磁性纳米颗粒的产热机制及在肿瘤热疗中的应用

磁热疗是继放射治疗、化学药物治疗后新兴的一种微创肿瘤治疗手段。磁性纳米颗粒在外加磁场下靶向病变部位并积集于此,在交变磁场中磁滞或弛豫产热,使病变部位快速升温。磁热在肿瘤微环境使其发生蛋白质变性、DNA损伤、免疫系统激活等,可在短时间内安全有效地杀死肿瘤细胞。综述磁性纳米颗粒的产热机制,在肿瘤磁热疗中与细胞的相互作用,及与其他肿瘤治疗方式的协同作用,并讨论其对细胞毒性和治疗的副作用。     

磁性纳米介质的毒理学研究进展

磁性纳米介质在医药等诸多领域有广泛的应用价值,如肿瘤磁感应热疗、影像诊断、药物载体等。而磁性介质的生物相容性是其在医学领域中应用的前提。本文主要对磁流体、磁性脂质体这类磁性纳米介质的毒理学研究进展磁性纳米介质体内、体外毒性评价实验,相关评价指标的研究进展及磁性介质毒理学研究中存在的问题进行综述。     

载磁性氧化铁CA-PLGA纳米颗粒对宫颈癌细胞的影响

目的 研究纳米四氧化三铁(Fe3O4)颗粒包裹不同外壳材料对宫颈癌细胞HeLa毒性的影响.方法 通过无溶剂热分解法制备磁性纳米Fe3O4颗粒并分别使用聚乳酸-羟基乙酸共聚物(PLGA)和胆酸(CA)修饰的PLGA(CA-PLGA)星型共聚物包裹,对其进行验证表征后,使用激光共聚焦显微镜观察HeLa细胞对纳米颗粒的摄取,并用噻唑蓝(MTT)法测定上述两种材料包裹的纳米Fe3O4颗粒对HeLa细胞的毒性作用.结果 制备的单个纳米Fe3O4颗粒粒径约7 nm,载Fe3O4的PLGA和CA-PLGA纳米颗粒均呈球状,粒径约200 nm,理论载药量为10％.当Fe3O4纳米颗粒的质量浓度相同(25 μg/ml)时,载Fe3O4的CA-PLGA纳米颗粒对HeLa细胞的毒性小于对应的PLGA纳米颗粒.结论 CA-PLGA星型共聚物可降低磁性纳米Fe3O4颗粒的细胞毒性,在生物体内具有广阔的应用前景.     

用于磁共振造影的纳米磁性微粒的制备与特性研究

目的：制备出磁响应性强、粒径小、分布均匀、且表面包覆一层助悬剂的磁性纳米微粒，为腹部磁共振造影提供一种新型材料。方法：用三氧化二铁作为磁性原料，羧甲基纤维素钠和黄原胶为助悬剂，水为基载液，利用研磨法制备出纳米磁性微粒。通过扫描电镜和原子力显微镜观察微粒的形态和大小，用磁强计检测微粒的磁响应性。结果：该法制备的包覆有助悬剂的三氧化二铁磁性微粒多呈球形，粒径为纳米级。常温下密封保存3个月性质不改变。在外加场强为10^4Oe、外部温度为18℃的条件下微粒的磁响应强度为（26．0±1.1）emu／g，撤除磁场时剩磁为零，显示微粒具有超顺磁性。结论：用该法制备的磁性微粒，具有有效粒径小、磁响应性好、不团聚、不沉降、且服用安全的优点，可作为一种新型磁共振口服造影剂．用于诊断胃肠道病变。     

羟基磷灰石纳米粒子细胞毒性和血液相容性的评价

目的研究羟基磷灰石纳米粒子细胞毒性和血液相容性。方法将羟基磷灰石纳米粒子以不同分散剂、不同终浓度作用于L929细胞,用MTT比色法观察其细胞毒性;用溶血试验检测其血液相容性。结果 MTT实验表明,不同浓度羟基磷灰石纳米粒子作用细胞后,细胞生长受到不同程度的抑制,这一抑制作用随羟基磷灰石纳米粒子浓度的升高而增强,同一样品各个浓度之间存在显著性差异。对于同一浓度,三种纳米粒子细胞毒性大小依次为：HAP3〉HAP2〉HAP1,而三种分散剂对细胞增殖的影响没有显著性差异。溶血试验表明,溶剂肝素钠、聚丙烯酸纳和三种不同浓度的HAP1纳米粒子均无溶血现象,而三种不同浓度的HAP2和HAP3均有溶血现象,HAP2对浓度存在依赖性,HAP3纳米粒子的三种浓度之间无显著性差异。结论羟基磷灰石纳米粒子对L929细胞增殖有抑制作用,血液相容性与不同的分散剂和纳米粒子浓度有关。     

静磁场靶向药物递送系统在肿瘤诊疗中的研究进展

化疗是治疗肿瘤的传统手段之一,但其具有组织非特异性,在抑制肿瘤细胞生长的同时也会对正常细胞产生毒副作用.磁靶向药物递送系统可通过具有生物相容性的、稳定的磁性纳米颗粒载体将抗癌药物在外磁场的引导下,靶向运输和浓聚在肿瘤组织.该技术不仅提高了药物运输的效率和药物的抗癌活性,还能降低药物用量和减轻毒副作用.载药磁性纳米颗粒和所应用的外磁场的性质是影响磁性纳米颗粒靶向肿瘤组织的重要影响因素.载药磁性纳米颗粒的靶向递送是否有效,主要依赖靶向目标位置处所应用的磁场和磁场强度是否足够吸引束缚载药磁性纳米颗粒在肿瘤组织中停留以及释放.对静磁场在引导磁性纳米颗粒靶向肿瘤组织研究的新进展进行综述,为静磁场在靶向肿瘤治疗方面提供一定的科研基础支持.     

纳米微粒磁性靶向热疗作用的应用研究(文献综述)

1 热疗及磁性靶向热疗的概念 将肿瘤部位加热到41℃以上治疗恶性肿瘤的方法称热疗（Hyperthermia）。高温治疗肿瘤由来已久，很早就被认为是有效的疗法。近30年来，随着高温设备的不断更新，加热技术、测温技术的不断发展，高温疗法已成为肿瘤治疗的重要手段之一。目前常用的热疗方法如射频、微波、激光、聚焦超声、全身热疗、隔离灌注等，因对肿瘤的靶向能力差，易导致周围组织的温度升高，具有一定的创伤性，其临床应用范围有限。近年来，随着纳米技术的研究进展，在纳米水平上研制纳米磁性微粒作为药物载体又引起了人们的广泛兴趣，磁性微粒不仅可以用作药物载体，而且在交变磁场下还可发热升温，引起了人们对其在肿瘤热疗方面的潜在价值的重视。     

用于肿瘤靶向性MRI对比剂双亲性超顺磁复合物的制备（英文）CSCD

背景:超顺磁四氧化三铁纳米粒子(Fe3O4NPs)被广泛应用于MRI成像,为防止其聚集和实现高精度肿瘤诊断,制备高度稳定性、生物相容性和肿瘤靶向性的超顺磁MRI对比剂至关重要。目的:合成具有基于叶酸受体靶向的肿瘤靶向性双亲性超顺磁复合粒子。方法:首先通过化学共沉淀法制备出Fe3O4NPs,再用N,N’-二环己基碳二亚胺作脱水剂,通过酯键将双亲性高分子Pluronic-F127(PF127)与叶酸(FA)分子连接,从而形成PF127-FA偶联物,最后用PF127-FA包裹Fe3O4纳米粒子,形成稳定的具有肿瘤靶向功能的双亲性超顺磁复合粒子。分别采用透射电镜、傅里叶红外光谱、紫外可见吸收光谱、热重分析、振动样品磁强计和T2加权成像对其进行表征,通过细胞毒性实验初步表征其细胞毒性。结果与结论:通过酯化反应制备了Pluronic-F127与FA偶联物,再用其包裹Fe3O4纳米粒子,成功制备出具有良好水溶性和生物相容性的超顺磁性复合粒子。该PF127-FA-Fe3O4复合粒子透射电镜观察到该复合粒子大部分粒径小于200 nm,Fe3O4核心大小为10-20 nm,傅里叶红外光谱和紫外可见吸收光谱结果证明了叶酸被成功修饰到超顺磁性复合粒子表面。热重分析结果表明PF127-FA占PF127-FA-Fe3O4复合粒子总量的27.2 wt%。磁性检测结果表明该复合粒子饱和磁强度Ms为47.35 emu/g,核磁共振仪成像测得其弛豫率为0.025×106 mol/s。细胞毒性实验表明显示了可以忽略的毒性。因此,实验成功制备了可用于肿瘤靶向性MRI对比剂的双亲性超顺磁复合物,实验所制备的PF127-FA-Fe3O4复合粒子有望用于肿瘤靶向性MRI对比剂。     

用于肿瘤靶向性MRI对比剂双亲性超顺磁复合物的制备（英文）

背景:超顺磁四氧化三铁纳米粒子(Fe3O4NPs)被广泛应用于MRI成像,为防止其聚集和实现高精度肿瘤诊断,制备高度稳定性、生物相容性和肿瘤靶向性的超顺磁MRI对比剂至关重要。目的:合成具有基于叶酸受体靶向的肿瘤靶向性双亲性超顺磁复合粒子。方法:首先通过化学共沉淀法制备出Fe3O4NPs,再用N,N’-二环己基碳二亚胺作脱水剂,通过酯键将双亲性高分子Pluronic-F127(PF127)与叶酸(FA)分子连接,从而形成PF127-FA偶联物,最后用PF127-FA包裹Fe3O4纳米粒子,形成稳定的具有肿瘤靶向功能的双亲性超顺磁复合粒子。分别采用透射电镜、傅里叶红外光谱、紫外可见吸收光谱、热重分析、振动样品磁强计和T2加权成像对其进行表征,通过细胞毒性实验初步表征其细胞毒性。结果与结论:通过酯化反应制备了Pluronic-F127与FA偶联物,再用其包裹Fe3O4纳米粒子,成功制备出具有良好水溶性和生物相容性的超顺磁性复合粒子。该PF127-FA-Fe3O4复合粒子透射电镜观察到该复合粒子大部分粒径小于200 nm,Fe3O4核心大小为10-20 nm,傅里叶红外光谱和紫外可见吸收光谱结果证明了叶酸被成功修饰到超顺磁性复合粒子表面。热重分析结果表明PF127-FA占PF127-FA-Fe3O4复合粒子总量的27.2 wt%。磁性检测结果表明该复合粒子饱和磁强度Ms为47.35 emu/g,核磁共振仪成像测得其弛豫率为0.025×106 mol/s。细胞毒性实验表明显示了可以忽略的毒性。因此,实验成功制备了可用于肿瘤靶向性MRI对比剂的双亲性超顺磁复合物,实验所制备的PF127-FA-Fe3O4复合粒子有望用于肿瘤靶向性MRI对比剂。     

纳米微粒偶联抗OX40/抗AFP抗体在细胞毒性T细胞抗肝癌中的作用

目的探讨乳酸-羧基乙酸共聚物(PLGA)制备的纳米微粒偶联抗OX40及抗AFP抗体(抗OX40/抗AFP-NP)对甲胎蛋白AFP158-166抗原肽特异性细胞毒性T细胞(CTL/AFP158-166)体外杀伤肝癌细胞的影响。方法用溶剂蒸发法制备纳米微粒(NP),并与抗OX40和抗AFP共价偶联。用扫描电镜观察所制得PLGA-NP纳米颗粒的形态;ZetaPlusTM粒度测定仪检测纳米微粒的粒径及电荷;用BCA蛋白定量方法检测纳米微粒偶联抗体的效率;用人外周血单核细胞诱导形成树突状细胞(DC),用AFP158-166抗原肽负载DC诱导AFP特异性的CTL/AFP158-166;分别用2-(4-碘苯)-3-(4硝基苯)-5-(2,4-磺苯基四氮唑)-2H-四唑单钠盐-1法(WST-1)法、ELISA及乳酸脱氢酶(LDH)法分别检测抗OX40/抗AFP-NP对CTL/AFP158-166细胞增殖能力、分泌IL-2和IFN-γ及杀瘤活性的影响。结果所制得的PLGA-NP为圆形,大小较均一,粒径约为(300±42)nm,带负电荷,约为-(25.12±5.34)mV。蛋白定量显示每mg的PLGA-NP偶联约100μg抗体,偶联效率为25%;增殖和活化实验显示偶联有抗OX40的纳米微粒能显著刺激CTL的增殖、IL-2和IFN-γ的分泌;杀伤实验显示,抗OX40/抗AFP-NP能显著增强AFP特异性CTL/AFP158-166细胞对HepG2细胞特异性杀伤作用,而对SMMC-7721杀伤作用无明显效果。结论抗OX40/抗AFP-NP能刺激CTL/AFP158-166细胞的增殖、细胞因子的分泌并增强CTL/AFP158-166细胞对AFP阳性肝癌细胞的特异性杀伤作用。     

Studien zur humoralen Regulation des erythropoetischen Proliferationsspeichers beim Menschen

Zusammenfassung Die Beeinflussung der Erythroblasten-Proliferation durch das Mikromilieu wurde in vitro mittels Auswertung durch Differential- und Mitosezählungen und Signifikanzberechnung vieler Versuchsreihen auch unter verschiedenen pathologischen Bedingungen getestet.Sowohl die Mitosehäufigkeit wie die Ausreifung waren positiv mit dem Erythropoetingehalt des Medium korreliert. Der Effekt wurde durch Folsäure, Ätiocholanolon und cAMP verstärkt. Cobalt stimulierte ebenso wie Testosteron und Methenolon in vitro unabhängig von der Erythropoetinkonzentration im Medium die Erythroblastenproliferation. Ein vermindertes Eisenangebot störte die endgültige Ausreifung der Erythroblasten zu Retikulozyten und bewirkte dadurch eine Ineffektivität der Erythorpoese. Anhaltspunkte für ein Erythrozyten-Chalon oder einen Erythropoetinhemmkörper ließen sich aus unserem Versuchsansatz nicht gewinnen, weil er die Transformation der pluripotenten in die erythropoetin-sensible Stammzelle nicht einschließt. Als Nebenbefund ergab sich eine Stimulation des granulozytopoetischen Proliferationsspeichers durch Serumzusatz zum Medium von Patienten nach akutem Blutverlust und bei Polycythämia vera.Unterstützt durch die Deutsche Forschungsgemeinschaft     

HLA study in Amerindian Bolivia La Paz Aymaras

Aymara people has been a relatively homogeneous group since Spanish Conquest by 1,532 CE, even if previously represented a group of various cultural defined populations who gave rise to them. They were and are established in Andean Altiplano around Titikaka Lake (Bolivia, Peru), Argentina and Chile neighborhood, speak Aymara language and have been maintained after Europeans arrival at a lower social status than Quechua (Inca) speaking people. However, both Aymara and Quechua populations acknowledge Titikaka Lake as center of their origins; both languages are also related. Specific high frequencies of HLA-A*02, -A*24 and -A*68, HLA-B*35, -B*39 and -B*48, HLA-DRB1*08:02, -DRB1*09:01, and -DRB1*14:02, and HLA-DQB1*04:02, -DQB1*03:02 and -DQB1*03:01 alleles are found in Aymaras and HLA class II haplotypes common to Andean Amerindians (DRB1*08:02-DQB1*04:02 and DRB1*04:03-DQB1*03:02), like Quechua, Aymara, Uros, Lamas and Mapuche are also found in Easter and other Pacific Islands. Giant human head stone statues at Tiwanaku (Titikaka Lake, Bolivia) are also found at Easter Island. Thus, it is possible a gene and cultural flow between Andean Amerindians and Easter and other Pacific Islands, as it was demonstrated by Thor Heyerdahl in his Kon-Tiki expedition which reached Pacific Islands sailing from El Callao Harbour (Lima, Peru).     

Lipid composition of metacestodes of Taenia taeniaeformis and lipid changes during growth

A lipid analysis was performed on developing metacestodes of Taenia taeniaeformis removed from the livers of rats at times varying from 3 to 35 weeks post infection. Lipid accounted for 7–21% of the dry weight of the parasites. The highest proportions were found at the earlier stages. The distribution was as follows; neutral lipid 27–45%; glycolipid 5–11%; and phospholipid 50–61%. The major neutral lipid was cholesterol, and minor neutral lipids were sterol esters, triglycerides, diglycerides and monoglycerides. Hydrocarbons were present throughout development, but in the highest amounts at the earlier stages. Five different glycolipids were found, all of which were identified as glycosphingolipids. An increase in the proportion of more complex glycolipids was noted as parasites grew older. Ten different phospholipids were identified, with the major components being phosphatidylcholine, phosphatidylethanolamine, and phosphatidylserine. Other phospholipids were: lysophosphatides, phosphatidylinositol, phosphatidic acid, diphosphatidylglycerol, sphingomyelin, and an unknown phospholipid component. Changes in the relative amounts of the two major phospholipids were found when the early and late stages were compared. Two lipids found throughout development were identified as glycosylated dolichol phosphates, and they comprised between 1 and 3% of the total phospholipid fraction. Nineteen fatty acids were detected, and the fatty acid distribution for each lipid class at each stage was determined. Seven major fatty acids were common to each. These were: hexadecanoic, octadecanoic, oleic, linoleic, arachidonic, docosanoic, and docosahexaenoic.     

Simple Serological Assays for Detecting Rice Tungro Viruses

An attempt was made to produce sensitive and specific polyclonal antisera against the viruses causing rice tungro disease, and to assess their potential for use in simple diagnostic tests. Using a multiple, sequential injection procedure, seven batches of polyclonal antisera against rice tungro bacilliform virus (RTBV) and rice tungro spherical virus (RTSV) were produced. These were characterized for their sensitivity and specificity using ring-interface precipitin test and double antibody sandwich (DAS) ELISA. Thirty-one weeks after the first immunization, antiserum batch B6b for RTBV showed the highest ring interface titer (DEP = 1:1920). For RTSV, batches S3, S4b and S5b all had similar titres (DEP = 1:640). In DAS-ELISA, however, significant differences among purified antisera (IgG) batches were observed only at IgG dilution of 10^-3. At that dilution, IgGB4b showed the greatest sensitivity, while IgGS3 showed greatest sensitivity for RTSV. When all IgG batches were tested against 11 tungro field isolates (dual RTBV-RTSV infections) at sample dilution of 1:10, IgGB4b and IgGB6b for RTBV and IgGS3 and IgGS6b for RTSV performed equally well. However, after cross adsorption with healthy plant extracts in a specially prepared healthy plant-Sepharose affinity column, only IgGB6b could be used specifically to detect RTBV in a simple tissue-print assay.     

Is it worthy to take full-course immunotherapy for allergic rhinitis? About efficacy biomarker of allergen immunotherapy

Nowadays, people pay more attention to biomarkers that can predict clinical efficacy of immunotherapy for allergic rhinitis. As the only recognized aetiological treatment, the efficacy of allergen immunotherapy (AIT) has been proved by many studies. However, treatment success depends on compliance and persistence greatly, which can be impaired by the lengthy duration of AIT and socioeconomic status of patients. Besides, ineffectiveness is another factor that accounts for non-adherence. If the clinical efficacy can be predicted in the early stage of immunotherapy, it can help patients choose appropriate treatment plans, increase patient compliance and optimize the allocation of medical resources. This paper mainly focuses on five candidate biomarkers, the sIgE/tIgE ratio before treatment, serum inhibitory activity for IgE, decreased basophil activation, upregulation of Tregs and tolerogenic DCs, reviews the time when potential biomarkers can predict or monitor the efficacy of AIT, discusses the reason why these indicators could serve as efficacy biomarkers and interactions among potential biomarkers.     

Neurotransmitter signaling pathways required for normal development in Xenopus laevis embryos: a pharmacological survey screen

Neurotransmitters are not only involved in brain function but are also important signaling molecules for many diverse cell types. Neurotransmitters are widely conserved, from evolutionarily ancient organisms lacking nervous systems through man. Here, results are reported from a loss‐ and gain‐of‐function survey, using pharmacological modulators of several neurotransmitter pathways to examine possible roles for these pathways in normal embryogenesis. Applying reagents targeting the glutamatergic, adrenergic and dopaminergic pathways to embryos of Xenopus laevis from gastrulation to organogenesis stages, we observed and quantified numerous malformations, including craniofacial defects, hyperpigmentation, muscle mispatterning and miscoiling of the gut. These data implicate several key neurotransmitters in new embryonic patterning roles, reveal novel earlier stages for processes involved in eye development, suggest new targets for subsequent molecular‐genetic investigation, and highlight the necessity for in‐depth toxicology studies of psychoactive compounds to which human embryos might be exposed during pregnancy.     

Uncombable Hair (cheveux incoiffables, pili trianguli et canaliculi) Syndrome: Brief Review and Role of Scanning Electron Microscopy in Diagnosis

Uncombable hair syndrome was first described some 3 decades ago as "cheveux incoiffables" and is also known as spun-glass hair and pili trianguli et canaliculi. Both inherited (autosomal dominant and recessive with variable levels of penetrance) and sporadic forms of uncombable hair syndrome have been described, both being characterized by scalp hair that is impossible to comb due to the haphazard arrangement of the hair bundles. A characteristic morphologic feature of hair in this syndrome is a triangular to reniform to heart shape on cross-sections, and a groove, canal or flattening along the entire length of the hair in at least 50%of hairs examined by scanning electron microscopy. Most individuals are affected early in childhood and the hair takeson a spun-glassappearance with the hair becoming dry, curly, glossy, lighter in color, and progressively uncombable. Only the scalp hair is affected. Several conditions are associated with uncombable hair, such as ectodermal dysplasia, retinal dysplasia/ pigmentary dystrophy, juvenile cataract, digit abnormalities, tooth enamel anomalies, oligodontia, and phalangoepiphyseal dysplasia. Other syndromes with hair abnormalities may also mimic uncombable hair syndrome clinically and these include, Rapp-Hodgkin ectodermal dysplasia; loose anagen hair syndrome; ectodermal dysplasia, ectrodatyly, cleft lip/ palate (EEC) syndrome; and familial tricho-odonto-onchyial ectodermal dysplasia with syndactyly. Unlike other conditions with an uncombable hair component, uncombable hair syndrome alone (cheveux incoiffables, pili trianguli etcanaliculi) is not associated with physical, neurologic, or mental abnormalities. In most cases of uncombable hair syndrome, the hair is grossly abnormal in infancy and early childhood, but may have improved manageability later in life. Scanning electron microscopy of hair samples provides definitive evidence for diagnosis of clinically suspected uncombable hair syndrome and eliminates other hair abnormalities from the differential diagnosis.     

A comparative study of cholinergic systems of the neocortex and hippocampus in rats with low and high resistance to hypoxia

Synaptic structures in the neocortex and hippocampus of the intact brain were compared between rats with low and high resistance to hypobaric hypoxia. Activities of choline acetyltransferase, acetylcholinesterase, Na,K-ATPase, and the portion of protein in the light and heavy synaptosome fractions and subfractions were measured. A discrepancy in cholinergic metabolism molecular mechanisms between high and low resistance animals have been found in the heavy somatosoma fraction from the neocortex. Activities of choline acetyltransferase, acetylcholinesterase, and Na,K-ATPase in the synaptolemmal subfraction of low resistant rats were much lower than in high resistant rats. This implies a less effective synaptic transmission in proper cholinergic neurons in the low resistance animals and, therefore, specifically changed neuron functioning in the circulation control. No differences in the cholinergic components of either neocortical light synaptosome fraction or hippocampal light and heavy synaptosome fractions were found between low and high resistance rats. Translated fromByulleten' Eksperimental'noi Biologii I Meditsiny, Vol. 125, No. 5, pp. 521–525, May, 1998     

BSACI guideline for the diagnosis and management of cow's milk allergy

This guideline advises on the management of patients with cow's milk allergy. Cow's milk allergy presents in the first year of life with estimated population prevalence between 2% and 3%. The clinical manifestations of cow's milk allergy are very variable in type and severity making it the most difficult food allergy to diagnose. A careful age‐ and disease‐specific history with relevant allergy tests including detection of milk‐specific IgE (by skin prick test or serum assay), diagnostic elimination diet, and oral challenge will aid in diagnosis in most cases. Treatment is advice on cow's milk avoidance and suitable substitute milks. Cow's milk allergy often resolves. Reintroduction can be achieved by the graded exposure, either at home or supervised in hospital depending on severity, using a milk ladder. Where cow's milk allergy persists, novel treatment options may include oral tolerance induction, although most authors do not currently recommend it for routine clinical practice. Cow's milk allergy must be distinguished from primary lactose intolerance. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for clinicians in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking the panel of experts in the committee reached consensus. Grades of recommendation are shown throughout. The document encompasses epidemiology, natural history, clinical presentations, diagnosis, and treatment.