1
|
Mayerhöfer T, Joannidis M, Peer A, Perschinka F, Fries D, Mair P, Gasteiger L, Bachler M, Kilo J, Herkner H, Schwameis M, Schellongowski P, Nagler B, Kornfehl A, Staudinger T, Buchtele N. Anticoagulation with argatroban using hemoclot™ targets is safe and effective in CARDS patients receiving venovenous extracorporeal membrane oxygenation: An exploratory bi-centric cohort study. Thromb Res 2024; 236:161-166. [PMID: 38452448 DOI: 10.1016/j.thromres.2024.02.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/19/2024] [Accepted: 02/24/2024] [Indexed: 03/09/2024]
Abstract
Direct thrombin inhibitors, including argatroban, are increasingly used for anticoagulation during venovenous extracorporeal membrane oxygenation (VV ECMO). In many centers activated partial thromboplastin time (aPTT) is used for monitoring, but it can be affected by several confounders. The aim of this study was to evaluate the safety and efficacy of anticoagulation with argatroban titrated according to diluted thrombin time targets (hemoclot™ assay) compared to anti-Xa guided anticoagulation with unfractionated heparin (UFH). METHODS This cohort study included adults at two tertiary care centers who required VV ECMO for severe COVID-19-related acute respiratory distress syndrome (CARDS). Patients received center-dependent argatroban or UFH for anticoagulation during ECMO. Argatroban was guided following a hemoclot™ target range of 0.4-0.6 μg/ml. UFH was guided by anti-factor Xa (antiXa) levels (0.2-0.3 IU/ml). The primary outcome was safety of argatroban compared to UFH, assessed by time to first clinically relevant bleeding event or death during ECMO. Secondary outcomes included efficacy (time to thromboembolism) and feasibility (proportion of anticoagulation targets within range). RESULTS From 2019 to 2021 57 patients were included in the study with 27 patients (47 %) receiving argatroban and 30 patients (53 %) receiving UFH. The time to the first clinically relevant bleeding or death during ECMO was similar between groups (HR (argatroban vs. UFH): 1.012, 95 % CI 0.44-2.35, p = 0.978). Argatroban was associated with a decreased risk for thromboembolism compared to UFH (HR 0.494 (95 % CI 0.26-0.95; p = 0.034)). The overall proportion of anticoagulation within target ranges was not different between groups (46 % (23-54 %) vs. 46 % (37 %-57 %), p = 0.45). CONCLUSION Anticoagulation with argatroban according to hemoclot™ targets (0.4-0.6 μg/ml) compared to antiXa guided UFH (0.2-0.3 IU/ml) is safe and may prolong thromboembolism-free time in patients with severe ARDS requiring VV ECMO.
Collapse
Affiliation(s)
- Timo Mayerhöfer
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Austria
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Austria
| | - Andreas Peer
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Austria
| | - Fabian Perschinka
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Austria
| | - Dietmar Fries
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Peter Mair
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Lukas Gasteiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Mirjam Bachler
- Institute for Sports Medicine, Alpine Medicine and Health Tourism (ISAG), UMIT - Private University for Health Sciences and Health Technology, Hall i.T., Austria
| | - Juliane Kilo
- Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Austria
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Austria
| | - Bernhard Nagler
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Austria
| | - Andrea Kornfehl
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Austria
| | - Thomas Staudinger
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Austria
| | - Nina Buchtele
- Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Austria.
| |
Collapse
|
2
|
Dooling K, Haan B. Monitoring and Dosing of Argatroban in a Patient With Antiphospholipid Syndrome. Hosp Pharm 2021; 56:706-708. [PMID: 34732926 DOI: 10.1177/0018578720946765] [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] [Indexed: 11/15/2022]
Abstract
Background: This case reports outlines argatroban dosing and necessary dose adjustments in a 56 year-old male with a past medical history of antiphospholipid syndrome and heparin-induced thrombocytopenia. Method: Argatroban was initiated as a fixed dose of 0.5 µg/kg/min with all initial aPTTs above goal. Argatroban was held for a procedure and re-initiated at 0.25 µg/kg/min. The dose was increased or decreased by 25% from the current rate based on supratherapeutic and subtherapeutic aPTTs, respectively. Results: The patient remained on argatroban for 6 total days, while achieving goal aPTT levels with no VTE or bleeding events. Conclusion: Our patient represents the first reported case of monitoring argatroban with aPTTs in an individual with APS.
Collapse
Affiliation(s)
| | - Bradley Haan
- Ascension Genesys Hospital, Grand Blanc, MI, USA
| |
Collapse
|
3
|
Nilius H, Kaufmann J, Cuker A, Nagler M. Comparative effectiveness and safety of anticoagulants for the treatment of heparin-induced thrombocytopenia. Am J Hematol 2021; 96:805-815. [PMID: 33857342 PMCID: PMC8252596 DOI: 10.1002/ajh.26194] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The effectiveness and safety of non-heparin anticoagulants for the treatment of heparin-induced thrombocytopenia (HIT) are not fully established, and the optimal treatment strategy is unknown. In a systematic review and meta-analysis, we aimed to determine precise rates of platelet recovery, new or progressive thromboembolism (TE), major bleeding, and death for all non-heparin anticoagulants and to study potential sources of variability. METHODS Following a detailed protocol (PROSPERO: CRD42020219027), EMBASE and Medline were searched for all studies reporting clinical outcomes of patients treated with non-heparin anticoagulants (argatroban, danaparoid, fondaparinux, direct oral anticoagulants [DOAC], bivalirudin, and other hirudins) for acute HIT. Proportions of patients with the outcomes of interest were pooled using a random-effects model for each drug. The influence of the patient population, the diagnostic test used, the study design, and the type of article was assessed. RESULTS Out of 3194 articles screened, 92 studies with 119 treatment groups describing 4698 patients were included. The pooled rates of platelet recovery ranged from 74% (bivalirudin) to 99% (fondaparinux), TE from 1% (fondaparinux) to 7% (danaparoid), major bleeding from 1% (DOAC) to 14% (bivalirudin), and death from 7% (fondaparinux) to 19% (bivalirudin). Confidence intervals were mostly overlapping, and results were not influenced by patient population, diagnostic test used, study design, or type of article. DISCUSSION Effectiveness and safety outcomes were similar among various anticoagulants, and significant factors affecting these outcomes were not identified. These findings support fondaparinux and DOACs as viable alternatives to conventional anticoagulants for treatment of acute HIT in clinical practice.
Collapse
Affiliation(s)
- Henning Nilius
- Department of Clinical ChemistryInselspital, Bern University HospitalBernSwitzerland
| | - Jonas Kaufmann
- Department of Clinical ChemistryInselspital, Bern University HospitalBernSwitzerland
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Michael Nagler
- Department of Clinical ChemistryInselspital, Bern University HospitalBernSwitzerland
- University of BernBernSwitzerland
| |
Collapse
|
4
|
Oliveira DC, Correia A, Oliveira C. The Issue of the Antiphospholipid Antibody Syndrome. J Clin Med Res 2020; 12:286-292. [PMID: 32489503 PMCID: PMC7239578 DOI: 10.14740/jocmr4154] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 04/15/2020] [Indexed: 11/15/2022] Open
Abstract
Antiphospholipid antibody syndrome (APS) is a state of hypercoagulability secondary to an autoimmune disorder. It is associated with thrombotic events in venous and arterial vessels, obstetric complications characterized by recurrent fetal losses, and increased perinatal morbidity. APS is classified as primary, when not associated with other pathologies; or secondary, when associated with an underlying autoimmune disease with, solid tumor, or hematological disorder. Clinical findings include livedo reticularis, thrombocytopenia or hemolytic anemia, maternal morbidity, and recurrent thrombotic episodes and others. Laboratory tests show circulating antiphospholipid antibodies (aPLs); however, even in the presence of these antibodies, patients can be asymptomatic. Estimates predict that about 5% of the populations have circulating aPLs, but the incidence of APS is only five cases per 100,000 people, as diagnosis of this syndrome requires clinical and laboratory findings to be simultaneously present. In cases of secondary APS, or in acute cases with imminent risk of death (as in catastrophic APS), it may be necessary to reduce aPL serum levels using immunomodulators, immunosuppressants, or plasmapheresis, in order to treat the associated pathologies. In other situations, the use of immunotherapy is not indicated. In other patients heparin, aspirin or anticoagulants either alone or associated should be administered depending on each specific case.
Collapse
Affiliation(s)
- Dinaldo C Oliveira
- Hospital das Clinicas, Federal University of Pernambuco, Recife-PE, Brazil
| | - Augusto Correia
- Hospital das Clinicas, Federal University of Pernambuco, Recife-PE, Brazil
| | - Carolina Oliveira
- Hospital das Clinicas, Federal University of Pernambuco, Recife-PE, Brazil
| |
Collapse
|
5
|
A case-report of successful use of thromboelastography to manage anticoagulation therapy in a patient with concomitant catastrophic antiphospholipid syndrome and heparin-induced thrombocytopenia. Blood Coagul Fibrinolysis 2019; 30:171-175. [DOI: 10.1097/mbc.0000000000000810] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
6
|
Zimmer E, Bek M, Wiessner M, Keyl C, Trenk D. Argatroban pharmacokinetics and pharmacodynamics in critically ill cardiac surgical patients with suspected heparin-induced thrombocytopenia. Thromb Haemost 2017; 115:1081-9. [DOI: 10.1160/th15-11-0847] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 12/28/2015] [Indexed: 11/05/2022]
Abstract
SummaryOnly limited data are available on the pharmacokinetic and pharmacodynamic properties of argatroban in critically ill patients under clinical conditions. We determined plasma concentrations of argatroban, and its main metabolite M1, within a time period of 48 hours in 25 critically ill cardiac surgical patients, who were suspected of heparininduced thrombocytopenia and had the clinical need for anticoagulation. Argatroban infusion was started at 0.5 µg/kg/minute, and adjusted in 0.1–0.25 µg/kg/minute increments when the activated partial thromboplastin time (aPTT) was not within the target range. Median argatroban plasma half-life was 2.7 hours (interquartile range 1.8 to 7.3). Linear regression analysis revealed that argatroban half-life was significantly related to the total bilirubin concentration (R2 = 0.66, p< 0.001), as well as to the metabolism of argatroban, which was assessed by the ratio of the areas under the concentration time curves (AUC) of argatroban and M1 (R2 = 0.60, p< 0.001). Continuous veno-venous haemodialysis did not significantly affect argatroban plasma half-life. The predictive property of argatroban plasma levels for aPTT was low (R2 = 0.28, p< 0.001). Multiple linear regression analysis revealed significant contributions of age and serum albumin levels to the effect of argatroban on aPTT, expressed as the AUC ratio argatroban/aPTT (R2 = 0.67, adjusted R2 = 0.65, p< 0.001). In conclusion, argatroban plasma half-life is markedly increased in critically ill cardiac surgical patients, and further prolonged by hepatic dysfunction due to impaired metabolism. Patient age and serum albumin concentration significantly contribute to the variability in the anticoagulant activity of argatroban.
Collapse
|
7
|
Antiphospholipid Syndrome: Role of Vascular Endothelial Cells and Implications for Risk Stratification and Targeted Therapeutics. J Am Coll Cardiol 2017; 69:2317-2330. [PMID: 28473138 DOI: 10.1016/j.jacc.2017.02.058] [Citation(s) in RCA: 98] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 02/21/2017] [Accepted: 02/28/2017] [Indexed: 12/28/2022]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disease characterized by venous thromboembolism, arterial thrombosis, and obstetric morbidities in the setting of persistently positive levels of antiphospholipid antibodies measured on 2 different occasions 12 weeks apart. Patients with APS are at increased risk for accelerated atherosclerosis, myocardial infarction, stroke, and valvular heart disease. Vascular endothelial cell dysfunction mediated by antiphospholipid antibodies and subsequent complement system activation play a cardinal role in APS pathogenesis. Improved understanding of their pathogenic function could help in the risk stratification of patients with APS and provide new molecular therapeutic targets.
Collapse
|
8
|
Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Anticoagulation and Thrombolysis. Pediatr Crit Care Med 2016; 17:S77-88. [PMID: 26945332 DOI: 10.1097/pcc.0000000000000623] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Thrombotic complications are increasingly being recognized as a significant cause of morbidity and mortality in pediatric and congenital heart disease. The objective of this article is to review the medications currently available to prevent and treat such complications. DATA SOURCES Online searches were conducted using PubMed. STUDY SELECTION Studies were selected for inclusion based on their scientific merit and applicability to the pediatric cardiac population. DATA EXTRACTION Pertinent information from each selected study or scientific review was extracted for inclusion. DATA SYNTHESIS Four classes of medications were identified as potentially beneficial in this patient group: anticoagulants, antiplatelet agents, thrombolytic agents, and novel oral anticoagulants. Data on each class of medication were synthesized into the follow sections: mechanism of action, pharmacokinetics, dosing, monitoring, reversal, considerations for use, and evidence to support. CONCLUSIONS Anticoagulants, antiplatelet agents, and thrombolytic agents are routinely used successfully in the pediatric patient with heart disease for the prevention and treatment of a wide range of thrombotic complications. Although the novel oral anticoagulants have been approved for a limited number of indications in adults, studies on the safety and efficacy of these agents in children are pending.
Collapse
|
9
|
Batal I, Cooper G, Fradkin D, Harrison J, Moerchen F, Hauskrecht M. An Efficient Pattern Mining Approach for Event Detection in Multivariate Temporal Data. Knowl Inf Syst 2016; 46:115-150. [PMID: 26752800 PMCID: PMC4704806 DOI: 10.1007/s10115-015-0819-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Revised: 08/31/2014] [Accepted: 12/06/2014] [Indexed: 11/27/2022]
Abstract
This work proposes a pattern mining approach to learn event detection models from complex multivariate temporal data, such as electronic health records. We present Recent Temporal Pattern mining, a novel approach for efficiently finding predictive patterns for event detection problems. This approach first converts the time series data into time-interval sequences of temporal abstractions. It then constructs more complex time-interval patterns backward in time using temporal operators. We also present the Minimal Predictive Recent Temporal Patterns framework for selecting a small set of predictive and non-spurious patterns. We apply our methods for predicting adverse medical events in real-world clinical data. The results demonstrate the benefits of our methods in learning accurate event detection models, which is a key step for developing intelligent patient monitoring and decision support systems.
Collapse
Affiliation(s)
| | - Gregory Cooper
- Department of Biomedical Informatics, University of Pittsburgh,
| | | | - James Harrison
- Department of Public Health Sciences, University of Virginia,
| | | | | |
Collapse
|
10
|
Tardy-Poncet B, Nguyen P, Thiranos JC, Morange PE, Biron-Andréani C, Gruel Y, Morel J, Wynckel A, Grunebaum L, Villacorta-Torres J, Grosjean S, de Maistre E. Argatroban in the management of heparin-induced thrombocytopenia: a multicenter clinical trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:396. [PMID: 26556106 PMCID: PMC4641392 DOI: 10.1186/s13054-015-1109-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 10/17/2015] [Indexed: 11/28/2022]
Abstract
Introduction The aim of this study was to collect data in France in patients with heparin-induced thrombocytopenia who required parenteral anticoagulation and for whom other non-heparin anticoagulant therapies were contraindicated including patients with renal failure, cross-reactivity to danaparoid or at high hemorrhagic risk. Methods A total of 20 patients, of mean age 72 ± 10 years, were enrolled in this open-label, multicenter clinical study. Exploratory statistical data analysis was performed with descriptive interpretation of intra-individual comparisons using simple univariate statistics. Results The diagnosis of HIT was confirmed in 16 subjects by an independent scientific committee. Fourteen patients (70 %) were in an intensive care unit during the course of the study. Patients were treated with argatroban for a mean duration of 8.5 ± 6.1 days. The mean starting dose of argatroban was 0.77 ± 0.45 μg/kg/min. Platelet recovery was rapid. aPTT and anti-IIa activity assays were used to monitor the dose of argatroban. The mean baseline aPTT value was 45.0 ± 9.8 sec and increased to 78.2 ± 35.8 sec two hours after initiating argatroban. At this time mean argatroban concentration was 0.34 ± 0.16 and 0.61 ± 0.28 μg/ml using ECT and TT measurements, respectively. New and/or extended thromboses were reported in 25 % of patients and major bleedings were documented in 15 %. Six patients died due to their underlying medical condition. Conclusion Considering its hepatic elimination and its short half-life, argatroban can be considered as a safe therapeutic option in HIT patients at high hemorrhagic risk and with renal failure, particularly in an ICU setting.
Collapse
Affiliation(s)
- Brigitte Tardy-Poncet
- EA 3065, Université Jean-Monnet, INSERM CIC 1408 - FCRIN-INNOVTE - Laboratory of Hematology, University Hospital of St Etienne, St Etienne, France.
| | - Philippe Nguyen
- Laboratory of Hematology, University Hospital of Reims, Reims, France.
| | - Jean-Claude Thiranos
- Department of Cardiovascular Surgery, University Hospitals of Strasbourg, Strasbourg, France.
| | | | | | - Yves Gruel
- Laboratory of Hematology, University Hospital of Tours, Tours, France.
| | - Jérome Morel
- Department of Intensive Care Unit, University Hospital of St Etienne, St Etienne, France.
| | | | - Lelia Grunebaum
- Laboratory of Hematology, University Hospitals of Strasbourg, Strasbourg, France.
| | | | - Sandrine Grosjean
- Intensive Care Medicine, University Hospital of Dijon, Dijon, France.
| | | |
Collapse
|
11
|
Batal I, Valizadegan H, Cooper GF, Hauskrecht M. A Temporal Pattern Mining Approach for Classifying Electronic Health Record Data. ACM T INTEL SYST TEC 2013; 4:10.1145/2508037.2508044. [PMID: 25309815 PMCID: PMC4192602 DOI: 10.1145/2508037.2508044] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 08/01/2013] [Indexed: 10/26/2022]
Abstract
We study the problem of learning classification models from complex multivariate temporal data encountered in electronic health record systems. The challenge is to define a good set of features that are able to represent well the temporal aspect of the data. Our method relies on temporal abstractions and temporal pattern mining to extract the classification features. Temporal pattern mining usually returns a large number of temporal patterns, most of which may be irrelevant to the classification task. To address this problem, we present the Minimal Predictive Temporal Patterns framework to generate a small set of predictive and non-spurious patterns. We apply our approach to the real-world clinical task of predicting patients who are at risk of developing heparin induced thrombocytopenia. The results demonstrate the benefit of our approach in efficiently learning accurate classifiers, which is a key step for developing intelligent clinical monitoring systems.
Collapse
|
12
|
Batal I, Valizadegan H, Cooper GF, Hauskrecht M. A Pattern Mining Approach for Classifying Multivariate Temporal Data. PROCEEDINGS. IEEE INTERNATIONAL CONFERENCE ON BIOINFORMATICS AND BIOMEDICINE 2011; 2011:358-365. [PMID: 22267987 PMCID: PMC3261774 DOI: 10.1109/bibm.2011.39] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We study the problem of learning classification models from complex multivariate temporal data encountered in electronic health record systems. The challenge is to define a good set of features that are able to represent well the temporal aspect of the data. Our method relies on temporal abstractions and temporal pattern mining to extract the classification features. Temporal pattern mining usually returns a large number of temporal patterns, most of which may be irrelevant to the classification task. To address this problem, we present the minimal predictive temporal patterns framework to generate a small set of predictive and non-spurious patterns. We apply our approach to the real-world clinical task of predicting patients who are at risk of developing heparin induced thrombocytopenia. The results demonstrate the benefit of our approach in learning accurate classifiers, which is a key step for developing intelligent clinical monitoring systems.
Collapse
Affiliation(s)
- Iyad Batal
- Department of Computer Science University of Pittsburgh
| | | | | | | |
Collapse
|
13
|
Lewis BE, Hursting MJ. Argatroban Therapy in Heparin-Induced Thrombocytopenia. HEPARIN-INDUCED THROMBOCYTOPENIA 2007. [DOI: 10.3109/9781420045093.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|