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Groeneveld DJ, Poole LG, Bouck EG, Schulte A, Wei Z, Williams KJ, Watson VE, Lisman T, Wolberg AS, Luyendyk JP. Robust coagulation activation and coagulopathy in mice with experimental acetaminophen-induced liver failure. J Thromb Haemost 2023; 21:2430-2440. [PMID: 37054919 PMCID: PMC10524846 DOI: 10.1016/j.jtha.2023.03.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/07/2023] [Accepted: 03/30/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Patients with acetaminophen (APAP)-induced acute liver failure (ALF) display both hyper- and hypocoagulable changes not necessarily recapitulated by standard hepatotoxic doses of APAP used in mice (eg, 300 mg/kg). OBJECTIVES We sought to examine coagulation activation in vivo and plasma coagulation potential ex vivo in experimental settings of APAP-induced hepatotoxicity and repair (300-450 mg/kg) and APAP-induced ALF (600 mg/kg) in mice. RESULTS APAP-induced ALF was associated with increased plasma thrombin-antithrombin complexes, decreased plasma prothrombin, and a dramatic reduction in plasma fibrinogen compared with lower APAP doses. Hepatic fibrin(ogen) deposits increased independent of APAP dose, whereas plasma fibrin(ogen) degradation products markedly increased in mice with experimental ALF. Early pharmacologic anticoagulation (+2 hours after 600 mg/kg APAP) limited coagulation activation and reduced hepatic necrosis. The marked coagulation activation evident in mice with APAP-induced ALF was associated with a coagulopathy detectable ex vivo in plasma. Specifically, prolongation of the prothrombin time and inhibition of tissue factor-initiated clot formation were evident even after restoration of physiological fibrinogen concentrations. Plasma endogenous thrombin potential was similarly reduced at all APAP doses. Interestingly, in the presence of ample fibrinogen, ∼10 times more thrombin was required to clot plasma from mice with APAP-induced ALF compared with plasma from mice with simple hepatotoxicity. CONCLUSION The results indicate that robust pathologic coagulation cascade activation in vivo and suppressed coagulation ex vivo are evident in mice with APAP-induced ALF. This unique experimental setting may fill an unmet need as a model to uncover mechanistic aspects of the complex coagulopathy of ALF.
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Affiliation(s)
- Dafna J Groeneveld
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Lauren G Poole
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Emma G Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Anthony Schulte
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Zimu Wei
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Kurt J Williams
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Victoria E Watson
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA
| | - Ton Lisman
- Section of Hepatobiliary Surgery and Liver Transplantation and Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - James P Luyendyk
- Department of Pathobiology & Diagnostic Investigation, Michigan State University, East Lansing, Michigan, USA; Department of Pharmacology & Toxicology, Michigan State University, East Lansing, Michigan, USA.
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2
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Meng H, Chen Z, Chen L, Tang W, He F, Yan X, Lin X, Se X, Xie M, Li Z, Lu L, Yu X. An outbreak of Amanita exitialis poisoning. Clin Toxicol (Phila) 2023; 61:270-275. [PMID: 36919497 DOI: 10.1080/15563650.2022.2159830] [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: 03/16/2023]
Abstract
BACKGROUND The mushroom Amanita exitialis is reported to cause acute liver injury. It is found in Southern China, and has been previously associated with a high incidence of mortality. METHODS We described a series of 10 patients with Amanita exitialis poisoning admitted to The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) in April 2022. Patient demographics, clinical features, laboratory results, therapeutic interventions, and outcome data were collected. RESULTS Among the 10 patients, 9 survived, while 1 died. Gastrointestinal symptoms were the first to appear (average latency period, 11 ± 4.2 h). Diarrhea was the most common clinical symptom (average duration, 4.4 days). Abdominal distention was an important sign, especially in severely-ill patients. Thrombocytopenia occurred on day 2 after mushroom ingestion and persisted for 3-4 days. Alanine aminotransferase and total bilirubin peaked on days 2-3. CONCLUSION Amanita exitialis poisoning is characterized by gastrointestinal symptoms and liver injury. In the patient who died, acute hepatic failure led to hepatic encephalopathy and cerebral edema. Abdominal distension accompanied by thrombocytopenia was common in critically ill patients in this outbreak.
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Affiliation(s)
- Hui Meng
- Department of Critical Care Medicine, The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) (Longgang District People's Hospital of Shenzhen), Shenzhen, China
| | - ZhaoYin Chen
- Department of Critical Care Medicine, The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) (Longgang District People's Hospital of Shenzhen), Shenzhen, China
| | - LanChun Chen
- Department of Critical Care Medicine, The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) (Longgang District People's Hospital of Shenzhen), Shenzhen, China
| | - WeiXin Tang
- Department of Critical Care Medicine, The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) (Longgang District People's Hospital of Shenzhen), Shenzhen, China
| | - Fang He
- Department of Health Management, The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) (Longgang District People's Hospital of Shenzhen), Shenzhen, China
| | - XianRang Yan
- Department of Critical Care Medicine, The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) (Longgang District People's Hospital of Shenzhen), Shenzhen, China
| | - XiaoHong Lin
- Department of Critical Care Medicine, The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) (Longgang District People's Hospital of Shenzhen), Shenzhen, China
| | - XiaoLong Se
- Department of Critical Care Medicine, The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) (Longgang District People's Hospital of Shenzhen), Shenzhen, China
| | - MingFei Xie
- Department of Critical Care Medicine, The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) (Longgang District People's Hospital of Shenzhen), Shenzhen, China
| | - ZhanHan Li
- Department of Critical Care Medicine, The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) (Longgang District People's Hospital of Shenzhen), Shenzhen, China
| | - LiJuan Lu
- Department of Critical Care Medicine, The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) (Longgang District People's Hospital of Shenzhen), Shenzhen, China
| | - Xuetao Yu
- Department of Critical Care Medicine, The Second Affiliated Hospital of the Chinese University of Hong Kong (Shenzhen) (Longgang District People's Hospital of Shenzhen), Shenzhen, China
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3
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Mohan S, Koziatek C, Swartz J, Howland MA, Su MK. Thromboelastography in the setting of acetaminophen-induced hepatotoxicity. Clin Toxicol (Phila) 2022; 60:651-653. [PMID: 35014913 DOI: 10.1080/15563650.2021.2016797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Severe acetaminophen (APAP) poisoning can result in fulminant hepatic failure and abnormal tests of coagulation. Although the international normalized ratio (INR) may be elevated, the actual hemostatic status of patients with APAP-induced hepatotoxicity is unknown. Few studies exist investigating the clinical use of thromboelastography (TEG) to evaluate the hemostatic status in the setting of APAP-induced hepatotoxicity. METHODS We performed a retrospective review of patients who were admitted for APAP toxicity and received TEG testing at a single transplant center. RESULTS Nine patients had detectable APAP concentrations and exhibited elevated aspartate and alanine aminotransferase activities. Seven had thrombocytopenia. TEG revealed a decreased median alpha angle and maximum amplitude but other values were within the normal reference range. DISCUSSION Based on our study of APAP-induced hepatotoxicity, TEG showed a decreased rate of fibrin formation and cross-linking, as well as reduced clot strength. These findings suggest that patients with APAP-induced hepatotoxicity and thrombocytopenia have a theoretically increased bleeding risk as demonstrated by both elevated INR and abnormal TEG values. However, these TEG findings are more likely related to thrombocytopenia rather than directly to APAP-induced hepatotoxicity. Further studies should be performed to elucidate the potential role of TEG in various stages of APAP-induced hepatotoxicity.
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Affiliation(s)
- Sanjay Mohan
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Christian Koziatek
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Jordan Swartz
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Mary Ann Howland
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA.,College of Pharmacy and Health Sciences, St. John's University, Queens, NY, USA
| | - Mark K Su
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
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4
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DeMorrow S, Cudalbu C, Davies N, Jayakumar AR, Rose CF. 2021 ISHEN guidelines on animal models of hepatic encephalopathy. Liver Int 2021; 41:1474-1488. [PMID: 33900013 PMCID: PMC9812338 DOI: 10.1111/liv.14911] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/05/2021] [Accepted: 04/01/2021] [Indexed: 02/07/2023]
Abstract
This working group of the International Society of Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) was commissioned to summarize and update current efforts in the development and characterization of animal models of hepatic encephalopathy (HE). As defined in humans, HE in animal models is based on the underlying degree and severity of liver pathology. Although hyperammonemia remains the key focus in the pathogenesis of HE, other factors associated with HE have been identified, together with recommended animal models, to help explore the pathogenesis and pathophysiological mechanisms of HE. While numerous methods to induce liver failure and disease exist, less have been characterized with neurological and neurobehavioural impairments. Moreover, there still remains a paucity of adequate animal models of Type C HE induced by alcohol, viruses and non-alcoholic fatty liver disease; the most common etiologies of chronic liver disease.
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Affiliation(s)
- S DeMorrow
- Division of Pharmacology and Toxicology, College of Pharmacy, The University of Texas at Austin, Texas, USA; Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Texas, USA; Research division, Central Texas Veterans Healthcare System, Temple Texas USA.,Correspondance: Sharon DeMorrow, PhD, ; tel: +1-512-495-5779
| | - C Cudalbu
- Center for Biomedical Imaging, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - N Davies
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom
| | - AR Jayakumar
- General Medical Research, Neuropathology Section, R&D Service and South Florida VA Foundation for Research and Education Inc; Obstetrics, Gynecology and Reproductive Sciences, University of Miami School of Medicine, Miami FL, USA
| | - CF Rose
- Hepato-Neuro Laboratory, CRCHUM, Université de Montréal, Montreal, Canada
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5
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Pavlick M, DeLaforcade A, Penninck DG, Webster CRL. Evaluation of coagulation parameters in dogs with gallbladder mucoceles. J Vet Intern Med 2021; 35:1763-1772. [PMID: 34196054 PMCID: PMC8295708 DOI: 10.1111/jvim.16203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 06/05/2021] [Accepted: 06/15/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Gallbladder mucocele (GBM) is a common biliary disorder in dogs. Limited information is available on the coagulation status of dogs with GBM. HYPOTHESIS/OBJECTIVES To determine patterns of coagulation alterations in dogs with GBM and correlate them with clinicopathologic abnormalities and ultrasonographic findings of disease severity. ANIMALS Twenty-three dogs with GBM identified on ultrasound examination were prospectively enrolled. METHODS At the time of GBM identification, blood and urine were collected for CBC, serum biochemical panel, urinalysis, prothrombin time, activated partial thromboplastin time (aPTT), factor VIII, protein C (PC), von Willebrand's factor (vWF), antithrombin activity, fibrinogen, D-dimers, and thromboelastrography (TEG). Gallbladder mucoceles were classified into ultrasound types 1 to 5. Medical records were reviewed for clinical presentation, underlying conditions and to determine if systemic inflammatory response syndrome (SIRS) was present. RESULTS Based on TEG parameters, maximal amplitude, and G, 19/23 (83%) of dogs with GBM had evaluations consistent with hypercoagulability. On plasma-based coagulation testing, dogs with GBM had increased total PC activity (20/23, 87%), fibrinogen (9/23, 39%), platelet count (9/23, 39%), and D-dimers (6/15, 40%) as well as prolongations in aPTT (9/22, 41%) and low vWF activity (5/21, 24%). No correlation was found between TEG G value and any coagulation or clinical pathology variables, ultrasound stage of GBM or disease severity as assessed by the presence of SIRS. CONCLUSIONS AND CLINICAL IMPORTANCE Dogs with ultrasonographically identified GBM have changes in whole blood kaolin-activated TEG supporting a hypercoagulable state although traditional plasma-based coagulation testing suggests that a complex state of hemostasis exists.
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Affiliation(s)
- Michelle Pavlick
- Cummings School of Veterinary Medicine at Tufts University, Grafton, Massachusetts, USA
| | - Armelle DeLaforcade
- Cummings School of Veterinary Medicine at Tufts University, Grafton, Massachusetts, USA
| | - Dominique G Penninck
- Cummings School of Veterinary Medicine at Tufts University, Grafton, Massachusetts, USA
| | - Cynthia R L Webster
- Cummings School of Veterinary Medicine at Tufts University, Grafton, Massachusetts, USA
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6
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Pradhan-Sundd T, Gudapati S, Kaminski TW, Ragni MV. Exploring the Complex Role of Coagulation Factor VIII in Chronic Liver Disease. Cell Mol Gastroenterol Hepatol 2021; 12:1061-1072. [PMID: 33705963 PMCID: PMC8342958 DOI: 10.1016/j.jcmgh.2021.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/25/2021] [Accepted: 02/25/2021] [Indexed: 12/22/2022]
Abstract
Chronic liver disease is one of the leading causes of death in the United States. Coagulopathy is often a sequela of chronic liver disease, however, the role and regulation of coagulation components in chronic liver injury remain poorly understood. Clinical and experimental evidence indicate that misexpression of the procoagulant factor VIII (FVIII) is associated with chronic liver disease. Nevertheless, the molecular mechanism of FVIII-induced chronic liver injury progression remains unknown. This review provides evidence supporting a pathologic role for FVIII in the development of chronic liver disease using both experimental and clinical models.
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Affiliation(s)
- Tirthadipa Pradhan-Sundd
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, Pittsburgh, Pennsylvania; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Shweta Gudapati
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, Pittsburgh, Pennsylvania
| | - Tomasz W Kaminski
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, Pittsburgh, Pennsylvania
| | - Margaret V Ragni
- Pittsburgh Heart, Lung and Blood Vascular Medicine Institute, Pittsburgh, Pennsylvania; Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania
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7
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Warrillow S, Fisher C, Tibballs H, Bailey M, McArthur C, Lawson-Smith P, Prasad B, Anstey M, Venkatesh B, Dashwood G, Walsham J, Holt A, Wiersema U, Gattas D, Zoeller M, Garcia Alvarez M, Bellomo R. Coagulation abnormalities, bleeding, thrombosis, and management of patients with acute liver failure in Australia and New Zealand. J Gastroenterol Hepatol 2020; 35:846-854. [PMID: 31689724 DOI: 10.1111/jgh.14876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/19/2019] [Accepted: 09/21/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM To study the management of coagulation and hematological derangements among severe acute liver failure (ALF) patients in Australia and New Zealand liver transplant intensive care units (ICUs). METHODS Analysis of key baseline characteristics, etiology, coagulation and hematological tests, use of blood products, thrombotic complications, and clinical outcomes during the first ICU week. RESULTS We studied 62 ALF patients. The first day median peak international normalized ratio was 5.5 (inter-quartile range [IQR] 3.8-8.7), median longest activated partial thromboplastin time was 62 s (IQR 44-87), and median lowest fibrinogen was 1.1 (IQR 0.8-1.6) g/L. Fibrinogen was only measured in 85% of patients, which was less than other tests (P < 0.0001). Median initial lowest platelet count was 83 (IQR 41-122) × 109 /L. Overall, 58% of patients received fresh frozen plasma, 40% cryoprecipitate, 35% platelets, and 15% prothrombin complex concentrate. Patients with bleeding complications (19%) had more severe overall hypofibrinogenemia and thrombocytopenia. Thrombotic complications were less common (10% of patients), were not associated with consistent patterns of abnormal hemostasis, and were not immediately preceded by clotting factor administration and half occurred only after liver transplantation surgery. CONCLUSION In ALF patients admitted to dedicated Australia and New Zealand ICUs, fibrinogen was measured less frequently than other coagulation parameters but, together with platelets, appeared more relevant to bleeding risk. Blood products and procoagulant factors were administered to most patients at variable levels of hemostatic derangement, and bleeding complications were more common than thrombotic complications. This epidemiologic information and practice variability provide baseline data for the design and powering of interventional studies.
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Affiliation(s)
- Stephen Warrillow
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine and Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Caleb Fisher
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
| | - Heath Tibballs
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
| | - Michael Bailey
- Department of Medicine and Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Victoria, Melbourne, Australia
| | - Colin McArthur
- Medical Research Institute of New Zealand, Auckland, New Zealand.,Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Pia Lawson-Smith
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | | | - Matthew Anstey
- Department of Intensive Care, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Bala Venkatesh
- Department of Intensive Care, Princess Alexandra Hospital, Brisbane, Australia
| | - Gemma Dashwood
- Department of Intensive Care, Princess Alexandra Hospital, Brisbane, Australia
| | - James Walsham
- Department of Intensive Care, Princess Alexandra Hospital, Brisbane, Australia
| | - Andrew Holt
- Department of Intensive Care, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Ubbo Wiersema
- Department of Intensive Care, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Gattas
- Department of Intensive Care, Royal Prince Alfred Hospital, Sydney, Australia
| | - Matthew Zoeller
- Department of Intensive Care, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mercedes Garcia Alvarez
- Department of Anesthesiology and Pain Medicine, Hospital Santa Creu i Sant Pau, University of Barcelona, Barcelona, Spain
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine and Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia.,Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Australia
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