Lymphangioma overview: Difference between revisions
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==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
Most of the patients with lymphangioma will develop a cervico-facial mass that often grows in proportion to the patient’s body growth rate. The mass usually recurs after [[surgical]] interventions. Common complications of lymphangioma include [[esophageal]] obstruction, [[upper respiratory tract]] obstruction, [[infection]]s, and compression of adjacent tissues such as [[nerves]] and [[blood vessel]]s. Prognosis of lymphangioma is generally excellent. | Most of the patients with lymphangioma will develop a cervico-facial mass that often grows in proportion to the patient’s body growth rate. The mass usually recurs after [[surgical]] interventions. Common complications of lymphangioma include [[esophageal]] obstruction, [[upper respiratory tract]] obstruction, [[infection]]s, and compression of adjacent tissues such as [[nerves]] and [[blood vessel]]s. Prognosis of lymphangioma is generally excellent. | ||
Lymphatic malformations — Lymphatic malformations (LM) are benign. [2]. They are classified as macrocystic (cystic hygroma), microcystic (lymphangioma circumscriptum), and mixed type. | |||
Macrocystic lymphatic malformation (cystic hygroma) — Macrocystic lymphatic malformation, also referred to as cystic hygroma, is composed of collections of large, interconnected lymphatic cysts lined by a thin endothelium. It presents at birth as a large, poorly delimitated, translucent, soft mass covered by normal skin, most commonly located in the cervicofacial region, axilla, or lateral chest wall (picture 6). Cystic hygroma can be detected prenatally in the first trimester of pregnancy and, in approximately 50 percent cases, is associated with chromosomal abnormalities, such as Down syndrome, Turner syndrome, and Noonan syndrome. (See "Cystic hygroma and increased nuchal translucency".) | |||
Microcystic lymphatic malformation (lymphangioma circumscriptum) — Lymphangioma circumscriptum is a type of microcystic lymphatic malformation that may be present at birth or appear in the first few years of life. The most frequent localizations are proximal extremities, trunk, axilla, and the oral cavity. Clinically, lymphangioma circumscriptum presents as a cluster of clear, translucent or hemorrhagic vesicles that may intermittently leak lymphatic fluid (picture 7). (See "Soft tissue lesions of the oral cavity in children", section on 'Lymphangiomas'.) | |||
Generally, symptoms from lymphatic malformations arise from compression or obstruction of nearby structures. Lymphatic malformations can involve any tissue. Usually they are found in only one area of the body (localized), but occasionally can be widespread (diffuse). When lymphatic malformations are widespread in bone and soft tissue, the condition may be referred to as lymphangiomatosis. Lymphatic malformations usually slowly grow larger as the patient grows, but once in a while they get smaller spontaneously. Certain events such as puberty, infection, trauma or bleeding into a lymphatic malformation can cause them to grow rapidly. | |||
It is important to note that affected individuals may not have all of the symptoms discussed below and that one child’s experience can vary dramatically from another child’s experience. Parents of affected children should talk to their physician and medical team about their child’s specific case, associated symptoms and overall prognosis. The specific symptoms that develop depend upon the size and exact location of a lymphatic malformation. | |||
Lymphatic malformations are associated with overgrowth (hypertrophy) and swelling of any affected area including the lips, tongue, jaws, cheeks, arms, legs, fingers or toes. Malformations affecting the tongue, windpipe (trachea) or mouth can cause difficulty breathing (dyspnea), difficulties with speech and difficulty swallowing (dysphagia) and feeding problems. If the eye socket (orbit) is involved, double vision (diplopia) or displacement of the eyeball can occur (proptosis). Lymphatic malformations affecting the chest can cause wheezing, chest pain, chest pressure, shortness of breath, difficulty breathing and potentially airway compromise. Lymphatic malformations affecting the gastrointestinal tract or pelvis can cause constipation, bladder obstruction, recurrent infection or protein loss. Lesions in bone can be associated with bone overgrowth or bone loss. | |||
Certain complications can occur with lymphatic malformations including recurrent inflammation or bleeding (hemorrhaging) into the malformation. When lymphatic malformations become inflamed, they swell, and the skin in the involved area becomes red and warm. This is known as cellulitis. Recurrent cellulitis can cause pain and disfigurement of the affected area. Some lymphatic malformation patients have abnormally low numbers of lymphocytes which make them prone to cellulitis. Bleeding into a lymphatic malformation can cause rapid pain, hardening, and swelling or enlargement of the malformation in the affected area. | |||
Radiographically lymphatic malformations have been categorized into three subtypes – macrocystic, microcystic, or mixed (a combination of the other two). Macrocystic and microcystic lymphatic malformations are differentiated by the size of the fluid-containing portion of the malformation. The macrocystic type is made up of large cysts, more than 2 centimeters in diameter; the microcystic type is made up of smaller cysts or soft tissue enlargement without cyst formation. Most lymphatic malformations have both macrocystic and microcystic portions and histologically there is no difference between these categories. Macrocystic lymphatic malformations are characterized by a single or multiple fluid-filled pockets or cysts that occur, most commonly in the nape of the neck. Macrocystic lymphatic malformations generally form soft, large translucent masses that can involve any area of the neck or chest. Overlying skin may have a bluish tinge. Although macrocystic lymphatic malformations typically appear on the back of the neck, they can, less frequently, originate near the armpits (axilla), in the groin, in the rear of the abdominal cavity, in the chest wall, or in the hip or tailbone region. Macrocystic lymphatic malformations can potentially be extremely large, even large enough to obstruct the airway at delivery. | |||
Microcystic lymphatic malformations may appear as several small, raised sacs (vesicles) on the skin that contain clear or bloody (hemorrhagic) fluid. They generally grow slowly usually in proportion with a growing child. Microcystic lymphatic malformations can thicken or swell causing enlargement of surrounding soft tissue and bones. They can be found on any area of skin or mucous membrane. | |||
Prognosis | |||
Lymphangiomas are benign hamartomatous malformations instead of true neoplasms. The prognosis for lymphangiomas is excellent. | |||
Rarely do cutaneous lymphangiomas interfere with the well-being of patients. Patients are expected to live a full healthy life, and they usually seek medical intervention because of cosmetic reason. | |||
Lymphangiomas represent hamartomatous malformations with no risk of malignant transformation. In the case of cystic hygroma, total surgical excision is appropriate to prevent complications such as respiratory compromise, aspiration, and infections in critical areas, such as the neck. Lymphangiomas have a strong tendency for local recurrence unless they are completely excised. Recurrent episodes of cellulitis and minor bleeding are not uncommon. | |||
The signs and symptoms of a lymphatic malformation (or lymphangioma) vary depending on the type, size and location of the mass. There are different ways of classifying lymphatic malformations. The classification most frequently used divides these lesions into 2 major groups based on the depth and the size of these abnormal lymph vessels. The superficial vesicles are called lymphangioma circumscriptum. The more deep-seated group includes cavernous lymphangioma and cystic hygroma:[3][4] | |||
Cystic hygroma, which is also known as cystic lymphangioma or macrocystic lymphatic malformation, is a red or bluish swelling of the skin in the neck, armpit or groin region that consists of large, fluid-filled spaces. Some say it is a type of cavernous lymphangioma. | |||
Cavernous lymphangioma is also considered a macrocystic lesion. It is a a bluish or red rubbery swelling under the skin that can affect any area of the body, including the tongue. | |||
Lymphangioma circumscriptum is a microcystic lymphatic malformation. It appears as a cluster of small, firm blisters most commonly on the shoulders, neck, underarm area, limbs, and in the mouth, especially the tongue. It consists of tiny, fluid-filled spaces and ranges in color from clear to pink, dark red, brown or black. | |||
Other classification includes macrocystic lymphatic malformation, microcystic lymphatic malformation and mixed type. | |||
In general, lymphatic malformations are always present at birth, although they typically grow over time and may become more apparent with age. They are most commonly found in the head and neck region, but can affect almost any part of the body (except the brain). Some may appear as a tiny blue or red spot while others are massive and affect an entire limb (arm or leg).[1][4] Symptoms usually develop if the lymphatic malformation compresses or blocks nearby body parts or organs. For example, lymphangiomas located in the mouth or neck region can cause dyspnea, speech problems, dysphagia and feeding problems. Certain complications can occur, including recurrent cellulitis, which can cause pain and disfigurement of the affected area, and bleeding, which may lead to pain, hardening or rapid enlargement of the mass.[1] | |||
==Diagnosis== | ==Diagnosis== | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Haytham Allaham, M.D. [2]
Overview
Lymphangioma arises from lymph vessels, which are normally involved in the re-circulation of excess body fluid back into the blood stream. The exact pathogenesis of lymphangioma is not fully understood. It is thought that lymphangioma is caused by either sequestration of lymph tissue, abnormal budding of lymph vessels, lack of fusion with the venous system, or obstruction of lymph vessels. Lymphangiomas most commonly develop at the head and neck regions. Lymphangioma is associated with a number of conditions that include Turner syndrome and Down syndrome. On gross pathology, characteristic findings of lymphangioma include a grey-white, well circumscribed, edematous mass with a variable size and consistency. On microscopic histopathological analysis, characteristic findings of lymphangioma include thin walled endothelial lining, intraluminal accumulation of eosinophilic deposits, and clusters of intraluminal lymphocytes. There are no known direct causes for lymphangioma. Lymphangioma must be differentiated from arteriovenous malformation, branchial cleft cyst, and dermoid cyst. Lymphangiomas are rare, accounting for 4% of all vascular tumors among children. The incidence of lymphangioma is estimated to be less than 2 cases per 100,000 individuals in the United States. Lymphangioma commonly affects individuals younger than 5 years of age. Lymphangioma affects men and women equally. There is no racial predilection to the lymphangioma. CT scan may be diagnostic of lymphangioma. Findings on CT scan suggestive of lymphangioma include a homogeneous, cystic, mass that may demonstrate intrinsic septations and compression of adjacent organs. The mainstay of therapy for lymphangioma is surgery. Treatment for lymphangioma involves the removal of the abnormal tissue; however complete removal may be impossible without removing other normal areas. Most patients need at least two procedures done for the removal process to be achieved.[1][2][3][4]
Pathophysiology
- Lymphangioma arises from lymph vessels, which are normally involved in the re-circulation of excess body fluid back into the blood stream.[5]
- The exact mechanism of development of abnormal malformations is not known.
- It is suggested that lymphangioma is formed as a result of one of four mechanisms:
- Whimster describes pathogenesis of lymphangioma as the collection of lymphatic cisterns in the deep subcutaneous plane which get detached from normal network, however they keep connected to superficial lymph vessels through short and dilated vessels.[6]
- The cisterns originally derive from primitive lymph sac, which fail to connect to normal circulation.
- These are covered with thick muscular coat, which on contraction increase intramural pressure.
- Ultimately leads to dilated sacs which are visible on skin as out-pouchings.[7]
- Whimster's description is proved with radio-graphic evidence as well.[8]
- Which showed large multilobulated cisterns extend deep in the dermis and laterally beyond the clinical lesions.
- These deep lymphangiomas had no connections with the adjacent normal lymphatics.
- Some lymphangiomas may represent vascular malformations during embryonic development rather than as true neoplasms.
- For more information on Vascular anamolies. Click here.
- Vascular endothelial growth factor (VEGF)–C and VEGF receptor-3 play a key role in development of lymphangiomas.[9]
- Acquired lymphangiomas [10]
Acquired lymphangioms arise as a cosequence of any interruption of previously normal lymphatic drainage such as surgery[11], trauma, Infection, malignancy, and radiation therapy.[10]
Causes
- There are no known direct causes for lymphangioma.
- Cystic hygroma usually presents in syndromes such as Turner syndrome and Down syndrome. Therefore it is thought that the lymphatic malformations can arise from gene mutations, occuring as missing or deleted part of chromosomes.[12]
- Acquired lymphangioma circumscriptum occur as a sequele of chronic lymphatic obstruction such as after surgery, infections or radiotherapy.
Differentiating Lymphangioma from other Diseases
Lymphangioma must be differentiated from arteriovenous malformation, branchial cleft cyst, and dermoid cyst.
Epidemiology and Demographics
- Lymphangiomas are rare, accounting for 4% of all vascular tumors among children.[6]
- The incidence of lymphangioma is estimated to be less than 2 cases per 100,000 individuals in the United States.
- Lymphangioma commonly affects individuals younger than 5 years of age.
- Lymphangioma affects men and women equally.
- There is no racial predilection to the lymphangioma.
Risk Factors
The most potent risk factor in the development of lymphangioma is the presence of genetic disorders such as Turner syndrome, Down syndrome, and Noonan syndrome.[12]
Natural History, Complications and Prognosis
Most of the patients with lymphangioma will develop a cervico-facial mass that often grows in proportion to the patient’s body growth rate. The mass usually recurs after surgical interventions. Common complications of lymphangioma include esophageal obstruction, upper respiratory tract obstruction, infections, and compression of adjacent tissues such as nerves and blood vessels. Prognosis of lymphangioma is generally excellent.
Lymphatic malformations — Lymphatic malformations (LM) are benign. [2]. They are classified as macrocystic (cystic hygroma), microcystic (lymphangioma circumscriptum), and mixed type.
Macrocystic lymphatic malformation (cystic hygroma) — Macrocystic lymphatic malformation, also referred to as cystic hygroma, is composed of collections of large, interconnected lymphatic cysts lined by a thin endothelium. It presents at birth as a large, poorly delimitated, translucent, soft mass covered by normal skin, most commonly located in the cervicofacial region, axilla, or lateral chest wall (picture 6). Cystic hygroma can be detected prenatally in the first trimester of pregnancy and, in approximately 50 percent cases, is associated with chromosomal abnormalities, such as Down syndrome, Turner syndrome, and Noonan syndrome. (See "Cystic hygroma and increased nuchal translucency".)
Microcystic lymphatic malformation (lymphangioma circumscriptum) — Lymphangioma circumscriptum is a type of microcystic lymphatic malformation that may be present at birth or appear in the first few years of life. The most frequent localizations are proximal extremities, trunk, axilla, and the oral cavity. Clinically, lymphangioma circumscriptum presents as a cluster of clear, translucent or hemorrhagic vesicles that may intermittently leak lymphatic fluid (picture 7). (See "Soft tissue lesions of the oral cavity in children", section on 'Lymphangiomas'.)
Generally, symptoms from lymphatic malformations arise from compression or obstruction of nearby structures. Lymphatic malformations can involve any tissue. Usually they are found in only one area of the body (localized), but occasionally can be widespread (diffuse). When lymphatic malformations are widespread in bone and soft tissue, the condition may be referred to as lymphangiomatosis. Lymphatic malformations usually slowly grow larger as the patient grows, but once in a while they get smaller spontaneously. Certain events such as puberty, infection, trauma or bleeding into a lymphatic malformation can cause them to grow rapidly.
It is important to note that affected individuals may not have all of the symptoms discussed below and that one child’s experience can vary dramatically from another child’s experience. Parents of affected children should talk to their physician and medical team about their child’s specific case, associated symptoms and overall prognosis. The specific symptoms that develop depend upon the size and exact location of a lymphatic malformation.
Lymphatic malformations are associated with overgrowth (hypertrophy) and swelling of any affected area including the lips, tongue, jaws, cheeks, arms, legs, fingers or toes. Malformations affecting the tongue, windpipe (trachea) or mouth can cause difficulty breathing (dyspnea), difficulties with speech and difficulty swallowing (dysphagia) and feeding problems. If the eye socket (orbit) is involved, double vision (diplopia) or displacement of the eyeball can occur (proptosis). Lymphatic malformations affecting the chest can cause wheezing, chest pain, chest pressure, shortness of breath, difficulty breathing and potentially airway compromise. Lymphatic malformations affecting the gastrointestinal tract or pelvis can cause constipation, bladder obstruction, recurrent infection or protein loss. Lesions in bone can be associated with bone overgrowth or bone loss.
Certain complications can occur with lymphatic malformations including recurrent inflammation or bleeding (hemorrhaging) into the malformation. When lymphatic malformations become inflamed, they swell, and the skin in the involved area becomes red and warm. This is known as cellulitis. Recurrent cellulitis can cause pain and disfigurement of the affected area. Some lymphatic malformation patients have abnormally low numbers of lymphocytes which make them prone to cellulitis. Bleeding into a lymphatic malformation can cause rapid pain, hardening, and swelling or enlargement of the malformation in the affected area.
Radiographically lymphatic malformations have been categorized into three subtypes – macrocystic, microcystic, or mixed (a combination of the other two). Macrocystic and microcystic lymphatic malformations are differentiated by the size of the fluid-containing portion of the malformation. The macrocystic type is made up of large cysts, more than 2 centimeters in diameter; the microcystic type is made up of smaller cysts or soft tissue enlargement without cyst formation. Most lymphatic malformations have both macrocystic and microcystic portions and histologically there is no difference between these categories. Macrocystic lymphatic malformations are characterized by a single or multiple fluid-filled pockets or cysts that occur, most commonly in the nape of the neck. Macrocystic lymphatic malformations generally form soft, large translucent masses that can involve any area of the neck or chest. Overlying skin may have a bluish tinge. Although macrocystic lymphatic malformations typically appear on the back of the neck, they can, less frequently, originate near the armpits (axilla), in the groin, in the rear of the abdominal cavity, in the chest wall, or in the hip or tailbone region. Macrocystic lymphatic malformations can potentially be extremely large, even large enough to obstruct the airway at delivery.
Microcystic lymphatic malformations may appear as several small, raised sacs (vesicles) on the skin that contain clear or bloody (hemorrhagic) fluid. They generally grow slowly usually in proportion with a growing child. Microcystic lymphatic malformations can thicken or swell causing enlargement of surrounding soft tissue and bones. They can be found on any area of skin or mucous membrane.
Prognosis
Lymphangiomas are benign hamartomatous malformations instead of true neoplasms. The prognosis for lymphangiomas is excellent.
Rarely do cutaneous lymphangiomas interfere with the well-being of patients. Patients are expected to live a full healthy life, and they usually seek medical intervention because of cosmetic reason.
Lymphangiomas represent hamartomatous malformations with no risk of malignant transformation. In the case of cystic hygroma, total surgical excision is appropriate to prevent complications such as respiratory compromise, aspiration, and infections in critical areas, such as the neck. Lymphangiomas have a strong tendency for local recurrence unless they are completely excised. Recurrent episodes of cellulitis and minor bleeding are not uncommon.
The signs and symptoms of a lymphatic malformation (or lymphangioma) vary depending on the type, size and location of the mass. There are different ways of classifying lymphatic malformations. The classification most frequently used divides these lesions into 2 major groups based on the depth and the size of these abnormal lymph vessels. The superficial vesicles are called lymphangioma circumscriptum. The more deep-seated group includes cavernous lymphangioma and cystic hygroma:[3][4] Cystic hygroma, which is also known as cystic lymphangioma or macrocystic lymphatic malformation, is a red or bluish swelling of the skin in the neck, armpit or groin region that consists of large, fluid-filled spaces. Some say it is a type of cavernous lymphangioma. Cavernous lymphangioma is also considered a macrocystic lesion. It is a a bluish or red rubbery swelling under the skin that can affect any area of the body, including the tongue. Lymphangioma circumscriptum is a microcystic lymphatic malformation. It appears as a cluster of small, firm blisters most commonly on the shoulders, neck, underarm area, limbs, and in the mouth, especially the tongue. It consists of tiny, fluid-filled spaces and ranges in color from clear to pink, dark red, brown or black. Other classification includes macrocystic lymphatic malformation, microcystic lymphatic malformation and mixed type.
In general, lymphatic malformations are always present at birth, although they typically grow over time and may become more apparent with age. They are most commonly found in the head and neck region, but can affect almost any part of the body (except the brain). Some may appear as a tiny blue or red spot while others are massive and affect an entire limb (arm or leg).[1][4] Symptoms usually develop if the lymphatic malformation compresses or blocks nearby body parts or organs. For example, lymphangiomas located in the mouth or neck region can cause dyspnea, speech problems, dysphagia and feeding problems. Certain complications can occur, including recurrent cellulitis, which can cause pain and disfigurement of the affected area, and bleeding, which may lead to pain, hardening or rapid enlargement of the mass.[1]
Diagnosis
History and Symptoms
The majority of patients with lymphangioma are asymptomatic.
Physical Exam
Lymphangioma patients often appear healthy. On physical exam a painless , compressible, soft neck mass that often transilluminates is a diagnostic finding on physical exam.
Laboratory Findings
There are no diagnostic lab findings associated with lymphangioma.
CT Scan
CT scan may be diagnostic of lymphangioma. Findings on CT scan suggestive of lymphangioma include a homogeneous, cystic, mass that may demonstrate intrinsic septations and compression of adjacent organs.
MRI
MRI may be diagnostic of lymphangioma. Findings on MRI suggestive of lymphangioma include hyperintense signal enhancement due to cyst formation.
Other Diagnostic Studies
The definitive diagnosis of lymphangioma is confirmed by a biopsy. Characteristic findings for lymphangioma on microscopic histopathological analysis can be found here.
Treatment
Medical Therapy
There is no medical treatment for lymphangioma; the mainstay of therapy is surgery.
Surgery
The mainstay of therapy for lymphangioma is surgery. Treatment for lymphangioma involves the removal of the abnormal tissue; however complete removal may be impossible without removing other normal areas. Most patients need at least two procedures done for the removal process to be achieved.
References
- ↑ Lymphangioma. Wikipedia (2016) https://en.wikipedia.org/wiki/Lymphangioma Accessed on March 3, 2015
- ↑ Lymphangioma. PathologyOutlines (2016) http://www.pathologyoutlines.com/topic/softtissuelymphangiomacystic.html Accessed on March 5, 2016
- ↑ Lymphangioma. Libre Pathology (2016) http://librepathology.org/wiki/Vascular_tumours#Lymphangioma Accessed on March 5, 2016
- ↑ Lymphangioma. Radiopeadia (2016) http://radiopaedia.org/articles/lymphangioma Accessed on March 5, 2016
- ↑ Wiegand S, Eivazi B, Barth PJ, von Rautenfeld DB, Folz BJ, Mandic R, Werner JA (July 2008). "Pathogenesis of lymphangiomas". Virchows Arch. 453 (1): 1–8. doi:10.1007/s00428-008-0611-z. PMID 18500536.
- ↑ 6.0 6.1 Ersoy AO, Oztas E, Saridogan E, Ozler S, Danisman N (March 2016). "An Unusual Origin of Fetal Lymphangioma Filling Right Axilla". J Clin Diagn Res. 10 (3): QD09–11. doi:10.7860/JCDR/2016/18516.7513. PMC 4843338. PMID 27134953.
- ↑ Chang MB, Newman CC, Davis MD, Lehman JS (September 2016). "Acquired lymphangiectasia (lymphangioma circumscriptum) of the vulva: Clinicopathologic study of 11 patients from a single institution and 67 from the literature". Int. J. Dermatol. 55 (9): e482–7. doi:10.1111/ijd.13264. PMID 26967121.
- ↑ Levy AD, Cantisani V, Miettinen M (June 2004). "Abdominal lymphangiomas: imaging features with pathologic correlation". AJR Am J Roentgenol. 182 (6): 1485–91. doi:10.2214/ajr.182.6.1821485. PMID 15149994.
- ↑ Ferrara N, Kerbel RS (December 2005). "Angiogenesis as a therapeutic target". Nature. 438 (7070): 967–74. doi:10.1038/nature04483. PMID 16355214.
- ↑ 10.0 10.1 Oliveti A, Biasi TB, Funchal G (2017). "Lymphangioma secondary to irradiation after mastectomy". An Bras Dermatol. 92 (3): 395–397. doi:10.1590/abd1806-4841.20173952. PMC 5514585. PMID 29186257. Vancouver style error: initials (help)
- ↑ Hwang J, Lee YK, Burm JS (March 2017). "Treatment of Tongue Lymphangioma with Intralesional Combination Injection of Steroid, Bleomycin and Bevacizumab". Arch Craniofac Surg. 18 (1): 54–58. doi:10.7181/acfs.2017.18.1.54. PMC 5556746. PMID 28913305.
- ↑ 12.0 12.1 Pootrakul L, Nazareth MR, Cheney RT, Grassi MA (June 2014). "Lymphangioma circumscriptum of the vulva in a patient with Noonan syndrome". Cutis. 93 (6): 297–300. PMID 24999641.