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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The utility of EBUS-TBNA in the diagnosis of sarcoidosis has recently been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Studies published have shown a higher diagnostic yield in favour of EBUS-TBNA&#44; compared to standard bronchoscopic diagnostic techniques&#44; particularly for stage I sarcoidosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;6</span></a> The main advantages identified&#44; beside the high diagnostic yield&#44; are the low complication rate and being able to avoid invasive procedures&#44; like mediastinoscopy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Several recent editorials reviewed the value of EBUS-TBNA in excluding other diagnoses in patients with suspected sarcoidosis&#46; In a recent editorial published in the <span class="elsevierStyleItalic">Journal of Bronchology and Intervention Pulmonology</span>&#44; Reich and colleagues estimated that 10&#44;000 patients with stage I sarcoidosis would have to be submitted to an invasive diagnostic procedure to identify&#44; at most&#44; 5 people with an alternative pathology&#44; and questioned the need for tissue confirmation in asymptomatic stage I sarcoidosis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Among the series published with patients in suspected stage I and II sarcoidosis that have undergone EBUS-TBNA&#44; only 10&#37; obtained an alternative diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However&#44; these alternative diagnoses should not be ignored&#46; A delay in this context can be harmful to the patient&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">What data exists that is available in relation to these questions&#63;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In our experience&#44; 48 patients with clinical and radiological findings suggestive of sarcoidosis underwent EBUS-TBNA &#40;74&#37; stage I and 26&#37; stage II&#59; mean age 45 years&#41;&#46; Final diagnosis of sarcoidosis was established in 81&#37; of the patients &#40;39 of 48 patients&#41;&#46; The diagnostic yield of EBUS-TBNA for sarcoidosis was 73&#37;&#44; with a sensitivity and specificity of 67&#37; and 100&#37;&#44; respectively&#46; The negative predictive value was 41&#37;&#46; Nine different diagnoses were found&#58; silicosis &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; tuberculosis &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41;&#44; non-Hodgkin lymphoma &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; and reactive adenopathy &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41;&#46; Thirteen patients received the final diagnosis of sarcoidosis after a negative EBUS-TBNA result&#46; Among them&#44; an additional histological biopsy was only performed in 3 patients &#40;bronchial biopsy&#44; peripheral lymph node biopsy &#40;found after whole-body gallium scan&#41; and surgical lung biopsy&#41;&#46; In the remaining 10 patients&#44; 9 had stage I sarcoidosis and 1 had asymptomatic stage II sarcoidosis&#44; the diagnosis was supported by broncoalveolar lavage &#40;CD4&#43;&#47;CD8&#43; ratio<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3&#46;5&#41;&#44; radiologic criteria and at least a minimum 6 months follow-up &#40;mean 19<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;7 months&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Tournoy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> published the results of large diagnostic algorithm implementation trial for sarcoidosis&#46; A total of 137 patients were included &#40;75&#37; stage I&#41;&#46; Bronchoscopy was done in 121 patients establishing the definite diagnosis of sarcoidosis in 57 cases &#40;42&#37;&#41;&#46; The sensitivity of endoscopic ultrasound following non-diagnostic standard bronchoscopic techniques was 71&#37; and endoscopic ultrasound prevented a surgical procedure in 47 of the 80 patients&#46; The author found that by adding EBUS<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>EUS to prior nondiagnostic bronchoscopy&#44; three patients had to be investigated in order to avoid one surgical diagnostic procedure&#46; Of the 33 patients left without pathological confirmation&#44; 22 underwent a surgical procedure and an alternative diagnosis was found in only 6 patients&#46; The other 11 patients were submitted to clinical surveillance&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Garwood et al&#46; included<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> 50 patients with suspected sarcoidosis and a final diagnosis of sarcoidosis was confirmed in 48 patients &#40;one patient was lost to follow-up&#41;&#46; The diagnostic yield of EBUS-TBNA was 85&#37; &#40;41 of 48 patients&#41; and was highest in stage I&#44; followed by stage II disease &#40;94&#37; vs&#46; 80&#37; respectively&#41;&#46; When EBUS-TBNA result was negative a further histological biopsy was performed in 5 patients &#40;EBUS-targeted TBNA&#44; transbronchial lung biopsy &#40;TBLB&#41; or supraclavicular lymph node biopsy&#41; and 2 were followed up clinically&#46; No patient was submitted to mediastinoscopy and no alternative diagnosis was found&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Wong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> included 65 patients with clinical and radiological findings suggestive of sarcoidosis &#40;74&#37; stage I&#41;&#46; The decision to proceed to TBLB was left to the discretion of the operators&#46; In 61 patients the final diagnosis of sarcoidosis was obtained&#44; 56 by EBUS-TBNA and 5 by mediastinoscopy&#46; Three patients with indefinite diagnosis were followed up for &#8805;18 months and showed no clinical or radiological deterioration&#46; One patient underwent video-assisted thoracoscopic surgery &#40;VATS&#41;&#44; after an inadequate EBUS-TBNA specimen&#44; which showed Wegener&#39;s granulomatosis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the Granuloma clinical trial&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> 303 patients with a clinical and radiologic suspicion of sarcoidosis stage I&#47;II &#40;51&#37; stage I&#41; were randomized&#58; 149 to conventional bronchoscopy and 155 to endosonography&#46; The final diagnosis was sarcoidosis in 278 of the 303 patients &#40;92&#37;&#41; which was based on tissue-proven granulomas in 250 of the 278 patients &#40;90&#37;&#41; and in 28 of the 278 patients &#40;10&#37;&#41; on clinical and radiologic follow-up&#46; For stage I sarcoidosis&#44; endosonography had a significantly higher diagnostic yield than bronchoscopy &#40;84&#37; vs&#46; 38&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; For stage II sarcoidosis&#44; the difference was not statistically significant &#40;66&#37; vs&#46; 77&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;18&#41;&#46; In the bronchoscopy group&#44; biopsies demonstrated eosinophilic and granulomatous vasculitis in one patient and metastasized thyroid cancer in another&#46; In the endosonography group&#44; non-caseating granulomas without necrosis were found in 2 patients&#44; of whom one received a diagnosis of tuberculosis and the other of metastasized non-small cell lung carcinoma&#46; In 2 more patients&#44; a non-small cell lung carcinoma and colon carcinoma nodal metastasis were found&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The EBUS-TBNA increases the diagnostic yield of sarcoidosis &#40;range 71&#8211;90&#37; in the studies presented&#41;&#44; and reduces the need for more invasive procedures&#46; In every study illustrated above&#44; alternative diagnoses were obtained in a minority of patients&#46; Similar to our results&#44; all authors described clinical follow-up as an alternative to invasive methods after negative EBUS-TBNA&#44;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The role of EBUS-TBNA in the diagnosis of sarcoidosis has become irreplaceable&#44; not only to confirm the diagnosis&#44; but also to exclude other diseases&#44; especially malignancy&#46; Nevertheless&#44; EBUS-TBNA can provide additional difficulties when a differential diagnosis&#44; such as lymphoma&#44; is concerned&#44; and in these cases further invasive procedures can have considerable value&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In our experience&#44; there was no question of performing EBUS-TBNA&#44; since tuberculosis and lymphoma were diagnosed&#46; On the other hand&#44; among negative EBUS-TBNA patients who did not perform additional investigations&#44; no alternative diagnosis emerged&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Nowadays&#44; the great challenge is to know when just EBUS is enough or when to proceed with invasive investigation&#46; What is the correct approach after an EBUS-TBNA negative result&#63;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In our opinion&#44; although looking for granulomatous inflammation is the concern&#44; lymph node sampling by EBUS-TBNA can give us significant information&#46; The appropriate patient selection is the key for the use of EBUS-TBNA in sarcoidosis&#44; and the decision to proceed to further investigation must be based in the pre-test probability of sarcoidosis vs&#46; alternative diagnosis&#44; mainly in stage I sarcoidosis&#46; This approach should be prospectively confirmed&#46;</p></span>"
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Letter to the Editor
EBUS in pulmonary sarcoidosis: What to expect?
EBUS (ecografia endobrônquica) na sarcoidose pulmonar: o que esperar?
I. Nevesa,
Corresponding author
inesneves.porto@gmail.com

Corresponding author.
, M. Sucenaa, A. Magalhãesa, G. Fernandesa,b
a Department of Pulmonology of Centro Hospitalar de São João, Porto, Portugal
b Faculty of Medicine, University of Porto, Portugal
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        "titulo" => "EBUS &#40;ecografia endobr&#244;nquica&#41; na sarcoidose pulmonar&#58; o que esperar&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The utility of EBUS-TBNA in the diagnosis of sarcoidosis has recently been reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> Studies published have shown a higher diagnostic yield in favour of EBUS-TBNA&#44; compared to standard bronchoscopic diagnostic techniques&#44; particularly for stage I sarcoidosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;6</span></a> The main advantages identified&#44; beside the high diagnostic yield&#44; are the low complication rate and being able to avoid invasive procedures&#44; like mediastinoscopy&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Several recent editorials reviewed the value of EBUS-TBNA in excluding other diagnoses in patients with suspected sarcoidosis&#46; In a recent editorial published in the <span class="elsevierStyleItalic">Journal of Bronchology and Intervention Pulmonology</span>&#44; Reich and colleagues estimated that 10&#44;000 patients with stage I sarcoidosis would have to be submitted to an invasive diagnostic procedure to identify&#44; at most&#44; 5 people with an alternative pathology&#44; and questioned the need for tissue confirmation in asymptomatic stage I sarcoidosis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Among the series published with patients in suspected stage I and II sarcoidosis that have undergone EBUS-TBNA&#44; only 10&#37; obtained an alternative diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However&#44; these alternative diagnoses should not be ignored&#46; A delay in this context can be harmful to the patient&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">What data exists that is available in relation to these questions&#63;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In our experience&#44; 48 patients with clinical and radiological findings suggestive of sarcoidosis underwent EBUS-TBNA &#40;74&#37; stage I and 26&#37; stage II&#59; mean age 45 years&#41;&#46; Final diagnosis of sarcoidosis was established in 81&#37; of the patients &#40;39 of 48 patients&#41;&#46; The diagnostic yield of EBUS-TBNA for sarcoidosis was 73&#37;&#44; with a sensitivity and specificity of 67&#37; and 100&#37;&#44; respectively&#46; The negative predictive value was 41&#37;&#46; Nine different diagnoses were found&#58; silicosis &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; tuberculosis &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41;&#44; non-Hodgkin lymphoma &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; and reactive adenopathy &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41;&#46; Thirteen patients received the final diagnosis of sarcoidosis after a negative EBUS-TBNA result&#46; Among them&#44; an additional histological biopsy was only performed in 3 patients &#40;bronchial biopsy&#44; peripheral lymph node biopsy &#40;found after whole-body gallium scan&#41; and surgical lung biopsy&#41;&#46; In the remaining 10 patients&#44; 9 had stage I sarcoidosis and 1 had asymptomatic stage II sarcoidosis&#44; the diagnosis was supported by broncoalveolar lavage &#40;CD4&#43;&#47;CD8&#43; ratio<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>3&#46;5&#41;&#44; radiologic criteria and at least a minimum 6 months follow-up &#40;mean 19<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;7 months&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Tournoy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> published the results of large diagnostic algorithm implementation trial for sarcoidosis&#46; A total of 137 patients were included &#40;75&#37; stage I&#41;&#46; Bronchoscopy was done in 121 patients establishing the definite diagnosis of sarcoidosis in 57 cases &#40;42&#37;&#41;&#46; The sensitivity of endoscopic ultrasound following non-diagnostic standard bronchoscopic techniques was 71&#37; and endoscopic ultrasound prevented a surgical procedure in 47 of the 80 patients&#46; The author found that by adding EBUS<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>EUS to prior nondiagnostic bronchoscopy&#44; three patients had to be investigated in order to avoid one surgical diagnostic procedure&#46; Of the 33 patients left without pathological confirmation&#44; 22 underwent a surgical procedure and an alternative diagnosis was found in only 6 patients&#46; The other 11 patients were submitted to clinical surveillance&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Garwood et al&#46; included<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> 50 patients with suspected sarcoidosis and a final diagnosis of sarcoidosis was confirmed in 48 patients &#40;one patient was lost to follow-up&#41;&#46; The diagnostic yield of EBUS-TBNA was 85&#37; &#40;41 of 48 patients&#41; and was highest in stage I&#44; followed by stage II disease &#40;94&#37; vs&#46; 80&#37; respectively&#41;&#46; When EBUS-TBNA result was negative a further histological biopsy was performed in 5 patients &#40;EBUS-targeted TBNA&#44; transbronchial lung biopsy &#40;TBLB&#41; or supraclavicular lymph node biopsy&#41; and 2 were followed up clinically&#46; No patient was submitted to mediastinoscopy and no alternative diagnosis was found&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Wong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> included 65 patients with clinical and radiological findings suggestive of sarcoidosis &#40;74&#37; stage I&#41;&#46; The decision to proceed to TBLB was left to the discretion of the operators&#46; In 61 patients the final diagnosis of sarcoidosis was obtained&#44; 56 by EBUS-TBNA and 5 by mediastinoscopy&#46; Three patients with indefinite diagnosis were followed up for &#8805;18 months and showed no clinical or radiological deterioration&#46; One patient underwent video-assisted thoracoscopic surgery &#40;VATS&#41;&#44; after an inadequate EBUS-TBNA specimen&#44; which showed Wegener&#39;s granulomatosis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the Granuloma clinical trial&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> 303 patients with a clinical and radiologic suspicion of sarcoidosis stage I&#47;II &#40;51&#37; stage I&#41; were randomized&#58; 149 to conventional bronchoscopy and 155 to endosonography&#46; The final diagnosis was sarcoidosis in 278 of the 303 patients &#40;92&#37;&#41; which was based on tissue-proven granulomas in 250 of the 278 patients &#40;90&#37;&#41; and in 28 of the 278 patients &#40;10&#37;&#41; on clinical and radiologic follow-up&#46; For stage I sarcoidosis&#44; endosonography had a significantly higher diagnostic yield than bronchoscopy &#40;84&#37; vs&#46; 38&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; For stage II sarcoidosis&#44; the difference was not statistically significant &#40;66&#37; vs&#46; 77&#37;&#44; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;18&#41;&#46; In the bronchoscopy group&#44; biopsies demonstrated eosinophilic and granulomatous vasculitis in one patient and metastasized thyroid cancer in another&#46; In the endosonography group&#44; non-caseating granulomas without necrosis were found in 2 patients&#44; of whom one received a diagnosis of tuberculosis and the other of metastasized non-small cell lung carcinoma&#46; In 2 more patients&#44; a non-small cell lung carcinoma and colon carcinoma nodal metastasis were found&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The EBUS-TBNA increases the diagnostic yield of sarcoidosis &#40;range 71&#8211;90&#37; in the studies presented&#41;&#44; and reduces the need for more invasive procedures&#46; In every study illustrated above&#44; alternative diagnoses were obtained in a minority of patients&#46; Similar to our results&#44; all authors described clinical follow-up as an alternative to invasive methods after negative EBUS-TBNA&#44;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The role of EBUS-TBNA in the diagnosis of sarcoidosis has become irreplaceable&#44; not only to confirm the diagnosis&#44; but also to exclude other diseases&#44; especially malignancy&#46; Nevertheless&#44; EBUS-TBNA can provide additional difficulties when a differential diagnosis&#44; such as lymphoma&#44; is concerned&#44; and in these cases further invasive procedures can have considerable value&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In our experience&#44; there was no question of performing EBUS-TBNA&#44; since tuberculosis and lymphoma were diagnosed&#46; On the other hand&#44; among negative EBUS-TBNA patients who did not perform additional investigations&#44; no alternative diagnosis emerged&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Nowadays&#44; the great challenge is to know when just EBUS is enough or when to proceed with invasive investigation&#46; What is the correct approach after an EBUS-TBNA negative result&#63;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In our opinion&#44; although looking for granulomatous inflammation is the concern&#44; lymph node sampling by EBUS-TBNA can give us significant information&#46; The appropriate patient selection is the key for the use of EBUS-TBNA in sarcoidosis&#44; and the decision to proceed to further investigation must be based in the pre-test probability of sarcoidosis vs&#46; alternative diagnosis&#44; mainly in stage I sarcoidosis&#46; This approach should be prospectively confirmed&#46;</p></span>"
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                      "titulo" => "Diagnostic utility of endobronchial ultrasound-guided transbronchial needle aspiration compared with transbronchial and endobronchial biopsy for suspected sarcoidosis"
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                        "fecha" => "2013"
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                          "etal" => true
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                  "contribucion" => array:1 [
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                      "titulo" => "Endosonography vs&#46; conventional bronchoscopy for the diagnosis of sarcoidosis&#58; the GRANULOMA randomized clinical trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "M&#46;B&#46; von Bartheld"
                            1 => "O&#46;M&#46; Dekkers"
                            2 => "A&#46; Szlubowski"
                            3 => "R&#46; Eberhardt"
                            4 => "F&#46;J&#46; Herth"
                            5 => "J&#46;C&#46; in &#8216;t Veen"
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Article information
ISSN: 08732159
Original language: English
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