Anthropological
studies among Libyans of Fazzan
Province
ABO
and Rh Systems.
Amer Tawati Kamal Salih,* Omran M Abdrhman,**,***
Bashir Elgadi,****
Mohamed H Abd
El Latef,*
Abstract
Background: ABO and RH D systems are related to ethnicity and
diseases.
Objectives: To study the ABO and Rh groups in Fazzan area where
the population are of mixed origin.
Setting: The 2nd March Hospital's blood transfusion
unit.
Material and Methods: The population in this study are those attending
delivery room and Obstetric units and those who donate blood during the period
between January 2003 and December 2003.
Results: Blood group O is found to be the most frequent blood group in this
study(48.2%): 50.4 % in male donors and 45.9 in female recipients. ORh+ is
42.4%in female recipients and 45.4% in male donors. On the other hand, the
least frequent group is group AB (4.8%). The highest percentage of blood group
O is found in Obari area (63.5%) and the least in Morzok (41%). About ninety
two per cent (92.3%) of the donors are Rh
positive, and 91% of the recipients are Rh positive. Both recipients and donors are 91.6 % Rh
positive. Attendants with Rh negative were
8.4%: female recipient are 9% and male donors are 7.7%. There is no
significant difference in the distribution of blood groups and Rh D system
between male donors and female recipients.
Conclusion: Our results show that the most frequent blood group
in Libyans of Fazzan province is group O and is nearly similar to that of
Africans. Blood group A is similar to that of Arabs and Africans. Blood group B is nearer to Africans more than
Arabs. The least frequent blood group is AB which is similar to that of
Africans. The study of blood groups in Libya
Introduction
Blood
transfusions were first attempted around 1600 by transfusing animal Blood into
humans. It proved disastrous. In the early 1800s an English obstetrician, James
Blundell, came up with the idea of human Blood for human beings. In 1909, Karl
Landsteiner classified the blood of human beings into the now well-known A, B,
AB, and O groups. These human blood group antigens are unique, inherited
polymorphisms on the extracellular surface of red blood cells. They have been
used as genetically discrete markers of human polymorphism. Many of these
antigens have been identified, the genes cloned, and their biological
significance elucidated .1
The
ABO and Rhesus blood group systems remain the most important blood group
systems clinically.2 The
medical literature contains a large number of publications attempting to
correlate blood groups with disease.3,4,5,6,7,8 Many of these
reports are poorly documented and have limited scientific validity.9
For example, Epidemiological studies demonstrated that individuals who are
blood group 0 positive are more likely to develop peptic ulcers.10
However, Keller et al. (2002)11 and Robertson et al (2003)5
found no association between secretor status or specific ABO blood group on
the one hand, and H. pylori infection or occurrence of gastroduodenal ulcers on
the other.
The
study of ABO and Rhesus blood group systems may provide a basic but useful
information concerning many ethnic groups.12,13,14 Blood groups have
provided anthropologists with a tool to study polymorphism in the different
peoples across the world and provided geneticists with inherited markers to
understand complex mechanisms of linkage and disease inheritance.1
The
distribution of ABO blood groups varies in the different geographical and
ethnic groups.15 Race is
thought to be one of the factors determining the level of ABO antibodies.16
For example, proto-Australoid
* Dept. of Anatomy, Faculty of medicine, Sebha University , Libya
** Dept.
of Microbiology, Faculty of medicine, Sebha
University , Libya
*** Dept.
of Surgery, Faculty of medicine, Sebha
University , Libya
****
Dept. of Gynaecology and Obstetrics, Faculty of Medicine, Sebha
University , Sebha , Libya
group
is characterized by
a high incidence of group A.17
Africans, Asians, and Arabs are characterized by high incidence of group O.18
The history of early tribal contact, as well as archaeological and linguistic
evidence, indicate that significant movements of people occurred between the
different region of the country and provided opportunities for genes to be
introduced from Arabs and, Africans.
In Africa ,
the genetic differentiation of the Negroes in relation to their linguistic
affiliation and geographic localization is evident. Papiha et al (1997)20
found that the racial differences between tribes are more likely to be
maintained by genetic drift, admixture, and inbreeding. For example, in the
Sudan, the Nuba and Nilotes have been found to have Negroid genetic
characteristics, while the Fur are intermediate between the Arabs and Negroids.21
Similarly, the Egyptian population appears as a mixture of African, Asiatic and
Arabian characteristics.22 The study of Bedouin and non-Bedouin
Jordanians confirms their Arab characteristics
with a small degree of African admixture.23
The
aim of the work:
Knowledge
of the frequencies of the different blood groups in Fazzan province, where
Africans and Arabs were mixed together, is very important for Blood Banks and
transfusion service policies. Knowledge of blood group phenotype distribution
is also important for clinical studies (for example disease association), as
well as for population studies.
Materials
and Methods:
A
retrospective study using data from the 2nd of March Hospital's blood
transfusion unit was done. All persons donate blood and those attended the
obstetric ward and delivery room between January 2003 and December 2003 were
included in the study. 2380 persons from different regions of Fazzan province
(1249 male donors, and 1131 female recipient were used in this study. Data from
the large six towns; Sebha, Alshati, Obari , Morzok, Gatron and Ghat were recorded. The results were analyzed
statistically using Chi squared test, P values of < 0.05 were considered
significant.24
Results:
The
frequency of blood group A was 29.1% in male donors, 31.5 % in female recipients and 30.3% in both donors
and recipients. The frequency of blood group B was 16.6%:(15.3% in male donors
and 18 % in female recipients). Blood group O was found to be the most frequent
group in this study(48.2%): 50.4 % in male donors and 45.9 in female
recipients. On the other hand, the least frequent group was group AB 4.9% (5.2%
in male donners and 4.6% in female recipients, (Table 1).
There
was no significant difference in the distribution of blood groups between male
donners and female recipient ( X² = 3.1,P > 0.05) (Table 2).
The
distribution of blood groups in different region of Fazzan province showed that
blood group A is more prevalent in Gaht (33.3%),and the least percentage was
found in Obari (21.9). The highest percentage of blood group B was found in
Morzok (24.6%), while the least percentage was found in Ghat (11.1%). AB Group
was also more common in Gaht (11.1%),and less common in Obari (4.2%). On the
other hand, the highest percentage of blood group O was found in Obari area
(63.5%) and the least in Morzok (41%), (Table 3).
About
ninety two per cent (92.3%) of the
donors were Rh positive, and 91% of the recipients were Rh positive. Both recipients and donors were 91.6% Rh
positive. Attendants with Rh negative were
8.4%: female recipient were 9% and male donors are 7.7%, (Table 4).
There was no significant difference in the Rh distribution between male donners
and female recipients (X² = 7.03, P > 0.05), Table 4.
Overall
frequency of ABO and Rhesus blood groups were the following: O-positive 43.9%;
A-positive 28.2%; B-positive, 15%; AB positive 4.4%; O negative 4.3%; A
negative 2%; B-negative 1.7%; and AB negative 0.5%,(Table 5).
Table1:Distribution of blood groups in Donors and Recipients of Fazzan province
|
Blood groups
|
Donors (n=1249)
|
Recipients (n=1131)
|
Total Number of attendants (n=2380)
|
Total Percentage
|
|
A
|
364 (29.1%)
|
356 (31.5%)
|
720
|
30.3
|
|
B
|
191 (15.3%)
|
204 (18%)
|
395
|
16.6
|
|
AB
|
65 (5.2%)
|
52 (4.6%)
|
117
|
4.9
|
|
O
|
629 (50.4%)
|
519 (45.9%)
|
1148
|
48.2
|
Table 2: Blood Groups distribution in Male donors and
Female recipients of Fazzan province* .
|
|
Group A
|
%
|
Group B
|
%
|
|
%
|
Group O
|
%
|
Total
|
|
Males
|
364
|
29.1
|
191
|
15.3
|
65
|
5.2
|
629
|
50.4
|
1249
|
|
Females
|
356
|
31.5
|
204
|
18.0
|
52
|
4.6
|
519
|
45.9
|
1131
|
*
X²=3.1, P>0.05.
Table 3: Distribution of Blood Groups In male Donors of
different regions
of Fazzan province (n=1234)
|
Region.
|
No.
|
A
|
B
|
AB
|
O
|
|
Sebha
|
905
|
29.6%
|
14.6%
|
5.0%
|
50.8%
|
|
Morzok
|
61
|
27.9%
|
24.6%
|
6.6%
|
41.0%
|
|
Obari
|
96
|
21.9%
|
19.4%
|
4.2%
|
63.5%
|
|
Alshati
|
149
|
29.5%
|
14.5%
|
7.4%
|
43.6%
|
|
Ghat
|
9
|
33.3%
|
11.1%
|
11.1%
|
44.4%
|
|
Gatron
|
14
|
28.6%
|
14.3%
|
--------
|
57.1%
|
Table 4: Rh in Male donors and Female recipiants*
|
|
Males
|
Females
|
|
|
|
|
No. %
|
No. %
|
Total
|
Percentage
|
|
Rh negative
|
97
7.7%
|
102 9.0%
|
199
|
8.4%
|
|
Rh positive
|
1152 92.3%
|
1029 91%
|
2181
|
91.6
|
*
X²=7.3, P>0.05.
Table 5: Rh distribution in Male donors and female recipients of Fazzan Province
|
|
Rh in blood donors
|
Rh in blood recipients
|
|
||
|
Blood groups
|
No.
|
%
|
No
|
%
|
Total%
|
|
A positive
|
346
|
27.7
|
326
|
28.8
|
28.2
|
|
A negative
|
18
|
1.4
|
30
|
2.7
|
2.0
|
|
B positive
|
180
|
14.4
|
176
|
15.6
|
15
|
|
B negative
|
11
|
0.9
|
28
|
2.4
|
1.7
|
|
AB positive
|
59
|
4.7
|
48
|
4.2
|
4.4
|
|
AB negative
|
6
|
0.5
|
4
|
0.4
|
0.5
|
|
O positive
|
567
|
45.4
|
479
|
42.4
|
43.9
|
|
O negative
|
62
|
5.0
|
40
|
3.5
|
4.3
|
* X²=0.11, P>0.05
Discussion:
This
study shows that the most frequent blood group is group O ( 48.2%): ORh+
43.9%,ORh- 4.3%. The frequency of blood group A is (30.3%): ARh+ 28.2%, ARh-2%,
while, group B is (16.6%): B Rh+ 15%, BRh-1.7%. The least frequent blood group
is group AB (4.9%):ABRh+ 4.4%,ABRh- 0.5%. These findings is in agreement with
those of Sudan , Kenya
The
results of the present study differs from that of Syrian Arabs;28 Nairobi Kenya13 and West
Africa12 in the frequency of ABO groups. The frequency of
ABO blood groups in Syrian Arabs is Group A (46.25%), Group O (37.5%) Group B
(13.13.%) and Group AB Nairobi
Kenya Group AB
The
inhabitants of the Fazzan area is a mixture of Arabs and Africans, their
anthropometric features substantiate the study of their blood markers. The
present study shows a striking predominance of blood group O in Obari (63.5%).
Blood group A is higher in Sebha (29.6% and Alshati (29.5%). Blood groups B and
AB are the highest in Morzok (24.6%) and Alshati (7.4%)respectively. As
compared with Beckman (2004).18 the population of Obari resembles that of the Sudanese (62%), and the
population of Sebha and Alshati resemble that of Africans and Arabs.
Furthermore, the population of Morzok is
midway between Arabs (29%) and Africans (19%). Blood group AB
Anthropometric
measurements reveals overall homogeneity of Tripoli ,
Benghazi Libya
The present study shows that blood group O
is predominant in both male donors (50.4%) and female recipients (45.9%). There
is no significant difference in the distribution of blood groups and Rh D
system between male donors and female recipients. However, in women of Russian Federation the predominance of blood
group A is the most pronounced.31 Among the Nomads of the Arabian
Peninsula, and the Berbers of the Atlas Mountains ,
two old populations, the frequency of the blood group O gene is high. Africans, on average, have more O genes and
less A genes than do Europeans. So it
can be seen that the gene carried by people who are blood group O is ancient by
evolutionary standards.32
The
Rh positive in Fazzan area is 92%. This is in agreement with Arabs of Saudi
Arabia (93%).27 Similarly it has been concluded that RhD antigen has a prevalence
in Africans.13 On the other hand, the Rh antigens in the series
studied by Lyko et al (1992)26 is the same as the findings of
Kulkarni et al (1985),12 96.1% and 96.4% respectively.
The
most plausible interpretation of these results is that the population of Fazzan
area may be a mixture between Arabs and Africans. Beckman (2004)18
stated that the distribution of ABO blood group in Arabs is Group O:34%, Group
A: 31% ,Group B: 29% and Group
AB Group
AB
Bosch
et al (1997)33 found that the main feature of the genetic landscape
in northern Africa is an east-west pattern of variation pointing to the
differentiation between the Berber and Arab population groups of the northwest
and the populations of Libya and Egypt. Moreover, Libya
and Egypt Africa appears to be small.
Differences
in ABO blood groups distribution between different parts of Fazzan province
together with environmental factors can determine predisposition of individuals
belonging of these subethnic groups to some diseases.
Conclusion:
Our
results show that the most frequent blood group in Libyans of Fazzan province
is group O and is nearly similar to that of Africans. Blood group A is similar
to that of Arabs and Africans. Blood
group B is nearer to Africans more than Arabs. The least frequent blood group
is AB which is similar to that of Africans. The study of blood groups in Libya
Acknowledgement: We would like to thank Dr Kamal Marzook ,who helped
us in the statistics, Mr Hafiz Koko , the Lab, Technician in the 2nd
March Hospital Blood Bank for his technical help.
References:
1. Storry JR. Human blood groups: inheritance and
importance in transfusion medicine. J Infus Nurs. 2003; 26(6):367-72.
2. Omotade OO, Adeyemo AA, Kayode CM,
Falade SL, Ikpeme S. Gene frequencies of ABO and Rh (D) blood group alleles in
a healthy infant population in Ibadan, Nigeria. West Afr J Med.1999;
18(4):294-7.
3. Dogru H, Tuz M, Uygur K. Correlation
between blood group and noise-induced hearing loss. Acta Otolaryngol. 2003;
123(8) :941-2.
4. Hudnall SD, Chen T, Rady P, Tyring S,
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43(1):85-90.
5.
Robertson MS, Cade JF, Savoia HF, Clancy RL. Helicobacter pylori infection in the Australian community: current
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(4):163-7.
6. Sienko J, Wisniewska M, Ostrowski M,
Ciechanowski K, Safranow K, Chudyk A, Fronczyk A, Rozanski J, Kaminski M,
Sulikowski T, Romanowski M, Pabisiak K, Paczkowski M, Mizerski A. Factors that
impact on immediate graft function in patients after renal transplantation.
Trans-plant Proc. 2003; 35(6):2153-4.
7. Choi JW, Pai SH. Associations between
ABO blood groups and osteoporosis in postmenopausal women. Ann Clin Lab
Sci.2004; 34(2):150-3.
8. Vadivelu MK, Damodaran S, Solomon J,
Rajaseharan A. Distribution of ABO blood groups in acute leukaemias and
lymphomas. Ann Hematol. 83(9):584-7. Epub 2004 Jun 03.
9. Rios M, Bianco C. The role of blood
group antigens in infectious diseases. Semin Hematol.2000; 37(2):177-85.
10. Odeigah PG. Influence of blood group
and secretor genes on susceptibility to duodenal ulcer. East
Afr Med J. 1990;67(7):487-500.
11. Keller R, Dinkel KC, Christl SU,
Fischbach W. Interrelation between ABH blood group 0, Lewis(B) blood group
antigen, Helicobacter pylori infection, and occurrence of peptic ulcer. Z
Gastroenterol. 2002; 40(5):273-6.
12. Kulkarni AG, Peter B, Ibazebo R,
Dash B, Fleming AF. The ABO and Rhesus groups in the north of Nigeria
13. Mwangi J. Blood group distribution
in an urban population of patient targeted blood donors. East
Afr Med J. 1999;76(11):615-8.
14. Pramanik T, Pramanik S. Distribution
of ABO and Rh blood groups in Nepalese medical students: a report. East Mediterr Health J. 2000;(1):156-8.
15. Su M, Lu SM, Tian DP, Zhao H, Li XY,
Li DR, Zheng ZC. Relationship between ABO blood groups and carcinoma of
esophagus and cardia in Chaoshan inhabitants of China
16. Adewuyi JO, Gwanzura C. Racial
difference between white and black Zimbabweans in the haemolytic activity of A,
B, O antibodies. Afr J Med Med Sci. 2001;30(1-2):71-4.
17. Datta UK, Mondal S, Mukherjee S. A
study of the distribution of ABO and Rh(D) blood groups amongst Lodha tribe in
Midnapore district of West Bengal. J Indian Med Assoc. 1997;95(9):497-8, 506.
18. Beckman L (2004). Contribution to
the physical Anthropology and population genetics. In: Racial and ethnic
distribution of ABO blood types.
www.bloodbook.com(2004). Visited on 31st of January 2005.
19. Federal Research Division. Library
of congress (1987).
20. Papiha SS, Singh BN, Lanchbury JS,
Mastana SS, Rao YS. Genetic study of the tribal populations of Andhra Pradesh,
south India
21. Tay JS, Saha N. Genetic
heterogeneity among the Negroid and Arab tribes of the Sudan
22. Mahmoud LA, Ibrahim AA, Ghonem HR,
Jouvenceaux A. Human blood groups in Dakahlya, Egypt. Ann Hum Biol. 1987; 14(6):487-93.
23. Saha N, Banerjee B. A study of some
blood genetic characteristics of Bedouin and non-Bedouin Arabs of Jordan. Hum
Hered. 1986; 36(5):276-80.
24. Conover WJ (1999). Some methods
based on ranks. In: Practical non-parametric statistic. Ed. By Conover WJ.Jhon
Wiley& sons, pp.288.
25. Khalil IA, Phrykian S, Farr AD.
Blood group distribution in Sudan
26. Lyko J, Gaertner H, Kaviti JN,
Kariithi MW, Akoto B. Blood-group systems ABO and RH in the Kenyan population.
Folia Med Cracov. 1992;33(1-4):85-92.
27. Bashwari LA, Al-Mulhim AA, Ahmad MS,
Ahmed MA. Frequency of ABO blood groups in the Eastern region of Saudi Arabia
28. Sakharov RS, Nofal' KhK. The
frequency of ABO blood groups and the expression of group antigens and
isohemagglutinins in Syrian Arabs. Sud Med Ekspert.1996; 39(2) :34-6.
29. Kamel K, 'Umar M, Ibrahim W, Mansour
A, Gaballah F, Selim O, Azim A, Hamza S, Sabry F, Moafy N, El-naggar A, Hoerman
K (1975). Anthropological studies among Libyans. Erythrocyte genetic factors,
serum haptoglobin phenotypes and anthropometry. Am J Phys Anthropol. 1975;
43(1):103-11.
30. Bonne-Tamir B, Ashbel S, Modai J.
Genetic markers in Libyan Jews. Hum Genet. 1977; 37(3):319-28.
31. Tomilin VV, Gurtovaia SV. The
incidence of finding ABO system antigens in the population of the Russian Federation
32. Cavalli-Sforza, LL, Menozzi, P.,
and Piazza, A. The History and Geography
of Human Genes (Princeton: Princeton
University
33. Bosch E, Calafell F, Perez-Lezaun A,
Comas D, Mateu E, Bertranpetit J. Population history of north Africa: evidence
from classical genetic markers. Hum Biol.1997; 69(3):295-311.
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59
30.4
21.48
Table No. 4
Time from admission till operation
|
Time
|
Acute appendicitis
|
Perforated
|
Normal
|
Total
|
|
<5hrs
|
20
|
8
|
2
|
30
|
|
5-10 hrs
|
32
|
14
|
6
|
52
|
|
> 10 hrs
|
18
|
10
|
7
|
35
|
|
Total
|
70
|
32
|
15
|
117
|
|
Range
|
1-48
|
2-72
|
3-72
|
1-72
|
|
Mean
|
8.8
|
15
|
18.4
|
11.8
|
Table No. 5
Only 117 cases out of 128 were operated.
11 cases treated conservatively as app. Mass.
Hospital stay in days
|
Days
|
Ac. app
|
Perf.
|
Mass
|
Normal
|
Total
|
|
< 5
|
64
|
7
|
3
|
12
|
86/ 67%
|
|
5-10
|
6
|
18
|
7
|
3
|
34/ 26.5%
|
|
> 10
|
0
|
7
|
1
|
0
|
8/ 6.25%
|
|
Range
|
2-6
|
3-29
|
3-11
|
2-6
|
2-29
|
|
Mean
|
3.1
|
7.9
|
6.45
|
3.8
|
4.7
|
Table No. 6
Postoperative complications
|
No.
|
Complication
|
Age (y)
|
Referred from
|
Appendicitis
|
Med. problems
|
Duration of symptoms.
|
|
1
|
Wound infection
|
40
|
Gatroun H.
|
Perforation
|
----
|
4d
|
|
2
|
Wound infection
|
12
|
Oubari H.
|
Perf/abscess
|
----
|
7d
|
|
3
|
Wound infection
|
7
|
Burgen H.
|
Perforation
|
----
|
8d
|
|
4
|
Wound infection
|
35
|
H.casuality
|
Perforation
|
----
|
3 hrs
|
|
5
|
Wound infection
|
18
|
H. Causality
|
Perforation
|
----
|
3d
|
|
6
|
Wound infection
|
34
|
H. Causality
|
Perforation
|
----
|
3d
|
|
7
|
Wound infection
|
32
|
H. Causality
|
Perforation
|
----
|
3hrs
|
|
8
|
Pelvic collection
|
40
|
Oubari H.
|
Perforation
|
----
|
2d
|
|
9
|
Acute renal failure
|
50
|
Murzok H.
|
Perforation
|
Hypertension
|
3d
|
|
10
|
Pneumonia
|
55
|
Murzok H.
|
Perforation
|
DM, SVT
|
4d
|
Table No – 7
Discussion:
In this study a male to female ratio is 9:7 or
1.28:1, this is comparable to 1.3: 1 by Rosemary et al.9 The rate of
normal appendix underwent surgery was 12.8% compared to 16%,9 14.5%3
and 15.9%.1 Female comprising 93 % others had 68 %.9
Perforated appendicitis represented 25% of the
operated cases with highest incidence in 4th decade 48%. Barouni1
had 20.1% incidence of perforation with highest incidence 47.3% in the 4th
decade. Perforation in children represented 42.8% compared to 46.6% by Barouni
and 47% by Gamal.8
The duration of symptoms is an important risk
factor for development of complications.The mean time for perforation and mass
is 24.4 and 59 hrs respectively, while 12.3 hrs for acute non-complicated
appendicitis.
The mean time from admission to surgery is 11.8 hrs
with high values for perforation 15 hrs and normal 18.4 hrs. We refer this to:
-
* Cases of appendicular mass on admission were
treated expectantly and only if signs of abscess develop are then operated.
Also a busy theatre with a single anesthetist.
A patient operated for normal appendix have the
highest mean time interval because of prolonged period of observation. Mean
hospital stay in days is 4.7 compared to 3.7 by others.3 Hospital
stay is prolonged with complicated cases 7.9 and 6.45 days.
Our postoperative complications represent 8.5 %,
wound infection represents 5.9%. 70% of complicated cases have symptoms for 3
days and more. Helmer et al2 found 9% incidence of wound infection.
Rosemary et al9 found 3% postoperative
complication and 47% patients with perforation.
Conclusion:
Proper knowledge and understanding of the pathology
and differential diagnosis of pain at right iliac fossa with special attention
to appendicitis and its early diagnosis by all doctors working in the
periphery, also early consultation are all among the important factors to minimize
morbidity associated with acute appendicitis.
References:
1. Barouni G. A.: Incidence of perforated
appendicitis. Jamahiriya. M.Journal. 2001, 1(1); 30-32.
2. Helmer K.S, et al:
Standardized patient care guidelines reduce infectious morbidity in
appendicectomy patients. Am. J. Surg. June 2002, 183(6): 608-613.
3. Ho.Hs:
Appendectomy. Scientific American Surgery. 1999, 1-18.
4. keddie N:
Management of appendicular mass. N. Br J Hosp. 1975, 175.
5. Krukowski
Z.H, Matheson N.A: Peritonitis. Surgery. 1984, 1,260.
6. Kevin G.
Bernard: Anthony E. Young eds, acute appendicitis. In: the new airds companion
in surgical studies. 1st ed. Churchill Livingstone London, New York,
1992, 908.
7. Puylaert
J. Rutgers P, et al: Imaging in acute appendicitis. N Eng J Med. 1987, 317:
666-669.
8. Reda
Jamal, Thomas C. Moore: Appendicitis in children aged 13 years and younger.
June 1990, 159(6): 589-592.
9. Rosemary
A. Kozar, Jod J. Roslyn: The appendix. In Schwartz. S. I et al (eds).
Principles of surgery. New York, London-McGraw Hill book Co. 7th ed.
1999, (2)1392.
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