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Cundell T, Atkins JW, Lau AF. Sterility Testing for Hematopoietic Stem Cells. J Clin Microbiol 2023; 61:e0165422. [PMID: 36847535 PMCID: PMC10035301 DOI: 10.1128/jcm.01654-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023] Open
Abstract
Over the last two decades, rapid technological advances have led to the wide adoption of cell and gene therapy products for the treatment of a variety of disease states. In this study, we reviewed the literature between 2003 and 2021 to provide a summary of overarching trends associated with microbial contamination in hematopoietic stem cells (HSCs) derived from peripheral blood, bone marrow, and cord blood. We provide a brief background on the regulatory context for human cells, tissues, and cellular and tissue-based products (HCT/Ps) as regulated by the US Food and Drug Administration (FDA), sterility testing expectations for autologous (Section 361) and allogeneic (Section 351) HSC products, and discuss clinical risks associated with the infusion of a contaminated HSC product. Finally, we discuss the expectations for current good tissue practices (cGTP) and current good manufacturing practices (cGMP) for the manufacturing and testing of HSC based on Section 361 and Section 351 categorization, respectively. We provide commentary on what is practiced in the field and discuss the critical need for updates to professional standards that keep pace with advancing technologies with an aim to clarify expectations for manufacturing and testing facilities to improve standardization across institutions.
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Affiliation(s)
- Tony Cundell
- Microbiological Consulting, LLC, Rye, New York, USA
| | - J. Wade Atkins
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Anna F. Lau
- Sterility Testing Service, Department of Laboratory Medicine, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
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Martin R, Lei R, Zeng Y, Zhu J, Chang H, Ye H, Cui Z. Membrane Applications in Autologous Cell Therapy. MEMBRANES 2022; 12:1182. [PMID: 36557091 PMCID: PMC9788437 DOI: 10.3390/membranes12121182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/03/2022] [Accepted: 11/07/2022] [Indexed: 06/17/2023]
Abstract
Stem cell and cell therapies, particularly autologous cell therapies, are becoming a common practice. However, in order for these technologies to achieve wide-scale clinical application, the prohibitively high cost associated with these therapies must be addressed through creative engineering. Membranes can be a disruptive technology to reshape the bioprocessing and manufacture of cellular products and significantly reduce the cost of autologous cell therapies. Examples of successful membrane applications include expansions of CAR-T cells, various human stem cells, and production of extracellular vesicles (EVs) using hollow fibre membrane bioreactors. Novel membranes with tailored functions and surface properties and novel membrane modules that can accommodate the changing needs for surface area and transport properties are to be developed to fulfil this key role.
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Affiliation(s)
- Risto Martin
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford OX3 7DQ, UK
| | - Rui Lei
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford OX3 7DQ, UK
| | - Yida Zeng
- Oxford Suzhou Centre for Advanced Research (OSCAR), University of Oxford, Suzhou 215123, China
| | - Jiachen Zhu
- Oxford Suzhou Centre for Advanced Research (OSCAR), University of Oxford, Suzhou 215123, China
| | - Hong Chang
- Oxford Suzhou Centre for Advanced Research (OSCAR), University of Oxford, Suzhou 215123, China
| | - Hua Ye
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford OX3 7DQ, UK
- Oxford Suzhou Centre for Advanced Research (OSCAR), University of Oxford, Suzhou 215123, China
| | - Zhanfeng Cui
- Department of Engineering Science, Institute of Biomedical Engineering, University of Oxford, Oxford OX3 7DQ, UK
- Oxford Suzhou Centre for Advanced Research (OSCAR), University of Oxford, Suzhou 215123, China
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Jacobs JW, Guarente J, Hendrickson JE, Tormey CA, Bar N. Autologous hematopoietic stem cell product contaminated with Salmonella due to occult salmonellosis in an asymptomatic donor. J Clin Apher 2021; 37:316-319. [PMID: 34953078 DOI: 10.1002/jca.21962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/23/2021] [Accepted: 12/20/2021] [Indexed: 11/06/2022]
Abstract
Recent advancements in infectious disease testing methods and pathogen reduction technologies have greatly reduced the incidence of microbial contamination of allogeneic blood products. Despite this significant reduction, contamination of autologous cellular therapy products remains a challenging issue, as many of these mitigation strategies are not feasible for such products. Most microorganisms isolated from cellular therapy products are Gram-positive normal skin flora, and studies have demonstrated that adverse effects are infrequent when these contaminated products are infused. However, no prior report has documented an autologous hematopoietic stem cell (HSC) or other cellular therapy product contaminated with Salmonella bacteria-a pathogenic Gram-negative organism. We present the first known case of Salmonella contaminating an HSC product secondary to occult salmonellosis in the donor, and discuss the implications of this contaminating organism and the therapeutic dilemma posed by this scenario.
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Affiliation(s)
- Jeremy W Jacobs
- Department of Laboratory Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Juliana Guarente
- Department of Laboratory Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Noffar Bar
- Section of Hematology, Department of Internal Medicine and Yale Cancer Center, Yale New Haven Hospital, New Haven, Connecticut, USA
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Garg V, Kodan P, Pushpam D, Bakhshi S, Kumar L, Sharma A, Gupta G, Gupta N. Impact of microbial contamination of haematopoietic stem cells on post-transplant outcomes: A retrospective study from tertiary care centre in India. Transfus Med 2021; 31:377-382. [PMID: 34396610 DOI: 10.1111/tme.12805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/17/2021] [Accepted: 07/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Haematopoietic stem cells (HSC) may act as a source of infection for the recipient due to manipulation at multiple levels from collection to infusion. Due to the high risk of contamination cultures are usually taken during multiple steps. The clinical significance of microbial contamination of HSC on the post-transplant course and the role of prophylactic antibiotics is relatively unknown. AIMS AND METHODS The aim of our study is to investigate the incidence of microbial contamination of haematopoietic stem cell and to assess its impact on the post-transplant febrile neutropenia, engraftment kinetics, hospitalisation and day 100 mortality. Details of all patients admitted in the bone marrow transplantation unit of a tertiary care centre in India between January 2014 and December 2018 were collected from case records. RESULTS Of the 1306 stem cell harvests from 503 patients sent for culture, 17 harvests (1.3%) were found to have a culture positive report. Sixteen patients had undergone autologous transplant. Multiple myeloma was most common indication of HSC transplant followed by Non-Hodgkin Lymphoma (NHL). Twelve of 17 HSC cultures were positive at the time of infusion and five were positive at the time of harvest. The five HSC that were culture positive at the time of harvest were culture negative at the time of infusion. Gram-positive organisms were isolated in six cultures and gram-negative in rest. All patients developed febrile neutropenia post-transplantation between day 1 and day 7. The median time of onset of fever was day +5 (1-7), the median duration of fever was 4 days (2-7), the median duration of antibiotic use was 11 days (9-16). Median day for neutrophil engraftment was 11 days (9-16), the median day for platelet engraftment was 14 days (10-25) and median duration of hospitalisation was 15 days (12-78). All patients were alive at day 100 of transplant. CONCLUSION This study shows that there appears to be minimal impact of culture positive HSC on transplant related outcomes in terms of engraftment kinetics, duration of hospitalisation and day 100 mortality. Discarding of contaminated HSC may not be required, though on development of febrile neutropenia appropriate antibiotics should be administered based on sensitivity pattern of HSC culture. Larger prospective studies are needed to determine the clinical relevance of such contaminations. Emphasis should be laid on better infection control practices to minimise contamination rates.
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Affiliation(s)
- Vikas Garg
- Department of Medical Oncology, BRAIRCH, AIIMS, Delhi, India
| | | | - Deepam Pushpam
- Department of Medical Oncology, BRAIRCH, AIIMS, Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, BRAIRCH, AIIMS, Delhi, India
| | - Lalit Kumar
- Department of Medical Oncology, BRAIRCH, AIIMS, Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, BRAIRCH, AIIMS, Delhi, India
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Damonti L, Buetti N, Droz S, Bacher U, Pabst T, Taleghani BM, Baerlocher GM, Marschall J. Prevalence and significance of bacterial contamination of autologous stem cell products. J Hosp Infect 2021; 114:175-179. [PMID: 33864895 DOI: 10.1016/j.jhin.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
There is limited and conflicting information on the prevalence of contamination of haematopoietic stem and progenitor cell products (HPCPs), and their optimal management remains unclear. The authors reviewed the microbial surveillance data of HPCPs collected between January 2002 and December 2019 for autologous transplantation at the study institution to determine the prevalence of microbial contamination and the potential infectious complications among recipients. Among 3935 HPCPs, 25 (0.6%) were contaminated. Ultimately, 22 patients received contaminated grafts, with pre-emptive antimicrobial therapy initiated in six of these patients. No patients developed subsequent infectious complications. These data suggest that microbial contamination of autologous HPCPs and associated adverse outcomes are rare.
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Affiliation(s)
- L Damonti
- Department of Infectious Diseases, Inselspital, University Hospital Bern, Bern, Switzerland; Ente Ospedaliero Cantonale, Division of Infectious Diseases, Regional Hospital Lugano, Lugano, Switzerland.
| | - N Buetti
- Department of Infectious Diseases, Inselspital, University Hospital Bern, Bern, Switzerland; Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland; UMR 1137 IAME Team 5 DeSCID: Decision Sciences in Infectious Diseases, Control and Care Inserm/University Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - S Droz
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - U Bacher
- Department of Haematology and Central Haematology Laboratory, Inselspital, University Hospital Bern, Bern, Switzerland
| | - T Pabst
- Department of Medical Oncology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - B M Taleghani
- Department of Haematology and Central Haematology Laboratory, Inselspital, University Hospital Bern, Bern, Switzerland
| | - G M Baerlocher
- Laboratory for Cellular Therapies, Department of Haematology and Central Haematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland; Laboratory for Haematopoiesis and Molecular Genetics, Department of BioMedical Research, University of Bern, Bern, Switzerland
| | - J Marschall
- Department of Infectious Diseases, Inselspital, University Hospital Bern, Bern, Switzerland
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Pamler I, Richter E, Hutchinson JA, Hähnel V, Holler E, Gessner A, Burkhardt R, Ahrens N. Bacterial contamination rates in extracorporeal photopheresis. Transfusion 2020; 60:1260-1266. [PMID: 32315092 DOI: 10.1111/trf.15801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/27/2020] [Accepted: 03/01/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Extracorporeal photopheresis (ECP) is an immunosuppressive treatment that involves leukocyte apheresis, psoralen and UV light treatment, and subsequent reinfusion. Patients treated with ECP are usually immunosuppressed. Bacterial contamination therefore poses a much unwanted risk, but incidence data are lacking. PATIENTS AND METHODS We screened all 1922 consecutive ECP procedures scheduled within a roughly 3-year period for eligibility. Those with missing data on ECP method (inline or offline) or type of venous access (peripheral or central) were excluded. ECPs with complete aerobic and anaerobic microbial testing of baseline patient blood samples (n = 1637) and of ECP cell concentrates (n = 1814) were included in the analysis. RESULTS A test for microbial contamination was positive for 1.82% of the cell concentrates, with central venous access was the most significant risk factor for the contamination (odds ratio = 19). Patient blood samples were positive in 3.85% of cases, but no patients became septic. Staphylococcus spp. were most abundant, and products with bacterial contamination did not cause side effects after reinfusion. There were no significant differences in contamination rates between inline and offline ECP. CONCLUSION These findings stress the importance of sterile procedures and the benefits of using peripheral over central venous access for reducing the risk of bacterial contamination in ECP.
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Affiliation(s)
- Irene Pamler
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg,, Germany
| | - Eva Richter
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg,, Germany
| | - James A Hutchinson
- Department of Surgery, University Hospital Regensburg, Regensburg,, Germany
| | - Viola Hähnel
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg,, Germany
| | - Ernst Holler
- Department of Hematology and Oncology, University Hospital Regensburg, Regensburg,, Germany
| | - André Gessner
- Institute of Clinical Microbiology and Hygiene, University Hospital Regensburg, Regensburg,, Germany
| | - Ralph Burkhardt
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg,, Germany
| | - Norbert Ahrens
- Institute for Clinical Chemistry and Laboratory Medicine, University Hospital Regensburg, Regensburg,, Germany.,Institute for Laboratory Diagnostics, Microbiology, and Transfusion Medicine, Sozialstiftung Bamberg, Germany
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Microbial contamination risk in hematopoietic stem cell products: retrospective analysis of 1996–2016 data. ACTA ACUST UNITED AC 2020. [DOI: 10.2478/ahp-2020-0007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AbstractQuality assurance and safety of hematopoietic stem cells (HSC) with special emphasis on bacterial and fungal contamination is the prerequisite for any transplantation procedure. The aim was to determine the incidence rate of such contamination during processing of transplantation material with regard to HSC source: peripheral blood stem cell (PBSC), bone marrow (BM), or cord blood (CB). Analysis involved autologous and allogenic products dedicated for patients and comprised in all 4135 donations, including 112 BM (2.70%), 3787 PBSC (91.60%), and 236 CB (5.70%) processed in cell bank over the period 1996–2016. Aerobic and anaerobic contamination was determined.Analysis of the 20-year data revealed 42 contaminated products: 25 PBSC (0.66% of tested units) and 17 CB (7.20% of tested units). No microbial contamination of BM products was detected. Overall percentage of contaminated products was 1.01%, mostly with Staphylococcus epidermidis (61.36%). Bacterial contamination rate at cell bank is relatively low and processing in a closed system does not seem as crucial as might be expected. This is particularly true for BM components. Equally important are evaluation of donor’s medical status and condition of the puncture site for collection of source material. Implementation of appropriate sample collection procedures should help minimize the risk of false-positive results due to environmental contamination.
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Understanding the formation and behaviors of droplets toward consideration of changeover during cell manufacturing. Regen Ther 2019; 12:36-42. [PMID: 31890765 PMCID: PMC6933465 DOI: 10.1016/j.reth.2019.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/15/2019] [Accepted: 04/05/2019] [Indexed: 11/22/2022] Open
Abstract
Preventing the contamination of processed cells is required for achieving reproducible manufacturing. A droplet is one of the potential causes contamination in cell manufacturing. The present study elucidates the formation mechanism and characteristics of droplets based on the observation and detection of droplets on the base surface of the biological safety cabinet (BSC) where cell processing is conducted under unidirectional airflow. Pouring fluorescent solution into the vessel using a measuring pipette was conducted to visualize the formation of droplets by videos as well as visual detection by blacklight irradiation on the base surface of the BSC. The experiments revealed that airborne and non-airborne droplets emerged from bursting bubbles, which formed when the entire solution was pushed out of the measuring pipette. Therefore, the improving procedure of pouring technique when entire solution was not pushed out of the pipette realized no formation of the droplets due to the prevention of emergence of bubble. In addition, an alternative procedure in which the entire solution was poured into the deep point of the test tube prevented the flying of non-airborne droplets outside the tube, while airborne droplets that escaped the tube rode the airflow of BSC. These results suggested a method for the prevention of the droplet formation, as well as the deposit control of droplets onto the surface in BSC, leading to cleanup area in the BSC for changeover with environment continuity. The droplets were formed by bursting bubbles while pouring the solution. Improved procedure for the prevention of emergence of droplets was proposed. Classification of droplets proposes the procedure for cleanup the BSC. Changeover was categorized based on the status for environment continuity.
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Golay J, Pedrini O, Capelli C, Gotti E, Borleri G, Magri M, Vailati F, Passera M, Farina C, Rambaldi A, Introna M. Utility of routine evaluation of sterility of cellular therapy products with or without extensive manipulation: Best practices and clinical significance. Cytotherapy 2018; 20:262-270. [DOI: 10.1016/j.jcyt.2017.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/18/2017] [Accepted: 11/14/2017] [Indexed: 10/18/2022]
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Hütter G. The Safety of Allogeneic Stem Cell Transplantation. STEM CELLS IN CLINICAL APPLICATIONS 2017. [DOI: 10.1007/978-3-319-59165-0_1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Detection of antibiotic resistance genes β-lactamics in bacterial strains isolated from Umbilical Cord Blood Units for transplant. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2017. [DOI: 10.1016/j.hgmx.2016.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Dal MS, Tekgündüz E, Çakar MK, Kaya AH, Namdaroğu S, Batgi H, Bekdemir F, Uncu Ulu B, Yiğenoğlu TN, Kılınç A, İskender D, Uğur B, Koçubaba Ş, İskender G, Altuntaş F. Does microbial contamination influence the success of the hematopoietic cell transplantation outcomes? Transfus Apher Sci 2016; 55:125-8. [PMID: 27184293 DOI: 10.1016/j.transci.2016.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Revised: 04/29/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Microbial contamination can be a marker for faulty process and is assumed to play an important role in the collection of hematopoietic progenitor cell (HPC) and infusion procedure. We aimed to determine the microbial contamination rates and evaluate the success of hematopoietic cell transplantation (HCT) in patients who received contaminated products. PATIENTS-METHODS We analyzed microbial contamination records of HPC grafts between 2012 and 2015, retrospectively. Contamination rates of autologous donors were evaluated for at three steps: at the end of mobilization, following processing with dimethyl sulfoxide, and just before stem cell infusion. Grafts of allogeneic donors were assessed only before HCT. RESULT A total of 445 mobilization procedures were carried out on 333 (167 autologous and 166 allogeneic) donors. The microbiological contamination of peripheral blood (323/333 donations) and bone marrow (10/333 donations) products were analyzed. Bacterial contamination was detected in 18 of 1552 (1.15 %) culture bottles of 333 donors. During the study period 248 patients underwent HCT and among these patients microbial contamination rate on sample basis was 1.3 % (16/1212). Microbial contamination detected in nine patients (7 autologous; 2 allogeneic). In 8 of 9 patients, a febrile neutropenic attack was observed. The median day for the neutropenic fever was 4 days (0-9). None of the patients died within the post-transplant 30 days who received contaminated products. CONCLUSION The use of contaminated products with antibiotic prophylaxis may be safe in terms of the first day of fever, duration of fever, neutrophil, platelet engraftment and duration of hospitalization.
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Affiliation(s)
- Mehmet Sinan Dal
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey.
| | - Emre Tekgündüz
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey
| | - Merih Kızıl Çakar
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey
| | - Ali Hakan Kaya
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey
| | - Sinem Namdaroğu
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey
| | - Hikmetullah Batgi
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey
| | - Filiz Bekdemir
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey
| | - Bahar Uncu Ulu
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey
| | - Tuğçe Nur Yiğenoğlu
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey
| | - Ali Kılınç
- Ankara Oncology Education and Research Hospital, Therapeutic Apheresis Center, Ankara, Turkey
| | - Dicle İskender
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey
| | - Bilge Uğur
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey
| | - Şerife Koçubaba
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey
| | - Gülşen İskender
- Ankara Oncology Education and Research Hospital, Department of Clinical Microbiology and Infectious Diseases, Ankara, Turkey
| | - Fevzi Altuntaş
- Ankara Oncology Education and Research Hospital, Hematology and Stem Cell Transplantation Clinic, Ankara, Turkey
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