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Kamfar S, Haghi S, Zeinali V, Tavana PM, Arjmand R, Malek F. The first national pediatric immune thrombocytopenia registry in Iran: research protocol and preliminary study results. BMC Health Serv Res 2024; 24:675. [PMID: 38807135 PMCID: PMC11134961 DOI: 10.1186/s12913-024-11102-z] [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: 09/17/2023] [Accepted: 05/10/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Disease registries are comprehensive databases that record detailed information on patients diagnosed with specific conditions, providing valuable insights into their diagnosis, treatment, and outcomes. This study aims to describe the pilot phase of the national pediatric Immune Thrombocytopenia(ITP) registry (NPITP) in Iran, serving as the inaugural interpretive report. METHODS This patient-centered software system was implemented as a national program across multiple pediatric centers in Iran. Several focus groups were conducted to establish a minimum data set (MDS) comprising six main classes, 14 sub-classes, and 187 data elements. Following expert consensus on the final data set, a web-based software tool was developed by the dedicated IT team, accessible online and offline via https://disreg.sbmu.ac.ir/q/ITP.html . The registry included children aged between two months and 18 years with a platelet count below 100 × 109/L, based on predefined inclusion criteria. RESULTS Within a four-month period, a total of 60 ITP patients were registered, including 41 (68.3%) newly diagnosed cases, 68 (13.6%) persistent cases, and 14 (23.3%) with chronic ITP. The mean age of the registered patients was 55.93 ± 9.72 months. The most frequently observed bleeding symptoms were petechiae (68.3%), purpura (51.6%), and ecchymosis (13.3%). Among the newly diagnosed patients, 20 (33.3%) received intravenous immunoglobulin (IVIG), 17 (28.3%) were treated with prednisolone, and 17 (28.3%) received combined IVIG and steroid therapy. Of all patients, 40 (66.7%) demonstrated a complete response to treatment, while 16 (26.7%) exhibited a partial response. Four patients (6.7%) remained unresponsive to therapy. Treatment-related complications, such as Cushing's syndrome, edema, weight gain, hirsutism, and mood disorders, were reported in 10 patients (16.6%). However, the majority of patients (81.7%) did not experience therapy-related complications. CONCLUSION The pilot phase of the NPITP registry successfully implemented a web-based software tool for data collection, aiming to enhance the quality of care, facilitate clinical research, and support health service planning in the future.
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Affiliation(s)
- Sharareh Kamfar
- Pediatric Congenital Hematologic Disorders Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sabahat Haghi
- Department of Hematology and Oncology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Vahide Zeinali
- Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Parastoo Molaei Tavana
- Department of pediatrics, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Arjmand
- Department of Pediatrics, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | - Fatemeh Malek
- Pediatric Congenital Hematologic Disorders Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Beyene DA, Sisay EA, Fentie AM, Gebremedhin A. Treatment outcomes and adherence to treatment in patients with immune thrombocytopenia in two Ethiopian teaching hospitals: a retrospective cohort study. Sci Rep 2024; 14:11917. [PMID: 38789461 PMCID: PMC11126412 DOI: 10.1038/s41598-024-62372-w] [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: 11/26/2023] [Accepted: 05/16/2024] [Indexed: 05/26/2024] Open
Abstract
The treatment of immune thrombocytopenia (ITP) is challenging and treatment outcomes depend on numerous unknown and patient-specific factors. Corticosteroids are the cornerstone of ITP treatment, but they are associated with many side effects. In this retrospective cohort study, treatment outcomes and treatment adherence in patients with ITP were investigated in 214 ITP patients from November 15, 2022 to March 15, 2023. Multinomial regression analysis models were used to identify predictive factors for treatment outcomes. A p value of less than 0.05 was considered statistically significant. Most study participants were female 161 (75.5%), and the majority 172 (80.4%) of them were taking prednisolone only. In terms of treatment adherence, 178 (83.2%) of the study participants adhered well to their ITP medications. The complete response rate at 3 months was 139 (65.0%). Predictive factors for partial response were increased negative impact of ITP on health-related quality of life (AOR = 1.221, 95% CI 1.096-1.360), being treated at Tikur Abessa Sepcialazed Hospital (AOR = 0.431, 95% CI 0.197-0.941) and the presence of heavy menstrual bleeding (AOR = 2.255, 95% CI 0.925-5.497) compared to patients with complete response. Hepatitis B virus-infected ITP patients (AOR = 0.052, 95% CI 0.004-0.621) were also a predictive factor for no response compared to complete response.
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Affiliation(s)
- Dessale Abate Beyene
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Tikur Anbessa Specialized Hospital, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Eskinder Ayalew Sisay
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Tikur Anbessa Specialized Hospital, Addis Ababa University, Addis Ababa, Ethiopia
| | - Atalay Mulu Fentie
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Tikur Anbessa Specialized Hospital, Addis Ababa University, Addis Ababa, Ethiopia
| | - Amha Gebremedhin
- School of Medicine, College of Health Sciences, Tikur Anbessa Specialized Hospital, Addis Ababa University, Addis Ababa, Ethiopia
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Aiello A, Mariano EE, Prada M, Teruzzi C, Martone N, Capri S, Carli G, Siragusa S. Budget impact analysis for avatrombopag in the treatment of chronic primary immune thrombocytopenia in adult patients refractory to other treatments. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2023; 11:2230663. [PMID: 37405228 PMCID: PMC10316730 DOI: 10.1080/20016689.2023.2230663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/31/2023] [Accepted: 06/23/2023] [Indexed: 07/06/2023]
Abstract
Introduction: Primary immune thrombocytopenia is a rare autoimmune disease characterised by a decreased platelet count resulting in an increased risk of bleeding events and even life-threatening haemorrhages. Thrombopoietin receptor agonists (TPO-RAs) are the standard of care second-line therapy for adult patients with chronic immune thrombocytopenia. The first TPO-RAs approved and reimbursed in Italy, eltrombopag and romiplostim, while effective, pose some issues in terms of safety (e.g., hepatotoxicity) or general management (e.g., dietary restrictions). Avatrombopag, an effective and well-tolerated TPO-RA, was recently granted reimbursement. Methods: A 3-year (2023-2025) budget impact analysis (BIA) was conducted to estimate its impact on the Italian National Health Service (NHS). Two scenarios were compared, of which one represents the current situation, without avatrombopag, and the other provides for an increasing market share of avatrombopag (up to 26.6%). Results: BIA shows that the increase in the use of avatrombopag correlates with savings for NHS: in the first year, saving would be €1,300,564, increasing to €2,774,210 in the third year, for a total of €6,083,231 over the 3-year period. The sensitivity analysis confirmed these savings in the scenario with avatrombopag. Conclusions: Based on this BIA, the introduction and reimbursement of avatrombopag is an efficient and advantageous choice for the Italian NHS.
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Affiliation(s)
| | | | | | | | | | - Stefano Capri
- School of Economics and Management, LIUC University, Castellanza, Italy
| | - Giuseppe Carli
- Department of Haematology, “S. Bortolo” Hospital, Vicenza, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMise), University of Palermo, Palermo, Italy
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Torere BE, Aiwuyo HO, Weigold J, Gerlach G, Ilerhunmwuwa N, Khan U, Belousova T. The Roles and Challenges of Advanced Therapies in the Management of Refractory Immune Thrombocytopenia: A Case Report and Review of the Literature. Cureus 2023; 15:e36146. [PMID: 37065402 PMCID: PMC10101511 DOI: 10.7759/cureus.36146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/18/2023] Open
Abstract
The management of primary immune thrombocytopenia (ITP) is becoming a subject of interest as there appears to be treatment failure and resistance to modern conventional treatment, necessitating a more universal and goal-directed approach to management. Our patient is a 74-year-old male who was diagnosed with ITP six years ago and recently presented to the emergency department (ED) with complaints of melena stools and severe fatigue lasting for two days. Prior to the ED presentation, he had received multiple lines of treatment including splenectomy. On admission, the pathology after splenectomy showed a benign enlarged spleen with a focal area of intraparenchymal hemorrhage/rupture and changes compatible with ITP. He was managed with multiple platelet transfusions, IV methyl prednisone succinate, rituximab, and romiplostim. His platelet counts improved to 47,000, and he was discharged home on oral steroids with outpatient hematology follow-up. However, in a few weeks, his condition deteriorated, and he presented with an increased platelet count and further multiple complaints. Romiplostim was discontinued, and he was continued on prednisone 20 mg daily, after which he improved, and his platelet count reduced to 273,000 on 20 mg prednisone. This case calls attention to the need to review the role of combination therapy in treating refractory ITP and the prevention of complications of thrombocytosis secondary to advanced therapy. Treatment needs to be more streamlined, focused, and goal-directed. Escalation and de-escalation of treatment should be synchronized to prevent adverse complications from overtreating or undertreating.
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Allegra A, Cicero N, Mirabile G, Giorgianni CM, Gangemi S. Novel Biomarkers for Diagnosis and Monitoring of Immune Thrombocytopenia. Int J Mol Sci 2023; 24:ijms24054438. [PMID: 36901864 PMCID: PMC10003036 DOI: 10.3390/ijms24054438] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 02/12/2023] [Accepted: 02/21/2023] [Indexed: 03/12/2023] Open
Abstract
Lower-than-normal platelet counts are a hallmark of the acquired autoimmune illness known as immune thrombocytopenia, which can affect both adults and children. Immune thrombocytopenia patients' care has evolved significantly in recent years, but the disease's diagnosis has not, and it is still only clinically achievable with the elimination of other causes of thrombocytopenia. The lack of a valid biomarker or gold-standard diagnostic test, despite ongoing efforts to find one, adds to the high rate of disease misdiagnosis. However, in recent years, several studies have helped to elucidate a number of features of the disease's etiology, highlighting how the platelet loss is not only caused by an increase in peripheral platelet destruction but also involves a number of humoral and cellular immune system effectors. This made it possible to identify the role of immune-activating substances such cytokines and chemokines, complement, non-coding genetic material, the microbiome, and gene mutations. Furthermore, platelet and megakaryocyte immaturity indices have been emphasized as new disease markers, and prognostic signs and responses to particular types of therapy have been suggested. Our review's goal was to compile information from the literature on novel immune thrombocytopenia biomarkers, markers that will help us improve the management of these patients.
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Affiliation(s)
- Alessandro Allegra
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98100 Messina, Italy
- Correspondence:
| | - Nicola Cicero
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences (BIOMORF), University of Messina, 98100 Messina, Italy
| | - Giuseppe Mirabile
- Division of Hematology, Department of Human Pathology in Adulthood and Childhood “Gaetano Barresi”, University of Messina, 98100 Messina, Italy
| | - Concetto Mario Giorgianni
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences (BIOMORF), University of Messina, 98100 Messina, Italy
| | - Sebastiano Gangemi
- Allergy and Clinical Immunology Unit, Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
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Westerink HJ, Kosse LJ, Jessurun NT, van Tubergen A, Vonkeman HE, Nurmohamed MT, van den Bemt BJF, de Vries M. Patients' and health care professionals' perspectives on adverse drug reaction burden attributed to the use of biological DMARDs: a qualitative study. Expert Opin Drug Saf 2022:1-8. [PMID: 36269284 DOI: 10.1080/14740338.2023.2134344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Previous studies showed a discrepancy between health care professionals' (HCPs') and patients' perspective on adverse drug reaction (ADR) burden. However, it is unclear which factors make an ADR burdensome. We aimed to give insight in why ADRs are perceived as burdensome by inflammatory rheumatic disease (IRD) patients, and whether this differs from the HCPs' perspective. RESEARCH DESIGN AND METHODS A qualitative study was conducted using XXX. Participants received bimonthly questionnaires on experienced ADRs attributed to biological DMARDs and were asked to elaborate on ADR burden using a Likert-type scale and an open-ended question for clarification. Data of 440 IRD patients were analysed following thematic analysis. Similar analysis was done with semi-structured interviews with 13 HCPs. RESULTS We identified seven themes associated with ADR burden: 'effect on medication prescription', 'impact on appearance', 'impact on autonomy', 'impact on daily life', 'psychological consequences', 'distressing aspects of ADR', and 'physical consequences'. Identical themes were identified by HCPs, although they identified most subthemes in 'psychological consequences', and less subthemes in 'impact on daily life' and 'impact on autonomy'. CONCLUSION Patients describe perceived ADR burden in both physical and psychological themes. The HCPs' perspective is comparable, but mostly focuses on psychological impact.
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Affiliation(s)
- Henrike J Westerink
- IQ Health, Radboud University Medical Center, Nijmegen, the Netherlands.,Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, the Netherlands
| | - Leanne J Kosse
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, the Netherlands.,Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Naomi T Jessurun
- Netherlands Pharmacovigilance Centre Lareb, 's-Hertogenbosch, the Netherlands
| | - Astrid van Tubergen
- Department of Rheumatology, Maastricht University Medical Center, Maastricht, the Netherlands.,Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Harald E Vonkeman
- Department of Rheumatology, Medisch Spectrum Twente, Enschede, the Netherlands.,Department of Psychology, Health and Technology, University of Twente, Enschede, the Netherlands
| | - Mike T Nurmohamed
- Amsterdam Rheumatology & Immunology Center, Reade, Amsterdam, the Netherlands
| | - Bart J F van den Bemt
- Department of Pharmacy, Sint Maartenskliniek, Ubbergen, the Netherlands.,Department of Pharmacy, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marieke de Vries
- Institute for computing and Information Sciences (iCIS), Radboud University, Nijmegen, the Netherlands
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7
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Rovó A, Cantoni N, Samii K, Rüfer A, Koenen G, Ivic S, Cavanna D, Benz R. Real-world impact of primary immune thrombocytopenia and treatment with thrombopoietin receptor agonists on quality of life based on patient-reported experience: Results from a questionnaire conducted in Switzerland, Austria, and Belgium. PLoS One 2022; 17:e0267342. [PMID: 35446925 PMCID: PMC9022837 DOI: 10.1371/journal.pone.0267342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 04/06/2022] [Indexed: 01/04/2023] Open
Abstract
Aims of the study Thrombopoietin receptor agonists (TPO-RAs) are approved for immune thrombocytopenia (ITP), but their impact on health-related quality of life (HRQoL) remains poorly investigated in clinical practice. This observational study aimed to gain insight into real-world patient-reported experiences of the burden of ITP and TPO-RAs. Method An online questionnaire of closed questions was used to collect views of patients with primary ITP from Switzerland, Austria, and Belgium, between September 2018 and April 2020. Results Of 46 patients who completed the questionnaire (total cohort), 41% were receiving TPO-RAs. A numerically higher proportion of patients reported being free from symptoms at the time of the questionnaire (54%) than at diagnosis (24%), irrespective of treatment type. Bleeding, the most frequently reported symptom at diagnosis (59%), was reduced at the time of the questionnaire (7%). Conversely, fatigue was reported by approximately 40% of patients at both diagnosis and the time of the questionnaire. Having a normal life and their disease under control was reported by 83% and 76%, respectively, but 41% were worried/anxious about their condition. Nearly 50% reported that ITP impaired their engagement in hobbies/sport or energy levels and 63% reported no impact on employment. When stratified by TPO-RA use, bleeding was better controlled in those receiving TPO-RAs than not (0% vs 11%). A numerically lower proportion receiving TPO-RAs than not reported worry/anxiety about their condition (16% vs 59%) and shifting from full-time to part-time employment (11% vs 22%). Similar proportions were satisfied with their therapy whether they were receiving TPO-RAs or not (89% vs 85%). Conclusions Many factors affect HRQoL in patients with ITP. Of patients receiving TPO-RAs, none experienced bleeding at the time of the questionnaire; they also showed a more positive perspective for some outcomes than those not using TPO-RAs. However, fatigue was not reduced by any treatment.
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Affiliation(s)
- Alicia Rovó
- INSELSPITAL, Department of Haematology and Central Haematology Laboratory, Bern University Hospital, Bern, Switzerland
- * E-mail:
| | - Nathan Cantoni
- Division of Oncology, Hematology and Transfusion Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Kaveh Samii
- Department of Oncology, Division of Hematology, University Hospitals of Geneva, Geneva, Switzerland
| | - Axel Rüfer
- Division of Hematology, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Giedre Koenen
- Novartis Pharma Schweiz AG, Risch-Rotkreuz, Switzerland
| | - Sandra Ivic
- Novartis Pharma Schweiz AG, Risch-Rotkreuz, Switzerland
| | | | - Rudolf Benz
- Division of Hematology and Oncology, Cantonal Hospital, Münsterlingen, Switzerland
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Yu J, Xu Z, Zhuo Y, Wei H, Ye Y, Xu Q, Li Y, Yu L, Feng W, Hong P, Zhang K. Development and validation of a nomogram for steroid-resistance prediction in immune thrombocytopenia patients. Hematology 2021; 26:956-963. [PMID: 34871524 DOI: 10.1080/16078454.2021.2003066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES Corticosteroid is first-line therapy in immune thrombocytopenia. However, nearly 30% of patients appear in steroid-resistance. Our research analyses the relevant indicators of patients and develops a risk prediction model to predict the poor response to steroid-therapy in ITP patients. METHODS We collected data from 111 ITP patients admitted to Xiamen University Zhongshan Hospital from 2013 to 2019 as the training cohort and 65 ITP patients during 2019-2020 as the external validation cohort. Screening significant factors(P < 0.05) in univariate analysis, and further identified to be independent variables in multivariable logistic regression analysis. Incorporated the significant risk factors in and presented them with a nomogram based on independent risk predictors. The nomogram was assessed by receiver operating characteristics curves and decision curve analysis. RESULTS We constructed a steroid-resistance prediction model based on the potential predictors including age, serum ferritin and expression of HBsAg. As a result, based on the area under the ROC curves, the training cohort (AUC: 0.718, 95% CI: 0.615-0.821) and the external validation cohort (AUC:0.799,95%CI:0.692-0.905), which displayed good discrimination. The decision curve showed that predicting the steroid-refractory risk in ITP patients using this nomogram with a range of the threshold probability between >16% and <70%. The nomogram appears good performance in predicting steroid-refractory ITP patients. CONCLUSION Prediction model shows that elder patients with a high level of ferritin and positive expression of HBsAg may appear a high possibility of steroid-resistance. For these patients, TPO-RAs can be considered to help patients to get better treatment effects and develop a better health-related quality of life.
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Affiliation(s)
- Jieni Yu
- Department of Hematology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine). Shaoxing, People's Republic of China.,Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China.,The Medical College, Xiamen University, Xiamen, People's Republic of China
| | - Zhiqiang Xu
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China
| | - Yuanyuan Zhuo
- Department of Laboratory, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China
| | - Huahua Wei
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China.,The Medical College, Xiamen University, Xiamen, People's Republic of China
| | - Yinhai Ye
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China.,The Third Clinical Medical College, Fujian Medical University, Fuzhou, People's Republic of China
| | - Qinhong Xu
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China.,The Medical College, Xiamen University, Xiamen, People's Republic of China
| | - Youli Li
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China.,The Third Clinical Medical College, Fujian Medical University, Fuzhou, People's Republic of China
| | - Lihong Yu
- Department of Emergency, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China.,The Third Clinical Medical College, Fujian Medical University, Fuzhou, People's Republic of China
| | - Weiying Feng
- Department of Hematology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine). Shaoxing, People's Republic of China
| | - Pan Hong
- Department of Hematology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine). Shaoxing, People's Republic of China
| | - Kejie Zhang
- Department of Hematology, Zhongshan Hospital, Xiamen University, Xiamen, People's Republic of China
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Stimpson ML, Wolf JS, Williams EL, Lait PJP, Schewitz-Bowers LP, Greenwood R, Pell J, Thomas I, Lee RWJ, Bradbury CA. CD4 + T cells from patients with glucocorticoid-refractory immune thrombocytopenia have altered cytokine expression. Br J Haematol 2021; 196:1113-1117. [PMID: 34632576 DOI: 10.1111/bjh.17884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 11/29/2022]
Affiliation(s)
| | - Julia S Wolf
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Emily L Williams
- Translational Health Sciences, University of Bristol, Bristol, UK
| | | | | | - Rosemary Greenwood
- Research Design Service, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Julie Pell
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Ian Thomas
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Richard W J Lee
- Translational Health Sciences, University of Bristol, Bristol, UK.,Institute of Ophthalmology, Faculty of Brain Sciences, University College London, London, UK
| | - Charlotte A Bradbury
- Translational Health Sciences, University of Bristol, Bristol, UK.,University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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10
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Bradbury CA, Pell J, Hill Q, Bagot C, Cooper N, Ingram J, Breheny K, Kandiyali R, Rayment R, Evans G, Talks K, Thomas I, Greenwood R. Mycophenolate Mofetil for First-Line Treatment of Immune Thrombocytopenia. N Engl J Med 2021; 385:885-895. [PMID: 34469646 DOI: 10.1056/nejmoa2100596] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Immune thrombocytopenia is a rare autoimmune disorder with associated bleeding risk and fatigue. Recommended first-line treatment for immune thrombocytopenia is high-dose glucocorticoids, but side effects, variable responses, and high relapse rates are serious drawbacks. METHODS In this multicenter, open-label, randomized, controlled trial conducted in the United Kingdom, we assigned adult patients with immune thrombocytopenia, in a 1:1 ratio, to first-line treatment with a glucocorticoid only (standard care) or combined glucocorticoid and mycophenolate mofetil. The primary efficacy outcome was treatment failure, defined as a platelet count of less than 30×109 per liter and initiation of a second-line treatment, assessed in a time-to-event analysis. Secondary outcomes were response rates, side effects, occurrence of bleeding, patient-reported quality-of-life measures, and serious adverse events. RESULTS A total of 120 patients with immune thrombocytopenia underwent randomization (52.4% male; mean age, 54 years [range 17 to 87]; mean platelet level, 7×109 per liter) and were followed for up to 2 years after beginning trial treatment. The mycophenolate mofetil group had fewer treatment failures than the glucocorticoid-only group (22% [13 of 59 patients] vs. 44% [27 of 61 patients]; hazard ratio, 0.41; range, 0.21 to 0.80; P = 0.008) and greater response (91.5% of patients having platelet counts greater than 100×109 per liter vs. 63.9%; P<0.001). We found no evidence of a difference between the groups in the occurrence of bleeding, rescue treatments, or treatment side effects, including infection. However, patients in the mycophenolate mofetil group reported worse quality-of-life outcomes regarding physical function and fatigue than those in the glucocorticoid-only group. CONCLUSIONS The addition of mycophenolate mofetil to a glucocorticoid for first-line treatment of immune thrombocytopenia resulted in greater response and a lower risk of refractory or relapsed immune thrombocytopenia, but with somewhat decreased quality of life. (Funded by the U.K. National Institute for Health Research; FLIGHT ClinicalTrials.gov number, NCT03156452; EudraCT number, 2017-001171-23.).
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Affiliation(s)
- Charlotte A Bradbury
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Julie Pell
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Quentin Hill
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Catherine Bagot
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Nichola Cooper
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Jenny Ingram
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Katie Breheny
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Rebecca Kandiyali
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Rachel Rayment
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Gillian Evans
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Kate Talks
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Ian Thomas
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
| | - Rosemary Greenwood
- From the Faculty of Translational Health Sciences (C.A.B.), University of Bristol (J.I., K.B., R.K.), and the Bristol Haematology and Oncology Centre (C.A.B.) and the Research Design Service (R.G.), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, the Centre for Trials Research, Cardiff University (J.P., I.T.), and the Department of Haematology, Cardiff and Vale University Health Board (R.R.), Cardiff, Leeds Teaching Hospitals NHS Trust, Leeds (Q.H.), Glasgow Royal Infirmary, Glasgow (C.B.), the Department of Immunology and Inflammation, Imperial College London, London (N.C.), East Kent Hospitals University NHS Foundation Trust, Canterbury (G.E.), and Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne (K.T.) - all in the United Kingdom
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11
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Cuker A, Liebman HA. Corticosteroid overuse in adults with immune thrombocytopenia: Cause for concern. Res Pract Thromb Haemost 2021; 5:e12592. [PMID: 34466771 PMCID: PMC8387601 DOI: 10.1002/rth2.12592] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/20/2021] [Accepted: 08/02/2021] [Indexed: 01/20/2023] Open
Abstract
Corticosteroids remain a crucial component of first-line therapy for immune thrombocytopenia (ITP) due to low cost, high initial response rates, and acceptable short-term tolerability. However, extended and recurrent use of corticosteroids is associated with substantial toxicity. Survey studies indicate that >95% of patients with ITP treated with corticosteroids report adverse effects, more than one-third of whom require reduction or discontinuation of treatment. In light of the heavy treatment burden of prolonged corticosteroid exposure, clinical practice guidelines recommend limiting corticosteroid treatment to no more than 6 weeks in adults with ITP receiving initial therapy. For patients who require subsequent therapy, clinical practice guidelines recommend treatments more suitable for long-term disease control such as thrombopoietin receptor agonists, rituximab, other immune-modulating medications, or splenectomy, rather than repeated courses of corticosteroids. Despite these recommendations, real-world evidence suggests that corticosteroids remain the most frequently used treatment for adults with ITP, not only in the first line, but also in the second and third line. In this review, we summarize evidence on the efficacy, safety, and tolerability of corticosteroids; discuss the problem of overuse; and suggest strategies for curtailing the excessive use of corticosteroids in adults with ITP.
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Affiliation(s)
- Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPAUSA
| | - Howard A. Liebman
- Jane Anne Nohl Division of HematologyDepartment of MedicineNorris Cancer CenterUniversity of Southern California‐Keck School of MedicineLos AngelesCAUSA
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12
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Stimpson ML, Lait PJP, Schewitz-Bowers LP, Williams EL, Thirlwall KF, Lee RWJ, Bradbury CA. IL-10 and IL-17 expression by CD4 + T cells is altered in corticosteroid refractory immune thrombocytopenia (ITP). J Thromb Haemost 2020; 18:2712-2720. [PMID: 32574429 DOI: 10.1111/jth.14970] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/22/2020] [Accepted: 06/11/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Corticosteroids remain the first-line treatment for patients with immune thrombocytopenia (ITP). However, 20% to 30% of patients do not respond to treatment at tolerable doses. This variation in corticosteroid efficacy is replicated in other autoimmune diseases and may have an adaptive immune basis. OBJECTIVE To test the hypothesis that CD4+ T-cell responses to corticosteroids are different in patients with clinically defined corticosteroid refractory ITP. METHODS In this prospective cohort study, CD4+ T cells from patients with ITP were cultured in the presence or absence of dexamethasone (Dex). Intracellular cytokine expression was then quantified by flow cytometry and compared with patients' clinical response to corticosteroid treatment. A control cohort of patients with autoimmune uveitis was also studied to evaluate whether our findings were limited to ITP or are potentially generalizable across autoimmune diseases. RESULTS The ratio of interleukin (IL)-10 to IL-17 expression following CD4+ T cell culture with Dex was able to discriminate between ITP patients with a clinically defined complete (n = 33), partial (n = 12) or nonresponse (n = 11) to corticosteroid treatment (P = .002). These findings were replicated in patients with autoimmune uveitis (complete response n = 14, nonresponse n = 22; P = .01). CONCLUSIONS There is a relative abrogation of IL-10 and persistence of IL-17 expression in the CD4+ T cells of patients who clinically fail corticosteroid therapy. This observation has potential to inform both our mechanistic understanding of the action of corticosteroids in the treatment of ITP, and as a biomarker for steroid refractory disease, with potential application across a range of hematological and nonhematological conditions.
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Affiliation(s)
- Madeleine L Stimpson
- Translational Health Sciences, University of Bristol, Biomedical Sciences Building, Bristol, UK
| | - Philippa J P Lait
- Translational Health Sciences, University of Bristol, Biomedical Sciences Building, Bristol, UK
| | | | - Emily L Williams
- Translational Health Sciences, University of Bristol, Biomedical Sciences Building, Bristol, UK
| | - Kimberley F Thirlwall
- Cellular and Molecular Medicine, University of Bristol, Biomedical Sciences Building, Bristol, UK
| | - Richard W J Lee
- Translational Health Sciences, University of Bristol, Biomedical Sciences Building, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Charlotte A Bradbury
- Cellular and Molecular Medicine, University of Bristol, Biomedical Sciences Building, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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13
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Witkowski M, Witkowska M, Robak T. Autoimmune thrombocytopenia: Current treatment options in adults with a focus on novel drugs. Eur J Haematol 2019; 103:531-541. [DOI: 10.1111/ejh.13319] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 12/13/2022]
Affiliation(s)
| | - Magdalena Witkowska
- Copernicus Memorial Hospital Lodz Poland
- Department of Experimental Hematology Medical University of Lodz Lodz Poland
| | - Tadeusz Robak
- Copernicus Memorial Hospital Lodz Poland
- Department of Hematology Medical University of Lodz Lodz Poland
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14
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Trotter P, Hill QA. Immune thrombocytopenia: improving quality of life and patient outcomes. PATIENT-RELATED OUTCOME MEASURES 2018; 9:369-384. [PMID: 30568522 PMCID: PMC6267629 DOI: 10.2147/prom.s140932] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is an immune-mediated disorder characterized by a reduced platelet count and patients may develop bruising or mucosal bleeding. Since 2003, generic health-related quality of life (HRQoL) measures have been applied and ITP-specific measures developed, alongside trials of novel therapeutic agents. These have identified significant morbidity in patients with ITP, including fatigue, fear of bleeding and a negative impact on role, social and work activities. This review critically evaluates HRQoL data in adults and children with ITP. It also considers the impact of treatment and how patient-reported outcomes might be applied to care to optimize patients' quality of life.
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Affiliation(s)
- Patrick Trotter
- Department of Surgery, University of Cambridge, Cambridge, UK.,National Health Service Blood and Transplant, Organ Donation and Transplant Directorate, Bristol, UK
| | - Quentin A Hill
- Department of Haematology, St James's University Hospital, Leeds, UK,
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15
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Sestøl HG, Trangbæk SM, Bussel JB, Frederiksen H. Health-related quality of life in adult primary immune thrombocytopenia. Expert Rev Hematol 2018; 11:975-985. [DOI: 10.1080/17474086.2018.1548930] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Hanna Gran Sestøl
- Depatment of Haematology, Odense University Hospital, Odense, Denmark
| | | | - James B Bussel
- Department of Pediatrics, Division of Hematology, New York Presbyterian Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Henrik Frederiksen
- Depatment of Haematology, Odense University Hospital, Odense, Denmark
- Quality of Life Research Center, Odense University Hospital, Odense, Denmark
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16
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Pell J, Greenwood R, Ingram J, Wale K, Thomas I, Kandiyali R, Mumford A, Dick A, Bagot C, Cooper N, Hill Q, Bradbury CA. Trial protocol: a multicentre randomised trial of first-line treatment pathways for newly diagnosed immune thrombocytopenia: standard steroid treatment versus combined steroid and mycophenolate. The FLIGHT trial. BMJ Open 2018; 8:e024427. [PMID: 30341143 PMCID: PMC6196935 DOI: 10.1136/bmjopen-2018-024427] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Immune thrombocytopenia (ITP) is an autoimmune condition that may cause thrombocytopenia-related bleeding. Current first-line ITP treatment is with high-dose corticosteroids but frequent side effects, heterogeneous responses and high relapse rates are significant problems with only 20% remaining in sustained remission with this approach. Mycophenolate mofetil (MMF) is often used as the next treatment with efficacy in 50%-80% of patients and good tolerability but can take up to 2 months to work. OBJECTIVE To test the hypothesis that MMF combined with corticosteroid is a more effective first-line treatment for immune thrombocytopenia (ITP) than current standard of corticosteroid alone. METHODS AND ANALYSIS DesignMulticentre, UK-based, open-label, randomised controlled trial. SETTING Haematology departments in secondary care. PARTICIPANTS We plan to recruit 120 patients >16 years old with a diagnosis of ITP and a platelet count <30x109/L who require first-line treatment. Patients will be followed up for a minimum of 12 months following randomisation. PRIMARY OUTCOME Time from randomisation to treatment failure defined as platelets <30x109/L and a need for second-line treatment. SECONDARY OUTCOMES Side effects, bleeding events, remission rates, time to relapse, time to next therapy, cumulative corticosteroid dose, rescue therapy, splenectomy, socioeconomic costs, patient-reported outcomes (quality of life, fatigue, impact of bleeding, care costs). ANALYSIS The sample size of 120 achieves a 91.5% power to detect a doubling of the median time to treatment failure from 5 to 10 months. This will be expressed as an HR with 95% CI, median time to event if more than 50% have had an event and illustrated with Kaplan-Meier curves. Cost-effectiveness will be based on the first 12 months from diagnosis. ETHICS AND DISSEMINATION Ethical approval from NRES Committee South West (IRAS number 225959). EudraCT Number: 2017-001171-23. Results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03156452.
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Affiliation(s)
- Julie Pell
- Centre for Trials Research, Cardiff University, Cardiff, Wales, UK
| | - Rosemary Greenwood
- Research and Design Service, South West, University of Bristol, Bristol, UK
| | - Jenny Ingram
- Research and Design Service, South West, University of Bristol, Bristol, UK
| | - Katherine Wale
- Research & Innovation, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Ian Thomas
- Centre for Trials Research, Cardiff University, Cardiff, Wales, UK
| | - Rebecca Kandiyali
- Research & Innovation, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew Mumford
- Cellular and Molecular Medicine, University of Bristol, Bristol, UK
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew Dick
- Cellular and Molecular Medicine, University of Bristol, Bristol, UK
- UCL-Institute of Ophthalmology, London, UK
| | - Catherine Bagot
- Department of Haematology, Glasgow Royal Infirmary, Glasgow, UK
| | - Nichola Cooper
- Department of Haematology, Imperial College London and Hammersmith Hospital, London, UK
| | - Quentin Hill
- Department of Haematology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Charlotte Ann Bradbury
- Cellular and Molecular Medicine, University of Bristol, Bristol, UK
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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17
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Gómez-Almaguer D. Eltrombopag-based combination treatment for immune thrombocytopenia. Ther Adv Hematol 2018; 9:309-317. [PMID: 30344993 PMCID: PMC6187430 DOI: 10.1177/2040620718798798] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/14/2018] [Indexed: 01/01/2023] Open
Abstract
Immune thrombocytopenia (ITP) is a bleeding disorder caused by a decrease in platelet count resulting from increased destruction and insufficient production of platelets. Although impaired regulatory T-lymphocyte activity plays a critical role in platelet destruction, many other immunologic abnormalities are also likely to be involved. Importantly, patients with ITP appear to have defects in a thrombopoietin-mediated physiological mechanism that compensates for a decrease in platelet count by increasing platelet production. Thus, simultaneous treatment of multiple pathogenic pathways involved in ITP could potentially result in synergistic efficacy. While conventional treatments for ITP suppress or modulate the immune system to reduce platelet destruction, a unique class of ITP therapy, namely thrombopoietin receptor agonists (TPO-RAs), improves platelet production by activating the thrombopoietin pathway. As hypothesized, preliminary studies show that combinations of eltrombopag, an oral TPO-RA, with conventional treatments improve outcomes in both newly diagnosed and refractory patients. In this review, the clinical experience with eltrombopag-based combinations in patients with ITP is summarized and the implications of the available data are discussed.
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Affiliation(s)
- David Gómez-Almaguer
- Hematology Service, Facultad de Medicina y Hospital Universitario Dr José Eleuterio González, Francisco I. Madero and José E. González, 64460 Monterrey, Mexico
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18
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Bussel J, Arnold DM, Grossbard E, Mayer J, Treliński J, Homenda W, Hellmann A, Windyga J, Sivcheva L, Khalafallah AA, Zaja F, Cooper N, Markovtsov V, Zayed H, Duliege A. Fostamatinib for the treatment of adult persistent and chronic immune thrombocytopenia: Results of two phase 3, randomized, placebo-controlled trials. Am J Hematol 2018; 93:921-930. [PMID: 29696684 PMCID: PMC6055608 DOI: 10.1002/ajh.25125] [Citation(s) in RCA: 185] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 04/17/2018] [Accepted: 04/22/2018] [Indexed: 01/19/2023]
Abstract
Spleen tyrosine kinase (Syk) signaling is central to phagocytosis-based, antibody-mediated platelet destruction in adults with immune thrombocytopenia (ITP). Fostamatinib, an oral Syk inhibitor, produced sustained on-treatment responses in a phase 2 ITP study. In two parallel, phase 3, multicenter, randomized, double-blind, placebo-controlled trials (FIT1 and FIT2), patients with persistent/chronic ITP were randomized 2:1 to fostamatinib (n = 101) or placebo (n = 49) at 100 mg BID for 24 weeks with a dose increase in nonresponders to 150 mg BID after 4 weeks. The primary endpoint was stable response (platelets ≥50 000/μL at ≥4 of 6 biweekly visits, weeks 14-24, without rescue therapy). Baseline median platelet count was 16 000/μL; median duration of ITP was 8.5 years. Stable responses occurred in 18% of patients on fostamatinib vs. 2% on placebo (P = .0003). Overall responses (defined retrospectively as ≥1 platelet count ≥50 000/μL within the first 12 weeks on treatment) occurred in 43% of patients on fostamatinib vs. 14% on placebo (P = .0006). Median time to response was 15 days (on 100 mg bid), and 83% responded within 8 weeks. The most common adverse events were diarrhea (31% on fostamatinib vs. 15% on placebo), hypertension (28% vs. 13%), nausea (19% vs. 8%), dizziness (11% vs. 8%), and ALT increase (11% vs. 0%). Most events were mild or moderate and resolved spontaneously or with medical management (antihypertensive, anti-motility agents). Fostamatinib produced clinically-meaningful responses in ITP patients including those who failed splenectomy, thrombopoietic agents, and/or rituximab. Fostamatinib is a novel ITP treatment option that targets an important mechanism of ITP pathogenesis.
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Affiliation(s)
| | - Donald M. Arnold
- McMaster University, Michael G. DeGroote School of Medicine, and Canadian Blood ServicesHamiltonOntarioCanada
| | | | - Jiří Mayer
- Fakultni nemocnice BrnoBrnoCzech Republic
| | - Jacek Treliński
- Wojewódzki Szpital Specjalistyczny im. M. Kopernika w ŁodziLodzPoland
| | - Wojciech Homenda
- Wojewódzki Szpital Specjalistyczny im. J. Korczaka i Akademia Pomorska w SłupskuSlupskPoland
| | - Andrzej Hellmann
- University Clinical Center, Medical University of GdańskGdańskPoland
| | - Jerzy Windyga
- Instytut Hematologii i TransfuzjologiiWarszawaPoland
| | - Liliya Sivcheva
- First Internal DepartmentMHAT Hristo Botev, AD, VratsaVratsaBulgaria
| | | | - Francesco Zaja
- Clinica Ematologica, DAME, University of UdineUdineItaly
| | | | | | - Hany Zayed
- Rigel PharmaceuticalsSouth San FranciscoCalifornia
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19
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Cuker A. Transitioning patients with immune thrombocytopenia to second-line therapy: Challenges and best practices. Am J Hematol 2018; 93:816-823. [PMID: 29574922 PMCID: PMC6055642 DOI: 10.1002/ajh.25092] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 03/11/2018] [Accepted: 03/14/2018] [Indexed: 01/19/2023]
Abstract
In patients with immune thrombocytopenia who do not adequately respond to first-line therapy, there is no clear consensus on which second-line therapy to initiate and when. This situation leads to suboptimal approaches, including prolonged exposure to treatments that are not intended for long-term use (eg, corticosteroids) and overuse of off-label therapies (eg, rituximab) while approved, more efficacious options exist. These approaches may not only fail to address symptoms and burden of disease, but may also worsen health-related quality of life. A better understanding of available second-line treatments may ensure best use of therapeutic options and thereby optimize patient outcomes.
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Affiliation(s)
- Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvania
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20
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Donga PZ, Bilir SP, Little G, Babinchak T, Munakata J. Comparative treatment-related adverse event cost burden in immune thrombocytopenic purpura. J Med Econ 2017; 20:1200-1206. [PMID: 28882075 DOI: 10.1080/13696998.2017.1370425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AIMS Real-world evidence on the safety profile and costs associated with immune thrombocytopenic purpura (ITP) treatment in adults is lacking. This study quantifies and compares adverse event (AE) crude rates and costs associated with ITP treatments as found in claims data. MATERIALS AND METHODS A retrospective claims-based analysis was conducted using IMS Pharmetrics Plus database. Included patients were ≥18 years old, with a diagnosis of ITP (2007-2012); an ITP-related claim for anti-D, intravenous immunoglobulin (IVIG), rituximab, romiplostim, or eltrombopag; and 1-year continuous enrollment (3-years for rituximab) during follow-up. AEs and event costs were identified during active treatment, defined from the first claim of each drug to a pre-defined treatment gap or end of study period. Descriptive statistics were reported with Wilcoxon rank-sum significance tests. RESULTS A total of 2,518 patients were identified (mean age = 50.8 (±16.3 years); 55.8% male). Of all patients, 22.8% experienced any AE. Significantly fewer anti-D patients had any AE (13.8% vs IVIG: 21.1%, rituximab: 29.4%, romiplostim: 28.1%, eltrombopag: 22.4%). Nausea/vomiting and arthralgia/musculoskeletal pain were most common across treatments, and hemolytic events did not differ significantly across treatments. Most costly AEs were urinary tract infection, aseptic meningitis, and fever ($5000+/case); headache, nasal congestion, and hemolytic event were $4,000-5,000/case. Cost per AE did not differ by treatment. LIMITATIONS AND CONCLUSIONS Although lower than trial-based AE rates, claims for ITP treatment-related AEs are common, with higher numbers for rituximab and lower numbers for anti-D. This disparity suggests a possible differential cost burden overall that future analysis should explore.
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Affiliation(s)
| | | | - Gregg Little
- c Emergent BioSolutions , Gaithersberg , MD , USA
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Sholapur NS, Hamilton K, Butler L, Heddle NM, Arnold DM. An evaluation of overall effectiveness and treatment satisfaction with intravenous immunoglobulin among patients with immune thrombocytopenia. Transfusion 2016; 56:1739-44. [PMID: 27145296 DOI: 10.1111/trf.13628] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 03/27/2016] [Accepted: 03/28/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND A global assessment of patient satisfaction that considers therapeutic effect, toxicities, and convenience is needed to evaluate the acceptability of intravenous immunoglobulin (IVIG) as a treatment for patients with immune thrombocytopenia (ITP). STUDY DESIGN AND METHODS We performed a cross-sectional pilot study to assess the feasibility and usefulness of a treatment satisfaction questionnaire for adult patients with ITP receiving IVIG in an academic hematology clinic. Treatment satisfaction was evaluated by administration of a validated survey-based tool 7 days after IVIG administration. The tool assessed treatment satisfaction across four domains (effectiveness, toxicity, convenience, and global satisfaction); results were summarized with mean scores. RESULTS Twelve patients were enrolled (nine females; median age, 44 years; interquartile range, 35-69 years). Mean platelet increment after infusion was 54.2 × 10(9) /L (SD, 47.6 × 10(9) /L). Treatment satisfaction scores were highest in the side effect burden domain (88.2/100; SD, 19.3; higher scores indicate a lower burden of side effects). Six participants reported IVIG-associated toxicities; most were "slightly" or "not at all" dissatisfied by the impact of side effects. The domain with the lowest score was convenience (62.0/100; SD, 24.7). CONCLUSION The assessment of treatment satisfaction using a survey-based assessment tool was feasible for patients receiving IVIG and provided meaningful results that discriminated between domains. Patients found IVIG treatment to be inconvenient, but were satisfied with its tolerability as an ITP treatment. Larger studies are needed to determine the precise impact on each domain and the reproducibility of study results. Patient satisfaction scores can be used to compare different ITP treatments.
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Affiliation(s)
- Naushin S Sholapur
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Health Research Methodology, Department of Biostatistics and Clinical Epidemiology; and the, McMaster University, Hamilton, Ontario, Canada
| | - Korinne Hamilton
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lianna Butler
- Department of Education Services, McMaster University, Hamilton, Ontario, Canada
| | - Nancy M Heddle
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Kuter DJ, Macahilig C, Grotzinger KM, Poston SA, Wang PF, Dawson KL, Ward M. Treatment patterns and clinical outcomes in patients with chronic immune thrombocytopenia (ITP) switched to eltrombopag or romiplostim. Int J Hematol 2015; 101:255-63. [PMID: 25586660 DOI: 10.1007/s12185-014-1731-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 12/16/2014] [Accepted: 12/19/2014] [Indexed: 11/28/2022]
Abstract
This observational study aimed to assess real-world treatment patterns and clinical outcomes for patients with chronic immune thrombocytopenia (ITP) currently being treated with eltrombopag or romiplostim after switching from corticosteroids, rituximab, or the alternate thrombopoietin receptor agonist (TPO-RA). The study examined the rationale for switching to TPO-RA therapy using aided responses. Dosing patterns were also analyzed before and after switching. Treatment outcomes were assessed through platelet counts at multiple time points including treatment initiation and after switching at the last office visit. A total of 280 patients were enrolled whose active therapy for ITP was replaced with either eltrombopag (n = 130) or romiplostim (n = 150). Efficacy-related issues (desired platelet count not achieved and/or lack of response to prior therapy) were the main drivers for therapy switching among all patients (54 % for eltrombopag vs. 57 % for romiplostim). Platelet counts at the last office visit showed improvement compared with counts at the initiation of either eltrombopag or romiplostim treatment. No significant differences were noted when comparing clinical outcomes between the eltrombopag and romiplostim treatment cohorts. Our results suggest that switching to the other TPO-RA may be beneficial if there is inadequate response to treatment with the initial TPO-RA.
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Affiliation(s)
- David J Kuter
- Hematology Division, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA,
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Matzdorff A, Neufeld EJ, Roganovic J. To treat or not to treat--from guidelines to individualized patient management. Semin Hematol 2014; 50 Suppl 1:S12-7. [PMID: 23664509 DOI: 10.1053/j.seminhematol.2013.03.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Immune thrombocytopenia (ITP) is a rare disorder. Evidence-based guidelines provide important information for hematologists, as well as diagnostic and therapeutic recommendations to other physicians with limited expertise in the field. However, guidelines in pediatric and adult ITP do not answer some imperative questions: which patient is at risk of severe bleeding and requires pharmacologic treatment? Who will recover spontaneously? Is splenectomy still an appropriate second-line treatment for all chronic or persistent ITP patients? This review summarizes the current approach to these important issues, the patients' perspective, and how we can improve individual patient management.
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Kirsch M, Klaassen RJ, De Geest S, Matzdorff A, Ionova T, Dobbels F. Understanding the importance of using patient-reported outcome measures in patients with immune thrombocytopenia. Semin Hematol 2014; 50 Suppl 1:S39-42. [PMID: 23664515 DOI: 10.1053/j.seminhematol.2013.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Incorporating patient-reported outcomes (PROs) when studying patients with immune thrombocytopenia (ITP) is essential since treatment decisions are complex and using platelet count only partly explains disease burden. Since most symptoms are only experienced subjectively and are seldom captured during clinician-based evaluations, using self-report is crucial for early symptom detection. However, capturing the patient's illness experience necessitates using well-developed and validated instruments. This article provides insight on the importance of using PROs in ITP, summarizes the methodological steps to develop PRO instruments, and discusses challenges related to integrating PROs into research and clinical practice.
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Affiliation(s)
- Monika Kirsch
- Institute of Nursing Science, University Basel, and Department of Hematology, University Hospital Basel, Basel, Switzerland
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