CARDIOVASCULAR JOURNAL OF AFRICA: VOLUME 28, ISSUE 6, NOV/DEC 2017
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  1. Title: From the Editor’s Desk
    Authors: PJ Commerford
    From: Cardiovascular Journal of Africa, Vol 28, Issue 6, November/December
    Published: 2017
    Pages: 343
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  2. Title: Editorial: Warfarin: better the devil you know
    Authors: Marc Blockman
    From: Cardiovascular Journal of Africa, Vol 28, Issue 6, November/December
    Published: 2017
    Pages: 344-345
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  3. Title: A preliminary review of warfarin toxicity in a tertiary hospital in Cape Town, South Africa
    Authors: Annemarie Jacobs, Fatima Bassa, Eric H Decloedt
    From:  Cardiovascular Journal of Africa, Vol 28, Issue 6, November/December
    Published: 2017
    Pages: 346–349
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    DOI Number:10.5830/CVJA-2017-029
    DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2017-029
    Aim: Warfarin is a widely used anticoagulant for the prevention and treatment of thromboembolism. We conducted a retrospective review to determine the causes and management of warfarin toxicity of patients admitted to Tygerberg hospital between June 2014 and June 2015.
    Results: We identified and evaluated 126 patients who met the inclusion criteria. The cause of warfarin toxicity was identified and addressed in only 14.3% (18/126) of patients. Where the cause was identified, 56% (10/18) was due to dosing errors and 17% (3/18) drug–drug interaction (DDI). However, 77% (97/126) of patients were retrospectively identified as receiving concomitant medicines known to interact with warfarin at the time of admission. Twenty-eight per cent (35/126) of patients presented with major bleeding, which included seven cases of intracranial haemorrhage. Patients were admitted for a median of eight days at an average treatment cost of R10 578.
    Conclusion: We found that warfarin toxicity carries significant mortality and cost, but little attention is paid to the causes of toxicity.

  4. Title: Medication adherence among cardiac patients in Khartoum State, Sudan: a cross-sectional study
    Authors: Abdelmoneim Awad, Nahid Osman, Siham Altayib
    From: Cardiovascular Journal of Africa, Vol 28, Issue 6, November/December
    Published: 2017
    Pages: 350–355
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    DOI Number:10.5830/CVJA-2017-016
    DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2017-016
    Introduction: Non-adherence to medication among cardiac patients is often the major risk factor for poor clinical outcomes, increased mortality rates and higher healthcare costs. The literature evaluating the prevalence of and reasons for non-adherence in resource-poor settings is extremely limited compared to resource-rich settings. There is a scarcity of data about medication adherence in Sudan hence this study was performed to identify prevalence, predictors and barriers of non-adherence to medication among cardiac patients in Khartoum State.
    Methods: A descriptive, cross-sectional survey was performed using a pre-tested, self-administered questionnaire on a sample of 433 randomly selected cardiac patients attending the largest three cardiac centres located in Khartoum State. Descriptive and multivariate logistic regression analyses were used for data analysis.
    Results: The response rate was 89.1%. The mean (± SD) number of chronic diseases among respondents was 2.3 (± 1.3) and that of medication use was 4.2 (± 1.9). The mean (± SD) duration of medication use among participants was 6.4 (± 5.4) years. Optimal adherence was defined as having a score of greater than six on the eight-item Morisky medication adherence scale. Using this cut-off point, 49% (95% CI: 43.9–54.1) of respondents had optimal adherence and 51% (95% CI: 45.9–56.1) had poor adherence. Respondents with a high level of education, low and middle income levels, and those taking five or more medications daily were found to be significantly more non-adherent to medication use than those with low to intermediate education levels (p < 0.001), those with high income levels (p < 0.001), and those taking one to four medications daily (p = 0.039). The top four barriers for poor medication adherence among the study participants were the high cost of drugs, polypharmacy and lack of pharmacist and physician communication with patients about their drug therapy.
    Conclusions: The current findings highlight the need for urgent, multifaceted interventions, given the burden of cardiovascular diseases and the clinical and economic consequences of medication non-adherence. These interventions include affordable medications, easy-to-use medication regimens with fewer daily doses, ongoing communication between patients and healthcare providers, and improvement of the patient– provider partnership.

  5. Title: Clinical profile, management and outcomes of patients with pulmonary embolism: a retrospective tertiary centre study in Angola
    Authors: Ana Manuel, Adelina Aufico, Rui Africano, Tomáz Peralta, Abel Salas, Adelaide Silva, José Ricardo, Pedro Sabola, Domingas Baião, Carlos Sotolongo, António Dias Neto, Telmo Martins, Vasco Sabino, Joaquim van Dúnem, António Pedro Filipe Júnior
    From: Cardiovascular Journal of Africa, Vol 28, Issue 6, November/December
    Published: 2017
    Pages: 356–361
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    DOI Number: 10.5830/CVJA-2017-017
    DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2017-017
    Objective: Pulmonary embolism (PE) is a potentially fatal disease. In Angola, few data are available on its occurrence. The aim of the study was to characterise the clinical profile, management and outcomes of patients with PE.
    Methods: A retrospective observational study was conducted at the Girassol Clinic in Luanda, Angola. The medical records of patients admitted to the intensive care unit were analysed from 2011 to 2015.
    Results: Fifty patients were included and the median age was 50.5 ± 17.8 years. Dyspnoea and immobilisation for more than 72 hours were the most frequently seen risk factors at admission; 28% of the patients had massive PE, 36% sub-massive PE, 28% were haemodynamically unstable at admission and 30% had a very high risk of mortality. The in-hospital mortality rate was 20%.
    Conclusions: The clinical characteristics of our patients were similar to those described in the literature. The high prevalence of patients with very high risk at admisson highlights the need to investigate the cause of worst cardiovascular disease outcomes in Africans.

  6. Title: Role of melatonin in glucose uptake by cardiomyocytes from insulin-resistant Wistar rats
    Authors: Frederic Nduhirabandi, Barbara Huisamen, Hans Strijdom, Amanda Lochner
    From:  Cardiovascular Journal of Africa, Vol 28, Issue 6, November/December
    Published: 2017
    Pages: 362–369
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    DOI Number: 10.5830/CVJA-2017-018
    DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2017-018
    Aim: Melatonin supplementation reduces insulin resistance and protects the heart in obese rats. However, its role in myocardial glucose uptake remains unknown. This study investigated the effect of short-term melatonin treatment on glucose uptake by cardiomyocytes isolated from obese and insulin-resistant rats.
    Methods: Cardiomyocytes were isolated from obese rats fed a high-calorie diet for 16 to 23 weeks, their age-matched controls, as well as young control rats aged four to eight weeks. After incubation with melatonin with or without insulin, glucose uptake was initiated by the addition of 2-deoxy-D-[3H] glucose and measured after 30 minutes. Additional control and obese rats received melatonin in the drinking water (4 mg/kg/day) for the last six weeks of feeding (20 weeks) and glucose uptake was determined in isolated cardiomyocytes after incubation with insulin. Intraperitoneal glucose tolerance and biometric parameters were also measured.
    Results: Obese rats (fed for more than 20 weeks) developed aglucose intolerance. Cardiomyocytes isolated from these obese rats had a reduced response to insulin-stimulated glucose uptake (ISGU) (p < 0.05). Melatonin administration in vitro had no effect on glucose uptake per se. However, it increased ISGU by cardiomyocytes from the young rats (p < 0.05), while having no effect on ISGU by cardiomyocytes from the older control and obese groups. Melatonin in vivo had no significant effect on glucose tolerance, but it increased basal (p < 0.05) and ISGU by cardiomyocytes from the obese rats (50.1 ± 1.7 vs 32.1 ± 5.1 pmol/mg protein/30 min, p < 0.01).
    Conclusion: These data suggest that short-term melatonin treatment in vivo but not in vitro improved glucose uptake and insulin responsiveness of cardiomyocytes in obesity and insulin-resistance states.

  7. Title: Prevalence and predictive value of electrocardiographic abnormalities in pulmonary hypertension: evidence from the Pan-African Pulmonary Hypertension Cohort (PAPUCO) study
    Authors: Irina Balieva, Anastase Dzudie, Friedrich Thienemann, Ana O Mocumbi, Kamilu Karaye, Mahmoud U Sani, Okechukwu S Ogah, Adriaan A Voors, Andre Pascal Kengne, Karen Sliwa
    From: Cardiovascular Journal of Africa, Vol 28, Issue 6, November/December
    Published: 2017
    Pages: 370–376
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    DOI Number: 10.5830/CVJA-2017-020
    DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2017-020
    Background: Pulmonary hypertension (PH) is prevalent in Africa and is still often diagnosed only at an advanced stage, therefore it is associated with poor quality of life and survival rates. In resource-limited settings, we assessed the diagnostic utility of standard 12-lead electrocardiograms (ECG) to detect abnormalities indicating PH.
    Methods: Sixty-five patients diagnosed with PH were compared with 285 heart disease-free subjects. The prevalence and diagnostic performance of ECG features indicative of PH and right heart strain were calculated.
    Results: Compared to the control group, all abnormalities were more frequent in the PH cohort where no patient had a completely normal ECG. The most prevalent (cases vs control) ECG abnormalities were: pathological Q wave in at least two contiguous peripheral leads (47.7 vs 6.7%), left ventricular hypertrophy (38.5 vs 9.8%) and p-pulmonale (36.9 vs 20.7%) (all p < 0.05). The sensitivity of ECG criteria for right heart strain ranged between 6.2 and 47.7%, while specificity ranged between 79.3 and 100%. Negative predictive value ranged between 81.5 and 88.9% and positive predictive value between 25 and 100%. Positive predictive value was lowest (25%) for right bundle branch block and QRS rightaxis deviation (≥ 100°), and highest (100%) for QRS axis ≥ +100° combined with R/S ratio in V1 ≥ 1 or R in V1 > 7 mm.
    Conclusion: When present, signs of PH on ECG strongly indicated disease, but a normal ECG cannot rule out disease. ECG patterns focusing on the R and S amplitude in V1 and right-axis deviation had good specificity and negative predictive values for PH, and warrant further investigation with echocardiography.

  8. Title: A survey of non-communicable diseases and their risk factors among university employees: a single institutional study
    Authors: Emmanuel I Agaba, Maxwell O Akanbi, Patricia A Agaba, Amaka N Ocheke, Zumnan M Gimba, Steve Daniyam, Edith N Okeke
    From:  Cardiovascular Journal of Africa, Vol 28, Issue 6, November/December
    Published: 2017
    Pages: 377–384
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    DOI Number: 10.5830/CVJA-2017-021
    DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2017-021
    Background: The incidence of non-communicable diseases (NCDs) is rising globally, with its attendant morbidity and mortality, especially in developing countries. This study evaluated the prevalence of NCDs and their risk factors among members of a university community.
    Methods: All employees of the university were invited to the University health clinic for screening, using the World Health Organisation’s STEPwise approach to NCDs.
    Results: A total of 883 (521; 59.0% males) employees with a mean age of 44 ± 10 years were studied. The median (IQR) number of NCD risk factors was three (two to three) per participant. The most common NCD risk factors were inadequate intake of fruit and vegetables (94.6%; 95% CI: 92.8–95.9), physical inactivity (77.8%; 95% CI: 74.9–80.5%) and dyslipidaemia (51.8%; 95% CI: 48.4–51.6%). Others included obesity (26.7%; 95% CI: 23.9–29.8%), alcohol use (24.0%; 95% CI: 21.3–27.0%) and cigarette smoking (2.9%; 95% CI: 2.0–4.3). Hypertension was the most common NCD (48.5%; 95% CI: 45.1–51.8%), followed by chronic kidney disease (13.6%; 95% CI: 11.4–16.1) and diabetes mellitus (8.0%; 95% CI: 6.4–10.1). There was no gender-specific difference in the prevalence of NCDs.
    Conclusion: This study identified that NCDs and their modifiable risk factors are highly prevalent in this community. Workplace policy to support the adoption of healthy living is needed.

  9. Title: Letter to the Editor
    Authors: Kahraman Cosansu, Mustafa Gokhan Vural, Mehmet Akif Cakar
    From: Cardiovascular Journal of Africa, Vol 28, Issue 6, November/December
    Published: 2017
    Pages: 384
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  10. Title: Relationship between coronary tortuosity and plateletcrit coronary tortuosity and plateletcrit
    Authors: Levent Cerit, Zeynep Cerit
    From: Cardiovascular Journal of Africa, Vol 28, Issue 6, November/December
    Published: 2017
    Pages: 385–388
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    DOI Number: 10.5830/CVJA-2017-023
    DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2017-023
    Background: Coronary tortuosity (CorT) is a common angiographic finding and may be associated with myocardial ischaemia, even without coronary artery disease. Platelets play a crucial role in inflammatory and thrombotic processes and the physiopathology of cardiovascular disease. Larger platelets are more active enzymatically and have higher thrombotic ability compared to smaller platelets. Plateletcrit (PCT) provides complete information on total platelet mass. We aimed to evaluate the relationship between CorT and PCT in patients with chronic stable angina.
    Methods: The medical records of consecutive patients who underwent coronary angiography from January 2013to January 2016 were retrospectively reviewed for CorT. CorT and clinical, echocardiographic, haematological and biochemical parameters were evaluated. Taking into consideration the inclusion criteria, 106 patients with CorT and 108 with normal coronary angiographies (control group) were included in the study. CorT was defined as three fixed bends during both systole and diastole, with each bend ≥ 45°.
    Results: The median PCT, mean platelet volume (MPV), platelet:large-cell ratio (P-LCR), neutrophil:lymphocyte ratio (NLR) and platelet:lymphocyte ratio (PLR) of the CorT group were significantly higher than those of the control group (0.26 ± 0.02 vs 0.2 ± 0.03%, p < 0.001; 10.6 ± 0.14 vs 9.6 ± 0.65 fl, p < 0.001; 29.3 ± 6.7 vs 23.4 ± 5.1, p < 0.001; 2.3 ± 1 vs 1.47 ± 0.48, p < 0.001; 1.28 ± 0.5 vs 0.82 ± 0.23, p < 0.001, respectively). The incidence of diabetes mellitus, hypertension and female gender were significantly higher in the CorT group (18.9 vs 1.9%, p < 0.001, 90.6 vs 50%, p < 0.001, 70.8 vs 44.4%, p < 0.001, respectively). Multivariate logistic regression analysis revealed age, hypertension, diabetes mellitus and plateletcrit were independently associated with CorT.
    Conclusion: CorT was associated with increased PCT, MPV, P-LCR, NLR and PLR, even in the absence of coronary artery disease. Age, hypertension, diabetes mellitus and plateletcrit were independently associated with CorT.

  11. Title: The effect of iloprost and sildenafil, alone and in combination, on myocardial ischaemia and nitric oxide and irisin levels
    Authors: Suna Aydin, Tuncay Kuloglu, Suleyman Aydin, Meltem Yardim, Davut Azboy, Zeki Temizturk, Ali Kemal Kalkan, Mehmet Nesimi Eren
    From:  Cardiovascular Journal of Africa, Vol 28, Issue  6, November/December
    Published: 2017
    Pages: 389–396
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    DOI Number: 10.5830/CVJA-2017-025
    DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2017-025
    Aim: Insufficient oxygen supply to organs and tissues due to reduced arterial or venous blood flow results in ischaemia, during which, although ATP production stops, AMP and adenosine continue to be produced from ATP. The fate of irisin, which causes the production of heat instead of ATP during ischaemia, is unknown. Iloprost and sildenafil are two pharmaceutical agents that mediate the resumption of reperfusion (blood supply) via vasodilatation during ischaemic conditions. Our study aimed to explore the effects of iloprost and sildenafil on irisin levels in the heart, liver and kidney tissues and whether these pharmaceutical agents had any impact on serum irisin and nitric oxide levels in rats with induced experimental myocardial ischaemia.
    Methods: The study included adult male Sprague-Dawley rats aged 10 months and weighing between 250 and 280 g. The animals were randomly allocated to eight groups, with five rats in each group. The groups were: sham (control), iloprost (ILO), sildenafil (SIL), ILO + SIL, myocardial ischaemia (MI), MI + ILO, MI + SIL and MI + ILO + SIL. The treatment protocols were implemented before inducing ischaemia, which was done by occluding the left coronary artery with a plastic ligature for 30 minutes. Following the reperfusion procedure, all rats were sacrificed after 24 hours, and their heart, liver and kidney tissues and blood samples were collected for analyses. An immunohistochemical method was used to measure the change in irisin levels, the ELISA method to quantify blood irisin levels, and Griess’ assay to determine nitric oxide (NO) levels in the serum and tissue. Myocardial ischaemia was confirmed based on the results of Masson’s trichrome staining, as well as levels of troponin and creatine kinase MB.
    Results: Irisin levels in biological tissue and serum dropped statistically significantly in the ischaemic group (MI), butwere restored with ILO and SIL administration. Individual SIL administration was more potently restorative than individual ILO administration or the combined administration of the two agents. NO level, on the other hand, showed the opposite tendency, reaching the highest level in the MI group, and falling with the use of pharmaceutical agents.
    Conclusions: Individual or combined administration of ILO and SIL reduced myocardial ischaemia and NO levels, andincreased irisin levels. Elevated levels of irisin obtained by drug administration could possibly contribute to accelerated wound recovery by local heat production. Sildenafil was more effective than iloprost in eliminating ischaemia and may be the first choice in offsetting the effects of ischaemia in the future.

  12. Title: The effect of lifestyle interventions on maternal body composition during pregnancy in developing countries: a systematic review
    Authors: Estelle D Watson, Shelley Macaulay, Kim Lamont, Philippe J-L Gradidge, Sandra Pretorius, Nigel J Crowther, Elena Libhaber
    From: Cardiovascular Journal of Africa, Vol 28, Issue  6, November/December
    Published: 2017
    Pages: 397–403
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    DOI Number: 10.5830/CVJA-2017-003
    DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2017-003
    Abstract: Optimal maternal body composition during pregnancy is a public health priority due to its implications on maternal health and infant development. We therefore aimed to conduct a systematic review of randomised, controlled trials, and case–control and cohort studies using lifestyle interventions to improve body composition in developing countries. Of the 1 708 articles that were searched, seven studies, representing three countries (Brazil, Iran and Argentina), were included in the review. Two articles suggested that intervention with physical activity during pregnancy may significantly reduce maternal weight gain, and five studies were scored as being of poor quality. This systematic review highlights the lack of research within developing countries on lifestyle interventions for the management of excessive weight gain during pregnancy. Similar reviews from developed countries demonstrate the efficacy of such interventions, which should be confirmed using well-designed studies with appropriate intervention methods in resource-limited environments.

  13. Title: Unusually aggressive immature neo-intimal hyperplasia causing in-stent restenosis
    Authors: Keir McCutcheon, Andreas S Triantafyllis, Johan Bennett, Tom Adriaenssensie
    From:  Cardiovascular Journal of Africa, Vol 28, Issue  6, November/December
    Published: 2017
    Pages: 404–405
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    DOI Number: 10.5830/CVJA-2017-024
    DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2017-024
    Abstract: This image illustrates a very unusual pattern of early and aggressive immature neo-intimal hyperplasia in a 52-year-old man with unstable angina, two months after deployment of a drug-eluting stent in the proximal left anterior descending artery..

  14. Title: Letter to the Editor: NT-pro BNP and plasma-soluble ST2 as promising biomarkers for hypertension, hypertensive heart disease and heart failure in sub-Saharan Africa
    Authors: Anastase Dzudie, MD, Bonaventure Suiru Dzekem, Andre Pascal Kengne
    From:  Cardiovascular Journal of Africa, Vol 28, Issue 6, November/December
    Published: 2017
    Pages: 406-407
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  15. Title: Congress News
    Authors: PA Brink
    From:  Cardiovascular Journal of Africa, Vol 28, Issue, 5, September/October
    Published: 2017
    Pages:408
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  16. Title: Efficacy of cardiac magnetic resonance imaging in a sub-aortic aneurysm case
    Authors: Ruchika Meel, Richard Nethononda, Ferande Peters, Mohammed Essop
    From: Cardiovascular Journal of Africa, Vol 28, Issue, 6, November/December
    Published: 2017
    Pages:e1-e3
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    DOI Number: 10.5830/CVJA-2017-027
    DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2017-027
    Abstract: Sub-aortic (SA) aneurysms are a rare entity of variable aetiology. We report the first case of a SA aneurysm assessed using cardiac magnetic resonance imaging (MRI). A 33-year-old female with human immunodeficiency virus and on highly active antiretroviral treatment presented with syncope and dyspnoea. Clinical examination suggested moderate to severe aortic regurgitation (AR) confirmed by transthoracic and transoesophageal echocardiograms. However, echocardiography was suboptimal in defining the precise mechanism and severity of AR. A cardiac MRI was done to elucidate the aetiology, severity and mechanism of regurgitation. It confirmed the presence of a SA aneurysm below the left coronary cusp and its retraction, resulting in an eccentric AR jet. An assessment of moderate AR, based on regurgitant volume, was made. Furthermore, the anatomical relationships of the aneurysm were clearly defined. Cardiac MRI allowed comprehensive assessment of this SA aneurysm..

  17. Title: Miller–Fisher syndrome after coronary artery bypass surgery
    Authors: Mustafa Aldag, Sebnem Albeyoglu, Ufuk Ciloglu, Hakan Kutlu, Levent Ceylanr
    From:  Cardiovascular Journal of Africa, Vol 28, Issue, 6, November/December
    Published: 2017
    Pages:e4-e5
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    DOI Number: 10.5830/CVJA-2017-033
    DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2017-033
    Abstract: Miller–Fisher syndrome (MFS) is an uncommon neurological disorder that is considered a variant of the Guillain–Barre syndrome (GBS). It is clinically defined by a triad of symptoms, namely ataxia, areflexia and ophthalmoplegia. These acute inflammatory polyradiculopathic syndromes can be triggered by viral infections, major surgery, pregnancy or vaccination. While the overall incidence of GBS is 1.2–2.3 per 100 000 per year, MFS is a relatively rare disorder. Only six cases of GBS after cardiac surgery have been reported, and to our knowledge, we describe the first case of MFS after coronary artery bypass surgery. Although cardiac surgery with cardiopulmonary bypass may increase the incidence of MFS and GBS, the pathological mechanism is unclear. Cardiac surgery may be a trigger for the immune-mediated response and may cause devastating complications. It is also important to be alert to de novo autoimmune and unexpected neurological disorders such as MFS after coronary bypass surgery.
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