Vol 14, No 1 (2023)

Original Study Articles

Electrochemical measurements of the levels of nitric oxide metabolites in the blood serum

Goroncharovskaya I.V., Evseev A.K., Klychnikova E.V., Tazina E.V., Bogdanova A.S., Shabanov A.K., Petrikov S.S.

Abstract

Background: Sepsis is a serious clinical condition caused by a dysregulated immune response to infection resulting in multiple organ failure. In the pathogenesis of sepsis, especially that of septic shock, great importance is given to the endothelial marker of vascular regulation, nitric oxide (NO). In septic shock, dysregulation of the vascular tone plays a key role in the development of hypotension. Therefore, the control of the level of nitric oxide and its stable metabolites in critically ill patients is a very important task.

Aim: the aim of this study was to evaluate the potential of the electrochemical nitrite detection in the patients’ blood serum.

Methods: The levels of nitric oxide stable metabolites in the blood serum of healthy individuals (n=20) and septic patients (n=25) were studied by the electrochemical method using a composite electrode and by the spectrophotometric method using the Griess reagent.

Results: The data in the groups of healthy people and patients with sepsis differ significantly (p <0.00001) both when measured using electrochemical and spectrophotometric methods. The median value of the current response in healthy people was 0.41 µA (0.33; 0.55), and the total content of nitric oxide metabolites (NOx) was 26.8 µmol/L (20.8; 31.0), while in patients with sepsis, these values were 0.79 µA (0.61; 1.28) and 38.89 µmol/L (29.64; 57.45), respectively. A negative correlation was found between the data obtained for practically healthy persons (r=-0.696, p=0.0007).

Conclusion: The obtained results allow us to conclude that the nitrite measurement in the blood serum by amperometry using a composite electrode is promising as a diagnostic technique.

Journal of Clinical Practice. 2023;14(1):6-11
pages 6-11 views

Clinical laboratory diagnostics of antibodies to SARS-CoV-2: from a QR code to the reality

Shansky Y.D., Gospodarik A.V., Komarova A.V., Esiev S.S., Ulakhanova L.A., Serkina A.S., Plotnikova L.V., Bespyatykh J.A.

Abstract

Background: The immune response to SARS-CoV-2 includes the production of specific immunoglobulins to protein antigens of SARS-CoV-2. Depending on the type and level of immunoglobulins, it is possible to assess the stage of the disease and evaluate the effectiveness of vaccination. The main approach to the determination of immunoglobulins to SARS-CoV-2 in human biological fluids is enzyme-linked sorbent immunoassay. Its data, in particular, are used to issue an electronic COVID-19 certificate with a QR code. However, the qualitative and quantitative composition of immunoglobulins for a QR code is not officially regulated.

Aim: measuring the immunoglobulins’ level in the human blood serum with different types of immunity to the new coronavirus infection (COVID-19) to select the most informative indicators of protective immunity.

Methods: The study included 76 blood serum samples from male and female volunteers (age, 18 to 50 y.o.) in compliance with the ethical standards. The detection of IgA, IgM, IgG (total to different regions of SARS-CoV-2, S-protein IgG and RBD-fragment IgG), IgG avidity, and the level of the SARS-CoV-2 N-antigen was performed by enzyme-linked immunosorbent assay (ELISA) using commercially available reagent kits.

Results: The indicators of the level of antibodies (both "protective" IgG and IgA of the initial phase of infection) are most pronounced in persons who have been vaccinated and have had COVID-19, and least pronounced in unvaccinated people. For recovered unvaccinated individuals, the level of total “protective” antibodies and IgG to the S-protein, including the RBD fragment, is the lowest; the avidity of IgG is lower than that in the other groups, too. The IgG avidity in vaccinated patients is higher than that in recovered ones. It should be noted that there were no differences in the level of both total IgG to SARS-CoV-2, to the S-protein and to the RBD-fragment of the S-protein for recovered and vaccinated individuals.

Conclusion: The analysis of COVID-19 immunoglobulins indicates a different profile of the humoral immune response following vaccination and previous infection with COVID-19. To quickly assess the immune response to previous and current COVID-19 infection, as well as to detect the post-vaccination immunity, it is advisable to use the total level of IgG to SARS-CoV-2. For deeper assessment of protective immunity and production of protective antibodies, it is better to evaluate the quantitative content of IgG to the S protein and its RBD fragment. The equal level of IgA in the experimental groups indicates an ongoing interaction with SARS CoV-2 in the population. Thus, the electronic COVID-19 certificate is of little use when it is formed by only one of the indicators without taking into account the rest.

Journal of Clinical Practice. 2023;14(1):12-20
pages 12-20 views

Morphological features of brain damage in severe COVID-19

Kanibolotskiy A.A., Zayratyants O.V.

Abstract

Background: The damage to the nervous system in COVID-19 reflects the systemic nature of the infection. The question of the neuroinvasive potential of SARS-CoV-2 remains open, the role of "pseudovirions" in the development of the endothelial dysfunction, as well as of the S1 subunit in the TLR activation, and the importance of the blood-brain barrier are discussed. The immunological, non-immunological, and cytopathic mechanisms of the virus's action are described; there is no clear understanding of the genesis of neuropathological changes caused by SARS-CoV-2. In this tragic pandemic, the lessons of the dead should help save lives and health.

Aim: to study and explain the features of brain damage in COVID-19.

Methods: Brain fragments from 20 patients who died due to severe COVID-19 were studied, the sections were stained with hematoxylin and eosin, according to van Gieson and Nissl, IHC reactions were performed with antibodies to the S-protein, CD68 and CD8, the changes were compared with those related to the lethal outcomes of pancreatic necrosis and ruptured aortic aneurysm.

Results: The following changes in the olfactory analyzer were revealed: sharp edema, dystrophic changes in neurons, gliosis, accumulations of starchy bodies, which explains the neuronal pathway of SARS-CoV-2 invasion; vascular plethora, erythrostasis and thrombosis, perivenular hemorrhages, diffuse edema, macroglia proliferation, perivascular astrocytosis and satellite. A positive reaction with the antibodies to the S1 and S2 subunits of the spike protein was detected, while the result of the reaction with antibodies to the N-protein of the virus, confirming the active replication of the virus, was doubtful. The S-protein expression in individual endotheliocytes makes the transendothelial route of the virus entry unlikely, in contrast to the hematogenous and neuronal pathways. The viral DNA was not detected by PCR. A weak inflammatory reaction was revealed in the form of perivascular accumulations of lymphocytes, scattered T-lymphocytes.

Conclusions: 2 groups of changes were identified, the first group included circulatory disorders with a tendency to thrombosis, edema, dystrophic-necrotic changes in neurons, glial proliferation, the second group included inflammatory-degenerative changes, a weak inflammatory reaction and amyloid-like bodies. Further morphometric and statistical studies are needed to obtain the reliable conclusions.

Journal of Clinical Practice. 2023;14(1):21-30
pages 21-30 views

Targeted training of the function of walking according to the stance and single support phase in patients in the early recovery period of cerebral stroke

Skvortsov D.V., Kaurkin S.N., Ivanova G.E., Suvorov A.Y.

Abstract

Background: The phases of support and single support on a limb are significant basic parameters of walking (phase of support means the whole limb support time, while the phase of single support is when only one limb is on the ground). Both can be used as targets for biofeedback training.

Aim: to investigate the effectiveness of both target parameters for training the function of walking with biofeedback in patients in the early recovery period of cerebral stroke.

Methods: The study involved 40 patients, 20 in each group, who underwent a training course to harmonize walking: the first group — for the period of support, and the second group — for the period of single support. The control group of healthy people also consisted of 20 people. We studied the spatiotemporal parameters of walking at an arbitrary pace at the beginning and after the end of the training course, as well as classical clinical scales. The treadmill training consisted of 10 sessions.

Results: The clinical and biomechanical parameters of walking changed their values in the direction of a significant improvement in the performance. At the same time, the biomechanical parameters of the second group indicated a more severe functional state before the start of the treatment, with the same clinical parameters according to the Barthel scale, Rivermead Mobility Index, modified Rankin scale, rehabilitation routing scale, and manual muscle testing. In the first group, indirect data were obtained on the possible effect of the target indicator on the training and direct data on its effect on the function of a healthy limb, which also allows increasing the load on the paretic one. In the second group, there were no reliable data on the effect of biofeedback training on the functional outcome.

Conclusion: The conducted study showed that the classical clinical assessment of the patient's condition may not correspond to the instrumental functional study of walking. When using the support period as the training target parameter, indirect evidence was obtained that such a training is effective.

Journal of Clinical Practice. 2023;14(1):31-43
pages 31-43 views

A fluorescent microspheres-based microfluidic test system for the detection of immunoglobulin G to SARS-CoV-2

Shakurov R.I., Shansky Y.D., Prusakov K.A., Sizova S.V., Dudik S.P., Plotnikova L.V., Manuvera V.A., Klinov D.V., Lazarev V.N., Bespyatykh J.A., Basmanov D.V.

Abstract

Background: The pandemic of the new coronavirus infection, COVID-19, is currently ongoing in the world. Over the years, the pathogen, SARS-CoV-2, has undergone a series of mutational genome changes, which has led to the spread of various genetic variants of the virus. Meanwhile, the methods used to diagnose SARS-CoV-2, to establish the disease stage and to assess the immunity, are nonspecific to SARS-CoV-2 variants and time-consumable. Thus, the development of new methods for diagnosing COVID-19, as well as their implementation in practice, is currently an important direction. In particular, application of systems based on chemically modified fluorescent microspheres (with a multiplex assay for target protein molecules) opens great opportunities.

Aim: development of a microfluidic diagnostic test system based on fluorescent microspheres for the specific detection of immunoglobulins G (IgG) to SARS-CoV-2.

Methods: A collection of human serum samples was characterized using enzyme-linked immunosorbent assay (ELISA) and commercially available reagent kits. IgG to SARS-CoV-2 in the human serum were detected by the developed immunofluorescent method using microspheres containing the chemically immobilized RBD fragment of the SARS-CoV-2 (“Kappa” variant) viral S-protein.

Results: The level of IgG in the blood serum of recovered volunteers was 9-300 times higher than that in apparently healthy volunteers, according to ELISA (p<0.001). Conjugates of fluorescent microspheres with the RBD-fragment of the S-protein, capable of specifically binding IgG from the blood serum, have been obtained. The immune complexes formation was confirmed by the fluorescence microscopy data; the fluorescence intensity of secondary antibodies in the immune complexes formed on the surface of microspheres was proportional to the content of IgG (r 0.963). The test system had a good predictive value (AUC 70.3%).

Conclusion: A test system has been developed, based on fluorescent microspheres containing the immobilized RBD fragment of the SARS-CoV-2 S-protein, for the immunofluorescent detection of IgG in the human blood serum. When testing the system on samples with different levels of IgG to SARS-CoV-2, its prognostic value was shown. The obtained results allow us to present the test system as a method to assess the level of immunoglobulins to SARS-CoV-2 in the human blood serum for the implementation in clinical practice. The test system can also be integrated into various microfluidic systems to create chips and devices for the point-of-care diagnostics.

Journal of Clinical Practice. 2023;14(1):44-53
pages 44-53 views

Correlation of the zinc level in the spermoplasm with the fertility characteristics of human ejaculate

Lutsky D.L., Lutskaya A.M., Mahmudov R.M., Palkina E.V., Polunin A.I.

Abstract

Background: Zinc is essential for the normal functioning of the male reproductive system. The data on the diagnostic value of the zinc level in the human spermoplasm and its relationship with the main parameters of the sperm fertility are contradictory.

Aim: study of the correlations between the zinc level in the spermoplasm and the spermogram characteristics.

Methods: The sperm of men of the reproductive age (n=486, average age 33.07±3.03 years) was studied. In addition to the standard spermogram, MAR tests (IgA, IgG and IgM) were performed in the sperm samples, the degree of fragmentation of the sperm DNA, the sperm interaction with hyaluronic acid, the acrosine activity, and the neutral alpha-glucosidase activity were assessed, the citric acid, fructose and glycodelin levels were determined, and the level of reactive oxygen species was studied. The zinc level determination in the spermoplasm was carried out by a standard spectrophotometric method with 5-Br-PAPS chromogen. The Pearson's formula was used for the correlation analysis. The study was conducted from 2018 to May 2022, once.

Results: A significant negative correlation of the zinc level in the spermoplasm with the age of men was revealed (r=-0.16; p <0.001). The level of zinc in the spermoplasm weakly negatively correlated with the dilution time and with the viscosity of the sperm. The positive correlation was found with the number of spermatozoa (r=0.13; p <0.01) and their mobility (r=0.38; p <0.00001). The level of zinc in the spermoplasm negatively correlated with the degree of the sperm DNA fragmentation and with the amount of reactive oxygen species, and positively correlated with the results of the test for binding to hyaluronic acid.

Conclusions: The level of zinc in the spermoplasm significantly correlates with a number of physiological and biochemical characteristics of the sperm. The data obtained allow us to recommend determination of the zinc level in the sperm plasma to not only assess the functional activity of the prostate gland, but also to diagnose the fertility of the ejaculate, as well as to optimize the therapy with zinc-containing drugs and improve the control over the effectiveness of the treatment.

Journal of Clinical Practice. 2023;14(1):54-65
pages 54-65 views

A pilot study to determine the relationship of changes in the characteristics of β1- and β2-adrenoreceptors against the background of the use of β2-agonists with clinically significant parameters in patients with cardiovascular pathology

Smolyakova E.V., Skoblov Y.S., Skoblova N.A., Rvacheva A.V., Bondarets O.V., Eremenko A.V., Kelekhsaev I.A., Chazova I.E., Zykov K.A.

Abstract

Background: Comorbid cardiovascular and bronchoobstructive diseases worsens disease course and prognosis and causes difficulties in therapy. Effectiveness β2-agonists (cornerstone of bronchoobstructive pathology treatment) depends on β-adrenoreceptors state. Therefore, a detailed study of the functional state of beta-adrenoreceptors is necessary.

Aim: to evaluate the relationship of changes in the characteristics of β1- and β2-adrenoreceptors, against the background of the use of β2-agonists in patients with cardiovascular and bronchoobstructive diseases with clinically significant parameters.

Methods: In the pilot single-center prospective study during 2.5 years 45 patients (15 with cardiovascular and 30 with bronchoobstructive diseases) were included. Anamnestic data and complaints were collected and laboratory and instrumental studies were performed. Modified radioligand analysis on blood T-lymphocytes using radiolabeled Cyanopindolol and unlabeled selective ligands (ICI 118551, CGP 20712) before and after salbutamol and formoterol was performed and the binding activity of β1- and β2-adrenoreceptors was determined.

Results: The correlation analysis between clinically significant parameters and changes in the specific binding index of β1- and β2-adrenoreceptors confirmed its clinical relevance. In test with beta-agonists in cardiovascular and bronchoobstructive diseases patients, an increase in the specific binding index of β1-adrenoreceptors is associated with clinical, laboratory and instrumental parameters of a favorable course of the disease, and an increase in the specific binding index of β2-adrenoreceptors is associated with negative. In the cardiovascular group without bronchoobstructive diseases with salbutamol an increase in the specific binding index of β1-adrenoreceptors was associated with parameters of unfavorable disease course, while an increase in the specific binding index of β2-adrenoreceptors did not have a clear associative relationship with clinical characteristics.

Conclusions: The association of changes in the specific binding index of β1- and β2-adrenoreceptors in patients with cardiovascular and bronchoobstructive diseases with clinically significant parameters during acute tests with short- and long-acting β2-agonists was revealed, which in the future may provide an opportunity to identify patients with an unfavorable course of the disease.

Journal of Clinical Practice. 2023;14(1):66-76
pages 66-76 views

Analysis of the results of the surgical treatment of plano-valgus foot deformity in children and adolescent

Trankovskiy S.E., Protsko V.G., Akhpashev A.A.

Abstract

Background: Plano-valgus deformity of the feet is a common reason for contacting an orthopedist. Pediatric orthopedics uses technologies, in particular, subtalar arthroeresis, that do not violate the physiological growth of the patient.

Aim: to choose the optimal methods for the correction of foot deformity in children and adolescents. Analysis of the results of the surgical treatment.

Methods: In the period from 2013 to 2022, 482 patients were operated on for flat-foot deformity. Subtalar arthroeresis surgery was performed in 405 cases in various combinations.

Results: The 9-year-long observation of the patients after the surgical treatment showed that in most cases there was a persistent positive effect, namely: no complaints of pain syndrome, no clinical and radiological pictures of a plano-valgus foot, patients led an active lifestyle, including sports. On average, after 17.7 months, 66 cases (16.1%) required replacement of the subtalar implant due to the physiological growth of patients. In 125 cases (31.2%) the implant was removed on average 31.2 months after placement. Unsatisfactory results were noted in 14 patients (3.4%).

Conclusions: The technique of subtalar arthroeresis, as a low-traumatic one, does not interfere with the physiological growth of the foot skeleton, does not limit physiological loads after the surgical treatment, and is actively used in the childhood and adolescence. The peculiarity of the subtalar arthroeresis in a patient with the physiological growth of the foot skeleton is a high probability of the subtalar implant replacement.

Journal of Clinical Practice. 2023;14(1):77-83
pages 77-83 views

Intraductal photodynamic therapy and its combination with intra-arterial chemoinfusion in the treatment of inoperable patients with Klatskin tumor

Kozlov A.V., Polikarpov A.A., Tarazov P.G., Moiseenko A.V., Jutkin M.V., Shapoval S.V., Turlak A.S., Granov D.A.

Abstract

Background: A palliative or symptomatic treatment is indicated for 70–80% of patients with Klatskin’s tumor because of the advanced lesion volume and the patient’s grave condition. Hepatic arterial infusion chemotherapy, chemoembolization, radioembolization are successfully used in the treatment of hepatocellular carcinoma and liver metastases.

Aim: to estimate the immediate and long-term results of photodynamic therapy (PDT) and its combination with hepatic arterial infusion in inoperable patients with Klatskin tumors.

Methods: Between 2010 and 2021, 83 palliative PDT sessions (from 1 to 8, average 2.4) were performed in 82 patients as a single treatment or in combination with hepatic arterial infusion. In all cases, percutaneous transhepatic biliary drainage was previously performed; no chemotherapy was applied. Two groups of 48 patients were stratified according to the ECOG status (2–3) and the numbers of PDT sessions (no more than two). The treatment group of the combination therapy consisted of 24 patients (13 male, 11 female) aged 38 to 85 (mean 63) years with the ECOG status of 2–4 (mean 2.4). This group received PDT with hepatic arterial infusion using a GemCis regimen. On average, 1.4 PDT sessions were performed, the treatment started on the 89th (27–225) day after the biliary drainage. The hepatic arterial infusion was performed on the 2d–3th day after the PDT. The control group received only PDT and consisted of 24 patients (13 male, 11 female) aged 51 to 83 (66 on average) years, with the ECOG status of 2–3 (mean 2.6). On average, 1.4 PDT sessions were performed, starting on the 106th (32–405) day after the biliary drainage.

Results: There were no serious adverse events associated with PDT in both groups. Toxic complications of hepatic arterial infusion were observed in 13 of 24 patients (54%): I–II grade hematological (54%) and gastrointestinal (69%); all were eliminated with medical therapy. Complications of the percutaneous transhepatic biliary drainage in three patients (hemobilia, n=2, and sepsis, n=1) were estimated as grade III by the CIRSE classification (2017) and successfully treated without surgery. In the combination treatment group, the overall mean survival and median survival were higher than those in the control group: 327.9±39.8 days (10.9 mo) versus 246.9±31.2 days (8.2 mo) and 275 days versus 244 days. However, these differences did not reach the statistical significance (p=0.12).

Conclusions: PDT is a safe method of a palliative treatment of critically ill patients with Klatskin tumor (ECOG 2–3). PDT alone has limited clinical efficacy. A combination of PDT and hepatic arterial infusion does not cause serious complications and may increase the survival rates.

Journal of Clinical Practice. 2023;14(1):84-94
pages 84-94 views

Reviews

Following a postoperative pain in the early and late period during surgical intervention on the cervical and lumbosacral spine

Solh Mohammed A.A., Belopasov V.V.

Abstract

From year to year, postoperative pain syndrome following a surgical intervention on the cervical and lumbar regions of the spine becomes an increasingly serious problem for spine surgeons. The treatment of such a pathology requires a multidisciplinary approach. Drug therapy does not always provide the desired outcome. Non-drug approaches, such as neuromodulation with a surgically implanted spinal cord stimulator or non-invasive transcutaneous electrical nerve stimulation, are currently in great demand. However, given the fact that prevention is always better than treatment, specialists have to always take into account the possible adverse factors which may contribute to the appearance of postoperative pain. The patient's psychoemotional state plays not the least important role among those factors.

Journal of Clinical Practice. 2023;14(1):95-100
pages 95-100 views

Anticoagulation after typical atrial flutter ablation

Bulavina I.A., Khamnagadaev I.A., Khamnagadaev I.I., Kokov M.L., Troitskiy A.V., Zotov A.S., Kokov L.S., Shkolnikova M.A.

Abstract

The specifics of the anticoagulant therapy after radiofrequency ablation of the cavotricuspid isthmus have not been sufficiently studied, therefore, the recommendations for prescribing the anticoagulant therapy usually do not distinguish between atrial flutter and atrial fibrillation. In contrast to the case of atrial fibrillation, the effectiveness of the interventional treatment for typical atrial flutter reaches 90%. This procedure may save the patient from a long-term anticoagulant therapy in the absence of recurrence of typical atrial flutter. The decision to stop the anticoagulant therapy after successful radiofrequency ablation of the cavotricuspid isthmus should take into account the potential induction of atrial fibrillation in patients undergoing the interventional treatment. In addition to the CHA2DS2-VASc scale, which characterizes the patient's comorbidity, it is important to take into account the echocardiographic morphofunctional criteria to assess the risk of atrial fibrillation. Currently, this protocol is not regulated in the clinical guidelines. The analysis of the literature data and the authors' own experience allow us to conclude that the optimal time for stopping the anticoagulant therapy is a relapse-free period of 3–4 months after the radiofrequency ablation of the cavotricuspid isthmus, since it is at this time that the effectiveness of the interventional treatment can be objectified.

Journal of Clinical Practice. 2023;14(1):101-107
pages 101-107 views

The possibilities of adapting the re-processing protocol in the practice of the ThinPrep Pap test usage

Aksamentov A.K., Melnikova N.V., Moshnina E.V., Kolyshkina N.A., Kucherova O.N., Baklaushev V.P.

Abstract

The method of liquid cytology is a newer diagnostic test compared to the traditional cytological examination of scrapings from the cervix and allows one to standardize the morphological examination and reduce the number of unsatisfactory samples. One of the factors determining the adequacy of the Pap test is the number of squamous epithelial cells in a sample. The abundance of blood elements, mucus, lubricant, or inflammatory elements may affect the informativeness of the sample. In the practice of the ThinPrep Pap test usage, when receiving an inadequate sample, a protocol for re-processing the contents of the vial is used, in order to neutralize the possible influence of such impurities on the final result. Here, we present a review on the methods of the re-processing protocol application and our own experience of adapting the protocol in the practice of a clinical diagnostic laboratory.

Journal of Clinical Practice. 2023;14(1):108-114
pages 108-114 views

Case reports

Fecal microbiota transplantation in the treatment of astrovirus infection in a recipient of an allogeneic hematopoietic stem cell transplant: a clinical case

Bespyatykh J.A., Gospodarik A.V., Zhuravel E.A., Seregin G.Z., Komarova A.V., Esiev S.S., Bronin G.O., Shansky Y.D.

Abstract

Background: Secondary immunodeficiency in recipients after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in the pediatric practice is often accompanied by bacterial and viral infections of the gastrointestinal tract (GIT), resistant to conventional therapy. Fecal microbiota transplantation (FMT) promotes intestinal recolonization and eradication of gastrointestinal symptoms.

Clinical case description: A 2.5-year-old patient underwent allo-HSCT from a haploidentical related donor (father) as a part of the treatment of acute myeloid leukemia. A month after the last procedure, diarrhea (up to 10 times a day) and abdominal pain appeared. The astrovirus RNA and Clostridium difficile toxin A were detected in the feces. The FMT was prescribed. After two FMT procedures, the intestinal syndrome leveled out, and the tests for the astrovirus RNA and clostridial toxins were negative. The content of cholic and, in particular, deoxycholic acids, as well as their conjugates with glycine and taurine, in the feces increased; the acetic acid content increased with a simultaneous decrease in the level of propionic acid, which indicates the restoration of the intestinal microbiota’s functional potential.

Conclusion: FMT contributes to the restoration of the normal intestinal microflora, the elimination of clostridial toxins, enteroinvasive E. coli and astrovirus infection in allo-HSCT recipients, as evidenced by the indicators of the intestinal microbiota activity, and can be used in allo-HSCT recipients with infections refractory to conventional therapy.

Journal of Clinical Practice. 2023;14(1):115-122
pages 115-122 views


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