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Lovelock T, Walker SR, Thoo C. Occam's Razor and Managing Acute Thrombosis in the COVID-19 Era. Vasc Endovascular Surg 2022; 56:454-458. [PMID: 35001753 DOI: 10.1177/15385744211068325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The COVID-19 pandemic has profoundly influenced the practice of medicine in Australia over the last 24 months. Recently, the development of several vaccines to COVID-19 has been accompanied by reports of an associated rare syndrome of thrombosis and thrombocytopaenia (VITTS). The possibility of this rare disorder confronts all clinicians who deal with acute thrombosis, particularly given the prevalence of patients who have recently been immunised. However, VITTS remains rare, and we believe unnecessary focus on its potential diagnosis may distract from other more common causes of acute thrombosis. We discuss this with reference to a recent case at our institution.
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Affiliation(s)
- Thomas Lovelock
- Department of Vascular Surgery, 34379Royal Hobart Hospital, Hobart, Tas, Australia.,Department of Surgery, University of Tasmania, Hobart, Tas, Australia
| | - Stuart R Walker
- Department of Vascular Surgery, 34379Royal Hobart Hospital, Hobart, Tas, Australia.,Department of Surgery, University of Tasmania, Hobart, Tas, Australia
| | - Catherine Thoo
- Department of Vascular Surgery, 34379Royal Hobart Hospital, Hobart, Tas, Australia
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2
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Powell BD, Lin FC, Beach KF, Kasthuri RS, Northam KA. Accuracy of a modified 4Ts score in predicting heparin-induced thrombocytopenia in critically ill patients: A pilot study. J Crit Care 2021; 67:88-94. [PMID: 34735904 DOI: 10.1016/j.jcrc.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/14/2021] [Accepted: 09/26/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE Thrombocytopenia is common among critically ill patients and heparin-induced thrombocytopenia (HIT) is often on the differential. Professional guidelines recommend calculating a pre-test probability score before performing HIT testing. The 4Ts score is widely utilized but accuracy has been questioned in critically ill patients. The HIT Expert Probability (HEP) score is available, but complexity limits use. Our objective was to compare a modified intensive care unit (ICU)-4Ts score to available scoring tools. MATERIALS AND METHODS This was a single-center retrospective pilot study. Adult ICU patients that were tested for HIT and had a documented 4Ts score were included. A blinded investigator retrospectively calculated the HEP and ICU-4Ts score. Receiver operating characteristics (ROC) area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were compared. RESULTS In 194 included patients, ROC AUC was significantly higher for the ICU-4Ts compared to the 4Ts score (0.80 versus 0.66, respectively; p = 0.044). The ICU-4Ts score had the highest specificity, PPV, and NPV. The sensitivity was similar between the HEP and ICU-4Ts score. CONCLUSIONS The ICU-4Ts score better predicted the diagnosis of HIT compared to the 4Ts score. Prospective validation studies are needed to confirm these results.
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Affiliation(s)
- Brandon D Powell
- Department of Pharmacy, University of North Carolina Medical Center, 101 Manning Drive, Chapel Hill, NC, USA
| | - Feng-Chang Lin
- Translational and Clinical Sciences Institute, University of North Carolina, 160 Medical Drive, Chapel Hill, NC, USA
| | - Katherine F Beach
- Department of Pharmacy, University of North Carolina Medical Center, 101 Manning Drive, Chapel Hill, NC, USA
| | - Raj S Kasthuri
- Division of Hematology, University of North Carolina, 101 Manning Drive, Chapel Hill, NC, USA; Blood Research Center, University of North Carolina, 101 Manning Drive, Chapel Hill, NC, USA
| | - Kalynn A Northam
- Department of Pharmacy, University of North Carolina Medical Center, 101 Manning Drive, Chapel Hill, NC, USA.
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3
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Stewart JJ, Turgeon R, Parker A, Koshman S, Omar MA. Comparison of risk-scoring systems for heparin-induced thrombocytopenia in cardiac surgery patients. Pharmacotherapy 2021; 41:1033-1040. [PMID: 34665467 DOI: 10.1002/phar.2636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/16/2021] [Accepted: 10/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Several risk-scoring tools have been developed to exclude heparin-induced thrombocytopenia (HIT) in patients with thrombocytopenia, but these scores have not been reproduced or compared in the cardiac surgery population. The objective of this study was to validate and compare the modified 4T's (m4T) and Lillo-Le Louet (LLL) scores for HIT screening in the cardiac surgery population. METHODS In this nested case-control study, we retrospectively calculated the m4T and the cardiac surgery-specific score by LLL for 18 cases (HIT-positive) and 54 matched controls (HIT-negative) using characteristics known at the time the HIT assay was ordered post-cardiac surgery and compared their performances by their c-statistic (area under the receiver operating characteristic curve), sensitivity and specificity. RESULTS The median time from surgery to HIT assay order was 9.5 days (IQR 3.75-11.0) in the HIT-positive group and 2 days (IQR 2.0-3.0) in the HIT-negative group (p < 0.0001). The c-statistics for the m4T and the LLL scores were 0.76 (95% CI 0.64-0.85) and 0.63 (95% CI 0.51-0.74), respectively (p = 0.051). Sensitivity and specificity were 61% and 91% for the m4T, and 94% and 32% for the LLL score. CONCLUSION Performance of the m4T and LLL scores in discriminating HIT-positive from HIT-negative patients was modest among patients post-cardiac surgery. However, differences between the sensitivities of these scores suggest that the LLL score may be a safer tool for ruling out HIT in this population.
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Affiliation(s)
- Jackson J Stewart
- Pharmacy Services, Alberta Health Services, University of Alberta Hospital, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Ricky Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Arabesque Parker
- Department of Critical Care, Division of Hematology Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sheri Koshman
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mohamed A Omar
- Pharmacy Services, Alberta Health Services, University of Alberta Hospital, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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Marcucci R, Berteotti M, Gori AM, Giusti B, Rogolino AA, Sticchi E, Liotta AA, Ageno W, De Candia E, Gresele P, Marchetti M, Marietta M, Tripodi A. Heparin induced thrombocytopenia: position paper from the Italian Society on Thrombosis and Haemostasis (SISET). BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2021; 19:14-23. [PMID: 33370230 PMCID: PMC7850929 DOI: 10.2450/2020.0248-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/14/2020] [Indexed: 12/21/2022]
Abstract
Heparin induced thrombocytopenia (HIT) is a rare immune mediated adverse drug reaction occurring after exposure to heparin. It is a serious and potentially fatal condition, which may be associated with the development of arterial or venous thrombotic events. Although known for many years, HIT is still often misdiagnosed. Pre- test clinical probability, screening for anti-PF4/heparin antibodies and documentation of their platelet activating capacity are the cornerstones of diagnosis. However, both clinical algorithms and test modalities have limited predictive values and limited diffusion so that the diagnosis and management is challenging in the clinical practice. For this reason, there is an unmet need for novel rational non-anticoagulant therapies based on the pathogenesis of HIT.The present paper reports the position of the Italian Society on Haemostasis and Thrombosis (SISET) in order to increase awareness of HIT among clinicians and other health care professionals and to provide information on the most appropriate management.
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Affiliation(s)
- Rossella Marcucci
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Martina Berteotti
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Anna M. Gori
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Betti Giusti
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Angela A. Rogolino
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Elena Sticchi
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Agatina Alessandrello Liotta
- Experimental and Clinical Medicine, University of Florence; Atherothrombotic Center, AOU Careggi, Florence, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Erica De Candia
- Department of Translational Medicine and Surgery, Catholic University of Rome, Rome, Italy
- Department of Image Diagnostics, Radiotherapy and Haematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Marina Marchetti
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Marco Marietta
- Department of Oncology and Haematology, University Hospital, Modena, Italy
| | - Armando Tripodi
- IRCCS “Ca’ Granda Maggiore” Hospital Foundation, “Angelo Bianchi Bonomi” Haemophilia and Thrombosis Center and “Fondazione Luigi Villa”, Milan, Italy
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Althaus K, Straub A, Häberle H, Rosenberger P, Hidiatov O, Hammer S, Nowak-Harnau S, Enkel S, Riessen R, Bakchoul T. Heparin-induced thrombocytopenia: Diagnostic challenges in intensive care patients especially with extracorporeal circulation. Thromb Res 2020; 188:52-60. [PMID: 32059134 DOI: 10.1016/j.thromres.2020.01.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/09/2020] [Accepted: 01/27/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is a serious drug induced reaction that may be associated with life threatening complications. Platelet-activating antibodies directed against platelet factor 4 (PF4)/heparin complexes cause the disease. The diagnosis of HIT is challenging, as thrombocytopenia is a frequent finding in intensive care (ICU) patient population, especially during extracorporeal membrane oxygenation. OBJECTIVE To investigate the performance of a diagnostic algorithm for HIT in ICU patients. METHODS ICU patients who developed thrombocytopenia or thrombosis under heparin treatment were included in this study. The pretest probability for HIT was estimated using the 4Ts-score and patient's sera were tested using two rapid immunoassays (RA) LFI-HIT and PaGIA (from Milenia Biotec and DiaMed), and within 72 h using the IgG enzyme immunoassay (EIA) from Hyphen and the heparin induced platelet activation assay (HIPA). RESULTS 392 consecutive ICU patients with suspected HIT were enrolled in this study, of whom 83/392 (21.2%) patients had extracorporeal circulation. Sera from 120/392 (30.6%) and 98/392 (25.0%) patients revealed positive results in RA and IgG EIA, respectively. The HIPA test revealed heparin-dependent platelet activation in a total of 15/392 (3.8%) ICU patients (3 medical and 12 surgical patients). In addition, sera from 7 patients revealed indeterminate HIPA results, of whom 2 patients had a clinical course compatible with HIT. CONCLUSIONS Data from our study confirm the high frequency of IgG PF4/heparin antibodies in ICU patients under unfractionated heparin and shows that the combination of 4Ts-score and RA does not reduce the laboratory overinvestigation for HIT in these patients.
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Affiliation(s)
- Karina Althaus
- Center for Clinical Transfusion Medicine, University of Tübingen, Tübingen, Germany; Transfusion Medicine, Medical Faculty of Tübingen, Tübingen, Germany
| | - Andreas Straub
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Helene Häberle
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, University of Tübingen, Tübingen, Germany
| | - Oleg Hidiatov
- Transfusion Medicine, Medical Faculty of Tübingen, Tübingen, Germany
| | - Stefanie Hammer
- Center for Clinical Transfusion Medicine, University of Tübingen, Tübingen, Germany
| | | | - Sigrid Enkel
- Center for Clinical Transfusion Medicine, University of Tübingen, Tübingen, Germany
| | - Reimer Riessen
- Medical Intensive Care Unit, Department of Medicine, University of Tübingen, Tübingen, Germany
| | - Tamam Bakchoul
- Center for Clinical Transfusion Medicine, University of Tübingen, Tübingen, Germany; Transfusion Medicine, Medical Faculty of Tübingen, Tübingen, Germany.
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Prospective comparison of the HEP score and 4Ts score for the diagnosis of heparin-induced thrombocytopenia. Blood Adv 2019; 2:3155-3162. [PMID: 30463915 DOI: 10.1182/bloodadvances.2018023077] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/23/2018] [Indexed: 12/31/2022] Open
Abstract
The HIT Expert Probability (HEP) score compared favorably with the 4Ts score in a retrospective study. We assessed the diagnostic accuracy of the HEP score compared with the 4Ts score in a prospective cohort of 310 patients with suspected heparin-induced thrombocytopenia (HIT). A member of the clinical team calculated the HEP score and 4Ts score. An independent panel adjudicated HIT status based on a clinical summary as well as the results of HIT laboratory testing. The prevalence of HIT in the study population was 14.7%. At a cutoff of ≥3, the HEP score was 95.3% sensitive (95% confidence interval [CI], 84.2-99.4) and 35.7% specific (95% CI, 29.8-42.0) for HIT. A 4Ts score of ≥4 had a sensitivity of 97.7% (95% CI, 86.2-99.8) and specificity of 32.9% (95% CI, 27.2-39.1). The areas under the receiver operating characteristic (ROC) curves (AUCs) for the HEP score and 4Ts score were similar (0.81 [95% CI, 0.74-0.87] vs 0.76 [95% CI, 0.69-0.83]; P = .12). The HEP score exhibited a significantly higher AUC than the 4Ts score in patients in the intensive care unit (ICU) (0.86 vs 0.79; P = .03). Among trainee scorers, the HEP score performed significantly better than the 4Ts score (AUC, 0.80 vs 0.73; P = .03). Our data suggest that either the 4Ts score or the HEP score may be used in clinical practice. The HEP score may be preferable in ICU patients and among less experienced clinicians.
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Morita M, Nakanishi K, Masuda K, Yoshida K, Shimomura D, Ishida A, Shiga S, Ichiyama S. Acute non-heparin-induced thrombocytopenia during hemodiafiltration in a patient with multiple myeloma. Clin Case Rep 2019; 7:699-702. [PMID: 30997067 PMCID: PMC6452500 DOI: 10.1002/ccr3.1997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 11/19/2018] [Accepted: 12/04/2018] [Indexed: 11/13/2022] Open
Abstract
This report demonstrates that not only heparin-induced thrombocytopenia, but also hemodialysis conditions (platelet activation due to hemodiafiltration and heparin underdosing) may markedly reduce the platelet count and cause clotting in the hemodialysis circuit in patients in a hypercoagulable state. The clot prevention effects of bortezomib are therefore of great importance.
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Affiliation(s)
- Makiko Morita
- Department of Clinical LaboratoryKyoto University HospitalKyotoJapan
| | - Kayoko Nakanishi
- Department of Clinical LaboratoryKyoto University HospitalKyotoJapan
| | - Kenta Masuda
- Department of Clinical LaboratoryKyoto University HospitalKyotoJapan
| | | | | | - Atsumi Ishida
- Department of Clinical LaboratoryKyoto University HospitalKyotoJapan
| | - Shuichi Shiga
- Department of Clinical LaboratoryKyoto University HospitalKyotoJapan
| | - Satoshi Ichiyama
- Department of Clinical LaboratoryKyoto University HospitalKyotoJapan
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8
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East JM, Cserti-Gazdewich CM, Granton JT. Heparin-Induced Thrombocytopenia in the Critically Ill Patient. Chest 2017; 154:678-690. [PMID: 29253554 DOI: 10.1016/j.chest.2017.11.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 11/22/2017] [Accepted: 11/29/2017] [Indexed: 01/19/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is associated with clinically significant morbidity and mortality. Patients who are critically ill are commonly thrombocytopenic and exposed to heparin. Although HIT should be considered, it is not usually the cause of thrombocytopenia in the medical-surgical ICU population. A systematic approach to the patient who is critically ill who has thrombocytopenia according to clinical features, complemented by appropriate laboratory confirmation, should lead to a reduction in inappropriate laboratory testing and reduce the use of more expensive and less reliable anticoagulants. If the patient is deemed as being at intermediate or high risk for HIT or if HIT is confirmed by means of the serotonin-release assay, heparin should be stopped, heparin-bonded catheters should be removed, and a direct antithrombin or fondaparinux should be initiated to reduce the risk of thrombosis. Warfarin is absolutely contraindicated in the acute phase of HIT; if administered, its effects must be reversed by using vitamin K.
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Affiliation(s)
- James M East
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | | | - John T Granton
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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Lee Y, Weeks P, Gass J, Sieg A. Evaluation of 4T's scoring system in the identification of heparin-induced thrombocytopenia in patients with mechanical circulatory support. Thromb Res 2017; 160:66-68. [DOI: 10.1016/j.thromres.2017.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/12/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
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10
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Selleng S, Selleng K. Heparin-induced thrombocytopenia in cardiac surgery and critically ill patients. Thromb Haemost 2017; 116:843-851. [DOI: 10.1160/th16-03-0230] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/16/2016] [Indexed: 11/05/2022]
Abstract
SummaryThrombocytopenia as well as anti-platelet factor 4/heparin (PF4/H) antibodies are common in cardiac surgery patients and those treated in the intensive care unit. In contrast, heparin-induced thrombocytopenia (HIT) is uncommon in these populations (∼1 % and ∼0.5 %, respectively). A stepwise approach where testing for anti-PF4/H antibodies is performed only in patients with typical clinical symptoms of HIT improves diagnostic specificity of the laboratory assays without losing sensitivity, thereby helping to avoid overdiagnosis and resulting HIT overtreatment. Short-term re-exposure to heparin, especially given intraoperatively for cardiovascular surgery, is a reasonable therapeutic option in patients with a history of HIT who subsequently test negative for HIT antibodies. Organ failure(s), enhanced bleeding risks, and other characteristics require special considerations regarding non-heparin anticoagulation: Argatroban is the alternative anticoagulant with pharmacokinetics independent of renal function, but it has a prolonged half-life in case of impaired liver function. For bivalirudin, protocols during cardiopulmonary bypass surgery are established, and it is suitable for patients with liver insufficiency. A major issue of direct thrombin inhibitors are false high activated partial thromboplastin time values in patients with comorbidities affecting prothrombin, which can result in systematic underdosing of the drugs. This is not the case for danaparoid and fondaparinux, which can be monitored by anti-factor Xa assays, but have long half-lives and no suitable antidote. This review includes also information on management of on- and off-pump cardiac surgery, ventricular assist devices, percutaneous interventions, continuous renal replacement therapy, and extracorporeal membrane oxygenation in patients with HIT.
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Lu BY, Kudlowitz D, Gardner LB. Clinical and laboratory characteristics associated with a high optical density anti-platelet factor 4 ELISA test. J Blood Med 2015; 6:277-83. [PMID: 26640392 PMCID: PMC4657791 DOI: 10.2147/jbm.s90179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Diagnosing heparin-induced thrombocytopenia, a potentially catastrophic immune-mediated disorder, continues to pose significant challenges for clinicians, as both clinical and laboratory tools lack specificity. There is mounting evidence supporting a positive correlation between definitive heparin-induced thrombocytopenia and optical density (OD) positivity from the widely available anti-platelet factor 4 enzyme-linked immunosorbent assays (PF4 ELISAs). However, the clinical features distinguishing these patients remain poorly understood. PATIENTS AND METHODS To better characterize this group, we conducted a case-controlled, retrospective chart review of patients from two large, urban academic institutions who underwent a PF4 ELISA at a central laboratory. Associations between OD and 18 clinical characteristics were calculated using the Fisher's exact test for categorical variables and Wilcoxon rank-sum test for continuous variables. RESULTS In total, 184 negative patients (OD <0.7), and 121 positive patients (OD >0.7), including 74 low-positive patients (0.7< OD <1.4) and 47 high-positive patients (OD >1.4) were identified. Several clinical variables were significantly different in the negative group compared with the positive group, including hospital day (P<0.001), previous admission within the past 3 months (P<0.001), and the presence of a new thrombus (P=0.003). However, many of these variables were not different between the negative and low-positive group, and were only distinct between the negative and high-positive group. When the low-positive and high-positive groups were compared, only the 4T score was significantly different (P=0.003). CONCLUSION These data indicate that those with OD >1.4 form a distinct clinical group and support the clinical utility of the 4T score.
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Affiliation(s)
- Benjamin Y Lu
- Department of Medicine, NYU School of Medicine, New York, NY, USA
| | - David Kudlowitz
- Department of Medicine, NYU School of Medicine, New York, NY, USA
| | - Lawrence B Gardner
- Department of Medicine, NYU School of Medicine, New York, NY, USA ; Department of Biochemistry and Molecular Pharmacology, NYU School of Medicine, New York, NY, USA ; The Perlmutter Cancer Center, NYU Langone Medical Center, NYU School of Medicine, New York, NY, USA
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