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Sanchez VA, Dinh PC, Rooker J, Monahan PO, Althouse SK, Fung C, Sesso HD, Einhorn LH, Dolan ME, Frisina RD, Travis LB. Prevalence and risk factors for ototoxicity after cisplatin-based chemotherapy. J Cancer Surviv 2023; 17:27-39. [PMID: 36637632 DOI: 10.1007/s11764-022-01313-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/07/2022] [Indexed: 01/14/2023]
Abstract
PURPOSE Ototoxicity is a prominent side effect of cisplatin-based chemotherapy. There are few reports, however, estimating its prevalence in well-defined cohorts and associated risk factors. METHODS Testicular cancer (TC) survivors given first-line cisplatin-based chemotherapy completed validated questionnaires. Descriptive statistics evaluated the prevalence of ototoxicity, defined as self-reported hearing loss and/or tinnitus. We compared patients with and without tinnitus or hearing loss using Chi-square test, two-sided Fisher's exact test, or two-sided Wilcoxon rank sum test. To evaluate ototoxicity risk factors, a backward selection logistic regression procedure was performed. RESULTS Of 145 TC survivors, 74% reported ototoxicity: 68% tinnitus; 59% hearing loss; and 52% reported both. TC survivors with tinnitus were more likely to indicate hypercholesterolemia (P = 0.008), and difficulty hearing (P < .001). Tinnitus was also significantly related to age at survey completion (OR = 1.79; P = 0.003) and cumulative cisplatin dose (OR = 5.17; P < 0.001). TC survivors with hearing loss were more likely to report diabetes (P = 0.042), hypertension (P = 0.007), hypercholesterolemia (P < 0.001), and family history of hearing loss (P = 0.044). Risk factors for hearing loss included age at survey completion (OR = 1.57; P = 0.036), hypercholesterolemia (OR = 3.45; P = 0.007), cumulative cisplatin dose (OR = 1.94; P = 0.049), and family history of hearing loss (OR = 2.87; P = 0.071). CONCLUSIONS Ototoxicity risk factors included age, cisplatin dose, cardiovascular risk factors, and family history of hearing loss. Three of four TC survivors report some type of ototoxicity; thus, follow-up of cisplatin-treated survivors should include routine assessment for ototoxicity with provision of indicated treatments. IMPLICATIONS FOR CANCER SURVIVORS Survivors should be aware of risk factors associated with ototoxicity. Referrals to audiologists before, during, and after cisplatin treatment is recommended.
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Affiliation(s)
- Victoria A Sanchez
- Department of Otolaryngology-Head & Neck Surgery, University of South Florida, 12901 Bruce B. Downs Blvd., MDC 73, Tampa, FL, 33612, USA.
| | - Paul C Dinh
- Department of Medical Oncology, Indiana University, Indianapolis, IN, USA
| | - Jennessa Rooker
- College of Nursing, University of South Florida, Tampa, FL, USA
| | - Patrick O Monahan
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, IN, USA
| | - Sandra K Althouse
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, IN, USA
| | - Chunkit Fung
- J.P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA
| | - Howard D Sesso
- Division of Preventive Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Lawrence H Einhorn
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, IN, USA
| | - M Eileen Dolan
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Robert D Frisina
- Department of Medical Engineering, University of South Florida, Tampa, FL, USA
| | - Lois B Travis
- Department of Biostatistics and Health Data Science, Indiana University, Indianapolis, IN, USA
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Paken J, Govender CD, Pillay M, Ayele BT, Sewram V. Feasibility and first results of a prospective cohort study to investigate cisplatin-associated ototoxicity amongst cancer patients in South Africa. BMC Cancer 2021; 21:822. [PMID: 34271863 PMCID: PMC8285889 DOI: 10.1186/s12885-021-08567-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/10/2021] [Indexed: 01/16/2023] Open
Abstract
Background Cervical cancer, one of the most common cancers affecting females in South Africa, commonly requires a cisplatin-based-treatment regimen, which has been associated with ototoxic side effects. However, cisplatin-associated ototoxicity is largely under-reported in South Africa, despite its impact of hearing loss having serious overt ramifications on the quality of life of these patients. Hence, a prospective cohort study was undertaken to assess the audiological changes in female cervical cancer patients receiving cisplatin therapy. Objective To present details of the feasibility study and initial results on hearing patterns in cervical cancer patients receiving cisplatin chemotherapy. . Methods Fifty cervical cancer patients commencing with cisplatin chemotherapy underwent audiological assessments at a hospital in South Africa at various time intervals. Assessments included case history, otoscopic examination, immittance audiometry, pure tone audiometry (including high-frequency audiometry), speech audiometry, and distortion product otoacoustic emission testing. Data analysis involved the use of descriptive statistics and the Cochran-Armitage trend test for a linear trend in proportions. Results Fifty participants, aged between 32 and 79 years (Mean: 53 years; SD = 11.00), were recruited. Clinical findings revealed an incidence of 100% ototoxic hearing loss at the one-month post-treatment, i.e., 98% after three cycles of cisplatin and 2% at one-month post-chemotherapy. Sensorineural hearing loss and high-frequency tinnitus were most common. Deterioration in hearing thresholds was more evident in the extended high-frequency range, with the number of “no-responses,” from 11,200 Hz to 20,000 Hz, increasing with each successive audiological evaluation. This study further indicated that recruitment and follow-up of study participants within a limited resource setting are possible. However, cognizance must be given to a multidisciplinary approach and constant engagement with participants through regular contact either telephonically or via a short-message-system. Conclusion Exposure to cisplatin treatment contributed to hearing loss in females with cervical cancer, highlighting the need for ototoxicity monitoring during chemotherapy treatments. Furthermore, the results indicate that it is possible to conduct prospective cohort studies, using a multidisciplinary approach in limited-resource environments with appropriate planning and training strategies, as this study was able to achieve its aim successfully.
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Affiliation(s)
- Jessica Paken
- Discipline of Audiology, School of Health Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban, 4000, South Africa.
| | - Cyril D Govender
- Discipline of Audiology, School of Health Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban, 4000, South Africa
| | - Mershen Pillay
- Discipline of Audiology, School of Health Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban, 4000, South Africa
| | - Birhanu T Ayele
- African Cancer Institute, Department of Global Health, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa
| | - Vikash Sewram
- African Cancer Institute, Department of Global Health, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa.
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Paken J, Govender CD, Pillay M, Ayele BT, Sewram V. Baseline audiological profiling of South African females with cervical cancer: an important attribute for assessing cisplatin-associated ototoxicity. BMC WOMENS HEALTH 2021; 21:164. [PMID: 33879158 PMCID: PMC8056627 DOI: 10.1186/s12905-021-01313-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/14/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Cisplatin is a popular antineoplastic agent used to treat cervical cancer in women from low and middle-income countries. Cisplatin treatment is associated with ototoxicity, often resulting in hearing loss. In light of this, it is crucial to conduct baseline audiological assessments prior to treatment initiation in order to evaluate the extent of cisplatin-associated-ototoxicity. Additionally, the identification of inherent risk factors and hearing patterns in specific patient cohorts is needed, especially in South Africa, a middle-income country characterized by the quadruple burden of disease (Human Immunodeficiency Virus (HIV), Tuberculosis (TB), Diabetes and Hypertension). METHODS This study aimed to describe a profile of risk factors and hearing in a cohort of females with cervical cancer before cisplatin treatment commenced. A descriptive study design that included 82 cervical cancer patients, who underwent audiological evaluation prescribed for ototoxicity monitoring was conducted. RESULTS All participants (n = 82) presented with risk factors (diabetes, hypertension, HIV, and antiretroviral therapy) for cisplatin ototoxicity and/or pre-existing sensorineural hearing loss. High-frequency tinnitus was the most common otological symptom experienced by 25 (31%) participants. Fifty-nine (72%) participants presented with normal hearing, twenty-two (27%) with a sensorineural hearing loss, and 36% were diagnosed with mild hearing loss. Abnormal Distortion Product Otoacoustic Emissions (DPOAE) findings were obtained bilaterally in two participants (2.4%), in the right ear only of another two (2.4%) participants and the left ear of three participants (3.7%). Most participants (94%) had excellent word recognition scores, demonstrating an excellent ability to recognize words within normal conversational levels under optimal listening conditions. Age was significantly associated with hearing loss at all thresholds. Among the co-morbidities, an HIV positive status significantly triggered hearing loss, especially at higher frequencies. CONCLUSION This study demonstrated that South African females with cervical cancer present with various co-morbidities, which may predispose them to develop cisplatin-associated -ototoxic hearing loss. Identification of these co-morbidities and hearing loss is essential for the accurate monitoring of cisplatin toxicities. Appropriate management of these patients is pivotal to reduce the adverse effects that hearing impairment can have on an individual's quality of life and to facilitate informed decision-making regarding the commencement of cisplatin chemotherapy.
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Affiliation(s)
- Jessica Paken
- Discipline of Audiology, School of Health Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban, 4000, South Africa.
| | - Cyril D Govender
- Discipline of Audiology, School of Health Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban, 4000, South Africa
| | - Mershen Pillay
- Discipline of Audiology, School of Health Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban, 4000, South Africa
| | - Birhanu T Ayele
- Division of Epidemiology and Biostatistics, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa
| | - Vikash Sewram
- Department of Global Health, African Cancer Institute, Faculty of Medicine and Health Sciences, Stellenbosch University, P.O. Box 241, Cape Town, 8000, South Africa.
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Santucci NM, Garber B, Ivory R, Kuhn MA, Stephen M, Aizenberg D. Insight into the current practice of ototoxicity monitoring during cisplatin therapy. J Otolaryngol Head Neck Surg 2021; 50:19. [PMID: 33766142 PMCID: PMC7995701 DOI: 10.1186/s40463-021-00506-0] [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: 12/03/2020] [Accepted: 02/22/2021] [Indexed: 11/20/2022] Open
Abstract
Background The aim of this study is to evaluate the current state of ototoxicity monitoring for patients receiving cisplatin chemotherapy in an academic medical center with particular attention to how closely monitoring adheres to national ototoxicity guidelines. Methods Case series including retrospective medical records review of patients (age > 18) treated with cisplatin at University of California Davis Medical Center between January 2014 and August 2017. Patient and ototoxicity related variables were analyzed. Patients that underwent a transfer of care during treatment and with less than 3 months of follow-up were excluded. Results Three hundred seventy-nine patients met study criteria, of which 104 (27.4%) had a prior history of hearing loss. Prior to treatment, 196 (51.7%) patients were counseled regarding the ototoxic nature of cisplatin and 92 (24.3%) patients had a pretreatment audiogram. During treatment, 91 (24%) patients had documented otologic complaints. Only 17 patients (4.5%) patients had an audiogram ordered during their cisplatin treatment period. 130 (34.3%) patients had otologic complaints following cisplatin treatment. Audiograms were ordered for 20 (7.8%), 13 (5.1%), and 16 (6.2%) patients at 1-month, 3-month, and 6-month follow-ups, respectively. No patients in the study cohort received baseline, treatment, and post-treatment audiograms as recommended by national ototoxicity monitoring protocols. Patients with Head and Neck Cancer (HNC) represented the largest subgroup that received cisplatin (n = 122, 32.2%) and demonstrated higher rates of ototoxicity counseling (n = 103, 84.4%) and pretreatment audiograms (n = 70, 57.4%) compared to the non HNC group (n = 36, 36.2%, P < 0.0001 and n = 22, 8.5%, P < 0.0001). Conclusions There is poor adherence to national ototoxicity monitoring guidelines at a large academic medical center. This is a missed opportunity for intervention and aural rehabilitation. Improved education and collaboration between otolaryngology, audiology, and medical oncology is needed to develop and promote an effective ototoxicity-monitoring program. Graphical abstract ![]()
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Affiliation(s)
- N M Santucci
- Oregon Health and Science University, School of Medicine, Portland, OR, USA
| | - B Garber
- University of California Davis Department of Otolaryngology-Head and Neck Surgery, 2521 Stockton Blvd., Sacramento, CA, 95817, USA
| | - R Ivory
- University of California Davis Medical Center, Sacramento, CA, USA
| | - M A Kuhn
- University of California Davis Department of Otolaryngology-Head and Neck Surgery, 2521 Stockton Blvd., Sacramento, CA, 95817, USA
| | - M Stephen
- University of California Davis Department of Internal Medicine - Hematology/Oncology, Sacramento, CA, USA
| | - D Aizenberg
- University of California Davis Department of Otolaryngology-Head and Neck Surgery, 2521 Stockton Blvd., Sacramento, CA, 95817, USA.
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Moodley S, Storbeck C, Gama N. Ototoxicity: A review of South African studies. S Afr Fam Pract (2004) 2021; 63:e1-e10. [PMID: 33764142 PMCID: PMC8377995 DOI: 10.4102/safp.v63i1.5187] [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: 07/06/2020] [Revised: 12/20/2020] [Accepted: 12/20/2020] [Indexed: 12/01/2022] Open
Abstract
Background Ototoxicity is damage to cells in the inner ear after administering a toxic drug, with a resultant hearing loss. Drugs used to treat illnesses such as cancer, tuberculosis, human immuno-deficiency virus (HIV) and infections are potentially ototoxic. South Africa has one of the highest rates of HIV and tuberculosis, and thus a potentially greater degree of the population is being affected by hearing loss from the medications used to treat these illnesses. Methods To determine the current status of research in ototoxicity, a systematic literature review was carried out to determine the focus areas of South African studies for the period 1989–2019. From the database search engines used (Science Direct, Ebscohost and Proquest), a total of 33 relevant articles were identified, including the themes of pharmacology, audiology and knowledge. Results Studies were conducted in the three most resourced provinces in South Africa. Findings indicate that there is a need for educating doctors regarding ototoxicity and a delineation of the role of the audiologist in monitoring and management of ototoxic hearing loss. There is a resultant need for audiology training on the pharmacology of ototoxic medication, otoprotective strategies and adherence to recommended guidelines. This has implications for university audiology training programmes and curriculum planning. The need for development of South Africa-specific audiology guidelines was highlighted. Conclusion Whilst it is noted that there is a lack of resources for effective implementation of ototoxicity-monitoring protocols, it is also noted that there are measures and otoprotective strategies that can be put in place without additional resources.
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Affiliation(s)
- Selvarani Moodley
- Centre for Deaf Studies, Faculty of Humanities, University of the Witwatersrand, Johannesburg.
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Protective effect of gallic acid against cisplatin-induced ototoxicity in rats. Braz J Otorhinolaryngol 2019; 85:267-274. [PMID: 29673779 PMCID: PMC9442874 DOI: 10.1016/j.bjorl.2018.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 03/08/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction Cisplatin is an antineoplastic agent widely used in the treatment of a variety of cancers. Ototoxicity is one of the main side-effects restricting the use of cisplatin. Objective The purpose of this study was to investigate the protective efficacy of gallic acid, in biochemical, functional and histopathological terms, against ototoxicity induced by cisplatin. Methods Twenty-eight female Sprague Dawley rats were included. Rats were randomly assigned into four groups of seven animals each. Cisplatin group received a single intraperitoneal dose of 15 mg/kg cisplatin. Gallic acid group received intraperitoneal gallic acid at 100 mg/kg for five consecutive days. Cisplatin + gallic acid group received intraperitoneal gallic acid at 100 mg/kg for five consecutive days and a single intraperitoneal dose of 15 mg/kg cisplatin at 3rd day. A control group received 1 mL intraperitoneal saline solution for five consecutive days. Prior to drug administration, all rats were exposed to the distortion product otoacoustic emissions test. The test was repeated on the 6th day of the study. All rats were then sacrificed; the cochleas were removed and set aside for biochemical and histopathological analyses. Results In cisplatin group, Day 6 signal noise ratio values were significantly lower than those of the other groups. Also, malondialdehyde levels in cochlear tissues were significantly higher, superoxide dismutase and glutathione peroxidase activities were significantly lower compared to the control group. Histopathologic evaluation revealed erosion in the stria vascularis, degeneration and edema in the connective tissue layer in endothelial cells, impairment of outer hair cells and a decrease in the number of these calls. In the cisplatin + gallic acid group, this biochemical, histopathological and functional changes were reversed. Conclusion In the light of our findings, we think that gallic acid may have played a protective role against cisplatin-induced ototoxicity in rats, as indicated by the distortion product otoacoustic emissions test results, biochemical findings and immunohistochemical analyses.
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Comparison of quick recovery outcome of inhalable doxorubicin and cisplatin in lung cancer patients: a randomized, double-blind, single-center trial. Drug Deliv Transl Res 2018; 8:985-993. [PMID: 29717473 DOI: 10.1007/s13346-018-0529-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Systematic chemotherapy has required high time span for recovery in cancer patients, serious toxic effects, and increased the time of cancer-free survival of patient but decreased the overall survival time of patients irrespective of diseased condition(s). To compare the quick recovery of inhalable doxorubicin and cisplatin in the lung cancer patients. A total of 240 patients with non-small cell lung cancer (NSCLC) patients were randomly divided into two groups of 120 each. Patients had inhaled 25 mg/m2 doxorubicin (DON group) or 10 mg/m2 cisplatin (CPN group) once in a day for 21 days. Volume, diameter, type, and a number of lung nodes, pulmonary function, and 21-day lung cancer risk assessment were evaluated. One-way ANOVA following Bonferroni multiple comparison tests was performed at 95% of confidence level. DON and CPN both groups had shrunken the lung cancer nodule, decreased solid nodules and non-solid nodules, and increased partially solid nodules. The DON group (5.88 ± 3.98%) had strongly decreased nodule size than the CPN group (4.15 ± 2.92%; p < 0.0001, q = 3.721). The incidence of nodular size reduction was 9.47 ± 1.13% higher for doxorubicin than cisplatin. The CPN group had 36.53 ± 0.66% and the DON group had 34.65 ± 0.7% lung cancer risk assessment after 21 days (p < 0.0001, q = 3.785). Inhalable doxorubicin might be an effective therapy in NSCLC patients with acceptable hematologic and non-hematologic toxic effects. TRIAL REGISTRY researchregistry3382, dated 28 December 2014 ( www.researchregistry.com ).
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Dzobo K, Hassen N, Senthebane DA, Thomford NE, Rowe A, Shipanga H, Wonkam A, Parker MI, Mowla S, Dandara C. Chemoresistance to Cancer Treatment: Benzo-α-Pyrene as Friend or Foe? Molecules 2018; 23:E930. [PMID: 29673198 PMCID: PMC6017867 DOI: 10.3390/molecules23040930] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 04/13/2018] [Accepted: 04/15/2018] [Indexed: 12/14/2022] Open
Abstract
Background: Environmental pollution such as exposure to pro-carcinogens including benzo-α-pyrene is becoming a major problem globally. Moreover, the effects of benzo-α-pyrene (BaP) on drug pharmacokinetics, pharmacodynamics, and drug resistance warrant further investigation, especially in cancer outpatient chemotherapy where exposure to environmental pollutants might occur. Method: We report here on the effects of benzo-α-pyrene on esophageal cancer cells in vitro, alone, or in combination with chemotherapeutic drugs cisplatin, 5-flurouracil, or paclitaxel. As the study endpoints, we employed expression of proteins involved in cell proliferation, drug metabolism, apoptosis, cell cycle analysis, colony formation, migration, and signaling cascades in the WHCO1 esophageal cancer cell line after 24 h of treatment. Results: Benzo-α-pyrene had no significant effect on WHCO1 cancer cell proliferation but reversed the effect of chemotherapeutic drugs by reducing drug-induced cell death and apoptosis by 30−40% compared to drug-treated cells. The three drugs significantly reduced WHCO1 cell migration by 40−50% compared to control and BaP-treated cells. Combined exposure to drugs was associated with significantly increased apoptosis and reduced colony formation. Evaluation of survival signaling cascades showed that although the MEK-ERK and Akt pathways were activated in the presence of drugs, BaP was a stronger activator of the MEK-ERK and Akt pathways than the drugs. Conclusion: The present study suggest that BaP can reverse the effects of drugs on cancer cells via the activation of survival signaling pathways and upregulation of anti-apoptotic proteins such as Bcl-2 and Bcl-xL. Our data show that BaP contribute to the development of chemoresistant cancer cells.
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Affiliation(s)
- Kevin Dzobo
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Cape Town Component, Wernher and Beit Building (South), University of Cape Town Medical Campus, Anzio Road, Observatory 7925, Cape Town, South Africa.
- Division of Medical Biochemistry and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - Naseeha Hassen
- Pharmacogenomics and Drug Metabolism Group, Division of Human Genetics, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - Dimakatso Alice Senthebane
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Cape Town Component, Wernher and Beit Building (South), University of Cape Town Medical Campus, Anzio Road, Observatory 7925, Cape Town, South Africa.
- Division of Medical Biochemistry and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - Nicholas Ekow Thomford
- Pharmacogenomics and Drug Metabolism Group, Division of Human Genetics, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - Arielle Rowe
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Cape Town Component, Wernher and Beit Building (South), University of Cape Town Medical Campus, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - Hendrina Shipanga
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Cape Town Component, Wernher and Beit Building (South), University of Cape Town Medical Campus, Anzio Road, Observatory 7925, Cape Town, South Africa.
- Division of Medical Biochemistry and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - Ambroise Wonkam
- Pharmacogenomics and Drug Metabolism Group, Division of Human Genetics, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - M Iqbal Parker
- Division of Medical Biochemistry and Institute of Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - Shaheen Mowla
- Division of Haematology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa.
| | - Collet Dandara
- Pharmacogenomics and Drug Metabolism Group, Division of Human Genetics, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa.
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