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis J Sieper, M Rudwaleit, X Baraliakos, J Brandt, J Braun, R Burgos-Vargas, M Dougados, K-G Hermann, R Landewé, W Maksymowych and D van der Heijde Ann Rheum Dis 2009;68;ii1-ii44 http://ard.bmj.com/cgi/content/full/68/Suppl_2/ii1 REFERENCES
  94. 94. Assessment and treatment of ankylosing spondylitis: current status and future directions Jane Zochling Current Opinion in Rheumatology 2008, 20:398–403 Assessment and treatment of ankylosing spondylitis: current status and future directions. Jane Zochling Current Opinion in Rheumatology 2008, 20:398–403 The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part II): validation and final selection M Rudwaleit,1 D van der Heijde,2 R Landewe´,3 J Listing,4 N Akkoc,5 J Brandt,6 J Braun,7 C T Chou,8 E Collantes-Estevez,9 M Dougados,10 F Huang,11 J Gu,12 M A Khan,13 Y Kirazli,14 W P Maksymowych,15 H Mielants,16 I J Sørensen,17 S Ozgocmen,18 E Roussou,19 R Valle-On˜ate,20 U Weber,21 J Wei,22 J Sieper1,23 Ann Rheum Dis 2009;68:777–783. doi:10.1136/ard.2009.108233 http://ard.bmj.com/ MRI in ankylosing spondylitis Walter P. Maksymowych Current Opinion in Rheumatology 2009,21:313–317 Radiografı´a convencional: BASRI total y SASSS Isabel Castrejo´n Ferna´ndez a,_ y Jesu´ s Sanz Sanz b a Servicio de Reumatologı´a, Hospital Universitario La Princesa, Madrid, Espan˜a b Servicio de Reumatologı´a, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Espan˜a 1699-258X/$ - see front matter & 2009 Elsevier Espan˜ a, S.L. Todos los derechos reservados. doi:10.1016/j.reuma.2009.12.003 New therapeutic approaches for spondyloarthritis Augustine M. Manadana, Neena Jamesb and Joel A. Block Curr Opin Rheumatol 19:259–264. _ 2007 Lippincott Williams & Wilkins. aJohn H. Stroger Hospital of Cook County and Rush University Medical Center, Chicago, Illinois, USA, bRush University Medical Center, Chicago, Illinois, USA and cSection of Rheumatology, Rush University Medical Center, Chicago, Illinois, USA Management and treatment of ankylosing spondylitis Jane Zochling and Ju¨ rgen Braun Curr Opin Rheumatol 17:418—425. ª 2005 Lippincott Williams & Wilkins. Rheumazentrum-Ruhrgebiet, St.Josefs-Krankenhaus, Landgrafenstr. 15, 44652 Herne, Germany Rehabilitation in ankylosing spondylitis Francine Ton Nghiem and John Patrick Donohue Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA Correspondence to Francine Ton Nghiem, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215, USA Current Opinion in Rheumatology 2008, 20:203–207 REFERENCES

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