|Year : 2020 | Volume
| Issue : 3 | Page : 93-101
Management algorithms for gaucher disease
Ayman Alhejazi1, Abdulkareem AlMomen2, Ahmad M Tarawah3, Ahmed M AlSuliman4, Hussain H Al Saeed5, Mahasen Saleh6, Marwan ElBagoury7, Ohoud F Kashari8, Omar M Hussein7
1 Department of Hematology/Oncology King Saud Bin Abdulaziz University for Health Sciences; Division of Adult Hematology & HSCT, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 Center of Excellence in Thrombosis and Hemostasis, King Saud University-Medical City, Riyadh, Saudi Arabia
3 Pediatrics Hematology/Oncology Department King Abdullah Medical City, Madinah, Saudi Arabia
4 Department of Medicine, Hematology Section, King Fahad Hospital, Hofuf, Saudi Arabia
5 Department of medicine, Qatif Central Hospital, Qatif, Eastern Province, Saudi Arabia
6 Department of Pediatric Hematology/Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
7 Department of Medical Affairs, Sanofi-Genzyme, Jeddah, Saudi Arabia
8 Department of Pediatrics, East Jeddah General Hospital, Jeddah, Saudi Arabia
|Date of Submission||18-Apr-2020|
|Date of Decision||25-May-2020|
|Date of Acceptance||06-Aug-2020|
|Date of Web Publication||16-Sep-2020|
Dr. Ayman Alhejazi
Department of Hematology/Oncology King Saud Bin Abdulaziz University for Health Sciences, Division of Adult Hematology & HSCT, King Abdulaziz Medical City, Riyadh
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Gaucher disease is a challenging disease because of the progressive nature and multiple systems that are involved. Gaucher disease is underdiagnosed in Saudi Arabia. It is sometimes misdiagnosed with other hematological diseases. The prevalence is apparently higher than what is currently reported in the available literature. This might be mainly due to the high percentage of consanguinity, especially among tribes. The main objective of this consensus was to provide a comprehensive algorithm for the diagnosis of Gaucher disease for hematologists mainly. Gaucher-related peer-reviewed literature was discussed and adapted to match the practice in Saudi Arabia. Discussion of different Clinical presentations for adult and pediatric patients and improving access to Diagnostic testing like Enzymatic analysis and genetic testing to be able to find solutions for the issue of delayed diagnosis of Gaucher Disease in Saudi Arabia.
METHODS: After a thorough literature review, the group discussed set of queries such as: The difference in adults and Pediatric Gaucher disease diagnostic algorithms in Saudi Arabia. The management goals for Gaucher disease and the local risk assessment parameters were discussed as well. In addition to the unmet needs in Gaucher disease, and reasons for delayed Gaucher disease diagnosis and their consequences. Then, the group adapted the algorithms after localizing each step.
RESULTS: After reviewing different Gaucher disease diagnostic algorithms by Mistry PK et al for the adult age group and Di Rocco M et al for the pediatric age group, We were able to draft complete detailed algorithms for diagnosis of Gaucher.
CONCLUSION: Gaucher disease is underdiagnosed or misdiagnosed. The actual prevalence can be higher than what is reported in the literature, and the current number of diagnosed cases does not reflect the actual prevalence.
Keywords: Algorithms, Gaucher disease, Kingdom of Saudi Arabia, management, Saudi Arabia
|How to cite this article:|
Alhejazi A, AlMomen A, Tarawah AM, AlSuliman AM, Al Saeed HH, Saleh M, ElBagoury M, Kashari OF, Hussein OM. Management algorithms for gaucher disease. J Appl Hematol 2020;11:93-101
|How to cite this URL:|
Alhejazi A, AlMomen A, Tarawah AM, AlSuliman AM, Al Saeed HH, Saleh M, ElBagoury M, Kashari OF, Hussein OM. Management algorithms for gaucher disease. J Appl Hematol [serial online] 2020 [cited 2020 Sep 22];11:93-101. Available from: http://www.jahjournal.org/text.asp?2020/11/3/93/295124
| Introduction|| |
Gaucher disease is the most globally prevalent autosomal recessive lysosomal storage disease resulting from the deficiency of glucocerebrosidase enzyme, leading to a build-up of glucocerebroside (glucosylceramide) inside macrophages' lysosomes. Macrophages puffed up with glycolipid–lipid are named as Gaucher cells, and their systemic accumulation within the reticuloendothelial system leads to diverse presentations comprising splenomegaly, abdominal discomfort, anemia, and chronic fatigability. Bruises and bleeding tendencies may happen because of either thrombocytopenia. In addition, hepatomegaly with abnormal liver functions and various forms of bone involvement may be present.
Infrequently, Gaucher disease involves other organs such as eyes, skin, heart, and kidneys. Rarely, the central nervous system could be involved, leading to degenerative changes that result in the neuronopathic variant. Other systems such as the respiratory and lymphatic systems may also be affected.
Three phenotypes of Gaucher disease are described: type 1 which spares the nervous system; type 2 which is characterized by aggressive neurological involvement and being lethal in infancy; and type 3, manifested by gradual progressive neurological disease, which usually causes death in children or young adults.
Type 1 Gaucher disease is more prevalent. Its worldwide prevalence ranges from 1/50,000 to 1/100,000.,,, Type 1 Gaucher disease has the largest phenotypic range in Gaucher disease, regarding the age of onset, progression rate, and involved organs.
In Saudi Arabia, around 75 patients have been diagnosed with Gaucher disease (45 of them were type 1 patients, 4 patients with type 2, and 26 with type 3); however, there is a huge under-diagnosis or misdiagnosis gap for Gaucher disease. The incidence is expected to be much higher due to high consanguinity and a high pregnancy rate per family.
Enzyme replacement therapy (ERT) is an effective treatment of type 1 Gaucher disease (and type 3). There is a body of evidence from Gaucher registry, sponsored by the International Collaborative Gaucher Group (ICGG), indicating that ERT reverses both visceral and hematological manifestations of Gaucher disease and relieves skeletal symptoms, leading to better quality of life.,,, Unfortunately, late-onset bone manifestations of Gaucher disease such as osteonecrosis, osteofibrosis, and osteolytic lesions are irreversible if ERT is not started early. Early commencement of ERT reduces the risk of such irreversible sequelae.,
Timely diagnosis is the best possible option for optimum Gaucher disease management. Symptoms of type 1 Gaucher disease are splenomegaly, anemia, thrombocytopenia, and bleeding tendency. Hence, Gaucher disease sufferers are usually referred to hematologists for diagnosis and optimal management. Ironically, only 20% of hematologists/oncologists would consider Gaucher disease in the differential diagnosis, despite the presence of all traditional symptoms as shown in one study.
Management goals for Gaucher disease according to the amended 2016 European Working Group Consensus were discussed and summarizedin [Table 1].
Since there is a compelling need to enhance the diagnosis of Gaucher disease in Saudi Arabia, it is important to provide a feasible, comprehensive algorithmic guideline for diagnosis and treatment of Gaucher disease for healthcare professionals, especially hematologists taking into consideration the complexity of the local healthcare system, patient referral dynamics, and disease awareness level among referring specialties.
| Queries Set|| |
We agreed on a set of queries to guide our discussion such as (i) How different are Gaucher disease diagnostic algorithms for adults and pediatrics in Saudi Arabia compared to standard algorithms? (ii) What are the management goals for Gaucher disease locally? (iii) What are the local risk assessment parameters for adults and children with Gaucher disease? (iv) What are the unmet needs in Gaucher disease? (v) Why is Gaucher disease missed? (v) Differential diagnosis? (vi) What are the consequences of a delay in diagnosis? (vii) How we can ensure correct diagnosis and management of bone manifestations in Gaucher patients?
The consensus process
Misdiagnosis patterns in Gaucher disease were reviewed presenting the clinical picture in Gaucher disease sufferers from our clinical experience and outlined in the published diagnostic algorithms for both adult and pediatric age groups. We identified key diagnostic features and consequently adapted those algorithms to match the Saudi situation.
| Results|| |
Gaucher disease diagnostic algorithms in adult groups
The authors discussed the Gaucher disease diagnostic algorithm which was reappraised by Mistry for the adult age group and Di Rocco et al. for the pediatric age group.
A dedicated Screening program for high risk patients suffering from thrombocytopenia with splenomegaly or with non-responding Immune thrombocytopenia can help to diagnose more patients. Further, splenomegaly and gammopathies or multiple myeloma at a young age should warrant alertness to Gaucher disease. Splenectomy associated with a history of thrombocytopenia should be considered as an alarming sign.
In patients with normal spleen and having isolated thrombocytopenia, the most common diagnosis is immune thrombocytopenia (ITP); unless it is refractory to treatment (corticosteroids, Intravenous immunogfvlobulin (IVIG), thrombopoietin receptor agonists) or associated with anemia, bone pain, or Monoclonal gammopathy of undetermined significance (MGUS), it is reasonable to go for bone marrow biopsy to rule out malignancy before testing for Gaucher disease using enzymatic assay. Ancillary factors that should raise suspicion of Gaucher disease are gammopathies, bone pain, and hyperferritinemia. [Figure 1] illustrates the proposed algorithm for the diagnosis of adults with Gaucher disease.
|Figure 1: Gaucher diagnostic algorithm for adults in Saudi Arabia. MGUS = Monoclonal gammopathy of unknown significance|
Click here to view
We discussed the cutoff value for the diagnosis of thrombocytopenia in the Saudi population. In the absence of locally validated platelet number for normal margins, we opted to consider if a platelet count of <150 × 109/L is enough to trigger testing for Gaucher disease.
Finding underlying mutations in patients with GD is important for:
- Genetic consulting
- Genotype/phenotype correlation, e.g., the N370S mutation which protects against neuronopathic GD, the D409H homozygosity that is associated with fetal cardiac disease.
Gaucher disease diagnostic algorithms in pediatric age groups
In the pediatric population, the panel especially pediatric hematologists reached a consensus agreement recommending a thorough investigation of splenomegaly causes, especially if it is of massive size before bone marrow biopsy. For that reason, they advise serology testing for infective pathway and/or peripheral blood film to see if there are abnormalities in other cell lines apart from thrombocytopenia. The patient journey for the pediatric age group is different from adults, and the parents are seeking medical help for other reasons such as intercurrent infections. Splenomegaly and thrombocytopenia are alarming signs for the general pediatrician that he or she will refer the patient to a pediatric hematologist or pediatric gastroenterologists. Hence, the general pediatrician plays a very important role in suspecting such cases and disease awareness; Continuous medical education (CME) will increase the screening as early as possible. Considering the presenting picture on referral, i.e., the presence of enlarged spleen +/− hepatomegaly associated with thrombocytopenia +/− anemia, the pediatric hematologist should not delay the bone marrow biopsy to rule out malignancy early and investigate the patient in a parallel approach for Gaucher disease if one or more symptom is present as shown in the algorithm in [Figure 2].
|Figure 2: A diagnostic algorithm draft for early diagnosis in pediatric patients in Saudi Arabia|
Click here to view
The main objective for the parallel approach is mainly as many patients are coming from rural areas and it would be a huge financial and effort burden to bring them multiple times. This is a cost- and time-saving approach and will help more patients to reach a diagnosis in a timely manner.
Gaucher disease: Short- and long-term management goals
- In the adult population, since splenomegaly is a fundamental sign for Gaucher disease diagnosis, which might overlap with liver cirrhosis, sickle cell disease and thalassemia, we recommend that portal hypertension, and hemoglobinopathies should be rolled out as an initial step in adults..
Risk assessments parameters for adults and children with Gaucher disease in Saudi Arabia
The advisors reviewed and agreed to adopt the risk assessment and treatment stratification as proposed by the ICGG with minor modifications as indicated in [Table 2] and [Table 3]:
|Table 2: Risk assessment model for adults with Gaucher disease frequency of assessment and monitoring|
Click here to view
- For pediatric risk assessment to use growth retardation instead of failure
- For adult to specify the judgment of liver and spleen disease using MRI.
Frequency of assessment and monitoring
The authors agreed on the importance of higher frequency of assessment and monitoring, especially for patients not on ERT and those not achieving treatment goals yet [as per the below assessment and monitoring schedule depicted in [Table 4].
|Table 4: Frequency of assessment and monitoring for Gaucher patients in Saudi Arabia|
Click here to view
Monitoring is important to all patients, also those who are treated and stable, for following comorbidities and changes in treatment response.
Usually, ERT is given in hospitals; in case of home therapy, regular follow-up is also important to assess compliance to therapy.
Patients should go through comprehensive regular assessment and monitoring according to the locally modified ICGG recommendations for monitoring of patients with Gaucher disease.
A new approach is available in some institutions which is the virtual clinic – where patients' needs can be handled without the need to travel long distances.
The unmet medical needs for Gaucher disease as identified in Saudi Arabia
Challenges and unmet medical needs are summarized in [Table 5].
|Table 5: Unmet medical needs in the management of Gaucher disease in Saudi Arabia|
Click here to view
Differential diagnosis: Hematologic diseases causing Gaucher disease to be missed in Saudi Arabia
In addition to hematological malignancies that mimic Gaucher disease in certain clinical signs and symptoms, we considered adding sickle cell disease, thalassemia, and refractory ITP; further, we considered that hairy cell leukemia is probably least relevant. Multiple myeloma in the younger age group needs to be checked for Gaucher disease. [Table 6] depicts the similarity of Gaucher disease to a variety of benign and malignant hematological disorders. We recommend considering Gaucher disease as a differential diagnosis when encountered during day-to-day practice.
|Table 6: Differential diagnosis of Gaucher disease,,,,,,,,,,,,,,|
Click here to view
Consequences of diagnostic delay of Gaucher disease in Saudi Arabia
Diagnostic delay might cause complications listed in literatures such as pathological bone fractures, progressive liver disease, chronic bone pain, growth retardation, life threatening bleeding and severe sepsis.
Multiple visits in their journey searching for a definitive diagnosis
Increased recognition and earlier diagnosis may allow the initiation of appropriate treatment that can decrease morbidity, prevent development of irreversible complications, and improve early recognition of Gaucher disease by pediatric physicians since a safe and effective treatment is available.
Management of bone manifestations
We propose the following scheme illustrated in [Figure 3] for the diagnosis and management of bone manifestations.
|Figure 3: Diagnosis and management of bone manifestations in Gaucher disease|
Click here to view
| Discussion|| |
Gaucher disease is underdiagnosed or misdiagnosed. Due to high consanguinity, especially in Saudi Arabia, and high rates of pregnancies, the actual prevalence can be higher than what is reported in the literature. We believe that, according to the global prevalence data, >150 cases are missed and that the current number of diagnosed cases does not reflect the actual prevalence.
Delayed diagnosis is the compelling issue with Gaucher disease in Saudi Arabia, and for that reason, we suggest the following actions:
- Enhance the identification and referral for patients to tertiary care centers
- Improve the patient access through increasing the number of centers of excellence treating Gaucher disease among the Kingdom
- Identify the milestones of clinical presentation that can be used to facilitate adult and pediatric patients' diagnosis
- Genetic consultation is a very important component in the assessment and follow-up of families with Gaucher Disease (GD) and also an important consequence of early diagnosis. Families with a child diagnosed with neuronopathic disease can be suggested pre-natal diagnosis/Preimplantation genetic diagnosis (PGD) before the birth of another child
- Increase disease awareness among internists, general pediatricians, family medicine specialists, and hematologists
- Increase access to enzyme assay by dried blood spot (DBS) test in the office and inpatient department
- DBS can be also used for sequencing of the GBA gene for mutations
- Gene mutation tested could be different from Saudi mutations as some patients are phenotype positive but not confirmed by genotype, and for that patients, there is a need to do gene sequencing
- ERTs are still the current standard treatment for Gaucher disease in Saudi Arabia. ERTs enhance the quality of life and reverse growth retardation. It is safe and well tolerated
- ERTs improve patients' quality of life and help in decreasing the therapeutic cost
- The abstract of this manuscript was published at Blood Journal Volume 134, on November 13, 2019.
- Sanofi Genzyme offered logistical support for the development of this consensus statement.
Financial support and sponsorship
Sanofi Genzyme has provided advisory board honoraria for authors.
Conflicts of interest
Marwan ElBagoury and Omar Hussein are employees of Sanofi Genzyme.
| References|| |
Stirnemann J, Belmatoug N, Camou F, Serratrice C, Froissart R, Caillaud C, et al
. A review of Gaucher disease pathophysiology, clinical presentation and treatments. Int J Mol Sci 2017;18:1-30.
Zak M, Bussel JB. Management of thrombocytopenia. F1000prime reports 2014;6:45. Doi: doi.org/10.12703/P6-45.
Cox TM, Schofield JP. Gaucher's disease: Clinical features and natural history. Baillieres Clin Haematol 1997;10:657-89.
Grabowski GA. Gaucher disease: Gene genotype/phenotype correlations. Genet Test 1982;1:5-12.
Horowitz M, Pasmanik-Chor M, Borochowitz Z, Falik-Zaccai T, Heldmann K, Carmi R, et al
. Prevalence of glucocerebrosidase mutations in the Israeli Ashkenazi Jewish population. Hum Mutat 1998;12:240-4.
Charrow J, Andersson HC, Kaplan P, Kolodny EH, Mistry P, Pastores G, et al
. The Gaucher registry: demographics and disease characteristics of 1698 patients with Gaucher disease. Archives of internal medicine 2000;160:2835-43. https://doi.org/10.1001/archinte.160.18.2835
Weinreb NJ, Charrow J, Andersson HC, Kaplan P, Kolodny EH, Mistry P, et al
. Effectiveness of enzyme replacement therapy in 1028 patients with type 1 Gaucher disease after 2 to 5 years of treatment: A report from the Gaucher Registry. Am J Med 2002;113:112-9.
Weinreb N, Barranger J, Packman S, Prakash-Cheng A, Rosenbloom B, Sims K, et al
. Imiglucerase (Cerezyme®) improves quality of life in patients with skeletal manifestations of Gaucher disease. Clin Genet 2007;71:576-88.
Wenstrup RJ, Kacena KA, Kaplan P, Pastores GM, Prakash-Cheng A, Zimran A, et al
. Effect of enzyme replacement therapy with imiglucerase on BMD in type 1 Gaucher disease. J Bone Miner Res 2007;22:119-26.
Charrow J, Dulisse B, Grabowski GA, Weinreb NJ. The effect of enzyme replacement therapy on bone crisis and bone pain in patients with type 1 Gaucher disease. Clin Genet 2007;71:205-11.
Sims KB, Pastores GM, Weinreb NJ, Barranger J, Rosenbloom BE, Packman S, et al
. Improvement of bone disease by imiglucerase (Cerezyme) therapy in patients with skeletal manifestations of type 1 Gaucher disease: Results of a 48-month longitudinal cohort study. Clin Genet 2008;73:430-40.
Mistry PK, Sadan S, Yang R, Yee J, Yang M. Consequences of diagnostic delays in type 1 Gaucher disease: the need for greater awareness among hematologists-oncologists and an opportunity for early diagnosis and intervention. American Journal of Hematology 2007;82:697-701. DOI: https://doi.org/10.1002/ajh.20908
Mistry PK, Deegan P, Vellodi A, Cole JA, Yeh M, Weinreb NJ. Timing of initiation of enzyme replacement therapy after diagnosis of type 1 Gaucher disease: Effect on incidence of avascular necrosis. Br J Haematol 2009;147:561-70.
Mistry P, Germain DP. Therapeutic goals in Gaucher disease. Rev Med Interne 2006;27 Suppl 1:S30-8.
Hughes D, Cappellini MD, Berger M, Van Droogenbroeck J, de Fost M, Janic D, et al
. Recommendations for the management of the haematological and onco-haematological aspects of Gaucher disease. Br J Haematol 2007;138:676-86.
Mistry PK, Cappellini MD, Lukina E, et al.
Consesnsus Conference: A reappraisal of Gaucher disease diagnosis and disease management algorithms. Am J Hematol 2012;86:110-5. doi:10.1002/ajh.21888. Consensus.
Di Rocco M, Andria G, Deodato F, Giona F, Micalizzi C, Pession A. Early diagnosis of Gaucher disease in pediatric patients: Proposal for a diagnostic algorithm. Pediatr Blood Cancer 2014;61:1905-9.
Biegstraaten M, Cox TM, Belmatoug N, Berger MG, Collin-Histed T, Dahl VS, et al
. Management goals for type 1 Gaucher disease: An expert consensus document from the European working group on Gaucher disease. Blood Cells, Molecules and Diseases 2018;68:203-8. https://doi.org/10.1016/j.bcmd.2016.10.008
Weinreb NJ, Aggio MC, Andersson HC, Andria G, Charrow J, Clarke JT, et al
. International Collaborative Gaucher Group (ICGG). Gaucher disease type 1: revised recommendations on evaluations and monitoring for adult patients. Seminars in Hematology 2004;41(4 Suppl 5):15-22. Doi: https://doi.org/10.1053/j.seminhematol.2004.07.010
Linari S, Castaman G. Clinical manifestations and management of Gaucher disease. Clin Cases Miner Bone Metab 2015;12:157-64.
Faderl S, Talpaz M, Estrov Z, O'Brien S, Kurzrock R, Kantarjian HM. The biology of chronic myeloid leukemia. N
Engl J Med 2002;341:164-72.
Inaba H, Greaves M, Mullighan CG. Acute lymphoblastic leukaemia. Lancet 2013;381:1943-55.
Shankland KR, Armitage JO, Hancock BW. Non-Hodgkin lymphoma. Lancet 2012;380:848-57.
Al-Farsi K. Multiple myeloma: An update. Oman Med J 2013;28:3-11.
McGann PT, Nero AC, Ware RE. Current management of sickle cell anemia. Cold Spring Harb Perspect Med 2013;3:1-17.
Potter M. Wintrobe's clinical hematology, Vol. 1 and 2. G. Lee R, Foerster J, Lukens J, Paraskevas F, Greer JP, Rodgers JP, (Eds). Williams & Wilkins. 1998. Price: ?120.00. ISBN: 0 683 182420. Hematol. Oncol 1999;17:84. doi: 10.1002/(SICI)1099-1069(199906)17:2<84::AID-HON639>3.0.CO;2-J.
Kayal L, Jayachandran S, Singh K. Idiopathic thrombocytopenic purpura. Contemp Clin Dent 2014;5:410-4.
] [Full text]
Thiele J, Kvasnicka HM, Schmitt-Graeff A, Kriener S, Engels K, Staib P, et al
. Effects of the tyrosine kinase inhibitor imatinib mesylate (STI571) on bone marrow features in patients with chronic myelogenous leukemia. Histol Histopathol 2004;19:1277-88.
Stirnemann J, Vigan M, Hamroun D, Heraoui D, Rossi-Semerano L, Berger MG, et al
. The French Gaucher's disease registry: clinical characteristics, complications and treatment of 562 patients. Orphanet Journal of Rare Diseases 2012;7:77. Doi: https://doi.org/10.1186/1750-1172-7-77
Tefferi A. Primary myelofibrosis: 2013 update on diagnosis, risk-stratification, and management. Am J Hematol 2013;88:141-50. doi:10.1002/ajh.23384.
Grabowski GA, Petsko GA, Kolodny EH. Gaucher disease. In: Beaudet AL, Vogelstein B, Kinzler KW, et al
., editors. The Online Metabolic and Molecular Bases of Inherited Disease. New York, NY: The McGraw-Hill Companies, Inc.; 2014. Available from: http://ommbid.mhmedical.com/content.aspx?aid=1102895727
. [Last accessed 2019 Jan 22].
Savage DG, Szydlo RM, Goldman JM. Clinical features at diagnosis in 430 patients with chronic myeloid leukaemia seen at a referral centre over a 16-year period. Br J Haematol 1997;96:111-6.
Sawyers CL. Chronic myeloid leukemia. N
Engl J Med 1999;340:1330-40.
Giuffrida G, Cappellini MD, Carubbi F, Di Rocco M, Iolascon G. Management of bone disease in Gaucher disease type 1: Clinical practice. Adv Ther 2014;31:1197-212.
Serratrice C, Carballo S, Serratrice J, Stirnemann J. Imiglucerase in the management of Gaucher disease type 1: An evidence-based review of its place in therapy. Core Evid 2016;11:37-47.
Alhejazi V, Almomen AK, Tarawah AM, AlSuliman AM, Al SaeeZ HH, et al
. Management Algorithms for Gaucher Disease Type 1 in Saudi Arabia: A Consensus Result from a National Meeting. Blood 2019;134 (Supplement_1): 4864. doi: https://doi.org/10.1182/blood-2019-122822
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]