scholarly journals Surgical treatment of ishemic mitral regurgitation: Repair, replacement or revascularization alone?

2010 ◽  
Vol 138 (7-8) ◽  
pp. 425-429
Author(s):  
Mile Vranes ◽  
Milos Velinovic ◽  
Mladen Kocica ◽  
Aleksandar Mikic ◽  
Svetozar Putnik ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Nyha Class ◽  
Heart Association ◽  
Long Term Results ◽  
Surgical Approaches ◽  
Mitral Insufficiency ◽  
Class Iii ◽  
Group Iii ◽  
Group I ◽  
Group Ii

Introduction. Treatment of ischemic mitral regurgitation in patients that require revascularization of myocardium is still debatable. Objective. The aim of this study was to compare three surgical approaches: valve repair and revascularization; valve replacement and revascularization, and revascularization alone. Methods. In 2006 and 2007 at the Institute for Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade, 1,040 patients with coronary disease underwent surgery. Forty-three patients (4.3%) had also mitral insufficiency 3-4+. The patients were examined clinically, echocardiographically and haemodynamically. In group I there were 14 (32.3%) patients, in group II 16 (37.2%) patients and in group III 3 (30.5%) patients. Ninetythree per cent of patients were classified as New York Heart Association (NYHA) class III and IV, and three (7%) patients had congestive heart weakness with ejection fraction ?30%. The decision as to surgical procedure was made by the surgeon. Postoperatively, patients were checked clinically and echocardiographically after 3, 6 and 12 months. The follow-up period was approximately 15 months (8-20). Results. Hospital mortality for the whole group was 6.9% (3 patients). In group I mortality was 14.2% (2 patients), in group II 6.25% and in group III there was no mortality. Long term results, up to 15 months, showed 100% survival in groups I and II, and in group III one patient died (7.7%). Conclusion. Short term results up to 30 days were best in group III, but longer term results were better in groups I and II.

scholarly journals The Long-Term Results of ReLEX® SMILE Depending on the Degree of the Corrected Myopia

2020 ◽  
Vol 17 (4) ◽  
pp. 711-718
Author(s):  
O. A. Klokova ◽  
R. O. Damashauskas ◽  
S. V. Kostenev ◽  
E. N. Kalaidin
Keyword(s):  
Visual Acuity ◽  
Laser System ◽  
Study Groups ◽  
Individual Characteristics ◽  
Long Term Results ◽  
Efficiency Coefficient ◽  
Group Iii ◽  
Group I ◽  
Group Ii

The purpose: prospective study of the long-term refractive and visual results of ReLEx® SMILE, depending on the degree of corrected myopia.Material and methods. The three study groups included 71 patients; the mean age was 26.48 ± 5.5 years. Group I consisted of 20 patients (39 eyes) mean SE –2.62 ± 0.87 D, group II — 26 patients (51 eyes), mean SE 4.68 ± 0.74 D, Group III — 25 patients (47 eyes), mean SE 6.88 ± 0.72 D. All patients underwent femtolaser correction of myopia using the ReLEx® SMILE method with the VisuMax™ laser system (Carl Zeiss Meditec AG).Results. Uncorrected visual acuity of 09 — 1.0 was noted in 34 eyes (87.2 %) in group I, in II — in 43 eyes (84.3 %), in 37 eyes (78.7 %) in group III. The efficiency coefficient was 1.0 in groups I — II and 0.89 in group III. There was no decrease in corrected visual acuity (CVA) during the correction of mild and moderate myopia, in group III it was recorded by 0.1 in two cases (4 %), by 0.2 in one case (2 %), the safety factor in I — II groups 1.0, in III 0,89. Two years after ReLEx® SMILE, refraction of ± 0.5 D from planned in the study groups was achieved, respectively, in 94.9, 88.2, 76.6 % of cases, ± 1.0 D in 100 % of cases in I, II groups, in 97 % of cases in III group. The predictability coefficient was 0.95 in group I, 0.88 in group II, and 0.77 in group III. Refractive regression compared with the results 1 month postoperatively was 0.08 D in group I, 0.1 D in group II, and 0.16 D in group III. Analysis of the long-term results of ReLEx® SMILE allows us to conclude: the method is safe and effective, provides high predictability of refractive results in correcting various degrees of myopia. Further study of the long-term results of the operation, the creation and use of nomograms, taking into account the individual characteristics of the cornea, will improve the predictability and stability of refractive results in the correction of high myopia. 

scholarly journals Demographic and Clinical Features in Patients with Mitral Insufficiency of Ischemic Genesis

2020 ◽  
pp. 29-32
Author(s):  
S. A. Rudenko ◽  
S. V. Potashev ◽  
A. V. Rudenko
Keyword(s):  
Diabetes Mellitus ◽  
Myocardial Infarction ◽  
Mitral Regurgitation ◽  
Functional Status ◽  
Heart Attack ◽  
Nyha Class ◽  
Ischemic Mitral Regurgitation ◽  
Mitral Insufficiency ◽  
Shortness Of Breath ◽  
Class Iii

Myocardial infarction is often associated with ischemic mitral regurgitation. In most patients, ischemic mitral regurgitation develops gradually due to remodeling of the ischemic myocardium and changes in hemodynamics in the left ventricle. Ischemic mitral regurgitation is associated with heart diseases and mortality and is therefore considered an unfavorable prognostic factor. The aim. To study the features of demographic data and the clinical condition of patients with mitral regurgitation of ischemic genesis. Materials and methods. From January 2012 to December 2019, 292 patients with ischemic mitral insufficiency underwent surgical intervention at the National Amosov Institute of Cardiovascular Surgery of the NAMS of Ukraine. Results and Discussion. Among patients with mitral regurgitation of ischemic genesis, the majority are men (78.8%). Women suffer from this pathology much less often (21.2%). The mean age of patients with mitral regurgitation of ischemic genesis was 61.9 ± 8.2 years. The proportion of patients with hypertension was almost half of the total number of patients. Every fourth patient suffered from diabetes mellitus (25.7%). In this group, 64.1% (187) patients had a history of myocardial infarction. The majority of patients, 49.3% (144), sought surgery after the first myocardial infarction, 11.0% (32) – after the second heart attack, and in 11 (3.8%) mitral regurgitation occurred only after the third heart attack. Shortness of breath complaints were reported in 249 (85.3%) patients. In most cases (61.3%), shortness of breath occurred only during exercise. Another 70 (24.0%) patients suffered from it even at rest. In this group, 55.1% of patients were classified as NYHA class III–IV. The functional status of 57 (19.5%) patients was so impaired that they were classified as NYHA class IV; 23.6% (69) of patients suffered from IIb degree, and one patient from III degree chronic circulatory insufficiency. Conclusions. Mitral regurgitation of ischemic genesis occurs more often in men (78.8%) of working age (61.1 ± 8.4 years). It leads to a significant reduction in functional status (55.1% of patients were classified as NYHA class III–IV) and physical activity (53.8%). Among the comorbidities, hypertension (47.3%) and diabetes mellitus (25.7%) are the most common.

scholarly journals The surgical correction of refractory venous trophic ulcers

2021 ◽  
pp. 38-46
Author(s):  
S. E. Katorkin ◽  
M. J. Kushnarchuk ◽  
M. A. Melnikov ◽  
A. A. Zhukov ◽  
P. F. Kravtsov ◽  
...  
Keyword(s):  
Surgical Treatment ◽  
Comparison Group ◽  
Complete Healing ◽  
Long Term Results ◽  
Group Iii ◽  
Results Of Treatment ◽  
Group I ◽  
Group Ii ◽  
Shave Therapy

Objectives. To study the effectiveness of layered dermatolipectomy and endoscopic fasciotomy in the surgical treatment of refractory venous trophic ulcers.Materials and methods. Patients (n = 105) of the C6 clinical class underwent crossectomy and short stripping. In group I (n = 35), free autodermoplasty of trophic ulcers with a perforated flap was performed. In group II (n = 36), shave therapy and autodermoplasty were performed. In group IIІ (n = 34), fasciotomy, shave therapy and autodermoplasty were performed. Long-term results of treatment were studied in the period from 1 to 12 months.Results. Complete healing of venous trophic ulcers was observed in group I at 49,4 ± 7,2, in II – at 31,4 ± 4,7, in III – at 32,1 ± 3,6 days сутки (t1-2 = 2,09; p1-2 = 0,049; t1-3 = 2,24; p1-3 = 0,024; t2-3 = 0,03; p2-3 = 0,763). Full engraftment of an autograft graft was recorded in 7 (19,4 %) patients of group I, in 27 (77,1 %) cases in group II and in 27 (79,4 %) patients of comparison group III (χ21-2 = 23,674; p1-2 = 0,001; χ21-3 = 25,173; p1-3 = χ22-3 = 0,052; p2-3 = 0,826).Conclusion. Layered dermatolipectomy with autodermoplasty and endoscopic decompression fasciotomy is an effective method for the treatment of persistent refractory venous trophic ulcers.

scholarly journals P749 Echocardiographic risk factors of functional ischemic mitral regurgitation in patients with first acute myocardial infarction

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
J Kochanowski ◽  
R Piatkowski ◽  
P Scislo ◽  
M Budnik ◽  
M Marchel ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Mitral Regurgitation ◽  
Left Ventricular ◽  
Group Iv ◽  
Ischemic Mitral Regurgitation ◽  
Mean Values ◽  
St Segment Elevation ◽  
Group Iii ◽  
Group I ◽  
Group Ii

Abstract Purpose The aim of this study was to assess the correlation between the size of acute functional ischemic mitral regurgitation (FIMR) and selected left ventricle echocardiography measurements in patients (pts) with first ST-segment elevation myocardial infarction (STEMI) treated with effective primary angioplasty (PCI). Methods We analyzed 1578 consecutive hospitalized pts with STEMI (M-914; 66,4 ± 10,2 years) treated with PCI. The echocardiographic examination was performed at up to 3 days after admission. We assessed the frequency and size of FIMR, left ventricular end diastolic diameter (LVEDd), ejection fraction (EF), wall motion score index (WMSI) and systolic sphericity index (Sls). Effective regurgitation orifice area (EROA) was used for quantitative FIMR assessment (mild: <10 mm², moderate: ≥10 and < 20 mm², severe: ≥ 20mm²). The study population was divided into four groups depending on the size of FIMR. Correlation coefficient was used to determine correlations between data sets. Results We observed mild FIMR in 550 pts (34,9%) - group I, moderate in 356 pts (22,5%) - group II, severe in 57 pts (3,6%) - group III, no FIMR in 615 pts (39%) – group IV. Mean values of selected echocardiographic parameters in each analyzed group are shown in table 1. The positive good correlations between SIs and size of FIMR were found (r = 0,68) as well as weak correlations between LVEDd, WMSI and FIMR (ro = 0,25, ro = 0,34, respectively). The negative weak correlation between EF and size of IMR was present (ro = - 0,34). Conclusions 1. FIMR is a common complication in pts with STEMI treated with PCI. 2. We found a statistically significant correlation between SIs and FIMR severity. Table 1 Group I Group II Group III Group IV p LVEDd (cm) 5,22 ± 0,64 5,42 ± 0,56 5,72 ± 0,64 4,98 ± 0,58 NS EF (%) 48 ± 6 42 ± 8 35 ± 8 51 ± 8 NS WMSI 1,34 ± 0,28 1,42 ± 0,24 1,68 ± 0,32 1,32 ± 0,22 NS SIs 0,22 ± 0,1 0,32 ± 0,1 0,68 ± 0,1 0,18 ± 0,1 0,01 NS - non-significant

THE MUMPS ANTIGEN SKIN TEST IN ENDOCARDIAL FIBROELASTOSIS

PEDIATRICS ◽  
1966 ◽  
Vol 37 (3) ◽  
pp. 423-429
Author(s):  
John D. Shone ◽  
Simon Muñoz Armas ◽  
James A. Manning ◽  
John D. Keith
Keyword(s):  
Viral Infection ◽  
Skin Reaction ◽  
Skin Test ◽  
In Utero ◽  
Mumps Virus ◽  
Mitral Insufficiency ◽  
Group Iii ◽  
Test Antigen ◽  
Group I ◽  
Group Ii

Skin testing with mumps virus antigen solution was performed in 50 children with clinically diagnosed primary E.F.E. (Group I), and in 202 children who served as a control group (Group II). A further group of children with congenital mitral insufficiency (Group III) were similarly skin tested. Approximately 91% of the children with clinical E.F.E. under the age of 2 years in Group I showed a "positive" reaction to the intradermal inoculation of mumps skin-test antigen solution. In contrast, approximately 91% of the children in a control series under the age of 2 years in Group II showed a negative skin reaction. Confirmatory evidence of E.F.E. was obtained by left atrial biopsy in 2 children in Group I and in three children with congenital mitral insufficiency (Group III). E.F.E. was confirmed at autopsy in a fourth child with clinically diagnosed congenital mitral insufficiency who had shown a "positive" skin reaction. Hematologic studies for determination of mumps serum antibody titer (M.S.A.T.) were performed on 24 children in Group I, 29 children in Group II, and 6 children in Group III. It was apparent from our study that "positivity" of the skin reaction in E.F.E. was not correlated with an elevated M.S.A.T. Isolated congenital mitral insufficiency is, almost invariably, associated with E.F.E. The high incidence of "positive" reactors in this group suggests that both conditions arise in utero at the same period of gestation and due to an identical etiologic agent (possibly viral) and associated with fetal immunologic deficiency. "Positivity" of the skin reaction in E.F.E. to mumps antigen solution may, therefore, represent either: (1) a non-specific hypersensitivity; or (2) "cross-reactivity" to viruses other than mumps virus, for example, Coxsackie B viruses or myxoviruses other than mumps virus; or (3) evidence of preexisting mumps viral infection in utero or during infancy, despite the absence of an elevated M.S.A.T. This is explicable on the basis of a partial immunologic deficiency whereby the fetus or infant is incapable of developing specific mumps antibodies, but remains capable of exhibiting a delayed cutaneous hypersensitivity response to mumps antigen. Such an immunologic deficiency could also explain the familial occurrence of E.F.E. It is hoped that this report will stimulate further studies in (1) the value of the mumps skin-test antigen solution as an ancillary aid in the diagnosis of E.F.E. and (2) the possible role of viral infection(s) in the etiology of E.F.E.

scholarly journals Using of modern types of drainage in glaucoma surgery: our experience

2020 ◽  
Vol 13 (1) ◽  
pp. 71-76
Author(s):  
T. V. Gavrilova ◽  
K. S. Lyubimov ◽  
S. N. Mukhamadeeva ◽  
M. V. Chereshneva
Keyword(s):  
Open Angle Glaucoma ◽  
Glaucoma Surgery ◽  
Hypotensive Effect ◽  
Early Postoperative Period ◽  
Long Term Results ◽  
Deep Sclerectomy ◽  
Group Iii ◽  
Group I ◽  
Group Ii ◽  
The Moment

Purpose. To evaluate antihypertensive efficiency and safeness of Xenoplast, Glautex, and Ex-PRESS drainage during glaucoma surgery. Material and methods. 249 patients with primary open angle glaucoma (253 eyes) underwent antihypertensive operations with Xenoplast (group I, 121 patients aged 68.6 ± 7.7 yrs), Glautex (group II, 49 patients aged 66.8 ± 7.7 yrs) and Ex-PRESS (group III, 79 patients aged 67.9 ± 8.3 yrs). In groups I and II, drainages were implanted during penetrating and non-penetrating surgery. Long-term results were traced for 2 years. Results. In the early postoperative period, all groups had complications typical for antiglaucoma surgery without drainage: I — 14.8 %, II — 16.8 %, III — 16.8 %. An absolute success of the operation (normalization of IOP without additional antihypertensive therapy) was achieved as follows. In group I for patients with non-penetrating deep sclerectomy it was achieved in 98.4 % of cases at the moment of discharge from hospital, whereupon the figure fell to 15.4 % in 18 months. In group I patients, with trabeculectomy the success was achieved in 96.7 %, dropping to 6.7 %. In group II for patients with non-penetrating deep sclerectomy the success claimed 96.3 %, but after 12 months it vanished completely. In group II with trabeculectomy the success reached 95.7 %, but dropped to 16.7 % after 24 months. In group III the success rate at the moment of discharge was 96.3 % but it dropped to 16.7 % after 24 months. In cases if target pressure could not be achieved the surgery was repeated. Conclusion. The absolute success originally achieved in all groups (96.3–98.4 %) was not persistent and after a 2-year observation, tended to disappear. The effect lasted longer in eyes after trabeculectomy with Glautex and Ex-PRESS. The hypotensive effect of primary antiglaucoma surgery was higher in penetrating operations.

Coronary Angioplasty in Patients with Unstable Angina, with Special Reference to Preceding Treatment with Antithrombin III and Heparin

1996 ◽  
Vol 2 (2) ◽  
pp. 107-115 ◽  
Author(s):  
Lars Grip ◽  
Christer Hellekant ◽  
Istvan Herzfeld ◽  
Klas Malmberg ◽  
Bertil Svane ◽  
...  
Keyword(s):  
Unstable Angina ◽  
Coronary Angioplasty ◽  
Antithrombin Iii ◽  
Artery Bypass ◽  
Long Term Results ◽  
Heparin Infusion ◽  
Group Iii ◽  
Group I ◽  
Group Ii ◽  
Transluminal Coronary Angioplasty

Seventy-nine patients undergoing percutane ous transluminal coronary angioplasty (PTCA) for unsta ble angina were analyzed with respect to preceding an tithrombin treatment; group I comprised patients (n = 26) without antecedent antithrombin therapy; group II, pa tients (n = 30) with heparin infusion for ≥24 h, and group III patients (n = 23) with ongoing heparin infusion and given antithrombin III concentrate immediately before the procedure because of plasma antithrombin III <85%. Immediate results were 89% (70 of 79) angiographic suc cess, five (6%) subacute occlusions (two subsequent non-Q wave infarctions), no emergency coronary artery bypass grafting (CABG), and no immediate mortality. There were no differences between the groups. From dis charge to 4 months, one patient died, one had a nonfatal infarction, and 24 (30%) had repeated PTCA or CABG. The cumulative 4-month event rate was 11 of 26 (42%) in group I, 10 of 30 (33%) in group II, and 7 of 23 (30%) in group III (NS). During PTCA, heparin bolus administra tion was guided by activated clotting time (ACT), aiming at>300 s. Baseline ACT was significantly less in patients not treated with heparin (129 ± 34 s in group I vs. 179 ± 38 and 162 ± 29 s in groups II and III, respectively; p < 0.05), but during the procedure, patients from all groups required the same amount of heparin (13,900 ± 4,800, 13,000 ± 6,800, and 13,000 ± 5,700 IU, respectively; NS) to reach similar maximum ACT levels (334 ± 36, 312 ± 32, and 319 ± 44 s, respectively; NS). Patients receiving warfarin ( n = 8) responded with a higher ACT (456 ± 110 s; p < 0.05) on lower doses of heparin (10,000 ± 3,800 IU). In conclusion, patients with unstable angina receiv ing individualized antithrombotic therapy can be success fully treated with PTCA, with an acute complication rate and long-term results comparable with those expected in patients undergoing elective procedures. The value of an tithrombin III substitution must be evaluated in random ized trials. Preprocedural heparin infusion does not re duce the need of extra heparin during the procedure. Key Words: Antithrombin III—Heparin—PTCA (percutane ous transluminal coronary angioplasty)—Unstable angina pectoris.

Ultrastructural Lesions Produced by Alcohol and Sucrose in the Heart and Liver of C57BL Mice

1970 ◽  
Vol 28 ◽  
pp. 208-209
Author(s):  
K.K. SEKHRI ◽  
C.S. ALEXANDER ◽  
H.T. NAGASAWA
Keyword(s):  
Osmium Tetroxide ◽  
Male Mice ◽  
Alcohol Group ◽  
Group Iii ◽  
Group I ◽  
C57bl Mice ◽  
Group Ii

C57BL male mice (Jackson Lab., Bar Harbor, Maine) weighing about 18 gms were randomly divided into three groups: group I was fed sweetened liquid alcohol diet (modified Schenkl) in which 36% of the calories were derived from alcohol; group II was maintained on a similar diet but alcohol was isocalorically substituted by sucrose; group III was fed regular mouse chow ad lib for five months. Liver and heart tissues were fixed in 2.5% cacodylate buffered glutaraldehyde, post-fixed in 2% osmium tetroxide and embedded in Epon-araldite.

Illness Perception and Its Changes During Six Months After Cardiac Rehabilitation

2019 ◽  
Vol 26 (3) ◽  
pp. 90-100
Author(s):  
Justė Lukoševičiūtė ◽  
Kastytis Šmigelskas
Keyword(s):  
New York ◽  
Social Factors ◽  
Nyha Class ◽  
Illness Perception ◽  
Heart Association ◽  
Class Iii ◽  
Cognitive Representations ◽  
Coronary Syndrome ◽  
Type D ◽  
New York Heart Association

Abstract. Illness perception is a concept that reflects patients' emotional and cognitive representations of disease. This study assessed the illness perception change during 6 months in 195 patients (33% women and 67% men) with acute coronary syndrome, taking into account the biological, psychological, and social factors. At baseline, more threatening illness perception was observed in women, persons aged 65 years or more, with poorer functional capacity (New York Heart Association [NYHA] class III or IV) and comorbidities ( p < .05). Type D personality was the only independent factor related to more threatening illness perception (βs = 0.207, p = .006). At follow-up it was found that only self-reported cardiovascular impairment plays the role in illness perception change (βs = 0.544, p < .001): patients without impairment reported decreasing threats of illness, while the ones with it had a similar perception of threat like at baseline. Other biological, psychological, and social factors were partly associated with illness perception after an acute cardiac event but not with perception change after 6 months.

Heterogeneity and Immunochemical Properties of Anti-β2-glycoprotein I Autoantibodies

1998 ◽  
Vol 80 (09) ◽  
pp. 393-398 ◽  
Author(s):  
V. Regnault ◽  
E. Hachulla ◽  
L. Darnige ◽  
B. Roussel ◽  
J. C. Bensa ◽  
...  
Keyword(s):  
Fluid Phase ◽  
Anticardiolipin Antibodies ◽  
Dual Reactivity ◽  
Group Iii ◽  
Important Group ◽  
Epitope Specificity ◽  
Glycoprotein I ◽  
Group I ◽  
Group Ii ◽  
Sufficient Concentration

SummaryMost anticardiolipin antibodies (ACA) associated with antiphospholipid syndrome (APS) are directed against epitopes expressed on β2-glycoprotein I (β2GPI). Despite a good correlation between standard ACA assays and those using purified human β2GPI as the sole antigen, some sera from APS patients only react in the latter. This is indicative of heterogeneity in anti-β2GPI antibodies. To characterize their reactivity profiles, human and bovine β2GPI were immobilized on γ-irradiated plates (β2GPI-ELISA), plain polystyrene precoated with increasing cardiolipin concentrations (CL/β2GPI-ELISA), and affinity columns. Fluid-phase inhibition experiments were also carried out with both proteins. Of 56 selected sera, restricted recognition of bovine or human β2GPI occurred respectively in 10/29 IgA-positive and 9/22 IgM-positive samples, and most of the latter (8/9) were missed by the standard ACA assay, as expected from a previous study. Based on species specificity and ACA results, IgG-positive samples (53/56) were categorized into three groups: antibodies reactive to bovine β2GPI only (group I) or to bovine and human β2GPI, group II being ACA-negative, and group III being ACA-positive. The most important group, group III (n = 33) was characterized by (i) binding when β2GPI was immobilized on γ-irradiated polystyrene or cardiolipin at sufficient concentration (regardless of β2GPI density, as assessed using 125I-β2GPI); (ii) and low avidity binding to fluid-phase β2GPI (Kd in the range 10–5 M). In contrast, all six group II samples showed (i) ability to bind human and bovine β2GPI immobilized on non-irradiated plates; (ii) concentration-dependent blockade of binding by cardiolipin, suggesting epitope location in the vicinity of the phospholipid binding site on native β2GPI; (iii) and relative avidities approximately 100-fold higher than in group III. Group I patients were heterogeneous with respect to CL/β2GPI-ELISA and ACA results (6/14 scored negative), possibly reflecting antibody differences in terms of avidity and epitope specificity. Affinity fractionation of 23 sera showed the existence, in individual patients, of various combinations of antibody subsets solely reactive to human or bovine β2GPI, together with cross-species reactive subsets present in all samples with dual reactivity namely groups III and II, although the latter antibodies were poorly purified on either column. Therefore, the mode of presentation of β2GPI greatly influences its recognition by anti-β2GPI antibodies with marked inter-individual heterogeneity, in relation to ACA quantitation and, possibly, disease presentation and pathogenesis.

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