Top

Published in:

01-05-2016 | Infections and Arthritis (K Winthrop, Section Editor)

Fungal Infections and New Biologic Therapies

Authors: Snigdha Vallabhaneni, Tom M. Chiller

Published in: Current Rheumatology Reports | Issue 5/2016

Abstract

The development of biologic therapies targeting proinflammatory mediators has led to significant advances in the treatment of immune-mediated inflammatory diseases (IMIDs). Blocking undesired inflammatory effects also has the potential to disrupt the body’s immune response and increase the risk for infections, including fungal infections. This review summarizes the published data on the frequency and risk for fungal infections among patients treated with biologics, with a focus on the newer therapies approved for use with IMIDs in the last 10 years. The use of biologics is associated with a small but important risk of fungal infections. Pneumocystis jirovecii pneumonia, histoplasmosis, and candidiasis are some of the most common fungal infections associated with biologics. Providers should be vigilant for fungal infection among patients taking biologics, be aware that biologic agents may alter the typical presentation of fungal infections, and take timely steps to diagnose and treat fungal infection to reduce resultant morbidity and mortality.

1.•

Novosad SA, Winthrop KL. Beyond tumor necrosis factor inhibition: the expanding pipeline of biologic therapies for inflammatory diseases and their associated infectious sequelae. Clin Infect Dis. 2014;58(11):1587–98. doi:10.1093/cid/ciu104. Good overall review of many of the biologic agents and their mechanism of action, date of approval, and associated infection risk.CrossRefPubMed

Doran MF, Crowson CS, Pond GR, et al. Frequency of infection in patients with rheumatoid arthritis compared with controls: a population-based study. Arthritis Rheum. 2002;46(9):2287–93. doi:10.1002/art.10524.CrossRefPubMed

Dixon WG, Suissa S, Hudson M. The association between systemic glucocorticoid therapy and the risk of infection in patients with rheumatoid arthritis: systematic review and meta-analyses. Arthritis Res Ther. 2011;13(4):R139. doi:10.1186/ar3453.CrossRefPubMedPubMedCentral

4.••

Kourbeti IS, Ziakas PD, Mylonakis E. Biologic therapies in rheumatoid arthritis and the risk of opportunistic infections: a meta-analysis. Clin Infect Dis. 2014;58(12):1649–57. doi:10.1093/cid/ciu185. Comprehensive analysis of risk of all opportunistic infections, including fungal infections. Particular strength is that this paper included many of the newer biologic agents.CrossRefPubMed

5.•

Baddley JW, Winthrop KL, Chen L, et al. Non-viral opportunistic infections in new users of tumour necrosis factor inhibitor therapy: results of the SAfety Assessment of Biologic ThERapy (SABER) Study. Ann Rheum Dis. 2014;73(11):1942–8. doi:10.1136/annrheumdis-2013-203407. Analysis of viral an non-viral opportunistic infections among TNF-alpha inhibitor users.CrossRefPubMedPubMedCentral

FDA. 2001. http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/ApprovalApplications/TherapeuticBiologicApplications/ucm113512.htm. Accessed Jan 29,2016.

Bongartz T, Sutton AJ, Sweeting MJ, et al. Anti-TNF antibody therapy in rheumatoid arthritis and the risk of serious infections and malignancies: systematic review and meta-analysis of rare harmful effects in randomized controlled trials. JAMA. 2006;295(19):2275–85. doi:10.1001/jama.295.19.2275.CrossRefPubMed

Ford AC, Peyrin-Biroulet L. Opportunistic Infections With Anti-Tumor Necrosis Factor-[alpha] Therapy in Inflammatory Bowel Disease: Meta-Analysis of Randomized Controlled Trials. Am J Gastroenterol. 2013;108(8):1268–76. doi:10.1038/ajg.2013.138.CrossRefPubMed

Galloway JB, Hyrich KL, Mercer LK, et al. Anti-TNF therapy is associated with an increased risk of serious infections in patients with rheumatoid arthritis especially in the first 6 months of treatment: updated results from the British Society for Rheumatology Biologics Register with special emphasis on risks in the elderly. Rheumatology (Oxford). 2011;50(1):124–31. doi:10.1093/rheumatology/keq242.CrossRef

10.

Salmon-Ceron D, Tubach F, Lortholary O, et al. Drug-specific risk of non-tuberculosis opportunistic infections in patients receiving anti-TNF therapy reported to the 3-year prospective French RATIO registry. Ann Rheum Dis. 2011;70(4):616–23. doi:10.1136/ard.2010.137422.CrossRefPubMed

11.

Tsiodras S, Samonis G, Boumpas DT, et al. Fungal infections complicating tumor necrosis factor alpha blockade therapy. Mayo Clin Proc. 2008;83(2):181–94.CrossRefPubMed

12.

Lee JH, Slifman NR, Gershon SK, et al. Life-threatening histoplasmosis complicating immunotherapy with tumor necrosis factor alpha antagonists infliximab and etanercept. Arthritis Rheum. 2002;46(10):2565–70. doi:10.1002/art.10583.CrossRefPubMed

13.

Bergstrom L, Yocum DE, Ampel NM, et al. Increased risk of coccidioidomycosis in patients treated with tumor necrosis factor alpha antagonists. Arthritis Rheum. 2004;50(6):1959–66. doi:10.1002/art.20454.CrossRefPubMed

14.

Filler SG, Yeaman MR, Sheppard DC. Tumor necrosis factor inhibition and invasive fungal infections. Clin Infect Dis. 2005;41 Suppl 3:S208–12. doi:10.1086/430000.CrossRefPubMed

15.••

Salt E, Wiggins AT, Rayens MK, et al. Risk factors for targeted fungal and mycobacterial infections in patients taking TNF-alpha inhibitors. Arthritis Rheum. 2015. doi:10.1002/art.39468. This article assesses risk of fungal infection in TNF-alpha inhibitor users (not limited to IMID patients) and is one of the few studies that focuses specifically on fungal infections in this population.

16.

Bykerk VP, Cush J, Winthrop K, et al. Update on the safety profile of certolizumab pegol in rheumatoid arthritis: an integrated analysis from clinical trials. Ann Rheum Dis. 2015;74(1):96–103. doi:10.1136/annrheumdis-2013-203660.CrossRefPubMedPubMedCentral

17.

Sandborn WJ, Lee SD, Randall C, et al. Long-term safety and efficacy of certolizumab pegol in the treatment of Crohn’s disease: 7-year results from the PRECiSE 3 study. Aliment Pharmacol Ther. 2014;40(8):903–16. doi:10.1111/apt.12930.CrossRefPubMed

18.

Mease PJ, Fleischmann R, Deodhar AA, et al. Effect of certolizumab pegol on signs and symptoms in patients with psoriatic arthritis: 24-week results of a phase 3 double-blind randomised placebo-controlled study (RAPID-PsA). Ann Rheum Dis. 2014;73(1):48–55. doi:10.1136/annrheumdis-2013-203696.CrossRefPubMedPubMedCentral

19.

Donahue KE, Jonas DE, Hansen RA, et al. AHRQ comparative effectiveness reviews. Drug therapy for rheumatoid arthritis in adults: an update. . 2012.

20.

Kay J, Fleischmann R, Keystone E, et al. Golimumab 3-year safety update: an analysis of pooled data from the long-term extensions of randomised, double-blind, placebo-controlled trials conducted in patients with rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis. Ann Rheum Dis. 2015;74(3):538–46. doi:10.1136/annrheumdis-2013-204195.CrossRefPubMedPubMedCentral

21.

Sandborn WJ, Feagan BG, Marano C, et al. Subcutaneous golimumab induces clinical response and remission in patients with moderate-to-severe ulcerative colitis. Gastroenterology. 2014;146(1):85–95. doi:10.1053/j.gastro.2013.05.048.CrossRefPubMed

22.

Sandborn WJ, Feagan BG, Marano C, et al. Subcutaneous golimumab maintains clinical response in patients with moderate-to-severe ulcerative colitis. Gastroenterology. 2014;146(1):96–109.e1. doi:10.1053/j.gastro.2013.06.010.CrossRefPubMed

23.

Schiff M. Abatacept treatment for rheumatoid arthritis. Rheumatology (Oxford). 2011;50(3):437–49. doi:10.1093/rheumatology/keq287.CrossRef

24.

Salliot C, Dougados M, Gossec L. Risk of serious infections during rituximab, abatacept and anakinra treatments for rheumatoid arthritis: meta-analyses of randomised placebo-controlled trials. Ann Rheum Dis. 2009;68(1):25–32. doi:10.1136/ard.2007.083188.CrossRefPubMedPubMedCentral

25.

Schiff M, Weinblatt ME, Valente R, et al. Head-to-head comparison of subcutaneous abatacept versus adalimumab for rheumatoid arthritis: two-year efficacy and safety findings from AMPLE trial. Ann Rheum Dis. 2014;73(1):86–94. doi:10.1136/annrheumdis-2013-203843.CrossRefPubMedPubMedCentral

26.

Lee YH, Bae SC. Comparative efficacy and safety of tocilizumab, rituximab, abatacept and tofacitinib in patients with active rheumatoid arthritis that inadequately responds to tumor necrosis factor inhibitors: a Bayesian network meta-analysis of randomized controlled trials. Int J Rheum Dis. 2015. doi:10.1111/1756-185x.12822.

27.

Mertens M, Singh JA. Anakinra for rheumatoid arthritis. Cochrane Database Syst Rev. 2009(1):Cd005121. doi:10.1002/14651858.CD005121.pub3.

28.

Lovell DJ, Ruperto N, Mouy R, et al. Long-term safety, efficacy, and quality of life in patients with juvenile idiopathic arthritis treated with intravenous abatacept for up to seven years. Arthritis Rheum. 2015;67(10):2759–70. doi:10.1002/art.39234.CrossRef

29.

Kremer JM, Peterfy C, Russell AS, et al. Long term safety, efficacy, and inhibition of structural damage progression over 5 years of treatment with abatacept in patients with rheumatoid arthritis in the abatacept in inadequate responders to methotrexate trial. J Rheumatol. 2014;41(6):1077–87. doi:10.3899/jrheum.130263.CrossRefPubMed

30.

Alten R, Kaine J, Keystone E, et al. Long-term safety of subcutaneous abatacept in rheumatoid arthritis: integrated analysis of clinical trial data representing more than four years of treatment. Arthritis Rheum. 2014;66(8):1987–97. doi:10.1002/art.38687.CrossRef

31.

Weinblatt M, Combe B, Covucci A, et al. Safety of the selective costimulation modulator abatacept in rheumatoid arthritis patients receiving background biologic and nonbiologic disease-modifying antirheumatic drugs: a one-year randomized, placebo-controlled study. Arthritis Rheum. 2006;54(9):2807–16. doi:10.1002/art.22070.CrossRefPubMed

32.

van Vollenhoven RF, Fleischmann RM, Furst DE, et al. Long term safety of rituximab: final report of the rheumatoid arthritis global clinical trial program over 11 years. J Rheumatol. 2015;42(10):1761–6. doi:10.3899/jrheum.150051.CrossRefPubMed

33.

Greenwald MW, Shergy WJ, Kaine JL, et al. Evaluation of the safety of rituximab in combination with a tumor necrosis factor inhibitor and methotrexate in patients with active rheumatoid arthritis: results from a randomized controlled trial. Arthritis Rheum. 2011;63(3):622–32. doi:10.1002/art.30194.CrossRefPubMed

34.

Papp K, Gottlieb AB, Naldi L, et al. Safety surveillance for ustekinumab and other psoriasis treatments from the Psoriasis Longitudinal Assessment and Registry (PSOLAR). J Drugs Dermatol. 2015;14(7):706–14.PubMed

35.

Papp KA, Griffiths CEM, Gordon K, et al. Long-term safety of ustekinumab in patients with moderate-to-severe psoriasis: final results from 5 years of follow-up. Br J Dermatol. 2013;168(4):844–54. doi:10.1111/bjd.12214.CrossRefPubMed

36.

Gordon KB, Papp KA, Langley RG, et al. Long-term safety experience of ustekinumab in patients with moderate to severe psoriasis (Part II of II): results from analyses of infections and malignancy from pooled phase II and III clinical trials. J Am Acad Dermatol. 2012;66(5):742–51. doi:10.1016/j.jaad.2011.06.041.CrossRefPubMed

37.

Ritchlin C, Rahman P, Kavanaugh A, et al. Efficacy and safety of the anti-IL-12/23 p40 monoclonal antibody, ustekinumab, in patients with active psoriatic arthritis despite conventional non-biological and biological anti-tumour necrosis factor therapy: 6-month and 1-year results of the phase 3, multicentre, double-blind, placebo-controlled, randomised PSUMMIT 2 trial. Ann Rheum Dis. 2014;73(6):990–9. doi:10.1136/annrheumdis-2013-204655.CrossRefPubMedPubMedCentral

38.

Cantini F, Niccoli L, Nannini C, et al. Tailored first-line biologic therapy in patients with rheumatoid arthritis, spondyloarthritis, and psoriatic arthritis. Semin Arthritis Rheum. doi:http://dx.doi.org/10.1016/j.semarthrit.2015.10.001.

39.

Sandborn WJ, Gasink C, Gao LL, et al. Ustekinumab induction and maintenance therapy in refractory Crohn’s disease. N Engl J Med. 2012;367(16):1519–28. doi:10.1056/NEJMoa1203572.CrossRefPubMed

40.

Poddubnyy D, Hermann KG, Callhoff J, et al. Ustekinumab for the treatment of patients with active ankylosing spondylitis: results of a 28-week, prospective, open-label, proof-of-concept study (TOPAS). Ann Rheum Dis. 2014;73(5):817–23. doi:10.1136/annrheumdis-2013-204248.CrossRefPubMed

41.

Campbell L, Chen C, Bhagat SS, et al. Risk of adverse events including serious infections in rheumatoid arthritis patients treated with tocilizumab: a systematic literature review and meta-analysis of randomized controlled trials. Rheumatology (Oxford). 2011;50(3):552–62. doi:10.1093/rheumatology/keq343.CrossRef

42.

Schiff MH, Kremer JM, Jahreis A, et al. Integrated safety in tocilizumab clinical trials. Arthritis Res Ther. 2011;13(5):R141. doi:10.1186/ar3455.CrossRefPubMedPubMedCentral

43.

Hoshi D, Nakajima A, Inoue E, et al. Incidence of serious respiratory infections in patients with rheumatoid arthritis treated with tocilizumab. Mod Rheumatol. 2012;22(1):122–7. doi:10.1007/s10165-011-0488-6.CrossRefPubMed

44.

Kremer J, Li ZG, Hall S, et al. Tofacitinib in combination with nonbiologic disease-modifying antirheumatic drugs in patients with active rheumatoid arthritis: a randomized trial. Ann Intern Med. 2013;159(4):253–61. doi:10.7326/0003-4819-159-4-201308200-00006.CrossRefPubMed

45.

Winthrop KL, Park S-H, Gul A, et al. Tuberculosis and other opportunistic infections in tofacitinib-treated patients with rheumatoid arthritis. Ann Rheum Dis. 2015. doi:10.1136/annrheumdis-2015-207319.

46.

Sandborn WJ, Feagan BG, Rutgeerts P, et al. Vedolizumab as induction and maintenance therapy for Crohn’s disease. N Engl J Med. 2013;369(8):711–21. doi:10.1056/NEJMoa1215739.CrossRefPubMed

47.

Wang MC, Zhang LY, Han W, et al. PRISMA—efficacy and safety of vedolizumab for inflammatory bowel diseases: a systematic review and meta-analysis of randomized controlled trials. Medicine. 2014;93(28):e326. doi:10.1097/md.0000000000000326.CrossRefPubMedPubMedCentral

48.

Dulai PS, Mosli M, Khanna R, et al. Vedolizumab for the treatment of moderately to severely active ulcerative colitis. Pharmacotherapy. 2015;35(4):412–23. doi:10.1002/phar.1561.CrossRefPubMed

49.

Langley RG, Elewski BE, Lebwohl M, et al. Secukinumab in plaque psoriasis—results of two phase 3 trials. N Engl J Med. 2014;371(4):326–38. doi:10.1056/NEJMoa1314258.CrossRefPubMed

50.

Mease PJ, McInnes IB, Kirkham B, et al. Secukinumab inhibition of interleukin-17A in patients with psoriatic arthritis. N Engl J Med. 2015;373(14):1329–39. doi:10.1056/NEJMoa1412679.CrossRefPubMed

51.

Baeten D, Sieper J, Braun J, et al. Secukinumab, an interleukin-17A inhibitor, in ankylosing spondylitis. N Engl J Med. 2015;373(26):2534–48. doi:10.1056/NEJMoa1505066.CrossRefPubMed

52.

Griffiths CE, Reich K, Lebwohl M, et al. Comparison of ixekizumab with etanercept or placebo in moderate-to-severe psoriasis (UNCOVER-2 and UNCOVER-3): results from two phase 3 randomised trials. Lancet. 2015;386(9993):541–51. doi:10.1016/s0140-6736(15)60125-8.CrossRefPubMed

53.

Genovese MC, Braun DK, Erickson JS, et al. Safety and efficacy of open-label subcutaneous ixekizumab treatment for 48 weeks in a phase ii study in biologic-naive and TNF-IR patients with rheumatoid arthritis. J Rheumatol. 2015. doi:10.3899/jrheum.140831.

54.

Grubbs JA, Baddley JW. Pneumocystis jirovecii pneumonia in patients receiving tumor-necrosis-factor-inhibitor therapy: implications for chemoprophylaxis. Curr Rheumatol Rep. 2014;16(10):445. doi:10.1007/s11926-014-0445-4.CrossRefPubMed

55.

Tokuda H, Sakai F, Yamada H, et al. Clinical and radiological features of Pneumocystis pneumonia in patients with rheumatoid arthritis, in comparison with methotrexate pneumonitis and Pneumocystis pneumonia in acquired immunodeficiency syndrome: a multicenter study. Intern Med. 2008;47(10):915–23.CrossRefPubMed

56.

Arnold TM, Sears CR, Hage CA. Invasive fungal infections in the era of biologics. Clin Chest Med. 2009;30(2):279–86. doi:10.1016/j.ccm.2009.02.007. vi.CrossRefPubMed

57.

Nedel WL, Kontoyiannis DP, Pasqualotto AC. Aspergillosis in patients treated with monoclonal antibodies. Rev Iberoam Micol. 2009;26(3):175–83. doi:10.1016/j.riam.2009.04.001.CrossRefPubMed

58.

Bardazzi F, Balestri R, Rech G, et al. Dermatophytosis during anti-TNF-alpha monoclonal antibody therapy. Mycoses. 2011;54(5):e619–20. doi:10.1111/j.1439-0507.2010.01930.x.CrossRefPubMed

59.

Balestri R, Rech G, Piraccini BM, et al. Pityriasis versicolor during anti-TNF-alpha monoclonal antibody therapy: therapeutic considerations. Mycoses. 2012;55(5):444–6. doi:10.1111/j.1439-0507.2012.02170.x.CrossRefPubMed

60.

Winthrop KL, Yamashita S, Beekmann SE, et al. Mycobacterial and Other serious infections in patients receiving anti-tumor necrosis factor and other newly approved biologic therapies: case finding through the emerging infections network. Clin Infect Dis. 2008;46(11):1738–40. doi:10.1086/587989.CrossRefPubMed

61.

Benedict K, Derado G, Mody R. Histoplasmosis-associated hospitalizations in the United States, 2001–2012 Open Forum Infectious Diseases. 2016 (in press).

62.

Ordonez ME, Farraye FA, Di Palma JA. Endemic fungal infections in inflammatory bowel disease associated with anti-TNF antibody therapy. Inflamm Bowel Dis. 2013;19(11):2490–500. doi:10.1097/MIB.0b013e31828f1fba.CrossRefPubMed

63.

Hage CA, Bowyer S, Tarvin SE, et al. Recognition, diagnosis, and treatment of histoplasmosis complicating tumor necrosis factor blocker therapy. Clin Infect Dis. 2010;50(1):85–92. doi:10.1086/648724.CrossRefPubMed

64.

Olson TC, Bongartz T, Crowson CS, et al. Histoplasmosis infection in patients with rheumatoid arthritis, 1998–2009. BMC Infect Dis. 2011;11:145. doi:10.1186/1471-2334-11-145.CrossRefPubMedPubMedCentral

65.

Taroumian S, Knowles SL, Lisse JR, et al. Management of coccidioidomycosis in patients receiving biologic response modifiers or disease-modifying antirheumatic drugs. Arthritis Care Res. 2012;64(12):1903–9. doi:10.1002/acr.21784.CrossRef

Title: Fungal Infections and New Biologic Therapies
Authors: Snigdha Vallabhaneni
Tom M. Chiller
Publication date: 01-05-2016
Publisher: Springer US
Published in: Current Rheumatology Reports / Issue 5/2016
Print ISSN: 1523-3774
Electronic ISSN: 1534-6307
DOI: https://doi.org/10.1007/s11926-016-0572-1

Live Webinar | 27-06-2024 | 18:00 (CEST)

Keynote webinar | Spotlight on medication adherence

Reserve your place

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

WHO estimates that half of all patients worldwide are non-adherent to their prescribed medication. The consequences of poor adherence can be catastrophic, on both the individual and population level.

Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.

Prof. Kevin Dolgin

Prof. Florian Limbourg

Prof. Anoop Chauhan

Developed by: Springer Medicine

Obesity Clinical Trial Summary

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.

Developed by: Springer Medicine

Highlights from the ACC 2024 Congress

Year in Review: Pediatric cardiology

Pediatric Cardiology Video

Watch Dr. Anne Marie Valente present the last year's highlights in pediatric and congenital heart disease in the official ACC.24 Year in Review session.

Year in Review: Pulmonary vascular disease

Cardiopulmonary Comorbidity Video

The last year's highlights in pulmonary vascular disease are presented by Dr. Jane Leopold in this official video from ACC.24.

Year in Review: Valvular heart disease

Valvular Heart Disease Video

Watch Prof. William Zoghbi present the last year's highlights in valvular heart disease from the official ACC.24 Year in Review session.

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discusses last year's major advances in heart failure and cardiomyopathies.

Watch now

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits

Illustration of figure on mountain summit/© Orapun / Stock.adobe.com, STEP AAG HeroTeaserCollection image/© Tarek / Generated with AI / Stock.adobe.com, ACC 2024 Pediatric and Congenital Heart Disease: Year in Review/© 2024 American College of Cardiology, ACC 2024 Pulmonary Vascular Disease: Year in Review/© 2024 American College of Cardiology, ACC 2024 Valvular Heart Disease: Year in Review/© 2024 American College of Cardiology, ACC 2024 HF and Cardiomyopathies: Year in Review/© 2024 American College of Cardiology, Woman out walking/© Seventyfour / stock.adobe.com (symbolic image with model), Woman checking smartwatch /© saltdium / stock.adobe.com (symbolic image with model), Cardiac catheterization/© Damian / stock.adobe.com

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 5/2016

Rheumatoid Arthritis Pharmacotherapies: Do They Have Anti-Atherosclerotic Activity?

Cognitive Dysfunction in Chronic Fatigue Syndrome: a Review of Recent Evidence

Prevention of Recurrent Thrombosis in Antiphospholipid Syndrome: Different from the General Population?

The Role of ANK in Calcium Pyrophosphate Deposition Disease

Pediatric Mixed Connective Tissue Disease

Is There a Role for Diet in the Therapy of Rheumatoid Arthritis?

Live: Thursday 27th June 2024, 18:00-19:30 (CEST)

Highlights from the ACC 2024 Congress

ACC 2024 Congress Coverage