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Radsak M, Platzbecker U, Schmidt CS, Hofmann WK, Nolte F. Infectious complications in patients with myelodysplastic syndromes: A review of the literature with emphasis on patients treated with 5-azacitidine. Eur J Haematol 2017; 99:112-118. [PMID: 28321924 DOI: 10.1111/ejh.12883] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 01/17/2023]
Abstract
Myelodysplastic Syndromes are oligo-clonal stem cell disorders that are associated with cytopenias in the peripheral blood. Major causes for morbidity and mortality in myelodysplastic syndromes (MDS) patients are infections mostly due to bacteria or fungi. Beside leucopenia per se in affected patients, function of white blood cells particularly that of neutrophils seems to be impaired. Here we summarize the available data on infections in MDS patients in general and particularly those treated with 5-azacitidine.
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Affiliation(s)
- Markus Radsak
- 3rd Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Uwe Platzbecker
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Cornelia S Schmidt
- 3rd Department of Medicine, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Wolf-Karsten Hofmann
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Florian Nolte
- Department of Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
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2
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Pohlen M, Marx J, Mellmann A, Becker K, Mesters RM, Mikesch JH, Schliemann C, Lenz G, Müller-Tidow C, Büchner T, Krug U, Stelljes M, Karch H, Peters G, Gerth HU, Görlich D, Berdel WE. Ciprofloxacin versus colistin prophylaxis during neutropenia in acute myeloid leukemia: two parallel patient cohorts treated in a single center. Haematologica 2016; 101:1208-1215. [PMID: 27470601 PMCID: PMC5046650 DOI: 10.3324/haematol.2016.147934] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/19/2016] [Indexed: 11/09/2022] Open
Abstract
Patients undergoing intensive chemotherapy for acute myeloid leukemia are at high risk for bacterial infections during therapy-related neutropenia. However, the use of specific antibiotic regimens for prophylaxis in afebrile neutropenic acute myeloid leukemia patients is controversial. We report a retrospective evaluation of 172 acute myeloid leukemia patients who received 322 courses of myelosuppressive chemotherapy and had an expected duration of neutropenia of more than seven days. The patients were allocated to antibiotic prophylaxis groups and treated with colistin or ciprofloxacin through 2 different hematologic services at our hospital, as available. The infection rate was reduced from 88.6% to 74.2% through antibiotic prophylaxis (vs without prophylaxis; P=0.04). A comparison of both antibiotic drugs revealed a trend towards fewer infections associated with ciprofloxacin prophylaxis (69.2% vs 79.5% in the colistin group; P=0.07), as determined by univariate analysis. This result was confirmed through multivariate analysis (OR: 0.475, 95%CI: 0.236-0.958; P=0.041). The prophylactic agents did not differ with regard to the microbiological findings (P=0.6, not significant). Of note, the use of ciprofloxacin was significantly associated with an increased rate of infections with pathogens that are resistant to the antibiotic used for prophylaxis (79.5% vs 9.5% in the colistin group; P<0.0001). The risk factors for higher infection rates were the presence of a central venous catheter (P<0.0001), mucositis grade III/IV (P=0.0039), and induction/relapse courses (vs consolidation; P<0.0001). In conclusion, ciprofloxacin prophylaxis appears to be of particular benefit during induction and relapse chemotherapy for acute myeloid leukemia. To prevent and control drug resistance, it may be safely replaced by colistin during consolidation cycles of acute myeloid leukemia therapy.
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Affiliation(s)
- Michele Pohlen
- Department of Medicine A, Hematology and Oncology, University Hospital of Muenster, Germany
| | - Julia Marx
- Department of Medicine A, Hematology and Oncology, University Hospital of Muenster, Germany
| | | | - Karsten Becker
- Institute of Medical Microbiology, University Hospital Muenster, Germany
| | - Rolf M Mesters
- Department of Medicine A, Hematology and Oncology, University Hospital of Muenster, Germany
| | - Jan-Henrik Mikesch
- Department of Medicine A, Hematology and Oncology, University Hospital of Muenster, Germany
| | - Christoph Schliemann
- Department of Medicine A, Hematology and Oncology, University Hospital of Muenster, Germany
| | - Georg Lenz
- Department of Medicine A, Hematology and Oncology, University Hospital of Muenster, Germany Translational Oncology, University Hospital Muenster, Germany Cluster of Excellence EXC 1003, Cells in Motion, Germany
| | - Carsten Müller-Tidow
- Department of Medicine A, Hematology and Oncology, University Hospital of Muenster, Germany Department of Medicine IV, Hematology and Oncology, University Hospital Halle, Germany
| | - Thomas Büchner
- Department of Medicine A, Hematology and Oncology, University Hospital of Muenster, Germany
| | - Utz Krug
- Department of Medicine A, Hematology and Oncology, University Hospital of Muenster, Germany Department of Medicine 3, Klinikum Leverkusen, Germany
| | - Matthias Stelljes
- Department of Medicine A, Hematology and Oncology, University Hospital of Muenster, Germany
| | - Helge Karch
- Institute of Hygiene, University Hospital Muenster, Germany Cluster of Excellence EXC 1003, Cells in Motion, Germany
| | - Georg Peters
- Institute of Medical Microbiology, University Hospital Muenster, Germany Cluster of Excellence EXC 1003, Cells in Motion, Germany
| | - Hans U Gerth
- Department of Medicine D, Nephrology and Rheumatology, University Hospital Muenster, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, University Muenster, Germany
| | - Wolfgang E Berdel
- Department of Medicine A, Hematology and Oncology, University Hospital of Muenster, Germany Cluster of Excellence EXC 1003, Cells in Motion, Germany
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Gafter-Gvili A, Fraser A, Paul M, Vidal L, Lawrie TA, van de Wetering MD, Kremer LCM, Leibovici L. Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy. Cochrane Database Syst Rev 2012; 1:CD004386. [PMID: 22258955 PMCID: PMC4170789 DOI: 10.1002/14651858.cd004386.pub3] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Bacterial infections are a major cause of morbidity and mortality in patients who are neutropenic following chemotherapy for malignancy. Trials have shown the efficacy of antibiotic prophylaxis in reducing the incidence of bacterial infections but not in reducing mortality rates. Our systematic review from 2006 also showed a reduction in mortality. OBJECTIVES This updated review aimed to evaluate whether there is still a benefit of reduction in mortality when compared to placebo or no intervention. SEARCH METHODS We searched the Cochrane Cancer Network Register of Trials (2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2011), MEDLINE (1966 to March 2011), EMBASE (1980 to March 2011), abstracts of conference proceedings and the references of identified studies. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention, or another antibiotic, to prevent bacterial infections in afebrile neutropenic patients. DATA COLLECTION AND ANALYSIS Two authors independently appraised the quality of each trial and extracted data from the included trials. Analyses were performed using RevMan 5.1 software. MAIN RESULTS One-hundred and nine trials (involving 13,579 patients) that were conducted between the years 1973 to 2010 met the inclusion criteria. When compared with placebo or no intervention, antibiotic prophylaxis significantly reduced the risk of death from all causes (46 trials, 5635 participants; risk ratio (RR) 0.66, 95% CI 0.55 to 0.79) and the risk of infection-related death (43 trials, 5777 participants; RR 0.61, 95% CI 0.48 to 0.77). The estimated number needed to treat (NNT) to prevent one death was 34 (all-cause mortality) and 48 (infection-related mortality).Prophylaxis also significantly reduced the occurrence of fever (54 trials, 6658 participants; RR 0.80, 95% CI 0.74 to 0.87), clinically documented infection (48 trials, 5758 participants; RR 0.65, 95% CI 0.56 to 0.76), microbiologically documented infection (53 trials, 6383 participants; RR 0.51, 95% CI 0.42 to 0.62) and other indicators of infection.There were no significant differences between quinolone prophylaxis and TMP-SMZ prophylaxis with regard to death from all causes or infection, however, quinolone prophylaxis was associated with fewer side effects leading to discontinuation (seven trials, 850 participants; RR 0.37, 95% CI 0.16 to 0.87) and less resistance to the drugs thereafter (six trials, 366 participants; RR 0.45, 95% CI 0.27 to 0.74). AUTHORS' CONCLUSIONS Antibiotic prophylaxis in afebrile neutropenic patients significantly reduced all-cause mortality. In our review, the most significant reduction in mortality was observed in trials assessing prophylaxis with quinolones. The benefits of antibiotic prophylaxis outweighed the harm such as adverse effects and the development of resistance since all-cause mortality was reduced. As most trials in our review were of patients with haematologic cancer, we strongly recommend antibiotic prophylaxis for these patients, preferably with a quinolone. Prophylaxis may also be considered for patients with solid tumours or lymphoma.
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Affiliation(s)
- Anat Gafter-Gvili
- Department of Medicine E, Beilinson Hospital, Rabin Medical Center, 39 Jabotinski Street, PetahTikva, 49100, Israel.
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Gafter-Gvili A, Fraser A, Paul M, van de Wetering M, Kremer L, Leibovici L. Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy. Cochrane Database Syst Rev 2005:CD004386. [PMID: 16235360 DOI: 10.1002/14651858.cd004386.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Bacterial infections are a major cause of morbidity and mortality in neutropenic patients following chemotherapy for malignancy. Trials have shown the efficacy of antibiotic prophylaxis in decreasing the incidence of bacterial infections, but not in reducing mortality rates. OBJECTIVES This review aimed to evaluate whether antibiotic prophylaxis in afebrile neutropenic patients reduced mortality when compared to placebo or no intervention. SEARCH STRATEGY Electronic searches on The Cochrane Cancer Network Register of Trials (2004), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (1966 to 2004) and EMBASE (1980 to 2004) and abstracts of conference proceedings; references of identified studies; the first author of each included trial was contacted. SELECTION CRITERIA RCTs or quasi-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention, or another antibiotic to prevent bacterial infections in afebrile neutropenic patients. DATA COLLECTION AND ANALYSIS Two authors independently appraised the quality of each trial and extracted data from the included trials. Relative risks (RR) or average differences, with their 95% confidence intervals (CI) were estimated. MAIN RESULTS One hundred trials (10,274 patients) performed between the years 1973 to 2004 met inclusion criteria. Antibiotic prophylaxis significantly decreased the risk for death when compared with placebo or no intervention (RR, 0.66 [95% CI 0.54 to 0.81]). The authors estimated the number needed to treat (NNT) in order to prevent 1 death from all causes as 60 (95% CI 34 to 268). Prophylaxis resulted in a significant decrease in the risk of infection-related death, RR 0.58 (95% CI 0.45 to 0.74) and in the occurrence of fever, RR 0.78 (95% CI 0.75 to 0.82). A reduction in mortality was also evident when the more recently conducted quinolone trials were analysed separately. Quinolone prophylaxis reduced the risk for all-cause mortality, RR 0.52 (95% CI, 0.37 to 0.84). AUTHORS' CONCLUSIONS Our review demonstrated that prophylaxis significantly reduced all-cause mortality. The most significant reduction in mortality was observed in trials assessing prophylaxis with quinolones. The benefit demonstrated in our review outweighs harm, such as adverse effects, and development of resistance, since all-cause mortality is reduced. Since most trials in our review were of patients with haematologic cancer, prophylaxis, preferably with a quinolone, should be considered for these patients.
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Affiliation(s)
- A Gafter-Gvili
- Rabin Medical Center, Department of Medicine E, Rabin Medical Center, Beilinson Campus, Petah-Tikva, Israel 49100.
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Kersun LS, Propert KJ, Lautenbach E, Bunin N, Demichele A. Early bacteremia in pediatric hematopoietic stem cell transplant patients on oral antibiotic prophylaxis. Pediatr Blood Cancer 2005; 45:162-9. [PMID: 15593235 DOI: 10.1002/pbc.20277] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Bacteremia occurs during hematopoietic stem cell transplant (HSCT) in 20%-25% of patients and the use of gut decontamination (GD) to decrease this risk is controversial. Our purpose was to determine the incidence of bacteremia and antimicrobial resistance post-HSCT in pediatric patients receiving GD, and to identify risk factors associated with infection. PROCEDURES This was a retrospective cohort study of 182 pediatric patients undergoing first HSCT for malignant disease at The Children's Hospital of Philadelphia from January, 1999 to December, 2002. We examined the impact of age, sex, race, diagnosis, disease status, conditioning regimen, recent bacteremia, stem cell source, donor, graft versus host disease prophylaxis agents, and mucositis severity using Cox proportional hazard models. GD consisted of amoxicillin (azithromycin, if penicillin allergic) and oral gentamicin. Outcome was first episode of bacteremia prior to absolute neutrophil count (ANC) 500/mm(3). Antibiotic susceptibilities were performed on all isolates. RESULTS Seventy-four patients (41%) developed bacteremia. The majority were Gram-positive cocci, with Staphylococcal (50%) and Streptococcal species (28%) the most common. Gram-negative organisms were identified in 22% with Pseudomonas (5.7%) and Klebsiella species (3.4%) the most common. Of the Streptococcal infections, 72% were resistant to ampicillin; only 25% of the Gram-negative bacteria were resistant to gentamicin. Race was the only factor associated with early bacteremia (hazard ratio 2.3 for non-Caucasian, non-African-American patients, CI 1.3-4.3, P = 0.007). CONCLUSIONS Early bacteremia is common after HSCT, despite the use of GD. Resistant Gram-positive organisms predominate, consistent with recent trends in immunocompromised patients. Although used in practice, there is no clear evidence for the efficacy of GD and this study provides the basis upon which to develop a randomized clinical trial evaluating the current GD regimen with placebo.
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Affiliation(s)
- Leslie S Kersun
- Department of Pediatrics, Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Mohty M, Jacot W, Faucher C, Bay JO, Zandotti C, Collet L, Choufi B, Bilger K, Tournilhac O, Vey N, Stoppa AM, Coso D, Gastaut JA, Viens P, Maraninchi D, Olive D, Blaise D. Infectious complications following allogeneic HLA-identical sibling transplantation with antithymocyte globulin-based reduced intensity preparative regimen. Leukemia 2003; 17:2168-77. [PMID: 12931226 DOI: 10.1038/sj.leu.2403105] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In the setting of reduced-intensity conditioning (RIC) regimens for allogeneic stem cell transplantation (allo-SCT), the epidemiology of transplant-related infections is still poorly defined. In 101 high-risk patients who received an HLA-identical sibling allo-SCT after RIC, including fludarabine, busulfan and antithymocyte globulin (ATG), we report during the first 6 months a cumulative incidence of positive CMV antigenemia of 42% (95% CI 32-52%), developing at a median of 37 (range 7-116) days without evidence of CMV disease (median follow-up, 434 days). The cumulative incidence of bacteremia was 25% (95% CI 17-33%), occurring at a median of 67 (range 7-172) days, while patients had recovered a full neutrophil count. In all, 65% of the bacteremia (95% CI 49-81%) were gram negative. The cumulative incidence of fungal infections was 8% (95% CI 3-13%), with a median onset of 89 (range 7-170) days. In multivariate analysis, stem cell source (bone marrow; P=0.0002) was significantly associated with the risk of positive CMV antigenemia, while higher doses of prednisone (>2 mg/kg) represented the major risk factor for bacteremia (P=0.0001). Infectious-related mortality was 5% (95% CI 1-9%), with aspergillosis being the principal cause. Collectively, these results suggest that prospective efforts are warranted to develop optimal antimicrobial preventive strategies after RIC allo-SCT.
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Affiliation(s)
- M Mohty
- Unité de Transplantation et de Thérapie Cellulaire, Institut Paoli-Calmettes, Marseille, France
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7
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Abstract
Opportunistic infections are major causes of morbidity and mortality following bone marrow transplantation. Technological advances in stem cell procurement, the introduction of hematologic growth factors to speed engraftment, the development of new immunosuppressive regimens to control graft-versus-host disease (GVHD), the development of technology to perform graft engineering with removal of T lymphocytes in toto or subpopulations of T lymphocytes, the use of molecular techniques to optimize donor and recipient matching, advances in blood banking, and development of international donor registries, are among the various factors that have led to tremendous changes in transplant practices. Because of such changes in transplant practices, along with the advent of new antimicrobial agents, and development of infection control measures affecting pathogen exposure, alterations in the interplay between host and potential pathogens have occurred. Shifts in the incidence and types of opportunistic pathogens are taking place. Several historically important infectious syndromes are today well controlled; others have diminished in importance early after transplant but are more problematic at a later time; new emerging pathogens are being recognized due to selection pressures from antimicrobial usage and new hosts, such as recipients of alternate donor allogeneic transplant procedures, with even more profound and prolonged immune suppression. Such shifts and new syndromes pose continuing new challenges to the transplant clinician.
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Affiliation(s)
- J R Wingard
- Bone Marrow Transplant Program, University of Florida College of Medicine, Gainesville, Florida 32610, USA.
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Harten P, Seyfarth B, Schmitz N. [Febrile neutropenia: practical aspects]. MEDIZINISCHE KLINIK (MUNICH, GERMANY : 1983) 1998; 93:598-611. [PMID: 9849051 DOI: 10.1007/bf03042675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Infections are a major cause of mortality in neutropenic patients. They require long hospital stays and highly expensive therapeutic measures. In this review we discuss the practical and pharmaco-economic aspects of the management of febrile neutropenia. PREVENTION AND THERAPY Prevention of fever of unknown origin (FUO) demands hygienic and antimicrobiotic measures. First-line antibiotic therapy consists of an aminoglycoside combined with an ureidopenicillin or a 3rd-generation cephalosporin. Double beta-lactam antibiotic combinations are equally effective and less toxic, but more expensive. Monotherapy with carbapenems, ceftazidime, or cefepime appear to offer comparable efficacy. Lung infiltrates require immediate treatment with amphotericin B. If the initial therapeutic regime fails, a carbapenem plus a glycopeptide antibiotic and a parenteral antimycotic drug should be applied after 3 to 4 days. The prophylactic or interventional administration of hematopoietic growth factors is only indicated in special high-risk situations. CONCLUSIONS Using the described therapeutic procedure, the response rate exceeds 90%. Consistent, step-wise escalating administration of antibiotics is essential. More evaluation is needed to determine whether selected patients with febrile neutropenia can be treated on an outpatient basis.
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Affiliation(s)
- P Harten
- II. Medizinische Klinik und Poliklinik, Christian-Albrechts-Universität Kiel.
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Carratala J, Fernandez-Sevilla A, Tubau F, Dominguez MA, Gudiol F. Emergence of fluoroquinolone-resistant Escherichia coli in fecal flora of cancer patients receiving norfloxacin prophylaxis. Antimicrob Agents Chemother 1996; 40:503-5. [PMID: 8834911 PMCID: PMC163147 DOI: 10.1128/aac.40.2.503] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
We studied 122 stool samples collected from 25 patients with hematologic malignancies who received prophylactic norfloxacin. Fecal samples were obtained at admission and twice weekly thereafter during prophylaxis. Fluoroquinolone-resistant Escherichia coli strains were isolated from the feces of 10 (40%) of the patients; two patients had fluoroquinolone-resistant E. coli strains prior to beginning norfloxacin treatment, and in the other eight patients, the strains appeared subsequently. One patient developed fluoroquinolone-resistant E. coli bacteremia after 10 days of norfloxacin administration.
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Affiliation(s)
- J Carratala
- Services of Infectious Diseases, University of Barcelona, Spain
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Affiliation(s)
- J P Donnelly
- Department of Haematology, University Hospital Nijmegen, Netherlands
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Perhaps not everyone knows that…. Ann Oncol 1994. [DOI: 10.1093/oxfordjournals.annonc.a058921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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