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McQuilten ZK, Weinkove R, Thao LTP, Crispin P, Degelia A, Dendle C, Gilbertson M, Johnston A, Keegan A, Pepperell D, Pullon H, Reynolds J, van Tonder T, Trotman J, Waters N, Wellard C, Weston H, Morrissey CO, Wood EM. Immunoglobulin replacement vs prophylactic antibiotics for hypogammaglobulinemia secondary to hematological malignancy. Blood Adv 2024; 8:1787-1795. [PMID: 38592710 PMCID: PMC11006812 DOI: 10.1182/bloodadvances.2023011231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/20/2023] [Indexed: 04/10/2024] Open
Abstract
ABSTRACT Immunoglobulin replacement and prophylactic antibiotics are commonly used to prevent infections in patients with secondary hypogammaglobulinemia due to hematological malignancies but have never been directly compared. In this randomized controlled feasibility trial conducted in 7 hospitals in Australia and New Zealand, we enrolled patients with secondary hypogammaglobulinemia with either a history of recurrent/severe infection or an immunoglobulin G level <4 g/L. Participants were randomized in a 1:2 ratio to immunoglobulin (0.4 g/kg per 4 weeks IV) or daily antibiotics (trimethoprim-sulfamethoxazole 160 mg/800 mg or, if contraindicated, 100 mg doxycycline) for 12 months. Participants allocated to antibiotics were allowed to crossover after grade ≥3 infections. The primary outcome was proportion of patients alive on the assigned treatment 12 months after randomization. Between August 2017 and April 2019, 63 patients were randomized: 42 to antibiotics and 21 to immunoglobulin. Proportion of participants alive on allocated treatment at 12 months was 76% in the immunoglobulin and 71% in the antibiotic arm (Fisher exact test P=.77; odds ratio, 0.78; 95% CI, 0.22-2.52). The lower quartile for time to first major infection (median, not reached) was 11.1 months for the immunoglobulin and 9.7 months for the antibiotic arm (log-rank test, P=.65). Three participants in the immunoglobulin and 2 in the antibiotic arm had grade ≥3 treatment-related adverse events. A similar proportion of participants remained on antibiotic prophylaxis at 12 months to those on immunoglobulin, with similar rates of major infections. Our findings support the feasibility of progressing to a phase 3 trial. Trial registration #ACTRN12616001723471.
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Affiliation(s)
- Zoe K. McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Haematology, Monash Health, Melbourne, Australia
| | - Robert Weinkove
- Te Rerenga Ora Wellington Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital, Coast & Hutt Valley, Wellington, New Zealand
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
- Department of Pathology & Molecular Medicine, University of Otago Wellington, Wellington, New Zealand
| | - Le Thi Phuong Thao
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Philip Crispin
- Department of Haematology, Canberra Hospital, Canberra, Australia
| | - Amber Degelia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Claire Dendle
- Monash Infectious Diseases, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | | | - Anna Johnston
- Department of Haematology, Royal Hobart Hospital, Hobart, Australia
- Department of Medicine, University of Tasmania, Hobart, Australia
| | - Anastazia Keegan
- PathWest Laboratory Medicine, King Edward Memorial Hospital, Perth, Australia
| | | | - Humphrey Pullon
- Department of Haematology, Waikato Hospital, Hamilton, New Zealand
| | - John Reynolds
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Tina van Tonder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Judith Trotman
- Department of Haematology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
| | - Neil Waters
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Cameron Wellard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Helen Weston
- Department of Haematology, Sunshine Coast University Hospital, Sunshine Coast, Australia
| | - C. Orla Morrissey
- Central Clinical School, Monash University, Melbourne, Australia
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia
| | - Erica M. Wood
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Haematology, Monash Health, Melbourne, Australia
| | - Australasian Leukaemia and Lymphoma Group
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Haematology, Monash Health, Melbourne, Australia
- Te Rerenga Ora Wellington Blood & Cancer Centre, Te Whatu Ora Health New Zealand Capital, Coast & Hutt Valley, Wellington, New Zealand
- Cancer Immunotherapy Programme, Malaghan Institute of Medical Research, Wellington, New Zealand
- Department of Pathology & Molecular Medicine, University of Otago Wellington, Wellington, New Zealand
- Department of Haematology, Canberra Hospital, Canberra, Australia
- Monash Infectious Diseases, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
- Department of Haematology, Royal Hobart Hospital, Hobart, Australia
- Department of Medicine, University of Tasmania, Hobart, Australia
- PathWest Laboratory Medicine, King Edward Memorial Hospital, Perth, Australia
- Department of Haematology, Fiona Stanley Hospital, Perth, Australia
- Department of Haematology, Waikato Hospital, Hamilton, New Zealand
- Central Clinical School, Monash University, Melbourne, Australia
- Department of Haematology, Concord Repatriation General Hospital, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
- Department of Haematology, Sunshine Coast University Hospital, Sunshine Coast, Australia
- Department of Infectious Diseases, Alfred Health, Melbourne, Australia
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McQuilten Z, Heritier S, Fox L, Fox V, Young L, Blombery P, Cunningham I, Curnow J, Higgins A, Hiwase DK, Filshie R, Firkin F, Lacaze P, Mason K, Mills AK, Pepperell D, Patil S, Stevenson W, Szer J, Waters N, Wilson K, Ting S, Wood E. Efficacy and safety of avatrombopag in combination with immunosuppressive therapy in treatment-naïve and relapsed/refractory severe aplastic anaemia: protocol for the DIAAMOND-Ava-FIRST and DIAAMOND-Ava-NEXT Bayesian Optimal Phase II trials. BMJ Open 2024; 14:e076246. [PMID: 38238183 PMCID: PMC10806710 DOI: 10.1136/bmjopen-2023-076246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/14/2023] [Indexed: 01/23/2024] Open
Abstract
INTRODUCTION Immunosuppressive therapy (IST) with antithymocyte globulin (ATG) and ciclosporin is standard of care for patients with severe aplastic anaemia (sAA) not eligible or suitable for allogeneic stem cell transplant. While patients respond to IST, few achieve complete responses and a significant proportion are refractory or relapse. The addition of eltrombopag, a thrombopoietin-receptor agonist (TPO-A), to IST has been shown to improve haematological responses in sAA. Avatrombopag is a second-generation TPO-A with potential advantages over eltrombopag. However, to date avatrombopag has not been studied in sAA. METHODS AND ANALYSIS Investigator-initiated, single-arm registry-based Bayesian Optimal Phase II trial of avatrombopag conducted in two cohorts, patients with untreated sAA (FIRST cohort) and in patients with sAA that has relapsed or is refractory to IST (NEXT cohort). In the FIRST cohort, participants receive IST (equine ATG and ciclosporin) plus avatrombopag from day 1 until day 180 at 60 mg oral daily, with dose adjusted according to platelet count. Participants in the NEXT cohort receive avatrombopag at 60 mg oral daily from day 1 until day 180, with or without additional IST at the discretion of the treating clinician.For each cohort, two primary endpoints (haematological response and acquired clonal evolution) are jointly monitored and the trial reviewed at each interim analysis where a 'go/no-go' decision is made by evaluating the posterior probability of the events of interests. ETHICS AND DISSEMINATION The trial has received ethics approval (Monash Health RES-18-0000707A). The trial conduct will comply with ICH-GCP and all applicable regulatory requirements. The results of the trial will be submitted to a peer-review journal for publication. TRIAL REGISTRATION NUMBER ACTRN12619001042134, ACTRN12619001043123.
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Affiliation(s)
- Zoe McQuilten
- Department of Haematology, Monash Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stephane Heritier
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lucy Fox
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Vanessa Fox
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lauren Young
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Piers Blombery
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Ilona Cunningham
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | - Jennifer Curnow
- Department of Haematology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Alisa Higgins
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Devendra K Hiwase
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- South Australian Health & Medical Research Institute, Adelaide, South Australia, Australia
| | - Robin Filshie
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Frank Firkin
- Haematology Department, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Paul Lacaze
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kylie Mason
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Anthony K Mills
- University of Queensland, Brisbane, Queensland, Australia
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Dominic Pepperell
- Department of Haematology, Fiona Stanley Hospital, Murdoch, Perth, Australia
| | - Sushrut Patil
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
| | - William Stevenson
- Department of Haematology, Royal North Shore Hospital, St Leonards, Sydney, Australia
| | - Jeff Szer
- Department of Clinical Haematology, Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Neil Waters
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kate Wilson
- University of Sydney, Sydney, New South Wales, Australia
| | - Stephen Ting
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Haematology, Eastern Health, Melbourne, Victoria, Australia
| | - Erica Wood
- Department of Haematology, Monash Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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O'Mahony B, Dunn AL, Leavitt AD, Peyvandi F, Ozelo MC, Mahlangu J, Peerlinck K, Wang JD, Lowe GC, Tan CW, Giermasz A, Tran H, Khoo TL, Cockrell E, Pepperell D, Chambost H, López Fernández MF, Kazmi R, Majerus E, Skinner MW, Klamroth R, Quinn J, Yu H, Wong WY, Robinson TM, Pipe SW. Health-related quality of life following valoctocogene roxaparvovec gene therapy for severe hemophilia A in the phase 3 trial GENEr8-1. J Thromb Haemost 2023; 21:3450-3462. [PMID: 37678546 DOI: 10.1016/j.jtha.2023.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 08/11/2023] [Accepted: 08/27/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Severe hemophilia A (HA) negatively impacts health-related quality of life (HRQOL). OBJECTIVES We aimed to analyze HRQOL in adult men with severe HA without inhibitors after valoctocogene roxaparvovec gene transfer in the phase 3 trial GENEr8-1. METHODS Participant-reported outcomes were the hemophilia-specific quality of life questionnaire for adults (Haemo-QOL-A), the EQ-5D-5L instrument, the Hemophilia Activities List (HAL), and the Work Productivity and Activity Impairment Questionnaire: Hemophilia Specific (WPAI+CIQ:HS). Participants completed the questionnaires at baseline and through 104 weeks postinfusion with 6 × 1013 vg/kg of valoctocogene roxaparvovec. Scores were analyzed per participant characteristics and outcomes. RESULTS For 132 HIV-negative participants, mean change from baseline in Haemo-QOL-A Total Score met the anchor-based clinically important difference (CID: 5.5) by week 12; the mean (SD) increase was 7.0 (12.6) at week 104. At week 104, improvement in Consequences of Bleeding, Treatment Concern, Worry, and Role Functioning domain scores exceeded the CID (6). EQ-5D-5L Utility Index scores improved above the CID at week 52, but not at week 104. EQ-5D-5L visual analog scale and HAL scores increased from baseline to week 104. Participants reported less activity and work impairment at week 104 than baseline. Participants with problem joints had lower mean baseline Haemo-QOL-A Total and domain scores than those without them, but improved over 104 weeks, except for 11 participants with ≥3 problem joints. Participants with 0 bleeds during the baseline prophylaxis period reported Haemo-QOL-A score improvements above the CID, including in the Consequences of Bleeding domain. CONCLUSION Valoctocogene roxaparvovec provided clinically meaningful HRQOL improvement for men with severe HA.
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Affiliation(s)
- Brian O'Mahony
- Irish Haemophilia Society, Dublin, Ireland; Trinity College, Dublin, Ireland.
| | - Amy L Dunn
- The Division of Hematology, Oncology, and BMT at Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Andrew D Leavitt
- University of California San Francisco, San Francisco, California, USA
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milan, Italy; Università degli Studi di Milano, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Margareth C Ozelo
- Hemocentro UNICAMP, Department of Internal Medicine, School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil
| | - Johnny Mahlangu
- Hemophilia Comprehensive Care Center, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand and NHLS, Johannesburg, South Africa
| | - Kathelijne Peerlinck
- Department of Vascular Medicine and Haemostasis and Haemophilia Centre, University Hospitals Leuven, Leuven, Belgium
| | - Jiaan-Der Wang
- Center for Rare Disease and Hemophilia, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Gillian C Lowe
- West Midlands Comprehensive Care Haemophilia Centre, Queen Elizabeth Hospital, Birmingham, UK
| | - Chee Wee Tan
- Department of Haematology, Royal Adelaide Hospital, Adelaide, South Australia, Australia; University of Adelaide, Adelaide, South Australia, Australia
| | - Adam Giermasz
- Hemophilia Treatment Center, University of California Davis, Sacramento, California, USA
| | - Huyen Tran
- Haemostasis & Thrombosis Unit, Haemophilia Treatment Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Teh-Liane Khoo
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Erin Cockrell
- Pediatric Hematology Oncology, Saint Joseph's Children's Hospital, Tampa, Florida, USA
| | - Dominic Pepperell
- Department of Haematology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Hervé Chambost
- AP-HM, Department of Pediatric Hematology Oncology, Children Hospital La Timone & Aix Marseille University, INSERM, INRA, C2VN, Marseille, France
| | | | - Rashid Kazmi
- Department of Haematology, Southampton University Hospital, Southampton, UK
| | - Elaine Majerus
- Department of Medicine, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Mark W Skinner
- Institute for Policy Advancement Ltd, Washington, DC, USA; McMaster University, Hamilton, Ontario, Canada
| | - Robert Klamroth
- Comprehensive Care Haemophilia Treatment Center, Vivantes Klinikum im Friedrichshain, Berlin, Germany; Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Germany
| | | | - Hua Yu
- BioMarin Pharmaceutical Inc, Novato, California, USA
| | - Wing Yen Wong
- BioMarin Pharmaceutical Inc, Novato, California, USA
| | | | - Steven W Pipe
- Departments of Pediatrics and Pathology, University of Michigan, Ann Arbor, Michigan, USA
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Tran HA, Deng L, Wood N, Choi P, Singleton S, Clarke L, Khanlari S, Maitland-Scott I, Bird R, Brown S, Manoharan B, Tan CW, Gold M, Hissaria P, Melody S, Chunilal S SD, Buttery J, Clothier H, Crawford NW, Phuong L, Pepperell D, Effler P, Parker C, Carter N, Macartney K, McStea M, Miller T, Nissen M, Larter C, Kay E, Chen VM. The clinicopathological features of thrombosis with thrombocytopenia syndrome following ChAdOx1-S (AZD1222) vaccination and case outcomes in Australia: a population-based study. Lancet Reg Health West Pac 2023; 40:100894. [PMID: 37701717 PMCID: PMC10494168 DOI: 10.1016/j.lanwpc.2023.100894] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/27/2023] [Accepted: 08/20/2023] [Indexed: 09/14/2023]
Abstract
Background Thrombosis with thrombocytopenia syndrome (TTS) associated with viral vector COVID-19 vaccines, including ChAdOx1-S (AstraZeneca AZD1222) vaccine, can result in significant morbidity and mortality. We report the clinicopathological features of TTS following ChAdOx1-S vaccination and summarise the case outcomes in Australia. Methods In this cohort study, patients diagnosed with TTS in Australia between 23 March and 31 December 2021 were identified according to predefined criteria. Cases were included if they met the Therapeutic Goods Administration (TGA) probable and confirmed case definitions and were reclassified using Centres for Disease Control and Prevention (CDC) definition for analysis. Data were collected on patient baseline characteristics, clinicopathological features, risk factors, treatment and outcomes. Findings A total of 170 TTS cases were identified, with most occurring after the first dose (87%) of ChAdOx1-S. The median time to symptom onset after vaccination and symptom onset to admission was 11 and 2 days respectively. The median age of cases was 66 years (interquartile range 55-74). All except two patients received therapeutic anticoagulation and 66% received intravenous immunoglobulin. Overall, 85.3% of cases were discharged home after a median hospitalisation of 6 days, 9.4% required ongoing rehabilitation and 5.3% died. Eight deaths were related to TTS, with another dying from an unrelated condition while receiving treatment for TTS. Deaths occurred more commonly in those classified as Tier 1 according to the CDC definition and were associated with more severe thrombocytopenia and disease-related haemorrhage. Interpretation TTS, while rare, can be severe and have catastrophic outcomes in some individuals. In Australia, the mortality rate was low compared to that reported in other high-income countries. Almost all received therapeutic anticoagulation with no bleeding complications and were successfully discharged. This emphasises the importance of community education and an established pathway for early recognition, diagnosis and treatment of TTS. Funding Australian Commonwealth Department of Health and Aged Care. H.A Tran, N. Wood, J. Buttery, N.W. Crawford, S.D. Chunilal, V.M. Chen are supported by Medical Research Future Funds (MRFF) grant ID 2015305.
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Affiliation(s)
- Huyen A. Tran
- The Alfred Hospital, Melbourne, Victoria, Australia
- Monash Medical Centre, Clayton, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Lucy Deng
- National Centre for Immunisation Research and Surveillance, Children's Hospital at Westmead, Westmead, New South Wales, Australia
- The University of Sydney Children's Hospital Westmead Clinical School, Westmead, New South Wales, Australia
| | - Nicholas Wood
- National Centre for Immunisation Research and Surveillance, Children's Hospital at Westmead, Westmead, New South Wales, Australia
- The University of Sydney Children's Hospital Westmead Clinical School, Westmead, New South Wales, Australia
| | - Philip Choi
- The Canberra Hospital, Canberra, Australian Capital Territory, Australia
- The John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Sally Singleton
- ACT Health Directorate, Canberra, Australian Capital Territory, Australia
| | - Lisa Clarke
- Department of Haematology, Sydney Adventist Hospital, Sydney, New South Wales, Australia
- Transfusion Policy and Education, Australian Red Cross Lifeblood, Sydney, New South Wales, Australia
| | - Sarah Khanlari
- New South Wales Ministry of Health, St Leonards, New South Wales, Australia
| | | | - Robert Bird
- Division of Cancer Services, Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Scott Brown
- Queensland Health, Brisbane, Queensland, Australia
| | - Bavahuna Manoharan
- Queensland Health, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Chee Wee Tan
- Royal Adelaide Hospital, Central Area Local Health Network, Adelaide, South Australia, Australia
- SA Pathology, Adelaide, South Australia, Australia
- University of Adelaide, South Australia, Australia
| | - Michael Gold
- Department of Allergy and Clinical Immunology, Women's and Children's Health Network, Adelaide, South Australia, Australia
- Discipline of Paediatrics, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Pravin Hissaria
- Royal Adelaide Hospital, Central Area Local Health Network, Adelaide, South Australia, Australia
- SA Pathology, Adelaide, South Australia, Australia
- University of Adelaide, South Australia, Australia
| | - Shannon Melody
- Public Health Services, Tasmania Department of Health, Hobart, Tasmania, Australia
| | - Sanjeev D. Chunilal S
- Monash Medical Centre, Clayton, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Jim Buttery
- SAEFVIC, Infection and Immunity, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Hazel Clothier
- SAEFVIC, Infection and Immunity, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Centre for Health Analytics, Melbourne Children's Centre, Parkville, Victoria, Australia
| | - Nigel W. Crawford
- SAEFVIC, Infection and Immunity, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Linny Phuong
- SAEFVIC, Infection and Immunity, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | | | - Paul Effler
- Western Australian Department of Health, Perth, Western Australia, Australia
| | - Claire Parker
- Western Australian Department of Health, Perth, Western Australia, Australia
| | - Nicola Carter
- National Centre for Immunisation Research and Surveillance, Children's Hospital at Westmead, Westmead, New South Wales, Australia
- The University of Sydney Children's Hospital Westmead Clinical School, Westmead, New South Wales, Australia
| | - Kristine Macartney
- National Centre for Immunisation Research and Surveillance, Children's Hospital at Westmead, Westmead, New South Wales, Australia
- The University of Sydney Children's Hospital Westmead Clinical School, Westmead, New South Wales, Australia
| | - Megan McStea
- Australian Commonwealth Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Todd Miller
- Australian Commonwealth Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Michael Nissen
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Claire Larter
- Australian Commonwealth Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Elspeth Kay
- Australian Commonwealth Department of Health and Aged Care, Canberra, Australian Capital Territory, Australia
| | - Vivien M. Chen
- Department of Haematology and NSW Health Pathology, Concord Hospital Sydney, New South Wales, Australia
- ANZAC Research Institute, Sydney Local Health District, New South Wales, Australia
- Sydney Medical School, University of Sydney, New South Wales, Australia
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Choi PYI, Hsu D, Tran HA, Tan CW, Enjeti A, Chen VMY, Merriman E, Yong AS, Simpson J, Gardiner E, Cherbuin N, Curnow J, Pepperell D, Bird R. Immune thrombocytopenia and COVID-19 vaccination: Outcomes and comparisons to prepandemic patients. Res Pract Thromb Haemost 2023; 7:100009. [PMID: 36531670 PMCID: PMC9744687 DOI: 10.1016/j.rpth.2022.100009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/01/2022] [Accepted: 10/07/2022] [Indexed: 01/12/2023] Open
Abstract
Background Immune thrombocytopenia (ITP) has been reported following COVID-19 vaccination. After index case fatalities, there was concern among patients both with and without a prior history of ITP in Australia. Objectives To describe treatment outcomes of ITP after COVID-19 vaccination and compare relapsed vs historical pre-COVID-19 ITP cohorts. Methods We collected ITP cases in Australia within 6 weeks of receiving any COVID-19 vaccination as part of primary vaccination (up to October 17, 2021). Second, we reviewed platelet charts in a historical ITP cohort to determine whether platelet variability was distinct from relapsed ITP after vaccination. Results We report on 50 patients (37 de novo, 13 relapsed ITP) vaccinated from March 22, 2021, to October 17, 2021. Although there was 1 fatality, bleeding was otherwise mostly minor: (70% WHO bleeding grade <2). De novo ITP was more likely after AstraZeneca ChAdOx1 nCoV-19 (89%) than Pfizer BNT162b2 (11%). Most patients responded quickly (median, 4 days; complete response, 40 of 45 [89%]). In the historical cohort, only 6 of 47 patients exhibited platelet variability (>50% decrease and platelets <100 × 109/L), but median platelet nadir was significantly higher than vaccination relapse (27 vs 6 × 109/L, P =.005). Conclusion ITP was more frequently reported after AstraZeneca ChAdOx1 nCoV-19 than Pfizer BNT162b2 vaccination. Standard ITP treatments remain highly effective for de novo and relapsed ITP (96%). Although thrombocytopenia can be severe after vaccination, bleeding is usually mild. Despite some sampling bias, our data do not support a change in treatment strategies for patients with ITP after vaccination.
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Affiliation(s)
- Philip Young-Ill Choi
- The Canberra Hospital, Canberra, Australian Capital Territory, Australia
- John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
- Correspondence Philip Choi, Haematology Department, Canberra Region Cancer Centre, Level 5, Building 19, The Canberra Hospital, Yamba Drive, Garran, ACT 2605, Australia. @philbaggins
| | - Danny Hsu
- Liverpool Hospital (New South Wales Health Pathology), Liverpool, NSW, Australia
- University of New South Wales, Australia
| | | | - Chee Wee Tan
- Royal Adelaide Hospital, South Australia Pathology, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Anoop Enjeti
- Calvary Mater Hospital, Newcastle, New South Wales, Australia
| | | | - Eileen Merriman
- Waitemata District Health Board, Department of Haematology, New Zealand
| | - Agnes S.M. Yong
- Department of Haematology, Royal Perth Hospital, Perth, Western Australia, Australia
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Jock Simpson
- Port Macquarie Base Hospital, New South Wales, Australia
| | - Elizabeth Gardiner
- John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Nicolas Cherbuin
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Jennifer Curnow
- Westmead Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Dominic Pepperell
- Fiona Stanley Hospital (PathWest), Murdoch, Western Australia, Australia
| | - Robert Bird
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Favaloro EJ, Clifford J, Leitinger E, Parker M, Sung P, Chunilal S, Tran H, Kershaw G, Fu S, Passam F, Ahuja M, Ho SJ, Duncan E, Yacoub O, Tan CW, Kaminskis L, Modica N, Pepperell D, Ballard L, Clarke L, Lee CSM, Gardiner EE, Young-Ill Choi P, Tohidi-Esfahani I, Bird R, Brighton T, Chen VM. Assessment of immunological anti-platelet factor 4 antibodies for vaccine-induced thrombotic thrombocytopenia (VITT) in a large Australian cohort: A multicenter study comprising 1284 patients. J Thromb Haemost 2022; 20:2896-2908. [PMID: 36107495 PMCID: PMC9828670 DOI: 10.1111/jth.15881] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Vaccine-induced thrombotic thrombocytopenia (VITT) is a rare complication of adenovirus-based vaccines aimed to prevent and minimize COVID-19 and related pathophysiology. OBJECTIVES To describe patterns of testing for anti-platelet factor 4 (PF4) antibodies using various ELISA assays in a large Australian cohort and comparative functional platelet activation assays in a subset. PATIENTS/METHODS Asserachrom HPIA IgG ELISA was performed in 1284 patients over a period of 12 months, supplemented in select cohorts by comparative ELISA using three other methods (n = 78-179), three different functional assays (flow cytometry, serotonin release assay, and/or Multiplate; n = 476), and rapid immunological chemiluminescence anti-PF4 assay (n = 460), in a multicenter study. RESULTS For first episode presentations, 190/1284 (14.8%) ELISA tests were positive. Conversely, most (445/460; 96.7%) chemiluminescence anti-PF4 test results were negative. All functional assays showed associations of higher median ELISA optical density with functional positivity and with high rates of ELISA positivity (64.0% to 85.2%). Data also identified functional positivity in 14.8%-36.0% of ELISA negative samples, suggesting false negative VITT by HPIA IgG ELISA in upward of one third of assessable cases. CONCLUSION To our knowledge, this is the largest multicenter evaluation of anti-PF4 testing for investigation of VITT. Discrepancies in test results (ELISA vs. ELISA or ELISA vs. functional assay) in some patients highlighted limitations in relying on single methods (ELISA and functional) for PF4 antibody detection in VITT, and also highlights the variability in phenotypic test presentation and pathomechanism of VITT.
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Affiliation(s)
- Emmanuel J Favaloro
- Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga, New South Wales, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Emma Leitinger
- Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Michael Parker
- Haematology, Monash Health, Melbourne, Victoria, Australia
| | - Pauline Sung
- Haematology, Monash Health, Melbourne, Victoria, Australia
| | | | - Huyen Tran
- Clinical Haematology Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Geoffrey Kershaw
- Haematology, NSW Health Pathology, Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Suki Fu
- Haematology, NSW Health Pathology, Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Freda Passam
- Haematology, NSW Health Pathology, Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Monica Ahuja
- Haematology, NSW Health Pathology, St George Hospital, Kogarah, New South Wales, Australia
| | - Shir Jing Ho
- Haematology, NSW Health Pathology, St George Hospital, Kogarah, New South Wales, Australia
| | - Elizabeth Duncan
- Haematology, SA Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Olivia Yacoub
- Haematology, SA Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Chee Wee Tan
- Haematology, SA Pathology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Lisa Kaminskis
- Haematology, PathWest, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Natasha Modica
- Haematology, PathWest, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Dominic Pepperell
- Haematology, PathWest, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Leanne Ballard
- Haematology, Qld Pathology, Royal Brisbane Hospital, Brisbane, Queensland, Australia
| | - Lisa Clarke
- Haematology, NSW Health Pathology, Concord Hospital, Concord, New South Wales, Australia
- Australian Red Cross Lifeblood, Sydney, New South Wales, Australia
| | - Christine S M Lee
- ANZAC Research Institute, University of Sydney, Concord Hospital, Concord, New South Wales, Australia
| | - Elizabeth E Gardiner
- John Curtin School of Medical Research, Division of Genome Sciences and Cancer, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Philip Young-Ill Choi
- John Curtin School of Medical Research, Division of Genome Sciences and Cancer, The Australian National University, Canberra, Australian Capital Territory, Australia
- Haematology, The Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Ibrahim Tohidi-Esfahani
- ANZAC Research Institute, University of Sydney, Concord Hospital, Concord, New South Wales, Australia
| | - Robert Bird
- Division of Cancer Services, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Timothy Brighton
- Haematology, NSW Health Pathology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Vivien M Chen
- Haematology, NSW Health Pathology, Concord Hospital, Concord, New South Wales, Australia
- ANZAC Research Institute, University of Sydney, Concord Hospital, Concord, New South Wales, Australia
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Choi PYI, Hsu D, Tran HA, Tan CW, Enjeti A, Chen VMY, Chong BH, Curnow J, Pepperell D, Bird R. Immune thrombocytopenia following vaccination during the COVID-19 pandemic. Haematologica 2021; 107:1193-1196. [PMID: 34435486 PMCID: PMC9052907 DOI: 10.3324/haematol.2021.279442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Indexed: 11/09/2022] Open
Abstract
Not available.
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Affiliation(s)
| | | | | | | | | | | | - Beng Hock Chong
- NSW Health Pathology, St George Hospital, University NSW, Sydney
| | - Jennifer Curnow
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW
| | | | - Robert Bird
- Princess Alexandra Hospital, Brisbane, Queensland
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Chuah H, Scott E, Dixon T, Phillips M, Ling J, Brown B, P'ng S, Pepperell D, Carnley B, Leahy M. The role of point-of-care tests in rapid evaluation of clinically significant rivaroxaban levels. Pathology 2018. [DOI: 10.1016/j.pathol.2017.12.303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Chuah H, Brown B, Dixon T, Phillips M, Ling J, Scott E, P'ng S, Pepperell D, Carnley B, Leahy M. Point of care tests and apixaban levels. Pathology 2018. [DOI: 10.1016/j.pathol.2017.12.285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Affiliation(s)
- P W X Foley
- Wessex Cardiac Unit, Southampton University Hospital, Southampton SO16 6YD, UK
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Thompson G, Pepperell D, Lawrence I, McGettigan BD. Crohn's disease complicated by Epstein-Barr virus-driven haemophagocytic lymphohistiocytosis successfully treated with rituximab. BMJ Case Rep 2017; 2017:bcr-2016-218578. [PMID: 28228435 DOI: 10.1136/bcr-2016-218578] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
We report a case of Epstein-Barr virus (EBV)-driven haemophagocytic lymphohistiocytosis (HLH) in a man with Crohn's disease treated with 6-mercaptopurine and adalimumab therapy who was successfully treated with rituximab therapy alone. This is the first published case in an adult patient with EBV-driven HLH in the setting of thiopurine use and inflammatory bowel disease to be successfully treated with rituximab therapy alone. Here, we will discuss putative immunological mechanisms which may contribute to this potentially life-threatening complication.
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Affiliation(s)
- Grace Thompson
- Department of Immunology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Dominic Pepperell
- Department of Haematology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Ian Lawrence
- Harry Perkins Institute of Medical Research Perkins South, Perth, Bahrain.,Centre for Inflammatory Bowel Diseases, Subiaco, Perth, Western Australia, Australia
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Nguyen TN, Pepperell D, Morel-Kopp MC, Cumming RG, Ward C, Hilmer SN. Effect of Frailty and Age on Platelet Aggregation and Response to Aspirin in Older Patients with Atrial Fibrillation: A Pilot Study. Cardiol Ther 2016; 5:51-62. [PMID: 26843016 PMCID: PMC4906083 DOI: 10.1007/s40119-016-0056-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Frailty is associated with changes in inflammation, coagulation, and possibly platelet function. Aspirin is still prescribed for stroke prevention in older patients with atrial fibrillation, although not recommended by current guidelines. In frail older people, it is unclear whether platelet aggregability and response to aspirin are altered. This study aims to investigate the effects of frailty and chronological age on platelet aggregability and on responses to aspirin in older patients with atrial fibrillation. METHODS Inpatients with atrial fibrillation aged ≥65 years were recruited from a tertiary referral hospital in Sydney, Australia. Frailty was determined using the Reported Edmonton Frail Scale. Platelet aggregation studies were performed using whole blood impedance aggregometry. RESULTS Data from 115 participants were analyzed (mean age 85 ± 6 years, 41% female, 52% frail). Spearman correlation coefficients found no significant associations of platelet aggregation with chronological age or with frailty score. Comparison between frail and non-frail groups showed that there was no impact of frailty status on aggregation assays amongst participants who were not taking any antiplatelet drugs. Amongst participants taking aspirin, the frail had higher adjusted arachidonic acid agonist (ASPI) test measures (AU per platelet) than the non-frail (0.11 ± 0.11 vs. 0.05 ± 0.04; p = 0.04), suggesting that in frail participants, platelet aggregation is less responsive to aspirin than in non-frail. CONCLUSIONS We found no effect of chronological age or frailty status on platelet aggregation amongst older patients with atrial fibrillation in this pilot study. However, frailty could be associated with reduced aspirin responsiveness among older patients with atrial fibrillation.
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Affiliation(s)
- Tu N Nguyen
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital and Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.
| | - Dominic Pepperell
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital and Northern Blood Research Centre, Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Marie-Christine Morel-Kopp
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital and Northern Blood Research Centre, Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Robert G Cumming
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Christopher Ward
- Department of Haematology and Transfusion Medicine, Royal North Shore Hospital and Northern Blood Research Centre, Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Sarah N Hilmer
- Departments of Clinical Pharmacology and Aged Care, Royal North Shore Hospital and Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Blombery P, Kivivali L, Pepperell D, McQuilten Z, Engelbrecht S, Polizzotto M, Phillips L, Wood E, Cohney S. Diagnosis and management of thrombotic thrombocytopenic purpura (TTP) in Australia: findings from the first 5 years of the Australian TTP/thrombotic microangiopathy registry. Intern Med J 2016; 46:71-9. [DOI: 10.1111/imj.12935] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 07/20/2015] [Accepted: 10/15/2015] [Indexed: 10/22/2022]
Affiliation(s)
- P. Blombery
- Department of Haematology; Peter MacCallum Cancer Centre; Melbourne Australia
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
| | - L. Kivivali
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
| | - D. Pepperell
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- Fiona Stanley Hospital; Perth Australia
| | - Z. McQuilten
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
| | - S. Engelbrecht
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- Gold Coast University Hospital; Queensland Australia
| | - M. N. Polizzotto
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- St Vincent's Hospital; Sydney Australia
- The Kirby Institute; University of New South Wales; Sydney Australia
| | - L. E. Phillips
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
| | - E. Wood
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- Monash Medical Centre; Melbourne Australia
| | - S. Cohney
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Australia
- Department of Medicine; University of Melbourne; Melbourne Australia
- Departments of Nephrology; Western and Royal Melbourne Hospitals; Melbourne Australia
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Soosapilla A, Pepperell D, Best G, Brizzi C, Mulligan CS, van Bilsen N, Mulligan SP. Monoclonal B-lymphocytosis in patients aged over 90 years is common but not inevitable, and has a prevalence comparable to that in individuals aged 65–90 years. Leuk Lymphoma 2015; 56:2182-4. [DOI: 10.3109/10428194.2014.976822] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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