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Kutaiba N, Varcoe JG, Barnes P, Succar N, Lau E, Patwala K, Low E, Ardalan Z, Gow P, Goodwin M. Radiation exposure from radiological procedures in liver transplant candidates with hepatocellular carcinoma. Eur J Radiol 2023; 158:110656. [PMID: 36542933 DOI: 10.1016/j.ejrad.2022.110656] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 10/25/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE Candidates for liver transplantation (LT) with hepatocellular carcinoma (HCC) undergo a large number of diagnostic and interventional radiology procedures. A significant proportion of such procedures involve ionizing radiation with increased lifetime risk of cancer. The objective of our study was to review LT candidates with HCC to quantify ionizing radiation doses from different radiology procedures performed at a single transplant center. METHOD We retrospectively reviewed 179 adult patients with HCC (median age 58.6 years [IQR, 55-62]; 155 [86.6%] males) who were accepted for LT between April 2010 and Dec 2018. Radiology procedures and radiation doses were retrieved and the total and median radiation effective dose in millisieverts (mSv) were calculated for different procedures. Exposure to ionizing radiation was categorized based on previously reported thresholds. RESULTS We assessed 9,986 radiology procedures for our cohort. Patients had a median effective dose prior to transplantation of 254 mSv (IQR, 130-421) with an annualized rate of 152 mSv (IQR, 92-266). Patient median dose increased to 316 mSv (IQR, 159-478) when including exposures post-LT within the study period. 85% of overall exposure was in the extremely high exposure category (>100 mSv). Interventional procedures represented 13% of procedures with substantial radiation and contributed to 45% of radiation exposure while abdominal CTs represented 39% of total procedures and contributed to 45% of radiation exposure. CONCLUSIONS Patients with HCC considered for LT undergo radiology procedures with significant cumulative radiation exposure. Attempts to reduce radiation exposure are suggested by minimizing unnecessary procedures and utilizing ones without ionizing radiation. Improving interventional techniques to reduce radiation doses is needed without compromising treatment delivery.
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Affiliation(s)
- Numan Kutaiba
- Radiology Department, Austin Health, Melbourne, Victoria, Australia; The University of Melbourne, Victoria, Australia.
| | - Joshua G Varcoe
- Australian Radiation Protection and Nuclear Safety Agency, Melbourne, Victoria, Australia; Medical Physics, Austin Health, Melbourne, Victoria, Australia
| | - Peter Barnes
- Medical Physics, Austin Health, Melbourne, Victoria, Australia
| | - Natalie Succar
- Radiology Department, Austin Health, Melbourne, Victoria, Australia
| | - Eddie Lau
- Radiology Department, Austin Health, Melbourne, Victoria, Australia; The University of Melbourne, Victoria, Australia; Molecular Imaging and Therapy, Austin Health, Melbourne, Victoria, Australia
| | - Kurvi Patwala
- Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Elizabeth Low
- Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Zaid Ardalan
- Department of Gastroenterology, Alfred Health and Monash University, Melbourne, Victoria, Australia
| | - Paul Gow
- The University of Melbourne, Victoria, Australia; Liver Transplant Unit, Austin Health, Melbourne, Victoria, Australia
| | - Mark Goodwin
- Radiology Department, Austin Health, Melbourne, Victoria, Australia; The University of Melbourne, Victoria, Australia
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Patwala K, Prince DS, Celermajer Y, Alam W, Paul E, Strasser SI, McCaughan GW, Gow P, Sood S, Murphy E, Roberts S, Freeman E, Stratton E, Davison SA, Levy MT, Clark-Dickson M, Nguyen V, Bell S, Nicoll A, Bloom A, Lee AU, Ryan M, Howell J, Valaydon Z, Mack A, Liu K, Dev A. Lenvatinib for the treatment of hepatocellular carcinoma-a real-world multicenter Australian cohort study. Hepatol Int 2022; 16:1170-1178. [PMID: 36006547 PMCID: PMC9525325 DOI: 10.1007/s12072-022-10398-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/24/2022] [Indexed: 11/30/2022]
Abstract
Introduction Hepatocellular carcinoma (HCC) is a serious complication of chronic liver disease. Lenvatinib is an oral multikinase inhibitor registered to treat advanced HCC. This study evaluates the real-world experience with lenvatinib in Australia. Methods We conducted a retrospective cohort study of patients treated with lenvatinib for advanced HCC between July 2018 and November 2020 at 11 Australian tertiary care hospitals. Baseline demographic data, tumor characteristics, lenvatinib dosing, adverse events (AEs) and clinical outcomes were collected. Overall survival (OS) was the primary outcome. Progression free survival (PFS) and AEs were secondary outcomes. Results A total of 155 patients were included and were predominantly male (90.7%) with a median age of 65 years (interquartile range [IQR]: 59–75). The main causes of chronic liver disease were hepatitis C infection (40.0%) and alcohol-related liver disease (34.2). Median OS and PFS were 7.7 (95% confidence interval [CI]: 5.8–14.0) and 5.3 months (95% CI: 2.8–9.2) respectively. Multivariate predictors of mortality were the need for dose reduction due to AEs (Hazard ratio [HR] 0.41, p < 0.01), new or worsening hypertension (HR 0.42, p < 0.01), diarrhoea (HR 0.47, p = 0.04) and more advanced BCLC stage (HR 2.50, p = 0.04). Multivariable predictors of disease progression were higher Child–Pugh score (HR 1.25, p = 0.04), the need for a dose reduction (HR 0.45, p < 0.01) and age (HR 0.96, p < 0.001). AEs occurred in 83.9% of patients with most being mild (71.6%). Conclusions Lenvatinib remains safe and effective in real-world use. Treatment emergent diarrhoea and hypertension, and the need for dose reduction appear to predict better OS. Supplementary Information The online version contains supplementary material available at 10.1007/s12072-022-10398-5.
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Affiliation(s)
- Kurvi Patwala
- Department of Gastroenterology, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia.
| | - David Stephen Prince
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia. .,Department of Gastroenterology, Liverpool Hospital, 75 Elizabeth Street, Liverpool, NSW, 2170, Australia.
| | - Yael Celermajer
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Waafiqa Alam
- Department of Gastroenterology, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Eldho Paul
- Department of Medicine, Monash University, Wellington Road, Clayton, VIC, 3800, Australia
| | - Simone Irene Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Geoffrey William McCaughan
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Paul Gow
- Department of Gastroenterology and Liver Transplant, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Siddharth Sood
- Department of Gastroenterology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC, 3050, Australia
| | - Elise Murphy
- Department of Gastroenterology, Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC, 3050, Australia
| | - Stuart Roberts
- Department of Medicine, Monash University, Wellington Road, Clayton, VIC, 3800, Australia.,Department of Gastroenterology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Elliot Freeman
- Department of Gastroenterology, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Elizabeth Stratton
- Department of Gastroenterology, Liverpool Hospital, 75 Elizabeth Street, Liverpool, NSW, 2170, Australia
| | - Scott Anthony Davison
- Department of Gastroenterology, Liverpool Hospital, 75 Elizabeth Street, Liverpool, NSW, 2170, Australia
| | - Miriam Tania Levy
- Department of Gastroenterology, Liverpool Hospital, 75 Elizabeth Street, Liverpool, NSW, 2170, Australia
| | - McCawley Clark-Dickson
- Department of Gastroenterology, Royal North Shore Hospital, Reserve Road, St Leonard's, NSW, 2065, Australia
| | - Vi Nguyen
- Department of Gastroenterology, Royal North Shore Hospital, Reserve Road, St Leonard's, NSW, 2065, Australia
| | - Sally Bell
- Department of Gastroenterology, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
| | - Amanda Nicoll
- Department of Gastroenterology, Eastern Health, 8 Arnold Street, Box Hill, VIC, 3128, Australia
| | - Ashley Bloom
- Department of Gastroenterology, Eastern Health, 8 Arnold Street, Box Hill, VIC, 3128, Australia
| | - Alice Unah Lee
- Department of Gastroenterology, Concord Repatriation General Hospital, Hospital Road, Concord, NSW, 2139, Australia
| | - Marno Ryan
- Department of Gastroenterology, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia
| | - Jessica Howell
- Department of Gastroenterology, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC, 3065, Australia.,Department of Medicine, University of Melbourne, Parkville, VIC, 3010, Australia.,Disease Elimination Program, Burnet Institute, 85 Commercial Road, Melbourne, VIC, 3004, Australia.,Department of Epidemiology and Preventative Medicine, Monash University, Wellington Road, Clayton, VIC, 3800, Australia
| | - Zina Valaydon
- Department of Gastroenterology, Western Health, 160 Gordon Street, Footscray, VIC, 3011, Australia
| | - Alexandra Mack
- Department of Gastroenterology, Western Health, 160 Gordon Street, Footscray, VIC, 3011, Australia
| | - Ken Liu
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2050, Australia
| | - Anouk Dev
- Department of Gastroenterology, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia
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Pham AD, Vaz K, Ardalan ZS, Sinclair M, Apostolov R, Gardner S, Majeed A, Mishra G, Kam NM, Patwala K, Kutaiba N, Arachchi N, Bell S, Dev AT, Lubel JS, Nicoll AJ, Sood S, Kemp W, Roberts SK, Fink M, Testro AG, Angus PW, Gow PJ. Clinical outcomes of patients with two small hepatocellular carcinomas. World J Hepatol 2021; 13:1439-1449. [PMID: 34786178 PMCID: PMC8568581 DOI: 10.4254/wjh.v13.i10.1439] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 06/28/2021] [Accepted: 09/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Management of single small hepatocellular carcinoma (HCC) is straightforward with curative outcomes achieved by locoregional therapy or resection. Liver transplantation is often considered for multiple small or single large HCC. Management of two small HCC whether presenting synchronously or sequentially is less clear.
AIM To define the outcomes of patients presenting with two small HCC.
METHODS Retrospective review of HCC databases from multiple institutions of patients with either two synchronous or sequential HCC ≤ 3 cm between January 2000 and March 2018. Primary outcomes were overall survival (OS) and transplant-free survival (TFS).
RESULTS 104 patients were identified (male n = 89). Median age was 63 years (interquartile range 58-67.75) and the most common aetiology of liver disease was hepatitis C (40.4%). 59 (56.7%) had synchronous HCC and 45 (43.3%) had sequential. 36 patients died (34.6%) and 25 were transplanted (24.0%). 1, 3 and 5-year OS was 93.0%, 66.1% and 62.3% and 5-year post-transplant survival was 95.8%. 1, 3 and 5-year TFS was 82.1%, 45.85% and 37.8%. When synchronous and sequential groups were compared, OS (1,3 and 5 year synchronous 91.3%, 63.8%, 61.1%, sequential 95.3%, 69.5%, 64.6%, P = 0.41) was similar but TFS was higher in the sequential group (1,3 and 5 year synchronous 68.5%, 37.3% and 29.7%, sequential 93.2%, 56.6%, 48.5%, P = 0.02) though this difference did not remain during multivariate analysis.
CONCLUSION TFS in patients presenting with two HCC ≤ 3 cm is poor regardless of the timing of the second tumor. All patients presenting with two small HCC should be considered for transplantation.
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Affiliation(s)
- Anh Duy Pham
- The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Karl Vaz
- The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Zaid S Ardalan
- The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
- Department of Gastroenterology, Alfred Health, Melbourne 3000, Victoria, Australia
| | - Marie Sinclair
- The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- The University of Melbourne, Parkville 3010, Victoria, Australia
| | - Ross Apostolov
- The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
- The University of Melbourne, Parkville 3010, Victoria, Australia
| | - Sarah Gardner
- The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Ammar Majeed
- Department of Gastroenterology, Alfred Health, Melbourne 3000, Victoria, Australia
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- Central Clinical School, Monash University, Melbourne 3004, Victoria, Australia
| | - Gauri Mishra
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
| | - Ning Mao Kam
- The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Kurvi Patwala
- The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
| | - Numan Kutaiba
- Department of Radiology, Austin Health, Heidelberg 3084, Victoria, Australia
- Department of Radiology, Eastern Health, Box Hill 3128, Victoria, Australia
| | - Niranjan Arachchi
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- Department of Gastroenterology, Western Health, Footscray 3011, Victoria, Australia
| | - Sally Bell
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- The University of Melbourne, Parkville 3010, Victoria, Australia
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
| | - Anouk T Dev
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
| | - John S Lubel
- Department of Gastroenterology, Alfred Health, Melbourne 3000, Victoria, Australia
- Central Clinical School, Monash University, Melbourne 3004, Victoria, Australia
| | - Amanda J Nicoll
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- Department of Gastroenterology, Eastern Health, Box Hill 3128, Victoria, Australia
| | - Siddharth Sood
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- The University of Melbourne, Parkville 3010, Victoria, Australia
- Department of Gastroenterology, Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - William Kemp
- Department of Gastroenterology, Alfred Health, Melbourne 3000, Victoria, Australia
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- Central Clinical School, Monash University, Melbourne 3004, Victoria, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, Alfred Health, Melbourne 3000, Victoria, Australia
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- Central Clinical School, Monash University, Melbourne 3004, Victoria, Australia
| | - Michael Fink
- The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- The University of Melbourne, Parkville 3010, Victoria, Australia
| | - Adam G Testro
- The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- The University of Melbourne, Parkville 3010, Victoria, Australia
| | - Peter W Angus
- The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- The University of Melbourne, Parkville 3010, Victoria, Australia
| | - Paul J Gow
- The Victorian Liver Transplant Unit, Austin Health, Heidelberg 3084, Victoria, Australia
- The Melbourne Liver Group, Melbourne 3000, Victoria, Australia
- The University of Melbourne, Parkville 3010, Victoria, Australia
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Phan T, Patwala K, Lipton L, Knight V, Aga A, Pianko S. Very Delayed Acute Hepatitis after Pembrolizumab Therapy for Advanced Malignancy: How Long Should We Watch? Curr Oncol 2021; 28:898-902. [PMID: 33617506 PMCID: PMC7985792 DOI: 10.3390/curroncol28010088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 01/14/2021] [Revised: 02/05/2021] [Accepted: 02/09/2021] [Indexed: 02/05/2023] Open
Abstract
Immune checkpoint inhibitors (ICIs) have led to major therapeutic advances in the management of malignancy. Despite promising outcomes for some cancers, ICIs are linked to unique side-effects known as immune-related adverse events (IrAEs). These may affect a wide array of organ systems. In particular, ICI-induced hepatitis is diagnostically challenging given its variable natural history and clinical manifestations. The onset of ICI-induced hepatitis often occurs between 6 and 14 weeks after treatment initiation and rarely exhibits delayed presentations or manifests after treatment cessation. We present a case of very delayed-onset ICI-induced hepatitis, stressing the importance of long-term surveillance for immune-indued hepatitis in patients initiated on ICIs even long after treatment cessation.
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Affiliation(s)
- Timothy Phan
- Monash Health, Clayton, Melbourne, VIC 3168, Australia; (K.P.); (S.P.)
- Correspondence: ; Tel.: +61-467-070-312
| | - Kurvi Patwala
- Monash Health, Clayton, Melbourne, VIC 3168, Australia; (K.P.); (S.P.)
| | - Lara Lipton
- The Royal Melbourne Hospital, Parkville, VIC 3052, Australia;
| | - Virginia Knight
- Cabrini Medical Centre, Malvern, VIC 3144, Australia; (V.K.); (A.A.)
| | - Ahmad Aga
- Cabrini Medical Centre, Malvern, VIC 3144, Australia; (V.K.); (A.A.)
| | - Stephen Pianko
- Monash Health, Clayton, Melbourne, VIC 3168, Australia; (K.P.); (S.P.)
- School of Clinical Sciences, Monash University, Melbourne, VIC 3168, Australia
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Low ESL, Patwala K, Apostolov R. Dyspnoea, clubbing, cirrhosis, and bubbles in both sides of the heart suggests hepatopulmonary syndrome. Lancet 2019; 394:510. [PMID: 31402029 DOI: 10.1016/s0140-6736(19)31720-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 03/08/2019] [Accepted: 07/04/2019] [Indexed: 10/26/2022]
Affiliation(s)
| | - Kurvi Patwala
- Liver Transplant Unit, Austin Hospital, Heidelberg, VIC, Australia
| | - Ross Apostolov
- Liver Transplant Unit, Austin Hospital, Heidelberg, VIC, Australia
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Patwala K, Crump N, De Cruz P. Guillain-Barré syndrome in association with antitumour necrosis factor therapy: a case of mistaken identity. BMJ Case Rep 2017; 2017:bcr-2017-219481. [PMID: 28679512 DOI: 10.1136/bcr-2017-219481] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an immune-mediated disease characterised by evolving ascending limb weakness, sensory loss and areflexia. Two-thirds of GBS cases are associated with preceding infection. However, GBS has also been described in association with antitumour necrosis factor (TNF) therapies including infliximab and adalimumab for chronic inflammatory disorders such as rheumatoid arthritis, ankylosing spondylitis and inflammatory bowel disease. We present the case of a patient who developed GBS while undergoing treatment with adalimumab in combination with azathioprine for severe fistulising Crohn's disease, and review the literature on neurological adverse events that occur in association with anti-TNF therapy. We also propose an approach to the optimal management of patients who develop debilitating neurological sequelae in the setting of anti-TNF therapy.
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Affiliation(s)
- Kurvi Patwala
- Department of Gastroenterology, Austin Health, Heidelberg, Australia
| | - Nicholas Crump
- Department of Neurology, Austin Health, Heidelberg, Australia
| | - Peter De Cruz
- Department of Gastroenterology, Austin Health, Heidelberg, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
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