Method for evaluating the severity of tuberculosis infection |
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IPC classes for russian patent Method for evaluating the severity of tuberculosis infection (RU 2305286):
 Method for predicting diabetic retinopathy / 2304786
Due to biochemical testing lacrimal fluid (LF0 it is necessary to detect the concentration of cholesterol, activity of superoxide dismutase (SOD) and catalase, in blood one should detect the concentration of nitrites and based upon the values obtained calculate Function 1 and Function 2. Function 1 = -3.4+0.29(NO2)+32.5(cholesterol)-0.97(catalase)-17.28(SOD) - corresponds to Y-axis values and Function 2 = -7.14+0.17(NO2)+37.2(cholesterol)+2.1(catalase)-17.28(SOD) - corresponds to X-axis values on the scheme to detect lesion type. If the point obtained is on the field of the 1st scheme one should detect the presence of nonproliferative DR form in a patient at no risk of proliferation; if it is on the field of the 2nd scheme - nonproliferative DR form with the risk of proliferation; if it is on the field of the 3d scheme - proliferative form of retinopathy in the phase of neovascularization. Application of the present method enables to carry out diagnostics in due time, differentiation in doubtful cases directed towards adequate treatment and decreasing the risk for DR progressing.
Method for predicting the development of postgastroresectional peptic ulcers / 2304785
The present innovation deals with predicting the development of postgastroresectional peptic ulcers in patients due to detecting the level of gastrin after stimulation, pepsinogen, prostaglandins PGE2 and PG F2α, correspondingly, in mucosa of gastric stump and in mucosa of gastroenteroanastomosis. At increasing gastrin level up to 12.5 pM/l and higher, that of pepsinogen up to 10.0 mcg/l and higher and decreasing the level of prostaglandin PGE2 up to 570 and lower and at the decrease of prostaglandin PG F2α level up to 652 ng/g and lower one should predict the development of postgastroresectional peptic ulcer. Application of the present innovation enables to increase the accuracy in predicting the development of postgastroresectional peptic ulcers.
Method for predicting the chance for osteomyelitis chronization in children / 2304784
During the moment of exacerbation and on ending the disease in question one should detect the content of alpha-1 proteinase inhibitor and alpha-1 acid glycoprotein in blood due to immunoturbidimetric technique. At decreased content of alpha-1 proteinase inhibitor from 2.3-2.6 g/l up to 1-1.2 g/l, and alpha-1 acid glycoprotein from 2.4-2.6 g/l up to 0.7-0.8 g/l one should predict the absence of osteomyelitis chronization. At decreased content of alpha-1 proteinase inhibitor from 2.9-3.1 g/l up to 1.8-1.6 g/l, and that of alpha-1 acid glycoprotein from 3-3.2 g/l up to 1.2-1.3 g/l one should predict osteomyelitis chronization. Application of the present method enables to predict the disease flow in shorter terms at high significance that provides the chance to prescribe the complex of efficient measures in due time which vary depending upon the disease flow.
Method for predicting the development of gestosis / 2304783
Starting from 22nd wk of pregnancy it is necessary to detect the concentration of neurospecific enolase and glyofibrous acid protein in blood serum. The development of gestosis in pregnant women should be predicted by the value of neurospecific enolase being above 12.4 ng/ml and glyofibrous acid protein being above 4 ng/ml. Moreover, severe gestosis should be predicted at the value of neurospecific enolase being 19 ng/ml and higher and glyofibrous acid protein being 10 ng/ml and higher. Application of the method enables to increase the accuracy of prediction.
Method for evaluating the results of surgical sanitation of inflammation focus in patients with chronic osteomyelitis / 2304781
The present innovation deals with laboratory investigations in case of traumatological pathology. One should simultaneously carry out microscopic investigation of material sample out of inflammation focus and blood from cubital vein to study the growth of microorganisms in the focus and in case of its absence and at registering positive index of digestion in blood with test culture S.aureus 209 P inside neutrophil after incubation, the value of IgM being 0.5-1.3 against the norm, the value of C-reactive protein being up to 12.0 mg/l it is possible to conclude upon satisfactory result of therapy conducted. Application of the present method enables to evaluate the degree of inflammatory process in bony tissue and, also, the state of phagocytic function of neutrophils as the first line of protection against microbial invasion.
Method for predicting the frequency of acute respiratory-viral infections due to evaluating the state of local immunity in children of primary-school age / 2303784
One should detect gamma-glutamyl transferase (GGT) in saliva sampled in the morning to an empty stomach. At GGT values being under 0.85 IU/l or above 3.4 IU/l it is possible to diagnose the decrease of local immunity in children and predict the risk for transferring a healthy child into the group of frequently sick patients. Application of the present method enables to predict the frequency of acute respiratory-viral infections (ARVI) before the procedure of prophylactic vaccinations, provides the chance for carrying out corresponding correction measures. The innovation is simple in application being noninvasive and could be applied in any age group.
 Method for quantitative determination of antibodies concentration specific to human endometrial tissue stromal cells antigen and in human biological fluid containing specific antibodies / 2303267
Method involves using the usual solid-phase enzyme immunoassay based on chemical binding antigen with microplate surface followed by placing antibodies-containing biological fluid on microplate, incubation, carrying out the color reaction and spectrophotometric evaluation of the color reaction indices. The end antigen is prepared by enzymatic hydrolysis of human normal tissue samples containing stromal cells of endometrial tissue. The enzymatic hydrolysis reaction is terminated by addition of chelating agent. Prepared mixed suspension of cells is centrifuged in continuous density gradient resulting isolation of stromal cells. Microsomal fraction of stromal cells is used as the end antigen that is diluted and bound covalently with microplate well surface. Then calibrating material prepared on basis of standard preparation antibodies specific to the end antigen is added into wells set, and biological fluid samples for analysis are added into another wells set. After carrying out the usual solid-phase enzyme immunoassay and using spectophotometry data a calibrating curve is plotted and the concentration of specific antibodies is determined using this curve. Invention provides the development of method for assay of antibodies amount specific to endometrial tissue stromal cells exceptionally that gives possibility for clinical diagnosis of autoimmune syndrome. Invention can be used in gynecology and obstetrics for diagnosis of autoimmune syndrome accompanying to clinical picture of endometriosis and other diseases in female reproductive system.
Method for predicting atrial fibrillation in cardiac ischemia patients / 2303266
Method involves applying immunoenzyme assay approach for analyzing blood for Chlamydia pneumoniae presence. Levels of inflammatory markers like C-reactive protein and tumor necrosis factor alpha are quantitatively determined. Seropositive result being the case with CRP level above 1.8 mg/l and TNF-α level above 2.4 pg/dl, atrial fibrillation occurrence is to be predicted.
Method for controlling climacteric disorders hormone replacement therapy safety in women in menopause period / 2303265
Method involves analyzing blood serum for alpha-2-glycoprotein associated with pregnancy taking concentration determined before administering hormone therapy for individual reference value and then, blood serum is analyzed once every half-year during the whole hormone replacement therapy application period. Alpha-2-glycoprotein associated with pregnancy having unchanged concentration or its concentration being increased by 50% when compared to the individual reference value, hormone replacement therapy application is to be continued. The concentration growing more than 50% high, when compared to the individual reference value, hormone replacement therapy application is to be prohibited.
 Method for identifying epitopes of t-cells and its using in preparing molecules of reduced immunogenicity / 2303264
Invention relates to a method for identifying epitopes of T-cells that induce the immune response in living organism-host. By this method immunogenicity-free biological compounds can be prepared or with reduced immunogenicity and in comparison with the corresponding unmodified object by decreasing or removing potential epitopes of T cells in limits of sequence of the parent immunogenic molecules. Also, invention relates to novel biological molecules being especially to proteins and antibodies prepared by the proposed invention. Invention provides reducing immunogenicity of biological compounds.
 Method for predicting the character of bacterial keratitis flow / 2245553
In lacrimal liquid one should detect the content of interleukin 8 (IL-8) and that of interleukin 1 beta (IL-1β) to calculate prognostic coefficient (PC) due to dividing the first value by the second one by the following formula:
Method for detecting the sequence of applied lesions / 2245555
For the purpose to detect the sequence of applied lesions at availability of several wounds, scratches and ecchymoses on a cadaver one should study the activity of alkaline peptides isolated out of affected tissue by the impact of blood neutrophils of healthy donors upon phagocytosis. Moreover, the highest stimulating effect belongs to the peptides isolated out of the lesion applied earlier. The method enables to detect the sequence of applied lesions more accurately and differentiate the repeated lesion applied 5 min later, or more.
Method for biochemical detecting the degree of chronic hepatitis activity / 2246112
In blood serum one should detect the level of lactoferrin and biliary acids. At their ratio being equal to 5-17 it is necessary to detect chronic hepatitis of high activity.
 Early diagnosis method for diagnosing external genital endometriosis in women / 2247391
Method involves determining cathepsin D activity in endometrium bioptate. The value being equal to or less than 0.1 units of enzymatic activity per hour, external genital endometriosis is diagnosed.
Method for estimating enteric detoxication in the cases of generalized peritonitis / 2247392
Method involves studying lactoferrin content in blood serum and peritoneal exudates in postoperative period every day during the first three days. Lactoferrin concentration in blood serum being concurrently reduced by 0.02 mcmole/l or less and increasing lactoferrin concentration in peritoneal exudates by 0.04 mcmole/l or more, enteric detoxication is considered to be effective.
Method for diagnosing septic process and predicting septic complications development in children / 2248572
Method involves determining plasminogen/plasmin, α2-macro-globulin, α1-antitripsin content at the first, third, fifth and tenth day. The plasminogen/plasmin level being equal to 66-74 mcmole/l or 100-120 mcmole/l, α2-macro-globulin level of 2.7-3.0 mcmole/l, α1-antitripsin content of 2.38-3.2 mcmole/l, systemic inflammatory response to purulent infection, light severity degree endotoxicosis is diagnosed and favorable disease outcome is predicted. The plasminogen/plasmin level being equal to 50-65 mcmole/l or 125-160 mcmole/l, α2-macro-globulin level of 2.3-2.6 mcmole/l, α1-antitripsin content of 3.3-4.0 mcmole/l, sepsis with organ and system dysfunction, moderate severity degree endotoxicosis is diagnosed and septic complication availability and lingering disease development course is predicted. The plasminogen/plasmin level being equal to 39-40 mcmole/l, α2-macro-globulin level of 1.58-2.08 mcmole/l, α1-antitripsin content of 5.0-6.2 mcmole/l, severe sepsis, septic shock, severe degree endotoxicosis is diagnosed and unfavorable disease outcome is predicted.
 Method for detecting oxidized tryptophan metabolites at endogenic intoxication / 2249219
At testing one should precipitate high-molecular compounds with acetonitrile and register supernatant's spectral characteristics. Supernatant should be applied onto a paper filter, dried and put into solution containing aromatic aldehyde, acetone and concentrated hydrochloric acid taken at weight ratio of 70:5:1 to be kept for 2-3 min. Then it should be once again dried up to detect qualitative and semiquantitative content of oxidized tryptophan metabolites by intensity and chromatic shades. Moreover, by chromatic shades of yellow dyeing it is possible to detect the content of hydroxylated metabolites and by chromatic shades of violet dyeing - that of unhydroxylated ones.
Method for predicting unfavorable result of metastatic peritonitis / 2251700
In patients one should study the content of lactoferrin in peritoneal exudates during the 1st d of postoperational period and at decreased value being below 3500 ng/ml on should predict unfavorable result. The suggested method provides correction of possible postoperational complications that deteriorate the flow of peritonitis and lead to lethal result.
Method for diagnosing endotoxicosis condition in cows suffering from acute pyocatarrhal endometritis / 2252418
Method involves determining low and middle molecular mass substances content in blood plasma and erythrocytes and general blood plasma albumin concentration. Integral index is calculated on basis of obtained values using formula II=100*S238-298(plasma)/S238-298(erythrocytes)*GAC, where S238-298(plasma) and S238-298(erythrocytes) are the low and middle molecular mass substances content in blood plasma and erythrocytes, respectively, determined from area of figures restricted by spectral curves in wavelength range of 238-298 nm and abscissa axis (conditional units2); GAC is the general blood plasma albumin concentration (g/l). The value being from 2.1 to 3.0, the first endotoxicosis degree is diagnosed. The value being from 3.1 to 4.5, the second endotoxicosis degree is diagnosed. The value being from 4.5 to 6.0, the third endotoxicosis degree is diagnosed. The value being greater than 6.0, the fourth endotoxicosis degree is diagnosed. The normal value is equal to 0.5-2.0.
Method for evaluating inflammatory process activity in infantine osteomyelitis cases / 2252419
Method involves separating blood serum proteins into fractions, determining albumins and alpha-2-globulins content and controlling their content changes during the disease development process. Gamma-globulin content is determined in per cent ratio with respect to total protein quantity. Then, changes in the fractions content are controlled from the first to the third week. Albumin content being in norm and alpha-2-globulins content becoming greater to the end of the first week by 30-50% when compared to normal value and dropping to norm at the second week end and gamma-globulin content increasing from norm by 10-30% to the second or the third week, high inflammatory process activity is to be diagnosed. Albumin content dropping by 10-30% from normal value at the second week, alpha-2-globulins content growing by 10-20% of norm and gamma-globulin content dropping by 30-50% at the second or the third week when compared to norm, low inflammatory process activity is to be diagnosed.
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FIELD: medicine, phthisiology. SUBSTANCE: in the experiment upon guinea pigs in blood plasma one should detect the concentration of taurine and glutamic acid and at taurine concentration being below 68 mcM/l and glutamic acid being below 76 mcM/l it is necessary to evaluate the state as severe, at taurine concentration ranged 68-89 mcM/l and that of glutamic acid ranged 125-227 mcM/l - as average severity degree, and at taurine and glutamic acid concentrations being above 89 and 227 mcM/l, correspondingly - as light severity degree. Application of the present method enables to increase information value and significance of the method in question and, also, detect body reactivity according to the state of its different systems. EFFECT: higher accuracy of evaluation. 3 ex, 2 tbl
The invention relates to medicine, in particular tuberculosis, and uses biochemical blood analysis to determine the number of amino acids. The severity of tuberculosis depends on the activity of the process and the reactivity of the organism and is determined by the degree of inflammatory reaction, intoxication syndrome and prevalence of the process. Known methods for determining the activity of tuberculosis on biochemical parameters of blood (for example, the patents of the Russian Federation 2187818, 2238564, 2161313). But the determination of the activity does not give the overall picture of the severity of TB, as it does not take into account the condition of the reactivity of the organism. There is a method of assessing the severity of tuberculosis, including the determination of biochemical parameters of blood (Hahamisha. The problem of tuberculosis, 2001, No. 7. - Pp.62-64). In the work determine C-reactive protein, haptoglobin, α1- antitripsin, fibrinogen and fibronectin, platelet activating factor, and the values of HCT-test that the parameters associated with the AOA, GENDER, immunological indexes and the number of ceruloplasmin. These parameters estimate the reactivity of the organism. It is well known that the indicators used in experiment and clinic as a non-specific characteristic of the systemic inflammatory response. Despite the high information content of the indicators, this method does not account for the activity of tuberculosis and matched with the public, unable to reliably estimate its severity. Furthermore, the method requires a large number of laboratory tests, which can be obtained only in the modern equipped laboratories and trained personnel to interpret the data received. Closest to the claimed is a method of assessing the severity of tuberculosis, including the determination of biochemical parameters of blood (As the USSR 1287010, 1987 - prototype). In this way as biochemical indicators determine the content of glucose-6-phosphatedehydrogenase (G-FDG). The level diagnose the severity of the disease. The content of G-FDG determined by any known method. The method is easy to use, reflects the activity of tuberculosis and the body's response to it, but not fully due to the low specificity D-FDG in relation to TB infection and low information content of the enzyme that is unable to assess the status of various systems of the body. Change the content of G-FDG in the blood is almost inflammation of any etiology and depends on the degree of intoxication syndrome. Moreover occurs inherited deficiency of this enzyme. Therefore, the level of G-FDG may not always characterize the severity of tuberculosis (Washeleski, Bgusau. The pathophysiology. - M.: VECHE, 2001. - S-569)that creatures of the NGO reduces the reliability of the method. In addition, determination of G-FDG can only be performed immediately after blood sampling, as it is well known that all the enzymes are destroyed during storage, including by freezing. The objective of the invention is a comprehensive assessment of the severity of tuberculosis. The technical result is an increase in the information content and reliability of the method; determination of reactivity on the status of various systems. This technical result is achieved in that in the method of assessing the severity of tuberculosis, including the determination of biochemical parameters of blood, the authors propose to determine in experiments on Guinea pigs in plasma concentrations of taurine and glutamic acid, and at concentrations of taurine less than 68 µmol/l and glutamic acid less than 76 µmol/l can appreciate how difficult, at concentrations of taurine in the interval 68-89 µmol/l and glutamic acid in the interval 125-227 µmol/l as moderate, and at concentrations of taurine and glutamic acid, exceeding 89 227 μmol/l, respectively, - as mild severity. Conducted by the author studies of amino acids in blood plasma of Guinea pigs showed that the most informative for assessing the severity of experimental tuberculosis are taurine and glutamic acid, as they are associated with the greatest number of PA is amerov, determining the reactivity of the organism and the activity of tuberculosis. Correlation analysis the authors found that in Guinea pigs concentrations of taurine and glutamic acid in plasma correlated with the various systems of the body, such as the AOA-FLOOR, immune, hematopoietic. Found that concentrations of taurine are associated with indices forming reactivity of the organism (AAO, GENDER, number of ceruloplasmin, NBT-test). The concentration of glutamic acid in plasma correlated with the same parameters, as well as with indicators myelogram, morphometrics and immunological indexes, which indicates its connection with the reactivity of the organism and the activity of tuberculous process. In addition, the experiment on Guinea pigs showed that tuberculosis taurine and glutamic acid in blood plasma are interconnected. Thus, the authors have shown that concentrations of taurine and glutamic acid in blood plasma in experimental tuberculosis reflect the state of reactivity of the organism and the activity of tuberculosis, resulting in their definition can be used to assess the severity of tuberculosis, while the information content and reliability of this assessment increase. It is known that changes in the concentration of amino acids, particularly glutamic acid specific for tuberculosis (M. Grigoryan. Soda is the content of free amino acids in serum, their deamination and synthesis of chemotherapy of tuberculosis. M, 1963. 16; Model L.M. Essays clinical pathophysiology of tuberculosis. - M.: Medgiz, 1962. - 323 C.). It is also known that taurine is one of the components determining the specific resistance tuberculosis (Pavlov V.A. ABOUT the biochemical mechanisms of different susceptibility to mycobacteria Guinea pigs // Probl. TB. 1998. No. 2. - P.30-32). Therefore, the use of glutamic acid and taurine as criteria for assessing the severity of tuberculosis increases the specificity of the method and, therefore, further increases the accuracy of determining the severity of tuberculosis in comparison with the prototype. It is known that tuberculosis is accompanied by a change in the number of amino acids in blood plasma (Iahaio. The content of free amino acids in serum of patients with pulmonary tuberculosis / Soviet medicine, 1972, No. 4, S-15; Biscevic, Eshooting. The content of free amino acids in serum of lung tuberculosis / Soviet medicine, 1973, No. 11, P.146-147), but there is no work showing the relation between the severity of TB from changes in the concentration of amino acids. The parameters that determine the severity of tuberculosis were identified by the authors on the model of experimental tuberculosis in Guinea pigs using a laboratory strain of H37Rv in doses of 0.01 mcgi of 0.001 µg. In the experiment used the following groups of animals (28 in each group): intact healthy animals of the control and infected with a laboratory strain of H37Rv at a dose of 0.01 μg, who does not receive treatment comparison No. 1 - infected laboratory strain of H37Rv at a dose of 0.01 μg receiving treatment with isoniazid at a dose of 5 mg/kg of body weight, comparison No. 2 - infected laboratory strain of H37Rv at a dose of 0.001 μg receiving treatment with isoniazid at a dose of 5 mg/kg of body weight. The experiment was continued for two months, after which the animals were killed and the study of tissues and blood samples. The burden of TB is determined by the dynamics of changes in body weight, the weights of the internal organs, according to crop the office of lung homogenates according to the methodical recommendations (guidelines for the study of anti-TB activity of pharmacological substances. The authors Guskov T.A., Golaszewska VI, Shulgin M.V., Martynov, L.P., Malkina G.N., Sokolova G.B. IN the Manual on experimental (preclinical) study of new pharmacological substances. - M.: Medicine, 2000. - Page 287-292; Methods of experimental chemotherapy: a Practical guide /edited by GI Pershin. - M.: Medicine, 1971. - P. 166-185). According to the survey the condition of the animals of the control group was regarded as severe, the group compared the possible No. 1 - as of moderate severity, the comparison group No. 2 - as mild severity. Average normal values of the investigated parameters obtained in intact animals group. In addition, conducted a histological examination of the internal organs, morphometry of the lung tissue, the study HALF of the AOA (total antioxidant activity, the amount of malondialdehyde), ceruloplasmin, myelogram, immunological indexes, NBT-test. Chromatographic method defined concentration of the entire spectrum of amino acids in plasma. The study has found that the spectrum of amino acids, the highest correlation coefficients with the studied parameters (more than 0.5) are taurine and glutamic acid (table 1). The results show that concentrations of taurine and glutamic acid in blood plasma shape reactivity of Guinea pigs with tuberculosis. In addition, the correlation coefficient between the concentration of glutamic acid and the prevalence of caseous necrotic changes in the lung tissue according to the morphometry was 0.7, and between the concentration of taurine to 0.6. The correlation coefficients between the number of intact lung tissue and the concentrations of glutamic acid and taurine was of 0.51 and 0.7, respectively. This is traget the relationship of concentrations of taurine and glutamic acid with active tuberculosis.
Thus, the concentration of taurine and glutamic acid correlated with the parameters of reactivity of Guinea pigs and activity of TB and therefore, in comparison with the prototype, most fully reflect the severity of tuberculosis and can be used as criteria for assessing the severity of experimental tuberculosis. In addition, the experiment established that the concentrations of taurine and glutamic acid in plasma there is also a correlation, which amounted to 0.75. Therefore, delapouite the reliability of determination of the severity of experimental tuberculosis advisable joint determination of the concentrations of these amino acids. In the experiment determined the concentrations of taurine and glutamic acid, corresponding to different degrees of severity of tuberculosis. The obtained data are presented in table 2.
The experimental data showed that different concentrations of taurine and glutamic acid correspond to different degrees of severity of tuberculosis. At concentrations of taurine less than 68 µmol/l and glutamic acid less than 76 µmol/l condition is assessed as severe, at concentrations of taurine in the interval 68-89 µmol/l and glutamic acid in the interval 125-227 µmol/l as moderate, and at concentrations of taurine and glutamic what th acid, more than 89 and 227 μmol/l, respectively, as mild severity. The obtained results statistically differ with p<0,05. Thus, the severity of tuberculosis in experimental animals can be judged by the concentrations of taurine and glutamic acid in plasma. The method is as follows. After the blood is prepared samples for analysis of amino acids (Abstract journal, Biochemistry, 1986. No. 25, abstract 4114). In the prepared samples on the chromatograph to determine the concentration of taurine and glutamic acid. The obtained values are compared with the established intervals and make a conclusion about the severity of experimental tuberculosis. Example 1. In the experiment in Guinea pigs infected with Mycobacterium tuberculosis H37Rv at a dose of 0.01 μg and not treated (control group), the analysis of the blood showed concentrations of taurine and glutamic acid 63,8 and 70,1 µmol/l, respectively. Comparing these values with the established borders of the intervals severity of tuberculosis (68 µmol/l taurine and less than 76 µmol/l glutamic acid), conclude severe disease in this animal. Example 2. In the experiment in Guinea pigs infected with Mycobacterium tuberculosis and treatment with isoniazid (group against the ment No. 1), the analysis of the blood showed concentrations of taurine and glutamic acid 79,1 and 180,2 µmol/l, respectively. Comparing these values with the established borders of the intervals severity of TB, the process is regarded as moderate. Example 3. In the experiment in Guinea pigs infected with Mycobacterium tuberculosis and treatment with isoniazid (comparison group No. 2), the analysis of the blood showed concentrations of taurine and glutamic acid of 148.4 and to 300.2 µmol/l, respectively. Comparing these values with the established borders of the intervals severity of TB, the process is regarded as mild severity. The method of assessing the severity of tuberculosis, including the determination of biochemical parameters of blood, characterized in that in the experiment on Guinea pigs in the blood plasma to determine the concentration of taurine and glutamic acid at concentrations of taurine less than 68 µmol/l and glutamic acid less than 76 µmol/l condition is assessed as severe, at concentrations of taurine in the interval 68-89 µmol/l and glutamic acid in the interval 125-227 µmol/l as moderate, and at concentrations of taurine and glutamic acid, exceeding 89 227 μmol/l, respectively - as mild severity.
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