Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-8448b6f56d-qsmjn Total loading time: 0 Render date: 2024-04-19T22:33:26.901Z Has data issue: false hasContentIssue false

18 - Iron overload in Native Africans and African-Americans

Published online by Cambridge University Press:  01 June 2011

James C. Barton ,
Corwin Q. Edwards ,
Pradyumna D. Phatak ,
Robert S. Britton  and
Bruce R. Bacon
By
James C. Barton ,
Corwin Q. Edwards ,
Pradyumna D. Phatak ,
Robert S. Britton  and
Bruce R. Bacon
James C. Barton
Affiliation:
University of Alabama, Birmingham
Corwin Q. Edwards
Affiliation:
University of Utah Medical Center
Pradyumna D. Phatak
Affiliation:
University of Rochester Medical Center, New York
Robert S. Britton
Affiliation:
St Louis University, Missouri
Bruce R. Bacon
Affiliation:
St Louis University, Missouri
James C. Barton
Affiliation:
University of Alabama, Birmingham
Corwin Q. Edwards
Affiliation:
University of Utah School of Medicine, Salt Lake City
Pradyumna D. Phatak
Affiliation:
University of Rochester Medical Center, New York
Robert S. Britton
Affiliation:
St Louis University, Missouri
Bruce R. Bacon
Affiliation:
St Louis University, Missouri
Get access

Summary

African iron overload

African iron overload occurs in 14%–18% of Bantu-speaking Natives in at least 15 countries in sub-Saharan Africa. This type of non-transfusion iron overload is due primarily to the ingestion of large quantities of iron contained in traditional beer, although unconfirmed evidence suggests that there is an African iron overload gene (Table 18.1).

History

Iron overload in native sub-Saharan Africans was first described by Strachan in his 1929 thesis on tuberculosis. The disorder was originally attributed to infections, to poisoning due to copper, tin, or zinc, or to malnutrition. In 1953, it was hypothesized that the intake of excessive quantities of iron leached from iron vessels used for food preparation could account for “Bantu siderosis.” In 1992, the etiology of African iron overload as a purely dietary disorder was contested with the demonstration that heritable factors may influence the development of this condition.

Clinical description

Patients with early iron overload identified during family or other group testing have no symptoms or signs attributable to iron overload. Symptoms usually do not occur until iron overload is severe; they may develop by late adolescence. Iron overload is progressive in most patients. Weakness and fatigue, abdominal discomfort or pain, or low back or hip pain are common presenting complaints. Iron overload occurs with greater frequency and severity among men than in women. Physical examination in subjects with severe iron overload may reveal hyperpigmentation, hepatomegaly, kyphosis, or femoral neck fracture.

Type
Chapter
Information
Handbook of Iron Overload Disorders , pp. 211 - 221
Publisher: Cambridge University Press
Print publication year: 2010

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Strachan, AS. Haemosiderosis and haemochromatosis in South African natives with a comment on the etiology of haemochromatosis. MD thesis. University of Glasgow, 1929.
Sheldon, JH.Haemochromatosis. Oxford, Oxford University Press, 1935.Google Scholar
Walker, ARP, Arvidsson, UB.Iron “overload” in the South African Bantu. Trans Royal Soc Trop Med Hyg 1964; 47: 1964.Google Scholar
Gordeuk, V, Mukiibi, J, Hasstedt, SJ, et al. Iron overload in Africa. Interaction between a gene and dietary iron content. N Engl J Med 1992; 326: 95–100.CrossRefGoogle ScholarPubMed
Pippard, MJ.Secondary iron overload. In: Brock, JH, Halliday, JW, Pippard, MJ, Powell, LW, eds. Iron Metabolism in Health and Disease. London, WB Saunders Company Ltd. 1994; 271–310.Google Scholar
Bothwell, TH, Charlton, RW, Cook, JD, Finch, CA.Alcohol, iron and liver disease. In: Bothwell, TH, Charlton, RW, Cook, JD, Finch, CA, eds. Iron Metabolism in Man. Oxford, Oxford University Press. 1979; 1564.Google Scholar
Bothwell, TH, Isaacson, C.Siderosis in the Bantu. A comparison of incidence in males and females. Br Med J 1962; 1: 522–4.CrossRefGoogle ScholarPubMed
Moyo, VM, Makunike, R, Gangaidzo, IT, et al. African iron overload and hepatocellular carcinoma (HA-7–0–080). Eur J Haematol 1998; 60: 28–34.CrossRefGoogle Scholar
Moyo, VM, Gangaidzo, IT, Gomo, ZA, et al. Traditional beer consumption and the iron status of spouse pairs from a rural community in Zimbabwe. Blood 1997; 89: 2159–66.Google ScholarPubMed
Moyo, VM, Mandishona, E, Hasstedt, SJ, et al. Evidence of genetic transmission in African iron overload. Blood 1998; 91: 1076–82.Google ScholarPubMed
Kasvosve, I, Delanghe, JR, Gomo, ZA, et al. Transferrin polymorphism influences iron status in blacks. Clin Chem 2000; 46: 1535–9.Google ScholarPubMed
McNamara, L, MacPhail, AP, Gordeuk, VR, Hasstedt, SJ, Rouault, T.Is there a link between African iron overload and the described mutations of the hereditary haemochromatosis gene?Br J Haematol 1998; 102: 1176–8.CrossRefGoogle Scholar
Roth, M, Giraldo, P, Hariti, G, et al. Absence of the hemochromatosis gene Cys282Tyr mutation in three ethnic groups from Algeria (Mzab), Ethiopia, and Senegal. Immunogenetics 1997; 46: 222.CrossRefGoogle Scholar
Gangaidzo, IT, Moyo, VM, Saungweme, T, et al. Iron overload in urban Africans in the 1990s. Gut 1999; 45: 278–83.CrossRefGoogle ScholarPubMed
Jeffery, S, Crosby, A, Plange-Rhule, J, et al. Evidence from a Ghanaian population of known African descent to support the proposition that hemochromatosis is a Caucasian disorder. Genet Test 1999; 3: 375.CrossRefGoogle ScholarPubMed
Barton, JC, Acton, RT, Rivers, CA, et al. Genotypic and phenotypic heterogeneity of African-Americans with primary iron overload. Blood Cells Mol Dis 2003; 31: 310–19.CrossRefGoogle ScholarPubMed
Beutler, E, Barton, JC, Felitti, VJ, et al. Ferroportin 1 (SCL40A1) variant associated with iron overload in African-Americans. Blood Cells Mol Dis 2003; 31: 305–9.CrossRefGoogle ScholarPubMed
Rivers, CA, Barton, JC, Gordeuk, VR, et al. Association of ferroportin Q248H polymorphism with elevated levels of serum ferritin in African-Americans in the Hemochromatosis and Iron Overload Screening (HEIRS) Study. Blood Cells Mol Dis 2007; 38: 2472.CrossRefGoogle ScholarPubMed
Gordeuk, VR, Caleffi, A, Corradini, E, et al. Iron overload in Africans and African-Americans and a common mutation in the SCL40A1 (ferroportin 1) gene. Blood Cells Mol Dis 2003; 31: 299–304.CrossRefGoogle Scholar
Barton, JC, Acton, RT, Lee, PL, West, C.SLC40A1 Q248H allele frequencies and Q248H-associated risk of non-HFE iron overload in persons of sub-Saharan African descent. Blood Cells Mol Dis 2007; 39: 206–11.CrossRefGoogle ScholarPubMed
Bothwell, TH, Seftel, H, Jacobs, P, Torrance, JD, Baumslag, N.Iron overload in Bantu subjects; studies on the availability of iron in Bantu beer. Am J Clin Nutr 1964; 14: 471.CrossRefGoogle ScholarPubMed
Gordeuk, VR, Boyd, RD, Brittenham, GM.Dietary iron overload persists in rural sub-Saharan Africa. Lancet 1986; 1: 1310–13.CrossRefGoogle ScholarPubMed
Mandishona, EM, Moyo, VM, Gordeuk, VR, et al. A traditional beverage prevents iron deficiency in African women of childbearing age. Eur J Clin Nutr 1999; 53: 722.CrossRefGoogle Scholar
MacPhail, AP, Mandishona, EM, Bloom, PD, Paterson, AC, Rouault, TA, Gordeuk, VR.Measurements of iron status and survival in African iron overload. S Afr Med J 1999; 89: 9662.Google ScholarPubMed
Bothwell, TH, Bradlow, BA.Siderosis in the Bantu. A combined histopathological and chemical study. Arch Pathol 1960; 70: 279–92.Google ScholarPubMed
Isaacson, C, Seftel, HC, Keeley, KJ, Bothwell, TH.Siderosis in the Bantu: the relationship between iron overload and cirrhosis. J Lab Clin Med 1961; 58: 8453.Google Scholar
Seftel, HC, Malkin, C, Schmaman, A, et al. Osteoporosis, scurvy, and siderosis in Johannesburg bantu. Br Med J 1966; 1: 642–6.CrossRefGoogle ScholarPubMed
Lynch, SR, Berelowitz, I, Seftel, HC, et al. Osteoporosis in Johannesburg Bantu males. Its relationship to siderosis and ascorbic acid deficiency. Am J Clin Nutr 1967; 20: 799–807.CrossRefGoogle ScholarPubMed
Wapnick, AA, Lynch, SR, Seftel, HC, Charlton, RW, Bothwell, TH, Jowsey, J.The effect of siderosis and ascorbic acid depletion on bone metabolism, with special reference to osteoporosis in the Bantu. Br J Nutr 1971; 25: 3676.CrossRefGoogle Scholar
Schnaid, E, MacPhail, AP, Sweet, MB.Fractured neck of femur in black patients: a prospective study. J Bone Joint Surg Br 2000; 82: 872.CrossRefGoogle ScholarPubMed
Gordeuk, VR, McLaren, CE, MacPhail, AP, Deichsel, G, Bothwell, TH.Associations of iron overload in Africa with hepatocellular carcinoma and tuberculosis: Strachan's 1929 thesis revisited. Blood 1996; 87: 3470–6.Google ScholarPubMed
MacPhail, AP, Simon, MO, Torrance, JD, Charlton, RW, Bothwell, TH, Isaacson, C.Changing patterns of dietary iron overload in black South Africans. Am J Clin Nutr 1979; 32: 1272–8.CrossRefGoogle ScholarPubMed
Bloom, PD, Burstein, GR, Gordeuk, VR.Iron overload in African-Americans. In: Barton, JC, Edwards, CQ, eds. Hemochromatosis: Genetics, Pathophysiology, Diagnosis and Treatment. Cambridge, Cambridge University Press. 2000; 475–83.CrossRefGoogle Scholar
Friedman, BM, Baynes, RD, Bothwell, TH, et al. Dietary iron overload in southern African rural blacks. S Afr Med J 1990; 78: 301.Google ScholarPubMed
Walker, AR, Segal, I.Iron overload in sub-Saharan Africa: to what extent is it a public health problem?Br J Nutr 1999; 81: 427–34.Google ScholarPubMed
Speight, AN, Cliff, J.Iron storage disease of the liver in Dar es Salaam: a preliminary report on venesection therapy. East Afr Med J 1974; 51: 895–902.Google Scholar
Cliff, JL, Speight, AN.Venesection therapy in haemosiderosis. East Afr Med J 1976; 53: 287–91.Google ScholarPubMed
Krainin, P, Kahn, BS.Hemochromatosis: report of a case in a Negro; discussion of iron metabolism. Ann Intern Med 1950; 33: 462.Google Scholar
Prasad, AS, Tranchida, L, Konno, ET, et al. Hereditary sideroblastic anemia and glucose-6-phosphate dehydrogenase deficiency in a Negro family. J Clin Invest 1968; 47: 1415–24.CrossRefGoogle Scholar
Barton, JC, Edwards, CQ, Bertoli, LF, Shroyer, TW, Hudson, SL.Iron overload in African-Americans. Am J Med 1995; 99: 616–23.CrossRefGoogle ScholarPubMed
Wurapa, RK, Gordeuk, VR, Brittenham, GM, Khiyami, A, Schechter, GP, Edwards, CQ.Primary iron overload in African-Americans. Am J Med 1996; 101: 9–18.CrossRefGoogle ScholarPubMed
Monaghan, KG, Rybicki, BA, Shurafa, M, Feldman, GL.Mutation analysis of the HFE gene associated with hereditary hemochromatosis in African-Americans. Am J Hematol 1998; 58: 213–17.3.0.CO;2-U>CrossRefGoogle ScholarPubMed
Barton, JC, Acton, RT.Inheritance of two HFE mutations in African-Americans: cases with hemochromatosis phenotypes and estimates of hemochromatosis phenotype frequency. Genet Med 2001; 3: 294–300.CrossRefGoogle ScholarPubMed
Rosner, IA, Askari, AD, McLaren, GD, Muir, A.Arthropathy, hypouricemia and normal serum iron studies in hereditary hemochromatosis. Am J Med 1981; 70: 870–4.CrossRefGoogle ScholarPubMed
Conrad, ME.Sickle cell disease and hemochromatosis. Am J Hematol 1991; 38: 150–2.CrossRefGoogle ScholarPubMed
Acton, RT, Barton, JC, Snively, BM, et al. Geographic and racial/ethnic differences in HFE mutation frequencies in the Hemochromatosis and Iron Overload Screening (HEIRS) Study. Ethn Dis 2006; 16: 815–21.Google ScholarPubMed
Adams, PC, Reboussin, DM, Leiendecker-Foster, C, et al. Comparison of the unsaturated iron-binding capacity with transferrin saturation as a screening test to detect C282Y homozygotes for hemochromatosis in 101 168 participants in the Hemochromatosis and Iron Overload Screening (HEIRS) Study. Clin Chem 2005; 51: 10482.CrossRefGoogle ScholarPubMed
Beutler, E, Felitti, V, Gelbart, T, Ho, N.The effect of HFE genotypes on measurements of iron overload in patients attending a health appraisal clinic. Ann Intern Med 2000; 133: 329–37.CrossRefGoogle ScholarPubMed
Barton, JC, Acton, RT, Dawkins, FW, et al. Initial screening transferrin saturation values, serum ferritin concentrations, and HFE genotypes in whites and blacks in the Hemochromatosis and Iron Overload Screening Study. Genet Test 2005; 9: 231–41.CrossRefGoogle ScholarPubMed
Lee, PL, Gelbart, T, West, C, Halloran, C, Felitti, V, Beutler, E.A study of genes that may modulate the expression of hereditary hemochromatosis: transferrin receptor-1, ferroportin, ceruloplasmin, ferritin light and heavy chains, iron regulatory proteins (IRP)-1 and -2, and hepcidin. Blood Cells Mol Dis 2001; 27: 783–802.CrossRefGoogle ScholarPubMed
Murugan, RC, Lee, PL, Kalavar, MR, Barton, JC.Early age-of-onset iron overload and homozygosity for the novel hemojuvelin mutation HJV R54X (exon 3; c.160>T) in an African-American male of West Indies descent. Clin Genet 2008; 74: 88–92.CrossRefGoogle Scholar
Lee, PL, Barton, JC, Brandhagen, D, Beutler, E.Hemojuvelin (HJV) mutations in persons of European, African-American and Asian ancestry with adult onset haemochromatosis. Br J Haematol 2004; 127: 224–9.CrossRefGoogle ScholarPubMed
Barton, JC, Rivers, CA, Niyongere, S, Bohannon, SB, Acton, RT.Allele frequencies of hemojuvelin gene (HJV) I222N and G320V missense mutations in white and African-American subjects from the general Alabama population. BMC Med Genet 2004; 5: 29.CrossRefGoogle ScholarPubMed
Barton, JC, Acton, RT, Leiendecker-Foster, C, et al. HFE C282Y homozygotes aged 25–29 years at HEIRS Study initial screening. Genet Test 2007; 11: 2695.CrossRefGoogle ScholarPubMed
Lee, PL, Halloran, C, West, C, Beutler, E.Mutation analysis of the transferrin receptor-2 gene in patients with iron overload. Blood Cells Mol Dis 2001; 27: 285–9.CrossRefGoogle ScholarPubMed
Barton, EH, West, PA, Rivers, CA, Barton, JC, Acton, RT.Transferrin receptor-2 (TFR2) mutation Y250X in Alabama Caucasian and African-American subjects with and without primary iron overload. Blood Cells Mol Dis 2001; 27: 279–84.CrossRefGoogle ScholarPubMed
Zaahl, MG, Merryweather-Clarke, AT, Kotze, MJ, , MS, Warnich, L, Robson, KJ.Analysis of genes implicated in iron regulation in individuals presenting with primary iron overload. Hum Genet 2004; 115: 409–17.CrossRefGoogle ScholarPubMed
Barton, JC, Rothenberg, BE, Bertoli, LF, Acton, RT.Diagnosis of hemochromatosis in family members of probands: a comparison of phenotyping and HFE genotyping. Genet Med 1999; 1: 89–93.CrossRefGoogle ScholarPubMed
Barton, JC, Lee, PL, Bertoli, LF, Beutler, E.Iron overload in an African-American woman with SS hemoglobinopathy and a promoter mutation in the X-linked erythroid-specific 5-aminolevulinate synthase (ALAS2) gene. Blood Cells Mol Dis 2005; 34: 226–8.CrossRefGoogle Scholar
Castro, O, Hasan, O, Kaur, K, Loyevsky, M, Gordeuk, V.Hemochromatosis in non-transfused African-American patient with sickle cell anemia. Blood 1998; 92 (suppl): 13b.Google Scholar
Collins, TS, Arcasoy, MO.Iron overload due to X-linked sideroblastic anemia in an African-American man. Am J Med 2004; 116: 501–2.CrossRefGoogle Scholar
Gordeuk, VR.African iron overload. Semin Hematol 2002; 39: 263–9.CrossRefGoogle ScholarPubMed
Duane, P, Raja, KB, Simpson, RJ, Peters, TJ.Intestinal iron absorption in chronic alcoholics. Alcohol Alcohol 1992; 27: 539–44.Google ScholarPubMed
Willner, IR, Reuben, A.Alcohol and the liver. Curr Opin Gastroenterol 2005; 21: 323–30.Google ScholarPubMed
Fletcher, LM, Powell, LW.Hemochromatosis and alcoholic liver disease. Alcohol 2003; 30: 131–6.CrossRefGoogle ScholarPubMed
Barton, JC, Acton, RT, Richardson, AK, Brissie, RM.Stainable hepatic iron in 341 African-American adults at coroner/medical examiner autopsy. BMC Clin Pathol 2005; 5: 2.CrossRefGoogle ScholarPubMed
Alter, MJ, Kruszon-Moran, D, Nainan, OV, et al. The prevalence of hepatitis C virus infection in the United States, 1988 through 1994. N Engl J Med 1999; 341: 556–62.CrossRefGoogle ScholarPubMed
Howell, C, Jeffers, L, Hoofnagle, JH.Hepatitis C in African-Americans: summary of a workshop. Gastroenterology 2000; 119: 1385–96.CrossRefGoogle ScholarPubMed
Ioannou, GN, Dominitz, JA, Weiss, NS, Heagerty, PJ, Kowdley, KV.Racial differences in the relationship between hepatitis C infection and iron stores. Hepatology 2003; 37: 795–801.CrossRefGoogle ScholarPubMed
Falck-Ytter, Y, Younossi, ZM, Marchesini, G, McCullough, AJ.Clinical features and natural history of non-alcoholic steatosis syndromes. Semin Liver Dis 2001; 21: 17–26.CrossRefGoogle Scholar
Caldwell, SH, Harris, DM, Patrie, JT, Hespenheide, EE.Is NASH underdiagnosed among African-Americans?Am J Gastroenterol 2002; 97: 149600.CrossRefGoogle ScholarPubMed
Mokdad, AH, Ford, ES, Bowman, BA, et al. Prevalence of obesity, diabetes, and obesity-related health risk factors, 2001. JAMA 2003; 289: 76–9.CrossRefGoogle ScholarPubMed
Schafer, AI, Cheron, RG, Dluhy, R, et al. Clinical consequences of acquired transfusional iron overload in adults. N Engl J Med 1981; 304: 319–24.CrossRefGoogle ScholarPubMed
Brown, KE, Khan, CM, Zimmerman, MB, Brunt, EM.Hepatic iron overload in blacks and whites: a comparative autopsy study. Am J Gastroenterol 2003; 98: 1594–8.CrossRefGoogle ScholarPubMed
Cotler, SJ, Bronner, MP, Press, RD, et al. End-stage liver disease without hemochromatosis associated with elevated hepatic iron index. J Hepatol 1998; 29: 257–62.CrossRefGoogle ScholarPubMed
Ludwig, J, Hashimoto, E, Porayko, MK, Moyer, TP, Baldus, WP.Hemosiderosis in cirrhosis: a study of 447 native livers. Gastroenterology 1997; 112: 882–8.CrossRefGoogle ScholarPubMed
Strasser, SI, Kowdley, KV, Sale, GE, McDonald, GB.Iron overload in bone marrow transplant recipients. Bone Marrow Transplant 1998; 22: 1673.CrossRefGoogle ScholarPubMed
Pietrangelo, A.Non-invasive assessment of hepatic iron overload: are we finally there?J Hepatol 2005; 42: 153–4.CrossRefGoogle Scholar
Dawkins, FW, Gordeuk, VR, Snively, BM, et al. African-Americans at risk for increased iron stores or liver disease. Am J Med 2007; 120: 734–9.CrossRefGoogle ScholarPubMed
Barton, JC, Alford, TJ, Bertoli, LF, Barton, NH, Edwards, CQ.Histochemically demonstrable hepatic iron excess in African-Americans [abstract]. Blood 1995; 86: 128a.Google Scholar
Phatak, PD, Sham, RL, Raubertas, RF, et al. Prevalence of hereditary hemochromatosis in 16,031 primary care patients. Ann Intern Med 1998; 129: 954–61.CrossRefGoogle Scholar
Adams, PC, Reboussin, DM, Barton, JC, et al. Hemochromatosis and iron-overload screening in a racially diverse population. N Engl J Med 2005; 352: 17698.CrossRefGoogle Scholar
Yang, Q, McDonnell, SM, Khoury, MJ, Cono, J, Parrish, RG.Hemochromatosis-associated mortality in the United States from 1979 to 1992: an analysis of Multiple-Cause Mortality Data. Ann Intern Med 1998; 129: 9463.CrossRefGoogle ScholarPubMed
Barton, JC, Acton, RT, Anderson, , Alexander, CB.A comparison between whites and blacks with severe multi-organ iron overload identified in 16 152 autopsies. Clin Gastroenterol Hepatol 2009; 7: 781.e2.CrossRefGoogle ScholarPubMed
Bassett, ML.Iron and hepatitis C: beginning to make sense. J Gastroenterol Hepatol 2007; 22: 1703–4.CrossRefGoogle ScholarPubMed
Desai, TK, Jamil, LH, Balasubramaniam, M, Koff, R, Bonkovsky, HL.Phlebotomy improves therapeutic response to interferon in patients with chronic hepatitis C: a meta-analysis of six prospective randomized controlled trials. Dig Dis Sci 2008; 53: 815–22.CrossRefGoogle ScholarPubMed
Barton, JC, McDonnell, SM, Adams, PC, et al. Management of hemochromatosis. Hemochromatosis Management Working Group. Ann Intern Med 1998; 129: 932–9.CrossRefGoogle ScholarPubMed
Gordeuk, VR, McLaren, CE, Looker, AC, Hasselblad, V, Brittenham, GM.Distribution of transferrin saturations in the African-American population. Blood 1998; 91: 2175–9.Google ScholarPubMed
Schnitzler, CM, MacPhail, AP, Shires, R, Schnaid, E, Mesquita, JM, Robson, HJ.Osteoporosis in African hemosiderosis: role of alcohol and iron. J Bone Miner Res 1994; 9: 18653.CrossRefGoogle ScholarPubMed

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×