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Chen L, Ding S, Cheng Y, Zhou L, Yan J, Cheng Q, Jin A, Zhou X, Huang H, Hu Y. Application of thromboelastography to predict the severity of bleeding after chimeric antigen receptor (CAR)-T cell therapy in patients with hematological malignancy. Eur J Haematol 2024; 112:257-265. [PMID: 37698159 DOI: 10.1111/ejh.14099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/25/2023] [Accepted: 08/27/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES We aim to analyze the predictive value of thromboelastography on bleeding severity of patients with chimeric antigen receptor (CAR)-T cell therapy. METHODS A total of 80 patients with refractory/relapsed hematological malignancy were enrolled and divided into two groups: the severe bleeding group and the non-severe bleeding group. The thromboelastography data was collected on the day of CAR-T infusion and the 3rd, 7th, 10th, 13th, 17th, and 20th day after CAR-T cell infusion. RESULTS The patients of the severe bleeding group had lower platelet (p < .007), maximum amplitude (p = .002), coagulation index (p = .005), and longer coagulation time (p = .019). Increasing trend in reaction time and coagulation time and decreasing trend in Alpha, maximum amplitude, and coagulation index on Days 0-10, opposite on Days 10-20. Univariate logistic regression analysis and multivariable logistic regression analysis showed maximum amplitude on the 3rd day after CAR-T cell infusion (MA3) (OR = 0.9; 95% CI = 0.84-0.95; p < .001) and cytokine release syndrome grade (OR = 2.57; 95% CI = 1.35-5.32; p = .006) were significantly associated with high bleeding severity. CONCLUSIONS Thromboelastography was considered to be a good predictor of bleeding severity.
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Affiliation(s)
- Liu Chen
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuyi Ding
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yin Cheng
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Linghui Zhou
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Jiali Yan
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Qiong Cheng
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Aiyun Jin
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoyu Zhou
- Department of Nursing, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - He Huang
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yongxian Hu
- Department of Hematology, Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
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Raso S, Lucchesi A, Sardo M, Annibali O, Sucato V, Ciaccio M, Vitale S, Dolce A, Giordano G, Siragusa S, Napolitano M. Global hemostasis assays in acute myeloid leukemia: results of an observational prospective study. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2024; 22:65-74. [PMID: 37458717 PMCID: PMC10812886 DOI: 10.2450/bloodtransfus.575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/24/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Acute myeloid leukemia (AML) is characterized by a complex spectrum of coagulopathy ranging from hemorrhagic to thrombotic symptoms. To date, platelet count (PLT) and conventional coagulation tests (CCTs) cannot predict hemorrhagic events and thrombotic risk. Thromboelastography (TEG) measures the viscoelastic properties of the clot, thus providing information on the entire process of blood coagulation. The primary aim of the study was to assess the hemostatic balance from AML diagnosis to the end of chemotherapy (CHT) by TEG. MATERIAL AND METHODS Here we present the results of a prospective study enrolling newly diagnosed AML patients treated with chemotherapy. Patients had complete blood counts (CBCs), TEG and CCTs performed at three time points: 1) diagnosis (T0); 2) during the first cycle of CHT (T1); and 3) at the end of CHT (T2). An algorithm of TEG indirectly calculated thrombin generation (TG). Patients underwent daily follow-up for bleeding and thrombotic episodes up to the time of hospital discharge or death. RESULTS Eighty consecutive patients were evaluated; forty were eligible for the study, and 21 completed the entire study. At T1, maximum amplitude (MA), TG and K-time were significantly shifted toward a hypocoagulability state compared to T0 (p<0.05), while a hypercoagulable state at T2 was shown by changes in α-angle, MA and TG values. Otherwise, there were no statistically significant differences in CCTs between the evaluated time points. DISCUSSION Overall, TEG revealed complex and dynamic coagulation abnormalities in patients with AML according to both the course of disease and therapy. Further studies are needed to investigate more fully the role of TEG in defining the hemostatic profile in patients with AML.
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Affiliation(s)
- Simona Raso
- University of Palermo, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), Palermo, Italy
- Department of Hematology and Rare Diseases, V Cervello Hospital, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Alessandro Lucchesi
- Hematology Unit, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Mariano Sardo
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo and Policlinico Paolo Giaccone, Unit of Hematology, Palermo, Italy
| | | | - Vincenzo Sucato
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo and Policlinico Cardiology Unit, Paolo Giaccone, Palermo, Italy
| | - Marcello Ciaccio
- Department and U.O.C. Laboratory Medicine, “Paolo Giaccone” University Hospital, Palermo, Italy
| | - Silvana Vitale
- Department and U.O.C. Laboratory Medicine, “Paolo Giaccone” University Hospital, Palermo, Italy
| | | | - Giulio Giordano
- Division of Internal Medicine, Hematology Service, Regional Hospital “A. Cardarelli”, Campobasso, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo and Policlinico Paolo Giaccone, Unit of Hematology, Palermo, Italy
| | - Mariasanta Napolitano
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo and Policlinico Paolo Giaccone, Unit of Hematology, Palermo, Italy
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Malik M, Al-Ghafry M, Haimed A, Su J, Lema M, Shore-Lessersson L, Acharya SS. Exploration of rotational thromboelastometry (ROTEM) to characterize the coagulation profiles of newly diagnosed pediatric leukemia patients. Thromb Res 2024; 233:109-118. [PMID: 38039723 DOI: 10.1016/j.thromres.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/18/2023] [Accepted: 11/15/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Viscoelastic testing has been used in adult hematologic malignancies in conjunction with conventional coagulation tests (CCTs) to predict coagulopathies and tailor blood product replacement. However, there is a paucity of similar pediatric studies. OBJECTIVES Analyze and correlate leukemia-associated coagulopathy in newly diagnosed pediatric leukemia patients using CCT's and Rotational Thromboelastometry (ROTEM). METHODS Pediatric patients with newly diagnosed acute leukemia underwent testing with ROTEM and CCTs on days 0, 15 and 29 of induction chemotherapy. RESULTS Sixty-two patients were enrolled. At presentation, 54.8 % of patients had platelets <50 K/μL, 73 % had prolonged PT, 1.6 % had fibrinogen <150 mg/dL. Fifteen patients (24.2 %) had WHO grade 1 bleeding and two patients (3 %) had WHO grade 4 bleeding. EXTEM/INTEM values at presentation (day 0) reflected hypocoagulability, however FIBTEM revealed hypercoagulability. Patients showed a progressive hypocoagulability in all ROTEM assays by day 15 (day 0 vs day 15, p < 0.001), with improvement by day 29 (day 15 vs day 29, p < 0.001). Day 0 ROTEM parameters were comparable to day 29. Fibrinogen strongly correlated with ROTEM at all three time points (p < 0.0001), along with platelet count with moderate correlations (p < 0.001). CONCLUSION Fibrinogen and platelets appear to be the drivers of leukemia associated coagulopathy in the pediatric population, suggesting the utility of using CCTs and ROTEM in this population to better evaluate hemostatic function and guide blood product replacement.
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Affiliation(s)
- Marium Malik
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant - Cohen Children's Medical Center, New Hyde Park, New York, United States of America; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America
| | - Maha Al-Ghafry
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant - Cohen Children's Medical Center, New Hyde Park, New York, United States of America; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America
| | - Abraham Haimed
- Department of Pediatrics - Cohen Children's Medical Center, New Hyde Park, New York, United States of America; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America
| | - Julia Su
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America
| | - Maribel Lema
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America
| | - Linda Shore-Lessersson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America; Division of Anesthesiology, North Shore University Hospital, Manhasset, New York, United States of America
| | - Suchitra S Acharya
- Division of Pediatric Hematology, Oncology and Stem Cell Transplant - Cohen Children's Medical Center, New Hyde Park, New York, United States of America; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States of America.
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CREST: clinical bleeding and risk evaluation in hematology-oncology patients: a systematic review and meta-analysis of thromboelastography's role. Blood Coagul Fibrinolysis 2022; 33:351-363. [PMID: 35946467 PMCID: PMC9594149 DOI: 10.1097/mbc.0000000000001141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Thrombocytopenia and bleeding are common complications of hematologic malignancies. Often, prophylactic platelets are administered to minimize bleeding risk, based on total platelet count (TPC). However, TPC is a poor predictor, and does not provide rapid information. This review presents a novel prospective in the use of point-of-care viscoelastic studies to assess bleeding risk and guide transfusion therapy in a haematological oncological population, where its use can be extended to a ward level as a bedside test. Monitoring TEG maximum amplitude trends may be useful to guide transfusion protocols, especially for patients with total platelet counts ranging 30-100 × 10 9 /l. Fibrinogen assessment in this group of patients may identify other blood components that require replacing to reduce bleeding risk. Normal maximum amplitude parameters for patients with low platelet counts can be a reassuring sign. This meta-analysis serves to remind the reader that absolute platelet quantity does not equate to the quality of clot formation.
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Wei YH, Miao ZX, Guo XJ. Thromboelastography in guiding preventive platelet transfusion in patients with haematologic diseases. Int J Lab Hematol 2022; 44:945-951. [PMID: 35748054 DOI: 10.1111/ijlh.13917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/31/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study analysed the relationships between the main thromboelastography (TEG) parameters, the platelet (PLT) count and clinical bleeding in patients with blood diseases. We explored the threshold of the relevant parameters in the pathological condition of bleeding, aiming to scientifically guide clinical prophylactic PLT transfusion. METHODS In total, 268 patients with clear diagnoses of blood diseases and thrombocytopenia were enrolled and divided into five groups, A, B, C, D and E, corresponding to PLT counts of 0-10 × 109 /L, 11-20 × 109 /L, 21-30 × 109 /L, 31-50 × 109 /L and 51-100 × 109 /L, respectively. TEG and routine blood testing were performed simultaneously, the main TEG parameters and the PLT count were analysed, and the thresholds of the main TEG parameters in each group when the patient had bleeding were obtained. RESULTS The maximum amplitude (MA) in groups A, B and C increased gradually, with a significant difference between each pair of these groups (P < 0.05). In groups A, B, C, D and E, the corresponding MA at the time of bleeding was 43.5 mm, 39.6 mm, 38.0 mm, 35.2 mm and 50.5 mm, respectively, with statistically significant differences (P < 0.05). CONCLUSIONS The MA can be used as a reference indicator for preventive PLT transfusion to a certain extent. When the PLT count is within different ranges, the MA threshold for preventive PLT transfusion also differs. It is recommended that different PLT counts be correlated with different MA thresholds to guide clinical prophylactic PLT transfusion.
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Affiliation(s)
- Yan-Hui Wei
- Department of Haematology, Puyang Oilfield General Hospital Affiliated with Xinxiang Medical University, Puyang, China.,School of Medicine, Southeast University, Nanjing, China
| | - Zhao-Xu Miao
- Department of Haematology, Puyang Oilfield General Hospital Affiliated with Xinxiang Medical University, Puyang, China
| | - Xue-Jun Guo
- Department of Haematology, Puyang Oilfield General Hospital Affiliated with Xinxiang Medical University, Puyang, China
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Hambley BC, Tomuleasa C, Ghiaur G. Coagulopathy in Acute Promyelocytic Leukemia: Can We Go Beyond Supportive Care? Front Med (Lausanne) 2021; 8:722614. [PMID: 34485349 PMCID: PMC8415964 DOI: 10.3389/fmed.2021.722614] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 07/26/2021] [Indexed: 11/24/2022] Open
Abstract
Acute promyelocytic leukemia (APL) is characterized by frequent complications due to a distinct coagulopathy. While advances in treatments have improved long-term survival, hemorrhagic and thrombotic complications remain the most common causes of death and morbidity. Improved understanding of the mechanisms of the coagulopathy associated with APL may lead to therapeutic interventions to mitigate the risk of hemorrhage and thrombosis.
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Affiliation(s)
- Bryan C Hambley
- Division of Hematology/Oncology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Ciprian Tomuleasa
- Department of Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Hematology, Ion Chiricuta Clinical Cancer Center, Cluj Napoca, Romania.,Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania
| | - Gabriel Ghiaur
- Medfuture Research Center for Advanced Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, Romania.,Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Mirlashari MR, Vetlesen A, Nissen-Meyer LSH, Naper C, Tjønnfjord GE, Njerve IU, Ezligini F, Landmark BF, Meinke S, Sandgren P, Höglund P, Hetland G. HLA class I depletion by citric acid, and irradiation of apheresis platelets for transfusion of refractory patients. Transfusion 2021; 61:1222-1234. [PMID: 33580979 DOI: 10.1111/trf.16282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 12/07/2020] [Accepted: 12/17/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients can form antibodies to foreign human leukocyte antigen (HLA) Class I antigens after exposure to allogeneic cells. These anti-HLA class I antibodies can bind transfused platelets (PLTs) and mediate their destruction, thus leading to PLT refractoriness. Patients with PLT refractoriness need HLA-matched PLTs, which require expensive HLA typing of donors, antibody analyses of patient sera and/or crossmatching. An alternative approach is to reduce PLT HLA Class I expression using a brief incubation in citric acid on ice at low pH. METHODS AND MATERIALS Apheresis PLT concentrates were depleted of HLA Class I complexes by 5 minutes incubation in ice-cold citric acid, at pH 3.0. Surface expression of HLA Class I complexes, CD62P, CD63, phosphatidylserine, and complement factor C3c was analyzed by flow cytometry. PLT functionality was tested by thromboelastography (TEG). RESULTS Acid treatment reduced the expression of HLA Class I complexes by 71% and potential for C3c binding by 11.5-fold compared to untreated PLTs. Acid-treated PLTs were significantly more activated than untreated PLTs, but irrespective of this increase in steady-state activation, CD62P and CD63 were strongly upregulated on both acid-treated and untreated PLTs after stimulation with thrombin receptor agonist peptide. Acid treatment did not induce apoptosis over time. X-ray irradiation did not significantly influence the expression of HLA Class I complexes, CD62P, CD63, and TEG variables on acid treated PLTs. CONCLUSION The relatively simple acid stripping method can be used with irradiated apheresis PLTs and may prevent transfusion-associated HLA sensitization and overcome PLT refractoriness.
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Affiliation(s)
| | - Annette Vetlesen
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Christian Naper
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | - Geir Erland Tjønnfjord
- Department of Hematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ida Unhammer Njerve
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | - Farshid Ezligini
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Stephan Meinke
- Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden.,Function Area Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Per Sandgren
- Function Area Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Petter Höglund
- Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden.,Function Area Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Geir Hetland
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Abstract
Transfusion medicine can be a lifesaving intervention. Component therapy has expanded the availability and blood products available. Patient safety and minimizing risk is important and can be accomplished through proper donor screening, collection, storage, compatibility testing, administration, and monitoring. The pros and cons of available products must be considered and tailored to each individual patient. Recent discoveries include new antigens and blood types, microbial effects on blood type, and the association between blood type and disease prevalence.
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Affiliation(s)
- Kendon W Kuo
- Emergency and Critical Care, Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, 1220 Wire Road, Auburn, AL 36849-5540, USA
| | - Maureen McMichael
- Emergency and Critical Care, Department of Clinical Sciences, College of Veterinary Medicine, Auburn University, 1220 Wire Road, Auburn, AL 36849-5540, USA.
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