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TH E MA N A G E M E N T
O F SI C K L E
CE L L DI S E A S E
N A T I O N A L I N S T I T U T E S O F H E A L T H
N A T IONAL HEART, LUNG, AND BLOOD INSTITUTE
Division of B l o o d D i s e a s e s a n d R e s o u r c e s
THE MANAGEMENT
OF SICKLE
CELL DISEASE
NATIONAL INSTITUTES
OF HEALTH
National Heart, Lung,
and Blood Institute
Division of Blood Diseases
and Resources
NIH PUBLICATION
NO. 02-2117
ORIGINALLY PRINTED 1984
PREVIOUSLY REVISED 1989, 1995
REPRINTED JUNE 1999
REVISED JUNE 2002
(FOURTH EDITION)
II
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
DIAGNOSIS AND COUNSELING
1. World Wide Web Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2. Neonatal Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
3. Sickle Cell Trait. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
4. Genetic Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
HEALTH MAINTENANCE
5. Child Health Care Maintenance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
6. Adolescent Health Care and Transitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
7. Adult Health Care Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
8. Coordination of Care: Role of Mid-Level Practitioners . . . . . . . . . . . . . . . . . 47
9. Psychosocial Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
TREATMENT OF ACUTE AND CHRONIC COMPLICATIONS
10. Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
11. Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
12. Transient Red Cell Aplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
13. Stroke and Central Nervous System Disease . . . . . . . . . . . . . . . . . . . . . . . . . 83
14. Sickle Cell Eye Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
15. Cardiovascular Manifestations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
16. Acute Chest Syndrome and Other Pulmonary Complications . . . . . . . . . . . 103
17. Gall Bladder and Liver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
III
CONTENTS
IV
18. Splenic Sequestration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
19. Renal Abnormalities in Sickle Cell Disease. . . . . . . . . . . . . . . . . . . . . . . . . . 123
20. Priapism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
21. Bones and Joints . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
22. Leg Ulcers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
SPECIAL TOPICS
23. Contraception and Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
24. Anesthesia and Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
25. Transfusion, Iron Overload, and Chelation . . . . . . . . . . . . . . . . . . . . . . . . . 153
26. Fetal Hemoglobin Induction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
27. Hematopoietic Cell Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
28. Genetic Modulation of Phenotype by Epistatic Genes . . . . . . . . . . . . . . . . 173
29. Highlights from Federally Funded Studies. . . . . . . . . . . . . . . . . . . . . . . . . . 181
iduals with sickle cell disease and provides
relevant online resources at the end of the
chapters, is to serve as an adjunct to recent
textbooks that delve more deeply into all
aspects of the disorder.
The authors hope that this book will be used
by medical students, house staff, general practitioners, specialists, nurses, social workers, psychologists, and other professionals as well as
the families and patients who are coping with
the complexities of sickle cell disease on a daily
basis. The book, any part of which can be
copied freely, will be placed on the National
Heart, Lung, and Blood Institute (NHLBI)
Web site and will be updated as needed.
Research is essential to provide the knowledge
required to improve the care of individuals
with sickle cell disease, but it is the physicians
and other health care personnel who must
ensure that the very best care is actually
delivered to each child and adult who has
this disorder. We hope that this book will
help to achieve this goal.
Claude Lenfant, M.D.
Director, NHLBI
Enclosed is the fourth edition of a book that
is dedicated to the medical and social issues of
individuals with sickle cell disease. This publication, which was developed by physicians,
nurses, psychologists, and social workers who
specialize in the care of children and adults
with sickle cell disease, describes the current
approach to counseling and also to management of many of the medical complications
of sickle cell disease.
Each chapter was prepared by one or more
experts and then reviewed by several others
in the field. Additional experts reviewed the
entire volume. This book is not the result of a
formalized consensus process but rather represents the efforts of those who have dedicated
their professional careers to the care of individuals with sickle cell disease. The names of
the authors, their affiliations, and their e-mail
addresses are listed in the front of the book.
Multiple new therapies are now available for
children and adults with sickle cell disease,
and often the options to be chosen present
a dilemma for both patients and physicians.
This book does not provide answers to many
of these newer questions but rather explains
the choices available. The book, which focuses
primarily on the basic management of indivV
PREFACE
VI
Henny Billett, M.D.
Director, Clinical Hematology
Albert Einstein College of Medicine
Comprehensive Sickle Cell Center
Montefiore Hospital Medical Center
111 East 210th Street
Bronx, NY 10467
Tel: (718) 920-7373
Fax: (718) 920-5095
E-mail: billett@aecom.yu.edu
E-mail: hbillett@montefiore.org
Carine Boehme, M.S.
Associate Professor
The Johns Hopkins University School of Medicine
CMSC Room 1004
600 North Wolfe Street
Baltimore, MD 21287-9278
Tel: (410) 955-0483
Fax: (410) 955-0484
E-mail: CBOEHM@jhmi.edu
Kenneth Bridges, M.D.
Associate Professor of Medicine
Director, Joint Center for Sickle Cell
and Thrombosis and Hemostasis Disorders
Brigham and Women’s Hospital
Harvard Medical School
75 Francis Street
Boston, MA 02115
Tel: (617) 732-5842
Fax: (617) 975-0876
E-mail: kbridges@rics.bwh.harvard.edu
Robert Adams, M.D.
Associate Professor, Department of Neurology
Room HB-2060
Medical College of Georgia
Augusta, GA 30912
Tel: (706) 721-4670
Fax: (706) 721-6757
E-mail: rjadams@neuro.mcg.edu
Kenneth I. Ataga, M.D.
Division of Hematology/Oncology
CB# 7305, 3009 Old Clinic Building
University of North Carolina at Chapel Hill
Chapel Hill, NC 27599-7305
Tel: (919) 843-7708
E-mail: kataga@med.unc.edu
Harold Ballard, M.D.
Assistant Chief, Hematology Division
New York Veterans Administration
Medical Services, 12th Floor
New York, NY 10010
Tel: (212) 951-3484
Fax: (212) 951-5981
Lennette Benjamin, M.D.
Associate Professor of Medicine
Montefiore Hospital Medical Center
Comprehensive Sickle Cell Center
111 East 210th Street
Bronx, NY 10467-2490
Tel: (718) 920-7375
Fax: (718) 798-5095
E-mail: lbenja2725@aol.com
VII
CONTRIBUTORS
VIII
Joseph DeSimone, Ph.D.
Geneticist
VA West Side Medical Center
Hematology Research (151C)
820 South Damen Avenue
Chicago, IL 60612
Tel: (312) 666-6500 x2683
Fax: (312) 455-5877
E-mail: Jdesimon@UIC.edu
Ann Earles, R.N., P.N.P.
Research Nurse
Children’s Hospital of Oakland
747 52nd Street
Oakland, CA 94609-1809
Tel: (510) 428-3453
Fax: (510) 450-5635
E-mail: aearles@mail.cho.org
James Eckman, M.D.
Professor of Medicine
Emory University School of Medicine
69 Butler Street
Atlanta, GA 30303
Tel: (404) 616-5982
Fax: (404) 577-9107
E-mail: jeckman@emory.edu
Morton Goldberg, M.D.
Director, Department of Ophthalmology
The Johns Hopkins Hospital
The Wilmer Ophthamological Institute
Maumanee Building, Room 729
600 North Wolfe Street
Baltimore, MD 21287-9278
Tel: (410) 955-6846
Fax: (410) 955-0675
E-mail: mgoldbrg@jhmi.edu
Harry E. Jergesen, M.D.
Department of Orthopaedic Surgery
University of California, San Francisco
500 Parnassus Avenue, MU-320W
San Francisco, CA 94143
Tel: (415) 476-8938
Fax: (415) 476-1301
E-mail: jergesen@orthosurg.ucsf.edu
Oswaldo Castro, M.D.
Professor of Medicine/Pediatrics
Howard University School of Medicine
Comprehensive Sickle Cell Center
2121 Georgia Avenue, NW
Washington DC 20059
Tel: (202) 806-7930
Fax: (202) 806-4517
E-mail: olcastro@aol.com
Samuel Charache, M.D.
2006 South Road
Baltimore, MD 21209-4510
Tel: (410) 466-6405
Fax: (410) 466-4330
E-mail: scharach@erols.com
Wesley Covitz, M.D.
Professor of Pediatrics
Wake Forest School of Medicine
Medical Center Boulevard
Winston-Salem, NC 27157-1081
Tel: (336) 716-4267
Fax: (336) 716-0533
E-mail: wcovitz@wfubmc.edu
Gary R. Cutter, Ph.D.
Professor of Medicine
Director, Center for Research Design
and Statistical Methods
UNR School of Medicine, Mail Stop 199
Reno, Nevada 89557
Tel: (775) 784-1565
Fax: (775) 784-1142
E-mail: cutterg@prodigy.net
Carlton Dampier, M.D.
Director, Marian Anderson SCC
Hematology/Oncology
St. Christopher’s Hospital for Children
Erie Avenue at Front Street
Philadelphia, PA 19134
Tel: (215) 427-5096
Fax: (215) 427-6684
E-mail: carlton.dampier@tenethealthcare.com
IX
Cage Johnson, M.D.
Professor of Medicine
University of Southern California
2025 Zonal Avenue
Los Angeles, CA 90033
Tel: (323) 442-1259
Fax: (323) 442-1255
E-mail: cagejohn@hsc.usc.edu
Adrena Johnson-Telfair, P.A.C.
Associate Director for Clinical Services
University of Alabama at Birmingham
Comprehensive Sickle Cell Center
1900 University Boulevard
513 Tinsley Harrison
Birmingham, AL 35294-0006
Tel: (205) 975-2281
Fax: (205) 975-5264
E-mail: ajtelfair@hotmail.com
Clinton Joiner, M.D., Ph.D.
Associate Professor of Pediatrics
Director, Comprehensive Sickle Cell Center
Children’s Hospital Medical Center
3333 Burnett Avenue, OSB 4
Cincinnati, OH 45229-3039
Tel: (513) 636-4541
Fax: (513) 636-5562
E-mail: clinton.joiner@chmcc.org
John Kark, M.D.
Professor, Hematology/Oncology
Howard University Hospital
5145 Tower Building
2041 Georgia Avenue, NW
Washington, DC 20060
Tel: (202) 865-1511
Fax: (202) 865-4607
E-mail: vkark@adventisthealthcare.com
Mabel Koshy, M.D.
University of Illinois
840 South Wood Street
MSC 787, Room 833
Chicago, IL 60612
Tel: (312) 996-5680
Fax: (312) 996-5984
Peter Lane, M.D.
Director, Colorado Sickle Cell Treatment
and Research Center
Campus Box C-222
University of Colorado Health Sciences Center
4200 East Ninth Avenue
Denver, CO 80262
Tel: (303) 372-9070
Fax: (303) 372-9161
E-mail: Peter.Lane@uchsc.edu
Dimitris Loukopoulos, M.D., D.Sci.
First Department of Medicine
University of Athens School of Medicine
Laikon Hospital
Athens 11527 GREECE
Tel: +30 1 7771 161
Fax: +30 1 7295 065
E-mail: dloukop@otenet.gr
Bertram Lubin, M.D.
Director of Medical Research
Children’s Hospital Oakland Research Institute
5700 Martin Luther King Junior Way
Oakland, CA 94609
Tel: (510) 450-7601
Fax: (510) 450-7910
E-mail: blubin@chori.org
Elysse Mandell, M.S.N.
Division of Hematology
Brigham and Women’s Hospital
75 Francis Street
Boston, MA 02115
Tel: (617) 732-8485
Fax: (617) 975-0876
E-mail: emandell@partners.org
Vipul Mankad, M.D.
Professor and Chairman
Kentucky Clinic, Room J406
University of Kentucky
Chandler Medical Center
Lexington, KY 40536-0284
Tel: (859) 323-5481
Fax: (859) 257-7706
E-mail: vnmank1@pop.uky.edu
X
Orah Platt, M.D.
Director, Department of Laboratory Medicine
Enders Research Building, Room 761
Children’s Hospital Medical Center
320 Longwood Avenue
Boston, MA 02146
Tel: (617) 355-6347
Fax: (617) 713-4347
E-mail: platt@tch.harvard.edu
Sonya Ross, B.S.
Director of Program Development
Sickle Cell Disease Association of America
P.O. Box 1956
Baltimore, MD 21203
Tel: (410) 363-7711
Fax: (410) 363-4052
E-mail: siross@sicklecelldisease.org
Frank Shafer, M.D.
St. Christopher’s Hospital for Children
Hematology/Oncology
Erie Avenue at Front Street
Philadelphia, PA 19134
Tel: (215) 427-4399
Fax: (215) 427-6684
E-mail: Frank.shafer@drexel.edu
Jeanne Smith, M.D.
Associate Professor of Clinical Research
Columbia University Comprehensive
Sickle Cell Center
Suite 6164
506 Lenox Avenue at 135th Street
New York, NY 10037
Tel: (212) 939-1701
Fax: (212) 939-1692
E-mail: mdjasmith@aol.com
Kim Smith-Whitley, M.D.
Associate Director for Clinic Sickle Cell Program
Children’s Hospital of Philadelphia
324 South 34th Street
Philadelphia, PA 19104
Tel: (215) 590-1662
Fax: (215) 590-5992
E-mail: whitleyk@e-mail.chop.edu
Marie Mann, M.D., M.P.H.
Deputy Chief, Genetic Services Branch
Maternal and Child Health Bureau
Health Resources and Services Administration
5600 Fishers Lane
Rockville, MD 20857
Tel: (301) 443-4925
Fax: (301) 443-8604
E-mail: Mmann@hrsa.gov
Ronald Nagel, M.D.
Head, Division of Hematology
Albert Einstein College of Medicine
1300 Morris Park Avenue
Bronx, NY 10461
Tel: (718) 430-2186
Fax: (718) 824-3153
E-mail: nagel@aecom.yu.edu
Ms. Kathy Norcott
Sickle Cell Disease Association of the Piedmont
P.O. Box 20964
Greensboro, NC 27420
Tel: (336) 274-1507 or (800) 733-8299
E-mail: knorcott@scdap.org
Kwaku Ohene-Frempong, M.D.
Director, Comprehensive Sickle Cell Center
Children’s Hospital of Philadelphia
324 South 34th Street and Civic Center Boulevard
Philadelphia, PA 19104
Tel: (215) 590-3423
Fax: (215) 590-3992
E-mail: ohene-frempong@email.chop.edu
Eugene Orringer, M.D.
Professor of Medicine
Director, Comprehensive Sickle Cell Program
University of North Carolina
125 MacNider Building
Chapel Hill, NC 27599-7000
Tel: (919) 843-9485
Fax: (919) 216-3602
E-mail: epo@med.unc.edu
XI
Martin Steinberg, M.D.
Director, Center for Excellence in Sickle Cell Disease
Boston Medical Center
88 East Newton Street
Boston, MA 02118
Tel: (617) 414-1020
Fax: (617) 414-1021
E-mail: msteinberg@medicine.bu.edu
Marie Stuart, M.D.
Professor of Pediatrics
Division of Pediatric Hematology
Thomas Jefferson University
1025 Walnut Street, Suite 727
Philadelphia, PA 19107
Tel: (215) 955-9820
Fax: (215) 955-8011
E-mail: Marie.Stuart@mail.tju.edu
Paul Swerdlow, M.D.
Director of Red Cell Disorders
Associate Professor, Wayne State University
Harper Hospital, 4 Brush South
Barbara Ann Karmanos Cancer Institute
3990 John R St.
Detroit, MI 48201
Tel: (313) 745-9669
Fax: (313) 993-0307
E-mail: swerdlow@Karmanos.org
Joseph Telfair, Dr.P.H., M.S.W., M.P.H.
Department of Maternal and Child Health
School of Public Health
University of Alabama at Birmingham
320 Royals Building
1665 University Boulevard
Birmingham, AL 35294-0022
Tel: (205) 934-1371
Fax: (205) 934-8248
E-mail: jtelfair@uab.edu
Tim Townes, Ph.D.
Professor, Department of Biochemistry
and Molecular Genetics
Schools of Medicine and Dentistry
University of Alabama at Birmingham
BBRB 260
1530 3rd Avenue South
Birmingham, AL 35294-0022
Tel: (205) 934-5294
Fax: (205) 934-2889
E-mail: ttownes@bmg.bhs.uab.edu
Marsha Treadwell, Ph.D.
Hematology Behavioral Services Coordinator
Children’s Hospital Oakland
747 52nd Street
Oakland, CA 94609-1809
Tel: (510) 428-3356
Fax: (510) 428-3973
E-mail: MTreadwell@mail.cho.org
Elliott Vichinsky, M.D.
Division Head, Hematology/Oncology
Director, Comprehensive Sickle Cell Center
Children’s Hospital of Oakland
747 52nd Street
Oakland, CA 94609-1809
Tel: (510) 420-3651
Fax: (510) 450-5647
E-mail: evichinsky@mail.cho.org
Mark Walters, M.D.
Fred Hutchinson Cancer Research Center
100 Fairview Avenue North, C1-169
P.O. Box 10924
Seattle, WA 98109-1024
Tel: (206) 667-4103
Fax: (206) 667-6084
E-mail: mwalters@mail.cho.org
Winfred Wang, M.D.
Department of Hematology/Oncology
St. Jude’s Children’s Research Center
P.O. Box 318
32 North Lauderdale
Memphis, TN 38101
Tel: (901) 495-3497
Fax: (901) 521-9005
E-mail: winfred.wang@stjude.org
XII
Robert Yamashita, Ph.D.
Interdisciplinary Studies in Science and Society
Liberal Studies Department
California State University
San Marcos, CA 92096-0001
Tel: (760) 750-4204
E-mail: yamashta@csusm.edu
NATIONAL INSTITUTES OF HEALTH
Barbara Alving, M.D.
Deputy Director
National Heart, Lung, and Blood Institute
Building 31, Room 5A47, MSC 2490
31 Center Drive
Bethesda, MD 20892-2490
Tel: (301) 594-5171
Fax: (301) 402-0818
E-mail: alvingb@nih.gov
Griffin Rodgers, M.D.
Deputy Director
National Institute of Diabetes and Digestive
Kidney Diseases
Building 31, Room 9A52, MSC 1822
31 Center Drive
Bethesda, MD 20892-1822
Tel: (301) 496-5741
Fax: (301) 402-2125
E-mail: rodgersg@extra.niddk.nih.gov
Henry Chang, M.D.
Health Scientist Administrator
Division of Blood Diseases and Resources
National Heart, Lung, and Blood Institute
6701 Rockledge Drive, MSC 7950
Bethesda, MD 20892-7950
Tel: (301) 435-0065
Fax (301) 480-0867
E-mail: changh@nih.gov
Charles Peterson, M.D.
Director, Division of Blood Diseases and Resources
National Heart, Lung, and Blood Institute
6701 Rockledge Drive, MSC 7950
Bethesda, MD 20892-7950
Tel: (301) 435-0080
Fax: (301) 480-0867
E-mail: petersoc@nih.gov
Russell Ware, M.D., Ph.D.
Professor of Pediatrics
Duke University Medical Center
Box 2916 DUMC
R-133 MSRB, Research Drive
Durham, NC 27710
Tel: (919) 684-5665
Fax: (919) 684-5752
E-mail: ware0005@mc.duke.edu
Doris Wethers, M.D.
1201 Cabrini Boulevard
Apartment #57
New York, NY 10033
Tel: (212) 928-2600
E-mail: dlwethers@earthlink.net
Charles Whitten, M.D.
President Emeritus, Sickle Cell Disease Association
of America
Distinguished Professor of Pediatrics and Associate Dean
Wayne State University School of Medicine
Scott Hall, Room 1201
540 East Canfield Street
Detroit, MI 48201
Tel: (313) 577-1546
Fax: (313) 577-1330
E-mail: cwhitten@med.wayne.edu
Wanda Whitten-Shurney, M.D.
Attending Pediatrician
Children’s Hospital of Michigan
3901 Beaubien Boulevard
Detroit, MI 48201
Tel: (313) 745-5613
Fax: (313) 745-5237
E-mail: wshurney@dmc.org
Nevada Winrow, Ph.D.
Postdoctoral Fellow
9624 Devedente Drive
Owings Mills, MD 21117
Tel: (240) 601-8683
Fax: (410) 902-3457
E-mail: nwinrow@jhmi.edu
Petronella Barrow
Office Manager
Division of Blood Diseases and Resources
National Heart, Lung, and Blood Institute
6701 Rockledge Drive, MSC 7950
Bethesda, MD 20892-7950
Tel: (301) 435-0080
Fax: (301) 480-0867
E-mail: barrowp@nih.gov
Kathy Brasier
Secretary
National Heart, Lung, and Blood Institute
Building 31, Room 5A47, MSC 2490
Bethesda, MD 20892-2490
Tel: (301) 496-1078
Fax: (301) 402-0818
E-mail: brasierk@nih.gov
Duane Bonds, M.D.
Health Scientist Administrator
Sickle Cell Disease Scientific Research Group
Division of Blood Diseases and Resources
National Heart, Lung, and Blood Institute
6701 Rockledge Drive, MSC 7950
Bethesda, MD 20892-7950
Tel: (301) 435-0055
Fax: (301) 480-0868
E-mail: bondsd@nih.gov
Greg Evans, Ph.D.
Health Scientist Administrator
Division of Blood Diseases and Resources
National Heart, Lung, and Blood Institute
6701 Rockledge Drive, MSC 7950
Bethesda, MD 20892-7950
Tel: (301) 435-0055
Fax: (301) 480-0868
E-mail: evansg@nih.gov
David Bodine, Ph.D.
Chief, Hematopoiesis Section
Genetics and Molecular Biology Branch
National Human Genome Research Institute,
Building 49, Room 3W16, MSC 4442
Bethesda, MD 20892-4442
Tel: (301) 402-0902
Fax: (301) 402-4929
E-mail: tedyaz@nhgri.nih.gov
Jonelle Drugan, Ph.D.
Program Analyst
Office of Science and Technology
National Heart, Lung, and Blood Institute
Building 31, Room 5A06, MSC 2482
Bethesda, MD 20892-2482
Tel: (301) 402-3423
Fax: (301) 402-1056
E-mail: druganj@nih.gov
XIII