1
|
Chumbita M, Puerta-Alcalde P, Yáñez L, Angeles Cuesta M, Chinea A, Español-Morales I, Fernandez-Abellán P, Gudiol C, González-Sierra P, Rojas R, Sánchez-Pina JM, Vadillo IS, Sánchez M, Varela R, Vázquez L, Guerreiro M, Monzo P, Lopera C, Aiello TF, Peyrony O, Soriano A, Garcia-Vidal C. High Rate of Inappropriate Antibiotics in Patients with Hematologic Malignancies and Pseudomonas aeruginosa Bacteremia following International Guideline Recommendations. Microbiol Spectr 2023; 11:e0067423. [PMID: 37367629 PMCID: PMC10434044 DOI: 10.1128/spectrum.00674-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/27/2023] [Indexed: 06/28/2023] Open
Abstract
Optimal coverage of Pseudomonas aeruginosa is challenging in febrile neutropenic patients due to a progressive increase in antibiotic resistance worldwide. We aimed to detail current rates of resistance to antibiotics recommended by international guidelines for P. aeruginosa isolated from bloodstream infections (BSI) in patients with hematologic malignancies. Secondarily, we aimed to describe how many patients received inappropriate empirical antibiotic treatment (IEAT) and its impact on mortality. We conducted a retrospective, multicenter cohort study of the last 20 BSI episodes caused by P. aeruginosa in patients with hematologic malignancies from across 14 university hospitals in Spain. Of the 280 patients with hematologic malignancies and BSI caused by P. aeruginosa, 101 (36%) had strains resistant to at least one of the β-lactam antibiotics recommended in international guidelines, namely, cefepime, piperacillin-tazobactam, and meropenem. Additionally, 21.1% and 11.4% of the strains met criteria for MDR and XDR P. aeruginosa, respectively. Even if international guidelines were followed in most cases, 47 (16.8%) patients received IEAT and 66 (23.6%) received inappropriate β-lactam empirical antibiotic treatment. Thirty-day mortality was 27.1%. In the multivariate analysis, pulmonary source (OR 2.22, 95% CI 1.14 to 4.34) and IEAT (OR 2.67, 95% CI 1.37 to 5.23) were factors independently associated with increased mortality. We concluded that P. aeruginosa-causing BSI in patients with hematologic malignancies is commonly resistant to antibiotics recommended in international guidelines, which is associated with frequent IEAT and higher mortality. New therapeutic strategies are needed. IMPORTANCE Bloodstream infection (BSI) caused by P. aeruginosa is related with an elevated morbidity and mortality in neutropenic patients. For this reason, optimal antipseudomonal coverage has been the basis of all historical recommendations in the empirical treatment of febrile neutropenia. However, in recent years the emergence of multiple types of antibiotic resistances has posed a challenge in treating infections caused by this microorganism. In our study we postulated that P. aeruginosa-causing BSI in patients with hematologic malignancies is commonly resistant to antibiotics recommended in international guidelines. This observation is associated with frequent IEAT and increased mortality. Consequently, there is a need for a new therapeutic strategy.
Collapse
Affiliation(s)
- Mariana Chumbita
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Pedro Puerta-Alcalde
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Lucrecia Yáñez
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | | | | | | | - Carlota Gudiol
- Hospital Universitario de Bellvitge, Institut Català d'Oncologia, IDIBELL, l'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Rafael Rojas
- Hospital Universitario Reina Sofia, Córdoba, Spain
| | | | | | | | | | - Lourdes Vázquez
- Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Patricia Monzo
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | - Carlos Lopera
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
| | | | - Oliver Peyrony
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
- Emergency Department, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alex Soriano
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Barcelona, Spain
| | - Carolina Garcia-Vidal
- Hospital Clínic de Barcelona-IDIBAPS, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red (CIBER) de Enfermedades Infecciosas, Barcelona, Spain
| |
Collapse
|
2
|
Azanza JR, Mensa J, Barberán J, Vázquez L, Pérez de Oteyza J, Kwon M, Yáñez L, Aguado JM, Cubillo Gracian A, Solano C, Ruiz Camps I, Fortún J, Salavert Lletí M, Gudiol C, Olave Rubio T, Solano C, García-Vidal C, Rovira Tarrats M, Suárez-Lledó Grande M, González-Sierra P, Dueñas Gutiérrez C. Recommendations on the use of azole antifungals in hematology-oncology patients. Rev Esp Quimioter 2023; 36:236-258. [PMID: 37017117 DOI: 10.37201/req/013.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
The administration of antifungals for therapeutic and, especially, prophylactic purposes is virtually a constant in patients requiring hematology-oncology treatment. Any attempt to prevent or treat Aspergillus or Mucor infections requires the administration of some drugs in the azole group, which include voriconazole, posaconazole and isavuconazole, noted for their activity against these pathogens. One very relevant aspect is the potential risk of interaction when associated with one of the antineoplastic drugs used to treat hematologic tumors, with serious complications. In this regard, acalabrutinib, bortezomib, bosutinib, carfilzomib, cyclophosphamide, cyclosporine A, dasatinib, duvelisib, gilteritinib, glasdegib, ibrutinib, imatinib, nilotinib, ponatinib, prednisone, ruxolitinib, tacrolimus, all-transretinoic acid, arsenic trioxide, venetoclax, or any of the vinca alkaloids, are very clear examples of risk, in some cases because their clearance is reduced and in others because of increased risk of QTc prolongation, which is particularly evident when the drug of choice is voriconazole or posaconazole.
Collapse
Affiliation(s)
- J R Azanza
- José Ramón Azanza,Servicio de Farmacología Clínica. Clínica Universitaria de Navarra. Pamplona. Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
García-Martín P, Díez AM, Maldonado JMS, Serrano AJC, Ter Horst R, Benavente Y, Landi S, Macauda A, Clay-Gilmour A, Hernández-Mohedo F, Niazi Y, González-Sierra P, Espinet B, Rodríguez-Sevilla JJ, Maffei R, Blanco G, Giaccherini M, Puiggros A, Cerhan J, Marasca R, Cañadas-Garre M, López-Nevot MÁ, Chen-Liang T, Thomsen H, Gámez I, Moreno V, Marcos-Gragera R, García-Álvarez M, Llorca J, Jerez A, Berndt S, Butrym A, Norman AD, Casabonne D, Luppi M, Slager SL, Hemminki K, Li Y, Alcoceba M, Campa D, Canzian F, de Sanjosé S, Försti A, Netea MG, Jurado M, Sainz J. Validation and functional characterization of GWAS-identified variants for chronic lymphocytic leukemia: a CRuCIAL study. Blood Cancer J 2022; 12:79. [PMID: 35581176 PMCID: PMC9114372 DOI: 10.1038/s41408-022-00676-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
| | - Ana Moñiz Díez
- Genomic Oncology Area, GENYO, Centre for Genomics and Oncological Research: Pfizer/University of Granada/Andalusian Regional Government, PTS, Granada, Spain
- Hematology department, Virgen de las Nieves University Hospital, Granada, Spain
- Instituto de Investigación Biosanitaria IBs.Granada, Granada, Spain
| | - José Manuel Sánchez Maldonado
- Genomic Oncology Area, GENYO, Centre for Genomics and Oncological Research: Pfizer/University of Granada/Andalusian Regional Government, PTS, Granada, Spain
- Hematology department, Virgen de las Nieves University Hospital, Granada, Spain
- Instituto de Investigación Biosanitaria IBs.Granada, Granada, Spain
| | - Antonio José Cabrera Serrano
- Genomic Oncology Area, GENYO, Centre for Genomics and Oncological Research: Pfizer/University of Granada/Andalusian Regional Government, PTS, Granada, Spain
- Hematology department, Virgen de las Nieves University Hospital, Granada, Spain
- Instituto de Investigación Biosanitaria IBs.Granada, Granada, Spain
| | - Rob Ter Horst
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Yolanda Benavente
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP) and University of Barcelona, Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Stefano Landi
- Department of Biology, University of Pisa, Pisa, Italy
| | - Angelica Macauda
- Genomic Epidemiology Group, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Alyssa Clay-Gilmour
- Department of Epidemiology & Biostatistics, Arnold School of Public Health, University of South Carolina, Greenville, SC, USA
| | - Francisca Hernández-Mohedo
- Hematology department, Virgen de las Nieves University Hospital, Granada, Spain
- Instituto de Investigación Biosanitaria IBs.Granada, Granada, Spain
| | - Yasmeen Niazi
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany
| | - Pedro González-Sierra
- Hematology department, Virgen de las Nieves University Hospital, Granada, Spain
- Instituto de Investigación Biosanitaria IBs.Granada, Granada, Spain
| | - Blanca Espinet
- Molecular Cytogenetics Laboratory, Pathology Department, Hospital del Mar, Barcelona, Spain
- Translational Research on Hematological Neoplasms Group, Cancer Research Program, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | | | - Rossana Maffei
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, Modena, Italy
| | - Gonzalo Blanco
- Molecular Cytogenetics Laboratory, Pathology Department, Hospital del Mar, Barcelona, Spain
- Translational Research on Hematological Neoplasms Group, Cancer Research Program, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | | | - Anna Puiggros
- Molecular Cytogenetics Laboratory, Pathology Department, Hospital del Mar, Barcelona, Spain
- Translational Research on Hematological Neoplasms Group, Cancer Research Program, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - James Cerhan
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, 55905, USA
| | - Roberto Marasca
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, Modena, Italy
| | - Marisa Cañadas-Garre
- Genomic Oncology Area, GENYO, Centre for Genomics and Oncological Research: Pfizer/University of Granada/Andalusian Regional Government, PTS, Granada, Spain
- Hematology department, Virgen de las Nieves University Hospital, Granada, Spain
- Instituto de Investigación Biosanitaria IBs.Granada, Granada, Spain
| | | | - Tzu Chen-Liang
- Hematology Department, Morales Meseguer University Hospital, Murcia, Spain
| | | | - Irene Gámez
- Hematology Department, Morales Meseguer University Hospital, Murcia, Spain
| | - Víctor Moreno
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Unit of Biomarkers and Susceptibility, Cancer Prevention and Control Program, IDIBELL, Catalan Institute of Oncology; Department of Clinical Sciences, Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Rafael Marcos-Gragera
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Epidemiology Unit and Girona Cancer Registry, Oncology Coordination Plan, Department of Health, Autonomous Government of Catalonia, Catalan Institute of Oncology, Girona Biomedical Research Institute (IdiBGi), and Universitat de Girona, Girona, Spain
- Josep Carreras Leukemia Research Institute, Girona, Spain
| | - María García-Álvarez
- Department of Hematology, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), Salamanca, Spain
| | - Javier Llorca
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- University of Cantabria, Santander, Spain
| | - Andrés Jerez
- Hematology Department, Morales Meseguer University Hospital, Murcia, Spain
| | - Sonja Berndt
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Aaron D Norman
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, 55905, USA
| | - Delphine Casabonne
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP) and University of Barcelona, Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Mario Luppi
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, AOU Policlinico, Modena, Italy
| | - Susan L Slager
- Division of Computational Genomics, Mayo Clinic, Rochester, MN, USA
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Kari Hemminki
- Division of Cancer Epidemiology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
- Faculty of Medicine and Biomedical Center in Pilsen, Charles University in Prague, 30605, Pilsen, Czech Republic
| | - Yang Li
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- Centre for Individualised Infection Medicine (CiiM) & TWINCORE, joint ventures between the Helmholtz-Centre for Infection Research (HZI) and the Hannover Medical School (MHH), Hannover, Germany
| | | | - Daniele Campa
- Department of Biology, University of Pisa, Pisa, Italy
| | - Federico Canzian
- Genomic Epidemiology Group, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Silvia de Sanjosé
- Catalan Institute of Oncology, Bellvitge Biomedical Research Institute (IDIBELL), Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP) and University of Barcelona, Barcelona, Spain
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Asta Försti
- Division of Pediatric Neurooncology, German Cancer Research Center (DKFZ), German Cancer Consortium (DKTK), Heidelberg, Germany
- Hopp Children's Cancer Center (KiTZ), Heidelberg, Germany
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
- Department for Immunology & Metabolism, Life and Medical Sciences Institute (LIMES), University of Bonn, 53115, Bonn, Germany
| | - Manuel Jurado
- Genomic Oncology Area, GENYO, Centre for Genomics and Oncological Research: Pfizer/University of Granada/Andalusian Regional Government, PTS, Granada, Spain
- Hematology department, Virgen de las Nieves University Hospital, Granada, Spain
- Instituto de Investigación Biosanitaria IBs.Granada, Granada, Spain
| | - Juan Sainz
- Genomic Oncology Area, GENYO, Centre for Genomics and Oncological Research: Pfizer/University of Granada/Andalusian Regional Government, PTS, Granada, Spain.
- Hematology department, Virgen de las Nieves University Hospital, Granada, Spain.
- Instituto de Investigación Biosanitaria IBs.Granada, Granada, Spain.
- Department of Biochemistry and Molecular Biology I, Faculty of Sciences, University of Granada (UGR), Granada, Spain.
| |
Collapse
|
4
|
Bastos-Oreiro M, Muntañola A, Panizo C, Gonzalez-Barca E, de Villambrosia SG, Córdoba R, López JLB, González-Sierra P, Terol MJ, Gutierrez A, Grande C, Ramirez MJ, Iserte L, Perez E, Navarro B, Gomez P, Salar A, Luzardo H, López A, Del Campo R, García-Belmonte D, Vida MJ, Infante M, Queizan-Hernandez JA, Novelli S, Moreno M, Penarrubia M, Gómez J, Domingo A, Donato E, Viguria MC, López F, Rodriguez MJ, Pardal E, Noriega V, Andreu R, Peñalver J, Martín A, Caballero D, López-Guillermo A. RELINF: prospective epidemiological registry of lymphoid neoplasms in Spain. A project from the GELTAMO group. Ann Hematol 2020; 99:799-808. [PMID: 32076827 DOI: 10.1007/s00277-020-03918-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 01/13/2020] [Indexed: 12/17/2022]
Abstract
Lymphomas are a large, heterogeneous group of neoplasms with well-defined characteristics, and this heterogeneity highlights the importance of epidemiological data. Knowledge of local epidemiology is essential to optimise resources, design clinical trials, and identify minority entities. Given there are few published epidemiological data on lymphoma in Spain, the Spanish Lymphoma and Autologous Bone Marrow Transplant Group created the RELINF project. The aim of this project is to determine the frequencies and distribution of lymphoid neoplasms in Spain and to analyse survival. We developed an online platform for the prospective collection of data on newly diagnosed cases of lymphoma in Spain between January 2014 and July 2018; 11,400 patients were registered. Diffuse large B cell lymphoma (DLBCL) and follicular lymphoma (FL) were the most frequent lymphomas in our series. Marginal B cell lymphoma frequency was higher than that reported in other studies, representing more than 11% of mature B cell lymphomas. Peripheral T cell lymphoma not otherwise specified (PTCL-NOS) was the most common subtype of T cell lymphoma, and NK/T cell lymphomas were more frequent than expected (5.4% of total). Hodgkin's lymphoma accounted for 12% of lymphoproliferative syndromes. Overall survival was greater than 90% at 2 years for indolent B cell lymphomas, and approximately 60% for DLBCL, somewhat lower than that previously reported. Survival was poor for PTCL-NOS and angioimmunoblastic T cell lymphoma, as expected; however, it was somewhat better than that in other studies for anaplastic large cell anaplastic lymphoma kinase lymphomas. This is the first prospective registry to report the frequencies, distribution, and survival of lymphomas in Spain. The frequencies and survival data we report here are globally consistent with that reported in other Western countries. These updated frequencies and survival statistics are necessary for developing appropriate management strategies for neoplasias in the Spanish population.
Collapse
Affiliation(s)
- Mariana Bastos-Oreiro
- Haematology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain. .,Health Research Institute, Gregorio Marañon, Madrid, Spain.
| | - Ana Muntañola
- Haematology Department, Hospital Universitario Mutua Tarrasa, Tarrasa, Cataluña, Spain
| | - Carlos Panizo
- Haematology Department, Clínica Universitaria de Navarra, Navarra, Spain
| | - Eva Gonzalez-Barca
- Haematology Department, ICO Duran y Reinalds, Bellvitlle, Cataluña, Spain
| | | | - Raúl Córdoba
- Haematology Department, Fundación Jimenez Díaz, Madrid, Madrid, Spain
| | - Jose Luís Bello López
- Haematology Department, University of Santiago Hospital Clinic, Santiago de Compostela, Galicia, Spain
| | | | - María José Terol
- Haematology Department, Valencia Hospital Clinic, Valencia, Spain
| | - Antonio Gutierrez
- Haematology Department, Hospital Son Espases, Palma de Mallorca, Spain
| | - Carlos Grande
- Haematology Department, Hospital 12 de Octubre, Madrid, Spain
| | | | - Laura Iserte
- Haematology Department, Hospital Arnau de Vilanova, Lleida, Cataluña, Spain
| | - Elena Perez
- Haematology department, Hospital Morales Meseguer, Murcia, Murcia, Spain
| | - Belén Navarro
- Haematology Department, University Hospital Puerta de Hierro, Mahadahonda, Madrid, Spain
| | - Pilar Gomez
- Haematology Department, La Paz University Hospital, Madrid, Spain
| | - Antonio Salar
- Haematology Department, Hospital del Mar, Barcelona, Cataluña, Spain
| | - Hugo Luzardo
- Hospital Negrin, Las Palmas de Gran Canaria, Canary Islands, Spain
| | - Andrés López
- Haematology Department, Hospital Vall d' Hebron, Barcelona, Cataluña, Spain
| | - Raquel Del Campo
- Haematology Department, Hospital Son Llátzer, Palma de Mallorca, Spain
| | | | - María Jesús Vida
- Haematology Department, Hospital of León, León, Castilla y León, Spain
| | - María Infante
- Haematology Department, Hospital Infanta Leonor, Madrid, Spain
| | | | - Silvana Novelli
- Haematology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Cataluña, Spain
| | - Miriam Moreno
- Haematology Department, Hospital Germans Trials y Pujol, Badalona, Cataluña, Spain
| | - Miriam Penarrubia
- Haematology Department, Hospital Clinic of Valladolid, Castilla y León, Spain
| | - Joaquín Gómez
- Haematology Department, Hospital Virgen de la Arrixaca, El Palmar, Murcia, Spain
| | - Abel Domingo
- Haematology Department, Hospital de Granollers, Barcelona, Cataluña, Spain
| | - Eva Donato
- Haematology Department, Hospital Dr. Peset, Valencia, Spain
| | | | | | - María José Rodriguez
- Haematology Department, Hospital Universitario de Canarias SCT, Tenerife, Canary Islands, Spain
| | - Emilia Pardal
- Haematology Department, Hospital Virgen del Puerto, Cáceres, Extremadura, Spain
| | - Victor Noriega
- Haematology Department, University Hospital A Coruña, A Coruña, Galicia, Spain
| | - Rafael Andreu
- Haematology Department, Hospital La Fe, Valencia, Spain
| | - Javier Peñalver
- Haematology Department, Hospital of Alcorcón, Alcorcón, Madrid, Spain
| | - Alejandro Martín
- Haematology Department, Hospital Clinic of Salamanca, Salamanca, Castilla y León, Spain
| | - Dolores Caballero
- Haematology Department, Hospital Clinic of Salamanca, Salamanca, Castilla y León, Spain
| | | |
Collapse
|