- Anatomic Pathology
- Gastrointestinal Pathology
Associate Professor - University Medical Line, Pathology
Member, Stanford Cancer Institute
Fellowship: Oregon Health and Science University Dept of Pathology (2008) OR
Board Certification: American Board of Pathology, Anatomic Pathology (2009)
Residency: Cedars Sinai Medical Center Pathology Residency (2007) CA
Internship: Naval Hospital San Diego Surgery Residency (1999) CA
Medical Education: George Washington University Office of the Registrar (1998) DC
Current Research and Scholarly Interests
I am the Director of the Research Autopsy Collaboration at Stanford (RACS) to collect organs and tissues from decedent donors for cancer and disease research. https://med.stanford.edu/racs
I have a number of research interests associated with my autopsy work, including how the time interval between death and collection (the PMI) affects the condition and research viability of the collected tissue, how valuable blood and tissue cultures behave after death, and how autopsy results affect clinical practice in an established information loop. I have projects exploring physician and family attitudes towards autopsy and the utilization of rapid autopsy tissue in characterizing cancer evolution from genetic and immunologic standpoints.
The SARS-CoV-2 spike protein binds and modulates estrogen receptors.
2022; 8 (48): eadd4150
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike (S) protein binds angiotensin-converting enzyme 2 as its primary infection mechanism. Interactions between S and endogenous proteins occur after infection but are not well understood. We profiled binding of S against >9000 human proteins and found an interaction between S and human estrogen receptor α (ERα). Using bioinformatics, supercomputing, and experimental assays, we identified a highly conserved and functional nuclear receptor coregulator (NRC) LXD-like motif on the S2 subunit. In cultured cells, S DNA transfection increased ERα cytoplasmic accumulation, and S treatment induced ER-dependent biological effects. Non-invasive imaging in SARS-CoV-2-infected hamsters localized lung pathology with increased ERα lung levels. Postmortem lung experiments from infected hamsters and humans confirmed an increase in cytoplasmic ERα and its colocalization with S in alveolar macrophages. These findings describe the discovery of a S-ERα interaction, imply a role for S as an NRC, and advance knowledge of SARS-CoV-2 biology and coronavirus disease 2019 pathology.
View details for DOI 10.1126/sciadv.add4150
View details for PubMedID 36449624
The SARS-CoV-2 spike protein binds and modulates estrogen receptors.
bioRxiv : the preprint server for biology
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spike (S) protein binds angiotensin-converting enzyme 2 (ACE2) at the cell surface, which constitutes the primary mechanism driving SARS-CoV-2 infection. Molecular interactions between the transduced S and endogenous proteins likely occur post-infection, but such interactions are not well understood. We used an unbiased primary screen to profile the binding of full-length S against >9,000 human proteins and found significant S-host protein interactions, including one between S and human estrogen receptor alpha (ERα). After confirming this interaction in a secondary assay, we used bioinformatics, supercomputing, and experimental assays to identify a highly conserved and functional nuclear receptor coregulator (NRC) LXD-like motif on the S2 subunit and an S-ERα binding mode. In cultured cells, S DNA transfection increased ERα cytoplasmic accumulation, and S treatment induced ER-dependent biological effects and ACE2 expression. Noninvasive multimodal PET/CT imaging in SARS-CoV-2-infected hamsters using [ 18 F]fluoroestradiol (FES) localized lung pathology with increased ERα lung levels. Postmortem experiments in lung tissues from SARS-CoV-2-infected hamsters and humans confirmed an increase in cytoplasmic ERα expression and its colocalization with S protein in alveolar macrophages. These findings describe the discovery and characterization of a novel S-ERα interaction, imply a role for S as an NRC, and are poised to advance knowledge of SARS-CoV-2 biology, COVID-19 pathology, and mechanisms of sex differences in the pathology of infectious disease.
View details for DOI 10.1101/2022.05.21.492920
View details for PubMedID 35665018
View details for PubMedCentralID PMC9164441
IgM anti-ACE2 autoantibodies in severe COVID-19 activate complement and perturb vascular endothelial function.
BACKGROUND: COVID-19 is a global pandemic caused by the novel coronavirus SARS-CoV-2. Some clinical features of severe COVID-19 represent blood vessel damage induced by activation of host immune responses, initiated by the virus. We hypothesized that autoantibodies against angiotensin converting enzyme-2 (ACE2), the SARS-CoV-2 receptor expressed on vascular endothelium, are generated during COVID-19, and are of mechanistic importance.METHODS: The study was done in an opportunity sample of 118 COVID-19 inpatients. Autoantibodies recognizing ACE2 were detected by ELISA. Binding properties of anti-ACE2 IgM from patients were analyzed via biolayer interferometry. The effects of anti-ACE2 IgM on complement activation and endothelial function were demonstrated in a tissue-engineered pulmonary microvessel model.RESULTS: Anti-ACE2 IgM (but not IgG) were associated with severe COVID-19, found in 18/66 (27.2%) patients with severe disease compared to 2/52 (3.8%) of patients with moderate disease (OR 9.38, 95% CI 2.38-42.0; p=0.0009, Fisher's exact test). Anti-ACE2 IgM were rare (2/50) in non-COVID-19 ventilated patients with ARDS. Unexpectedly, ACE2-reactive IgM in COVID-19 do not undergo class-switching to IgG, and have apparent KD values of 5.6-21.7nM, indicating that they are T-independent. Anti-ACE2 IgM activated complement and initiated complement-binding and functional changes in endothelial cells in microvessels, suggesting that they contribute to the angiocentric pathology of COVID-19.CONCLUSIONS: Our results identify anti-ACE2 IgM as a mechanism-based biomarker strongly associated with severe clinical outcomes in SARS-CoV-2 infection, which has therapeutic implications. We anticipate that additional IgM responses may identify other COVID-19 subgroups with severe disease, and potentially other serious pandemic illnesses.
View details for DOI 10.1172/jci.insight.158362
View details for PubMedID 35349483
Updating Normal Organ Weights Using a Large Current Sample Database.
Archives of pathology & laboratory medicine
Organ weights are an essential part of autopsy analysis. Deviations from normal organ weights provide important clues to disease processes. The assessment of normal organ weights depends on reliable reference tables, but most widely available reference tables are based on data that are either decades old or derived from relatively small sample sizes.To provide an updated reference table of organ weights based on contemporary sources and a large sample size.Organ weights from 4197 carefully screened autopsies performed on adults at the Palm Beach County Medical Examiner's Office in West Palm Beach, Florida, and the Mayo Clinic Hospital in Rochester, Minnesota.Height and body weight data in this study reflect the well-recognized increases in both variables, but most particularly in body weight, seen during the last decades. The study data show a strong positive association between organ weight and body weight for the heart, liver, and spleen. There is a similar but weaker association between body weight and the weight of the lungs and kidneys. Brain weight is independent of body weight but shows a strong negative association with age. Even when controlling for body weight, men's organs are heavier, except for the weight of the liver, which is comparable in men and women. These associations are in agreement with the findings of previous studies. The current study suggests that, for some of the commonly weighed organs, there has been an increase in median organ weight when compared with existing references.The tables presented here provide an updated reference that should prove useful to autopsy pathologists in the forensic and hospital settings.
View details for DOI 10.5858/arpa.2021-0287-OA
View details for PubMedID 35344994
Endothelial thrombomodulin downregulation caused by hypoxia contributes to severe infiltration and coagulopathy in COVID-19 patient lungs.
1800; 75: 103812
BACKGROUND: Thromboembolism is a life-threatening manifestation of coronavirus disease 2019 (COVID-19). We investigated a dysfunctional phenotype of vascular endothelial cells in the lungs during COVID-19.METHODS: We obtained the lung specimens from the patients who died of COVID-19. The phenotype of endothelial cells and immune cells was examined by flow cytometry and immunohistochemistry (IHC) analysis. We tested the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the endothelium using IHC and electron microscopy.FINDINGS: The autopsy lungs of COVID-19 patients exhibited severe coagulation abnormalities, immune cell infiltration, and platelet activation. Pulmonary endothelial cells of COVID-19 patients showed increased expression of procoagulant von Willebrand factor (VWF) and decreased expression of anticoagulants thrombomodulin and endothelial protein C receptor (EPCR). In the autopsy lungs of COVID-19 patients, the number of macrophages, monocytes, and T cells was increased, showing an activated phenotype. Despite increased immune cells, adhesion molecules such as ICAM-1, VCAM-1, E-selectin, and P-selectin were downregulated in pulmonary endothelial cells of COVID-19 patients. Notably, decreased thrombomodulin expression in endothelial cells was associated with increased immune cell infiltration in the COVID-19 patient lungs. There were no SARS-CoV-2 particles detected in the lung endothelium of COVID-19 patients despite their dysfunctional phenotype. Meanwhile, the autopsy lungs of COVID-19 patients showed SARS-CoV-2 virions in damaged alveolar epithelium and evidence of hypoxic injury.INTERPRETATION: Pulmonary endothelial cells become dysfunctional during COVID-19, showing a loss of thrombomodulin expression related to severe thrombosis and infiltration, and endothelial cell dysfunction might be caused by a pathologic condition in COVID-19 patient lungs rather than a direct infection with SARS-CoV-2.FUNDING: This work was supported by the Johns Hopkins University, the American Heart Association, and the National Institutes of Health.
View details for DOI 10.1016/j.ebiom.2022.103812
View details for PubMedID 35033854
Upregulation of pulmonary tissue factor, loss of thrombomodulin and immunothrombosis in SARS-CoV-2 infection
2021; 39: 101069
SARS-CoV-2 infection is associated with thrombotic and microvascular complications. The cause of coagulopathy in the disease is incompletely understood.A single-center cross-sectional study including 66 adult COVID-19 patients (40 moderate, 26 severe disease), and 9 controls, performed between 04/2020 and 10/2020. Markers of coagulation, endothelial cell function [angiopoietin-1,-2, P-selectin, von Willebrand Factor Antigen (WF:Ag), von Willebrand Factor Ristocetin Cofactor, ADAMTS13, thrombomodulin, soluble Endothelial cell Protein C Receptor (sEPCR), Tissue Factor Pathway Inhibitor], neutrophil activation (elastase, citrullinated histones) and fibrinolysis (tissue-type plasminogen activator, plasminogen activator inhibitor-1) were evaluated using ELISA. Tissue Factor (TF) was estimated by antithrombin-FVIIa complex (AT/FVIIa) and microparticles-TF (MP-TF). We correlated each marker and determined its association with severity. Expression of pulmonary TF, thrombomodulin and EPCR was determined by immunohistochemistry in 9 autopsies.Comorbidities were frequent in both groups, with older age associated with severe disease. All patients were on prophylactic anticoagulants. Three patients (4.5%) developed pulmonary embolism. Mortality was 7.5%. Patients presented with mild alterations in the coagulogram (compensated state). Biomarkers of endothelial cell, neutrophil activation and fibrinolysis were elevated in severe vs moderate disease; AT/FVIIa and MP-TF levels were higher in severe patients. Logistic regression revealed an association of D-dimers, angiopoietin-1, vWF:Ag, thrombomodulin, white blood cells, absolute neutrophil count (ANC) and hemoglobin levels with severity, with ANC and vWF:Ag identified as independent factors. Notably, postmortem specimens demonstrated epithelial expression of TF in the lung of fatal COVID-19 cases with loss of thrombomodulin staining, implying in a shift towards a procoagulant state.Coagulation dysregulation has multifactorial etiology in SARS-Cov-2 infection. Upregulation of pulmonary TF with loss of thrombomodulin emerge as a potential link to immunothrombosis, and therapeutic targets in the disease.John Hopkins University School of Medicine.
View details for DOI 10.1016/j.eclinm.2021.101069
View details for Web of Science ID 000704058900004
View details for PubMedID 34377969
View details for PubMedCentralID PMC8342934
Pathology Residency Program Special Expertise Tracks Meet the Needs of an Evolving Field
2021; 8: 23742895211037034
Pathologists who enter the workforce must have a diverse skill set beyond that of clinical diagnostics alone. Anticipating this need, the Johns Hopkins Pathology Residency Program developed Special Expertise Tracks to enhance training in relevant subspecialty domains. Using a combination of discussions and surveys, we assessed: (1) our current resident curriculum; (2) perceived curricular strengths and needs; (3) resident career preferences and ultimate career paths; (4) perceived barriers to implementing an advanced elective curriculum; and (5) available departmental/institutional resources. Additionally, we utilized the Accreditation Council for Graduate Medical Education Pathology Milestones as a curricular guide. Six professional residency training Special Expertise Tracks were established: Education, Physician-Scientist Research, Informatics, Quality Improvement/Quality Assurance/Value-Based Care, Health Policy/Hospital Management and Global Health. After implementation in 2017, the Education track has had 4 residents complete the curriculum successfully; the Physician-Scientist Research track has had 2 residents and the Informatics and Global Health tracks have each had one resident successfully complete their respective curricula. Currently, 5 residents are pursuing the Education track, one is pursuing the Physician-Scientist Research track, one is pursuing the Informatics track, and 2 residents are pursuing the Global Health track. Five residents have completed long-term projects including developing several e-learning modules, an online free digital cytopathology atlas, peer-reviewed articles, book chapters, and books. The Johns Hopkins Pathology Resident Special Expertise Track program provides pathology residents an opportunity to gain meaningful experience and additional skills tailored to their individual career interests.
View details for DOI 10.1177/23742895211037034
View details for Web of Science ID 000709226200001
View details for PubMedID 34485688
View details for PubMedCentralID PMC8411632
Pulmonary hypoplasia correlates with the length of anhydramnios in patients with early pregnancy renal anhydramnios (EPRA)
JOURNAL OF PERINATOLOGY
2021; 41 (8): 1924-1929
Early pregnancy renal anhydramanios (EPRA) occurs when the fetus is anuric before 22 weeks gestational age (GA) and is considered universally lethal. Serial amnioinfusions have successfully ameliorated the lethal pulmonary hypoplasia associated with EPRA and have resulted in cases of neonatal survival, peritoneal dialysis, and renal transplant.We sought to evaluate the lung pathology of untreated fetuses and neonates that had EPRA.This is a retrospective case series of all fetuses and neonates diagnosed with isolated EPRA that underwent autopsy at a single tertiary care center between 1987 and 2018. Autopsy data were correlated with ultrasound findings and GA at delivery. Fetal weights, lung weights, and lung developmental stage were recorded.Nineteen cases met criteria for analysis and ranged from 16 to 38 weeks GA at termination or birth. The observed-to-expected (O/E) lung-to-body-weight ratio was significantly associated with GA (r = -0.51, p = 0.03), such that as GA increased the O/E ratio decreased. When limited to patients >22 weeks, this relationship strengthened (r = -0.75, p = 0.01). Importantly, overall O/E body weight had no relationship with GA.This study shows that the degree of pulmonary hypoplasia in EPRA increases with the length of anhydramnios. This suggests that amnioinfusions are likely to be of most benefit the soonest they can feasibly be initiated.
View details for DOI 10.1038/s41372-021-01128-0
View details for Web of Science ID 000670168300003
View details for PubMedID 34230606
Role of androgen receptor splice variant-7 (AR-V7) in prostate cancer resistance to 2nd-generation androgen receptor signaling inhibitors (vol 39, pg 6935, 2020)
2021; 40 (22): 3914-3916
View details for DOI 10.1038/s41388-021-01805-6
View details for Web of Science ID 000648041500005
View details for PubMedID 33958727
SARS-CoV-2 infection drives endothelial dysfunction indirectly through hypoxia and increased pro-inflammatory cytokine production
AMER ASSOC IMMUNOLOGISTS. 2021
View details for Web of Science ID 000713665800203
Y A Postmortem Portrait of the Coronavirus Disease 2019 (COVID-19) Pandemic
ARCHIVES OF PATHOLOGY & LABORATORY MEDICINE
2021; 145 (5): 529-535
This study represents the largest compilation to date of clinical and postmortem data from decedents with coronavirus disease 2019 (COVID-19). It will augment previously published small series of autopsy case reports, refine clinicopathologic considerations, and improve the accuracy of future vital statistical reporting.To accurately reflect the preexisting diseases and pathologic conditions of decedents with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection through autopsy.Comprehensive data from 135 autopsy evaluations of COVID-19-positive decedents is presented, including histologic assessment. Postmortem examinations were performed by 36 pathologists at 19 medical centers or forensic institutions in the United States and Brazil. Data from each autopsy were collected through the online submission of multiple-choice and open-ended survey responses.Patients dying of or with COVID-19 had an average of 8.89 pathologic conditions documented at autopsy, spanning a combination of prior chronic disease and acute conditions acquired during hospitalization. Virtually all decedents were cited as having more than 1 preexisting condition, encompassing an average of 2.88 such diseases each. Clinical conditions during terminal hospitalization were cited 395 times for the 135 autopsied decedents and predominantly encompassed acute failure of multiple organ systems and/or impaired coagulation. Myocarditis was rarely cited.Cause-of-death statements in both autopsy reports and death certificates may not encompass the severity or spectrum of comorbid conditions in those dying of or with COVID-19. If supported by additional research, this finding may have implications for public health decisions and reporting moving forward through the pandemic.
View details for DOI 10.5858/arpa.2020-0786-SA
View details for Web of Science ID 000646027600002
View details for PubMedID 33449998
Myosin specific T-RM cells mediate increased severity of immune checkpoint inhibitor myocarditis
AMER ASSOC IMMUNOLOGISTS. 2021
View details for Web of Science ID 000713665801278
Pericardial macrophages and their role in myocardial infarction
AMER ASSOC IMMUNOLOGISTS. 2021
View details for Web of Science ID 000713665801180
Resistance to androgen receptor signaling inhibition does not necessitate development of neuroendocrine prostate cancer
2021; 6 (8)
Resistance to AR signaling inhibitors (ARSis) in a subset of metastatic castration-resistant prostate cancers (mCRPCs) occurs with the emergence of AR- neuroendocrine prostate cancer (NEPC) coupled with mutations/deletions in PTEN, TP53, and RB1 and the overexpression of DNMTs, EZH2, and/or SOX2. To resolve whether the lack of AR is the driving factor for the emergence of the NE phenotype, molecular, cell, and tumor biology analyses were performed on 23 xenografts derived from patients with PC, recapitulating the full spectrum of genetic alterations proposed to drive NE differentiation. Additionally, phenotypic response to CRISPR/Cas9-mediated AR KO in AR+ CRPC cells was evaluated. These analyses document that (a) ARSi-resistant NEPC developed without androgen deprivation treatment; (b) ARS in ARSi-resistant AR+/NE+ double-positive "amphicrine" mCRPCs did not suppress NE differentiation; (c) the lack of AR expression did not necessitate acquiring a NE phenotype, despite concomitant mutations/deletions in PTEN and TP53, and the loss of RB1 but occurred via emergence of an AR-/NE- double-negative PC (DNPC); (d) despite DNPC cells having homogeneous genetic driver mutations, they were phenotypically heterogeneous, expressing basal lineage markers alone or in combination with luminal lineage markers; and (e) AR loss was associated with AR promoter hypermethylation in NEPCs but not in DNPCs.
View details for DOI 10.1172/jci.insight.146827
View details for Web of Science ID 000642643500015
View details for PubMedID 33724955
View details for PubMedCentralID PMC8119192
Muscle Biopsy Findings in a Case of SARS-CoV-2-Associated Muscle Injury
JOURNAL OF NEUROPATHOLOGY AND EXPERIMENTAL NEUROLOGY
2021; 80 (4): 377-378
View details for DOI 10.1093/jnen/nlaa155
View details for Web of Science ID 000648962000009
View details for PubMedID 33355335
View details for PubMedCentralID PMC7799012
Rapid Autopsy Programs and Research Support: The Pre- and Post-COVID-19 Environments
AJSP-REVIEWS AND REPORTS
2021; 26 (2): 100-107
Each rapid autopsy is a powerful opportunity to supply multiple researchers with many valuable tissue specimens at the same time. Since the beginning of the development of rapid autopsy, the overriding organizing principle for all RAPs has been that the samples or organs must be removed and processed as rapidly as possible. To accomplish this some rapid autopsy programs are focused just on one tumor type, while others accept patients demonstrating all tumor types and sometimes other diseases as well. RAPs are logistically complicated and labor-intensive structures, therefore, the key to their success is program flexibility and maintaining a multidisciplinary focus. The necessary collaborations in the complex relationships between clinicians and researchers can be broken down into a series of thought and action steps that must be understood, accepted, and practiced by all participants. A crucial part of the pre-case steps (prior to death) for a rapid autopsy is the study consenting process. It is extremely important that this individualized consent is obtained for postmortem specimens and that it is written in general enough terms to be used for patients with all types of diseases and for an appropriate range of future research uses. The advent of Sars-CoV-2/COVID-19 has presented new challenges and opportunities to the field of autopsy pathology. Guidelines and practice had to be created and adapted to protect physicians and staff while maximizing diagnostic yield. However, any autopsy performed on a patient dying of or with COVID-19 represents a unique opportunity to contribute to understanding of disease mechanisms and to improve death certification, thus assisting in both clinical care and the development of health public policy.
View details for DOI 10.1097/PCR.0000000000000435
View details for Web of Science ID 000631939700004
View details for PubMedID 33718610
View details for PubMedCentralID PMC7954201
The Genetic Evolution of Treatment-Resistant Cutaneous, Acral, and Uveal Melanomas
CLINICAL CANCER RESEARCH
2021; 27 (5): 1516-1525
Melanoma is a biologically heterogeneous disease composed of distinct clinicopathologic subtypes that frequently resist treatment. To explore the evolution of treatment resistance and metastasis, we used a combination of temporal and multilesional tumor sampling in conjunction with whole-exome sequencing of 110 tumors collected from 7 patients with cutaneous (n = 3), uveal (n = 2), and acral (n = 2) melanoma subtypes.Primary tumors, metastases collected longitudinally, and autopsy tissues were interrogated. All but 1 patient died because of melanoma progression.For each patient, we generated phylogenies and quantified the extent of genetic diversity among tumors, specifically among putative somatic alterations affecting therapeutic resistance.In 4 patients who received immunotherapy, we found 1-3 putative acquired and intrinsic resistance mechanisms coexisting in the same patient, including mechanisms that were shared by all tumors within each patient, suggesting that future therapies directed at overcoming intrinsic resistance mechanisms may be broadly effective.
View details for DOI 10.1158/1078-0432.CCR-20-2984
View details for Web of Science ID 000625367700031
View details for PubMedID 33323400
View details for PubMedCentralID PMC7925434
Assessing Brain Capillaries in Coronavirus Disease 2019
2021; 78 (6): 760-762
View details for DOI 10.1001/jamaneurol.2021.0225
View details for Web of Science ID 000617178200001
View details for PubMedID 33576767
View details for PubMedCentralID PMC7881367
Role of androgen receptor splice variant-7 (AR-V7) in prostate cancer resistance to 2nd-generation androgen receptor signaling inhibitors (vol 39, pg 6935, 2020)
2021; 40 (11): 2148
View details for DOI 10.1038/s41388-021-01640-9
View details for Web of Science ID 000616489100008
View details for PubMedID 33564077
Evaluating T-cell cross-reactivity between tumors and immune-related adverse events with TCR sequencing: pitfalls in interpretations of functional relevance
JOURNAL FOR IMMUNOTHERAPY OF CANCER
2021; 9 (7)
T-cell receptor sequencing (TCRseq) enables tracking of T-cell clonotypes recognizing the same antigen over time and across biological compartments. TCRseq has been used to test if cross-reactive antitumor T cells are responsible for development of immune-related adverse events (irAEs) following immune checkpoint blockade. Prior studies have interpreted T-cell clones shared among the tumor and irAE as evidence supporting this, but interpretations of these findings are challenging, given the constraints of TCRseq. Here we capitalize on a rare opportunity to understand the impact of potential confounders, such as sample size, tissue compartment, and collection batch/timepoint, on the relative proportion of shared T-cell clones between an irAE and tumor specimens. TCRseq was performed on tumor-involved and -uninvolved tissues, including an irAE, that were obtained throughout disease progression and at the time of rapid autopsy from a patient with renal cell carcinoma treated with programmed death-1 (PD-1) blockade. Our analyses show significant effects of these confounders on our ability to understand T-cell receptor overlap, and we present mitigation strategies and study design recommendations to reduce these errors. Implementation of these strategies will enable more rigorous TCRseq-based studies of immune responses in human tissues, particularly as they relate to antitumor T-cell cross-reactivity in irAEs following checkpoint blockade.
View details for DOI 10.1136/jitc-2021-002642
View details for Web of Science ID 000691845400002
View details for PubMedID 34230111
View details for PubMedCentralID PMC8261872
Fatal SARS-CoV-2 Inflammatory Syndrome and Myocarditis in an Adolescent: A Case Report.
The Pediatric infectious disease journal
2021; 40 (2): e72-e76
BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), an entity in children initially characterized by milder case presentations and better prognoses as compared with adults. Recent reports, however, raise concern for a new hyperinflammatory entity in a subset of pediatric COVID-19 patients.METHODS: We report a fatal case of confirmed COVID-19 with hyperinflammatory features concerning for both multi-inflammatory syndrome in children (MIS-C) and primary COVID-19.RESULTS: This case highlights the ambiguity in distinguishing between these two entities in a subset of pediatric patients with COVID-19-related disease and the rapid decompensation these patients may experience.CONCLUSIONS: Appropriate clinical suspicion is necessary for both acute disease and MIS-C. SARS-CoV-2 serologic tests obtained early in the diagnostic process may help to narrow down the differential but does not distinguish between acute COVID-19 and MIS-C. Better understanding of the hyperinflammatory changes associated with MIS-C and acute COVID-19 in children will help delineate the roles for therapies, particularly if there is a hybrid phenotype occurring in adolescents.
View details for DOI 10.1097/INF.0000000000002978
View details for PubMedID 33181783
End-of-Life Care: A Multimodal and Comprehensive Curriculum for Graduating Medical Students Utilizing Experiential Learning Opportunities.
MedEdPORTAL : the journal of teaching and learning resources
2021; 17: 11149
Introduction: End-of-life (EOL) care is an essential skill for most physicians and health care providers, yet there continues to be an educational gap in medical education literature for these skills. The Johns Hopkins School of Medicine developed the Transition to Residency, Internship, and Preparation for Life Events (TRIPLE) curriculum with the primary goal of preparing graduating medical students for life after medical school.Methods: The EOL module was one of many within the TRIPLE curriculum and consisted of two half-day sessions that targeted EOL care, death, dying, and communication skills. The first half-day session focused on a standardized patient encounter where learners initiated and completed an EOL care goals conversation around a living will. The second half-day session focused on death and dying. It included didactic sessions on organ donation, autopsy/death certificates, a simulation-based learning session on ending a resuscitation, and a standardized patient encounter where learners disclosed the death of a loved one. End-of-day and end-of-course evaluations were collected via anonymous online surveys.Results: In 2019, 120 students and 26 instructors participated in TRIPLE. Students rated the EOL module overall as 4.6 of 5 (SD = 0.6) and rated instructors overall as 4.6 of 5 (SD = 0.6).Discussion: By implementing a thorough and diverse curriculum with a variety of modalities and targeted skills, learners may be better prepared to care for patients dealing with EOL care issues. Further, the generalization of these skills may assist learners in a variety of other aspects of patient and family care.
View details for DOI 10.15766/mep_2374-8265.11149
View details for PubMedID 33928187
Overview of Pathologic Findings of Vaping in the Context of an Autopsy Patient With Chronic Injury
ARCHIVES OF PATHOLOGY & LABORATORY MEDICINE
2020; 144 (11): 1408-1413
Electronic cigarettes are handheld devices that heat an inner liquid containing chemicals to be aerosolized and inhaled, and have become a popular alternative to conventional cigarettes. Their use, termed vaping, has been linked to severe injury, with 2711 cases of associated lung injury and 60 deaths reported to the Centers for Disease Control and Prevention at the time of writing. Published case reports and series have emerged detailing clinical and imaging characteristics of vaping-induced lung injury. However, the pathologic characteristics of these induced injuries are still being established, particularly findings occurring over time.To illustrate the autopsy findings of an older patient who died of vaping-induced injury after prolonged symptomology and to provide a review of the most recent literature regarding the basic science, epidemiology, clinical presentation, imaging characteristics, and pathology of vaping-induced lung injury.Autopsy case and peer-reviewed literature.Vaping-induced lung injury has emerged as a public health issue, and this case represents a rare opportunity to evaluate this issue at autopsy. Most commonly, the injury has been attributed to tetrahydrocannabinol product use as opposed to nicotine. This case demonstrates that as today's young and relatively healthy "vapers" grow older and develop the comorbidities that come with advanced age, there is serious risk of chronic lung damage from vaping that could result in death. Further observations and studies, particularly autopsy evidence, are clearly important to understand the possible outcomes.
View details for DOI 10.5858/arpa.2019-0637-RA
View details for Web of Science ID 000582675700017
View details for PubMedID 32383974
IgM autoantibodies recognizing ACE2 are associated with severe COVID-19.
medRxiv : the preprint server for health sciences
SARS-CoV-2 infection induces severe disease in a subpopulation of patients, but the underlying mechanisms remain unclear. We demonstrate robust IgM autoantibodies that recognize angiotensin converting enzyme-2 (ACE2) in 18/66 (27%) patients with severe COVID-19, which are rare (2/52; 3.8%) in hospitalized patients who are not ventilated. The antibodies do not undergo class-switching to IgG, suggesting a T-independent antibody response. Purified IgM from anti-ACE2 patients activates complement. Pathological analysis of lung obtained at autopsy shows endothelial cell staining for IgM in blood vessels in some patients. We propose that vascular endothelial ACE2 expression focuses the pathogenic effects of these autoantibodies on blood vessels, and contributes to the angiocentric pathology observed in some severe COVID-19 patients. These findings may have predictive and therapeutic implications.
View details for DOI 10.1101/2020.10.13.20211664
View details for PubMedID 33083808
SARS-CoV-2 Virus Isolated From the Mastoid and Middle Ear: Implications for COVID-19 Precautions During Ear Surgery
JAMA OTOLARYNGOLOGY-HEAD & NECK SURGERY
2020; 146 (10): 964-966
View details for DOI 10.1001/jamaoto.2020.1922
View details for Web of Science ID 000604968900018
View details for PubMedID 32701126
View details for PubMedCentralID PMC7378866
Role of androgen receptor splice variant-7 (AR-V7) in prostate cancer resistance to 2nd-generation androgen receptor signaling inhibitors
2020; 39 (45): 6935-6949
The role of truncated androgen receptor splice variant-7 (AR-V7) in prostate cancer biology is an unresolved question. Is it simply a marker of resistance to 2nd-generation androgen receptor signaling inhibitors (ARSi) like abiraterone acetate (Abi) and enzalutamide (Enza) or a functional driver of lethal resistance via its ligand-independent transcriptional activity? To resolve this question, the correlation between resistance to ARSi and genetic chances and expression of full length AR (AR-FL) vs. AR-V7 were evaluated in a series of independent patient-derived xenografts (PDXs). While all PDXs lack PTEN expression, there is no consistent requirement for mutation in TP53, RB1, BRCA2, PIK3CA, or MSH2, or expression of SOX2 or ERG and ARSi resistance. Elevated expression of AR-FL alone is sufficient for Abi but not Enza resistance, even if AR-FL is gain-of-function (GOF) mutated. Enza resistance is consistently correlated with enhanced AR-V7 expression. In vitro and in vivo growth responses of Abi-/Enza-resistant LNCaP-95 cells in which CRISPR-Cas9 was used to knockout AR-FL or AR-V7 alone or in combination were evaluated. Combining these growth responses with RNAseq analysis demonstrates that both AR-FL- and AR-V7-dependent transcriptional complementation are needed for Abi/Enza resistance.
View details for DOI 10.1038/s41388-020-01479-6
View details for Web of Science ID 000573446900002
View details for PubMedID 32989253
View details for PubMedCentralID PMC7655549
Association of Impaired Spermatogenesis With the Use of Immune Checkpoint Inhibitors in Patients With Metastatic Melanoma
2020; 6 (8): 1297-1299
View details for DOI 10.1001/jamaoncol.2020.1641
View details for Web of Science ID 000562846800022
View details for PubMedID 32556068
View details for PubMedCentralID PMC7303895
Comparison of skeletal and soft tissue pericytes identifies CXCR4(+) bone forming mural cells in human tissues
2020; 8 (1)
View details for DOI 10.1038/s41413-020-0097-0
View details for Web of Science ID 000536962800002
Comparison of skeletal and soft tissue pericytes identifies CXCR4+ bone forming mural cells in human tissues.
2020; 8 (1): 22
Human osteogenic progenitors are not precisely defined, being primarily studied as heterogeneous multipotent cell populations and termed mesenchymal stem cells (MSCs). Notably, select human pericytes can develop into bone-forming osteoblasts. Here, we sought to define the differentiation potential of CD146+ human pericytes from skeletal and soft tissue sources, with the underlying goal of defining cell surface markers that typify an osteoblastogenic pericyte. CD146+CD31-CD45- pericytes were derived by fluorescence-activated cell sorting from human periosteum, adipose, or dermal tissue. Periosteal CD146+CD31-CD45- cells retained canonical features of pericytes/MSC. Periosteal pericytes demonstrated a striking tendency to undergo osteoblastogenesis in vitro and skeletogenesis in vivo, while soft tissue pericytes did not readily. Transcriptome analysis revealed higher CXCR4 signaling among periosteal pericytes in comparison to their soft tissue counterparts, and CXCR4 chemical inhibition abrogated ectopic ossification by periosteal pericytes. Conversely, enrichment of CXCR4+ pericytes or stromal cells identified an osteoblastic/non-adipocytic precursor cell. In sum, human skeletal and soft tissue pericytes differ in their basal abilities to form bone. Diversity exists in soft tissue pericytes, however, and CXCR4+ pericytes represent an osteoblastogenic, non-adipocytic cell precursor. Indeed, enrichment for CXCR4-expressing stromal cells is a potential new tactic for skeletal tissue engineering.
View details for DOI 10.1038/s41413-020-0097-0
View details for PubMedID 32509378
View details for PubMedCentralID PMC7244476
Sacral protuberance with cleft lip and palate: Prenatal presentation of 3MC syndrome
AMERICAN JOURNAL OF MEDICAL GENETICS PART A
2020; 182 (7): 1812-1814
3MC syndromes are rare heterogeneous autosomal recessive conditions previously designated as Mingarelli, Malpuech, Michels, and Carnevale syndromes, characterized by dysmorphic facial features, facial clefts, growth restriction, and intellectual disability. 3MC is secondary to mutations in the MASP1, MASP3, COLEC11, and COLEC10 genes. The number of patients with 3MC syndrome with known mutations in the COLEC11 or MASP1 is, to date, less than 50. At the time this case presented (2015), the only gene identified in Online Mendelian Inheritance in Man to be associated with 3MC syndrome was MASP1. We present, to the best of our knowledge, the first prenatal report of 3MC syndrome, secondary to a homozygous variant in MASP1. Fetal findings included bilateral cleft lip and palate, abnormality of the sacral spine, a right echogenic pelvic kidney, and brachycephaly. 3MC syndrome should be considered as part of the differential diagnosis when fetal ultrasound detects facial clefts and spinal defects, as the risk of recurrence is significant and a molecularly confirmed diagnosis allows for alternate reproductive options.
View details for DOI 10.1002/ajmg.a.61624
View details for Web of Science ID 000534786900001
View details for PubMedID 32441374
View details for PubMedCentralID PMC7780158
Innate Lymphoid Cells Play a Pathogenic Role in Pericarditis
2020; 30 (9): 2989-+
We find that cardiac group 2 innate lymphoid cells (ILC2s) are essential for the development of IL-33-induced eosinophilic pericarditis. We show a pathogenic role for ILC2s in cardiac inflammation, in which ILC2s activated by IL-33 drive the development of eosinophilic pericarditis in collaboration with cardiac fibroblasts. ILCs, not T and B cells, are required for the development of pericarditis. ILC2s transferred to the heart of Rag2-/-Il2rg-/- mice restore their susceptibility to eosinophil infiltration. Moreover, ILC2s direct cardiac fibroblasts to produce eotaxin-1. We also find that eosinophils reside in the mediastinal cavity and that eosinophils transferred to the mediastinal cavity of eosinophil-deficient ΔdblGATA1 mice following IL-33 treatment migrate to the heart. Thus, the serous cavities may serve as a reservoir of cardiac-infiltrating eosinophils. In humans, patients with pericarditis show higher amounts of ILCs in pericardial fluid than do healthy controls and patients with other cardiac diseases. We demonstrate that ILCs play a critical role in pericarditis.
View details for DOI 10.1016/j.celrep.2020.02.040
View details for Web of Science ID 000517773300012
View details for PubMedID 32130902
View details for PubMedCentralID PMC7332109
Inhibition of glutaminase to reverse fibrosis in iatrogenic laryngotracheal stenosis
2020; 130 (12): E773-E781
Glutamine metabolism is a critical energy source for iatrogenic laryngotracheal stenosis (iLTS) scar fibroblasts, and glutaminase (GLS) is an essential enzyme converting glutamine to glutamate. We hypothesize that the GLS-specific inhibitor BPTES will block glutaminolysis and reduce iLTS scar fibroblast proliferation, collagen deposition, and fibroblast metabolism in vitro.Test-tube Lab Research.Immunohistochemistry of a cricotracheal resection (n = 1) and a normal airway specimen (n = 1) were assessed for GLS expression. GLS expression was assessed in brush biopsies of subglottic/tracheal fibrosis and normal airway from patients with iLTS (n = 6). Fibroblasts were isolated and cultured from biopsies of subglottic/tracheal fibrosis (n = 6). Fibroblast were treated with BPTES and BPTES + dimethyl α-ketoglutarate (DMK), an analogue of the downstream product of GLS. Fibroblast proliferation, gene expression, protein production, and metabolism were assessed in all treatment conditions and compared to control.GLS was overexpressed in brush biopsies of iLTS scar specimens (P = .029) compared to normal controls. In vitro, BPTES inhibited iLTS scar fibroblast proliferation (P = .007), collagen I (Col I) (P < .0001), collagen III (P = .004), and α-smooth muscle actin (P = .0025) gene expression and protein production (P = .031). Metabolic analysis demonstrated that BPTES reduced glycolytic reserve (P = .007) but had no effects on mitochondrial oxidative phosphorylation. DMK rescued BPTES inhibition of Col I gene expression (P = .0018) and protein production (P = .021).GLS is overexpressed in iLTS scar. Blockage of GLS with BPTES significantly inhibits iLTS scar fibroblasts proliferation and function, demonstrating a critical role for GLS in iLTS. Targeting GLS to inhibit glutaminolysis may be a successful strategy to reverse scar formation in the airway.NA Laryngoscope, 2020.
View details for DOI 10.1002/lary.28493
View details for Web of Science ID 000505636800001
View details for PubMedID 31904876
View details for PubMedCentralID PMC7335682
The problem with autopsy today may be us.
Autopsy & case reports
2020; 10 (1): e2020142
View details for DOI 10.4322/acr.2020.142
View details for PubMedID 32039069
Cancer biology as revealed by the research autopsy
NATURE REVIEWS CANCER
2019; 19 (12): 686-697
A research autopsy is a post-mortem medical procedure performed on a deceased individual with the primary goal of collecting tissue to support basic and translational research. This approach has increasingly been used to investigate the pathophysiological mechanisms of cancer evolution, metastasis and treatment resistance. In this Review, we discuss the rationale for the use of research autopsies in cancer research and provide an evidence-based discussion of the quality of post-mortem tissues compared with other types of biospecimens. We also discuss the advantages of using post-mortem tissues over other types of biospecimens, including the large amounts of tissue that can be obtained and the extent of multiregion sampling that is achievable, which is not otherwise possible in living patients. We highlight how the research autopsy has supported the identification of the clonal origins and modes of spread among metastases, the extent that selective pressures imposed by treatments cause bottlenecks leading to parallel and convergent tumour evolution, and the creation of rare tissue banks and patient-derived model systems. Finally, we comment on the future of the research autopsy as an integral component of precision medicine strategies.
View details for DOI 10.1038/s41568-019-0199-4
View details for Web of Science ID 000498825600006
View details for PubMedID 31519982
View details for PubMedCentralID PMC7453489
Comparing anti-tumor and anti-self immunity in a patient with melanoma receiving immune checkpoint blockade
View details for Web of Science ID 000496473200356
Prenatal diagnosis of Desbuquois dysplasia Type 1: Utilization of high-density SNP array to map homozygosity and identify the gene
AMERICAN JOURNAL OF MEDICAL GENETICS PART A
2019; 179 (12): 2490-2493
Desbuquois dysplasia (DBQD1 [MIM 251450]) is an autosomal recessive chondrodysplasia with micromelia, severe joint laxity and dislocations, and a characteristic radiographic "monkey wrench" appearance at the proximal femur. Type 1 Desbuquois dysplasia is caused by mutations in CANT1 and is distinct from Type 2, caused by mutations in XYLT1, in that the former has unique hand anomalies including accessory phalangeal ossification centers, advanced carpal bone maturation, and/or axial phalangeal deviation. Severe prenatal presentations have been rarely reported. We report a Pakistani female in a consanguineous relationship with a diagnosis of Type 1 Desbuquois dysplasia in three consecutive pregnancies. Multiple similar severe fetal limb anomalies were detected by ultrasound in Pregnancy 1 and 2. Regions of homozygosity within the single nucleotide polymorphism (SNP)-microarray from both terminated fetuses were compared, revealing CANT1 as a likely disease-causing candidate gene. Insufficient fetal DNA precluded confirmatory testing, therefore parents were tested; both had a previously reported heterozygous CANT1 mutation (c.643G>T; Glu215Term). The patient presented with a third pregnancy revealing similarly abnormal limb position and probable polysyndactyly by ultrasound. Targeted testing of CANT1 revealed homozygous c.643G>T CANT1 mutations and this pregnancy was terminated. In clinical situations in which ample DNA is not available or more expensive testing (e.g., whole exome sequencing) with a longer turnaround time is not feasible, utilization of SNP-microarray in consanguineous families at risk for rare autosomal recessive disorders may dramatically narrow the list of candidate genes.
View details for DOI 10.1002/ajmg.a.61372
View details for Web of Science ID 000491121500001
View details for PubMedID 31587486
Rapid research autopsy is a stealthy but growing contributor to cancer research
2019; 125 (17): 2915-2919
View details for DOI 10.1002/cncr.32184
View details for Web of Science ID 000480603300004
View details for PubMedID 31090935
View details for PubMedCentralID PMC6690796
Mannose Receptor-positive Macrophage Infiltration Correlates with Prostate Cancer Onset and Metastatic Castration-resistant Disease
EUROPEAN UROLOGY ONCOLOGY
2019; 2 (4): 429-436
M2 tumor-associated macrophages (M2-TAMs) can suppress inflammation in the tumor microenvironment and have been reported to modulate cancer progression. We and others have previously reported M2-TAM infiltration in metastatic castration-resistant prostate cancer (mCRPC).To determine whether the extent of M2-TAM infiltration correlates with PC aggressiveness.Normal prostate tissue, localized PC, and mCRPC samples from 192 patients were retrospectively analyzed.We analytically validated an immunohistochemistry assay for detection of the human mannose receptor (CD206) to assess M2 macrophage involvement.Multiplex immunofluorescent staining showed that a small fraction of CD206 staining co-localized with the endothelial cells of lymphatic vessels, while the vast majority of staining occurred in CD68-positive macrophages. The area fraction of staining for CD206-positive macrophages increased in a stepwise fashion from normal (ie, no inflammation) prostate tissue, to primary untreated carcinomas, to hormone-naïve regional lymph node metastases, to mCRPC. Complementary studies using flow cytometry confirmed CD206-positive M2-TAM infiltration. Limitations include the small number of rapid autopsy samples and the lack of neuroendocrine PC samples.Our results revealed a progressive increase in CD206-positive macrophages from normal prostate to mCRPC. Given the immunosuppressive nature of macrophages and the lack of clinical success of immunotherapy for PC patients, our results provide a rationale for therapeutic targeting of macrophages in the PC microenvironment as a potential method to augment immunotherapeutic responses.In this report we used 192 prostate cancer samples to determine if M2 macrophage infiltration is correlated with castration resistance in prostate cancer.
View details for DOI 10.1016/j.euo.2018.09.014
View details for Web of Science ID 000474616500013
View details for PubMedID 31277779
View details for PubMedCentralID PMC7039332
Disconnect between Fibrotic Response and Right Ventricular Dysfunction
AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
2019; 199 (12): 1550-1560
Rationale: Remodeling and fibrosis of the right ventricle (RV) may cause RV dysfunction and poor survival in patients with pulmonary hypertension. Objectives: To investigate the consequences of RV fibrosis modulation and the accompanying cellular changes on RV function. Methods: Expression of fibrotic markers was assessed in the RV of patients with pulmonary hypertension, the murine pulmonary artery banding, and rat monocrotaline and Sugen5416/hypoxia models. Invasive hemodynamic and echocardiographic assessment was performed on galectin-3 knockout or inhibitor-treated mice. Measurements and Main Results: Established fibrosis was characterized by marked expression of galectin-3 and an enhanced number of proliferating RV fibroblasts. Galectin-3 genetic and pharmacologic inhibition or antifibrotic treatment with pirfenidone significantly diminished RV fibrosis progression in the pulmonary artery banding model, without improving RV functional parameters. RV fibrotic regions were populated with mesenchymal cells coexpressing vimentin and PDGFRα (platelet-derived growth factor receptor-α), but generally lacked αSMA (α-smooth muscle actin) positivity. Serum levels of galectin-3 were increased in patients with idiopathic pulmonary arterial hypertension but did not correlate with cardiac function. No changes of galectin-3 expression were observed in the lungs. Conclusions: We identified extrapulmonary galectin-3 as an important mediator that drives RV fibrosis in pulmonary hypertension through the expansion of PDGFRα/vimentin-expressing cardiac fibroblasts. However, interventions effectively targeting fibrosis lack significant beneficial effects on RV function.
View details for DOI 10.1164/rccm.201809-1737OC
View details for Web of Science ID 000471677100019
View details for PubMedID 30557518
View details for PubMedCentralID PMC6580669
Preclinical rationale for entinostat in embryonal rhabdomyosarcoma
2019; 9: 12
Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in the pediatric cancer population. Survival among metastatic RMS patients has remained dismal yet unimproved for years. We previously identified the class I-specific histone deacetylase inhibitor, entinostat (ENT), as a pharmacological agent that transcriptionally suppresses the PAX3:FOXO1 tumor-initiating fusion gene found in alveolar rhabdomyosarcoma (aRMS), and we further investigated the mechanism by which ENT suppresses PAX3:FOXO1 oncogene and demonstrated the preclinical efficacy of ENT in RMS orthotopic allograft and patient-derived xenograft (PDX) models. In this study, we investigated whether ENT also has antitumor activity in fusion-negative eRMS orthotopic allografts and PDX models either as a single agent or in combination with vincristine (VCR).We tested the efficacy of ENT and VCR as single agents and in combination in orthotopic allograft and PDX mouse models of eRMS. We then performed CRISPR screening to identify which HDAC among the class I HDACs is responsible for tumor growth inhibition in eRMS. To analyze whether ENT treatment as a single agent or in combination with VCR induces myogenic differentiation, we performed hematoxylin and eosin (H&E) staining in tumors.ENT in combination with the chemotherapy VCR has synergistic antitumor activity in a subset of fusion-negative eRMS in orthotopic "allografts," although PDX mouse models were too hypersensitive to the VCR dose used to detect synergy. Mechanistic studies involving CRISPR suggest that HDAC3 inhibition is the primary mechanism of cell-autonomous cytoreduction in eRMS. Following cytoreduction in vivo, residual tumor cells in the allograft models treated with chemotherapy undergo a dramatic, entinostat-induced (70-100%) conversion to non-proliferative rhabdomyoblasts.Our results suggest that the targeting class I HDACs may provide a therapeutic benefit for selected patients with eRMS. ENT's preclinical in vivo efficacy makes ENT a rational drug candidate in a phase II clinical trial for eRMS.
View details for DOI 10.1186/s13395-019-0198-x
View details for Web of Science ID 000468852800001
View details for PubMedID 31113472
View details for PubMedCentralID PMC6528217
Advancing the pathologic phenotype of giant axonal neuropathy: early involvement of the ocular lens
ORPHANET JOURNAL OF RARE DISEASES
2019; 14: 27
Giant axonal neuropathy (GAN; ORPHA: 643; OMIM# 256850) is a rare, hereditary, pediatric neurodegenerative disorder associated with intracellular accumulations of intermediate filaments (IFs). GAN knockout (KO) mouse models mirror the IF dysregulation and widespread nervous system pathology seen in human GAN. Validation of therapeutic efficacy and viral vector delivery systems with these GAN KO models has provided the springboard for the development of a viral vector being delivered intrathecally in an ongoing Phase I gene therapy clinical trial for the treatment of children with GAN ( https://clinicaltrials.gov/ct2/show/NCT02362438 ). During the course of a comprehensive pathologic characterization of the GAN KO mouse, we discovered the very early and unexpected involvement of the ocular lens. Light microscopy revealed the presence of intracytoplasmic inclusion bodies within lens epithelial cells. The inclusion bodies showed strong immunohistochemical positivity for glial fibrillary acidic protein (GFAP). We confirmed that intracytoplasmic inclusion bodies are also present within lens epithelial cells in human GAN. These IF inclusion bodies in lens epithelial cells are unique to GAN. Similar IF inclusion bodies in lens epithelial cells have not been reported previously in experimental animal models or human diseases. Since current paradigms in drug discovery and drug repurposing for IF-associated disorders are often hindered by lack of validated targets, our findings suggest that lens epithelial cells in the GAN KO mouse may provide a potential target, in vivo and in vitro, for evaluating drug efficacy and alternative therapeutic approaches in promoting the clearance of IF inclusions in GAN and other diseases characterized by intracellular IF accumulations.
View details for DOI 10.1186/s13023-018-0957-5
View details for Web of Science ID 000457462000002
View details for PubMedID 30709364
View details for PubMedCentralID PMC6359799
The HDAC3-SMARCA4-miR-27a axis promotes expression of the PAX3:FOXO1 fusion oncogene in rhabdomyosarcoma
2018; 11 (557)
Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma of childhood with an unmet clinical need for decades. A single oncogenic fusion gene is associated with treatment resistance and a 40 to 45% decrease in overall survival. We previously showed that expression of this PAX3:FOXO1 fusion oncogene in alveolar RMS (aRMS) mediates tolerance to chemotherapy and radiotherapy and that the class I-specific histone deacetylase (HDAC) inhibitor entinostat reduces PAX3:FOXO1 protein abundance. Here, we established the antitumor efficacy of entinostat with chemotherapy in various preclinical cell and mouse models and found that HDAC3 inhibition was the primary mechanism of entinostat-induced suppression of PAX3:FOXO1 abundance. HDAC3 inhibition by entinostat decreased the activity of the chromatin remodeling enzyme SMARCA4, which, in turn, derepressed the microRNA miR-27a. This reexpression of miR-27a led to PAX3:FOXO1 mRNA destabilization and chemotherapy sensitization in aRMS cells in culture and in vivo. Furthermore, a phase 1 clinical trial (ADVL1513) has shown that entinostat is tolerable in children with relapsed or refractory solid tumors and is planned for phase 1B cohort expansion or phase 2 clinical trials. Together, these results implicate an HDAC3-SMARCA4-miR-27a-PAX3:FOXO1 circuit as a driver of chemoresistant aRMS and suggest that targeting this pathway with entinostat may be therapeutically effective in patients.
View details for DOI 10.1126/scisignal.aau7632
View details for Web of Science ID 000451217900005
View details for PubMedID 30459282
View details for PubMedCentralID PMC6432638
Report and Recommendations of the Association of Pathology Chairs' Autopsy Working Group
2018; 5: 2374289518793988
Autopsy has been a foundation of pathology training for many years, but hospital autopsy rates are notoriously low. At the 2014 meeting of the Association of Pathology Chairs, some pathologists suggested removing autopsy from the training curriculum of pathology residents to provide additional months for training in newer disciplines, such as molecular genetics and informatics. At the same time, the American Board of Pathology received complaints that newly hired pathologists recently certified in anatomic pathology are unable to perform an autopsy when called upon to do so. In response to a call to abolish autopsy from pathology training on the one hand and for more rigorous autopsy training on the other, the Association of Pathology Chairs formed the Autopsy Working Group to examine the role of autopsy in pathology residency training. After 2 years of research and deliberation, the Autopsy Working Group recommends the following:Autopsy should remain a component of anatomic pathology training.A training program must have an autopsy service director with defined responsibilities, including accountability to the program director to record every autopsy performed by every resident.Specific entrustable activities should be defined that a resident must master in order to be deemed competent in autopsy practice, as well as criteria for gaining the trust to perform the tasks without direct supervision.Technical standardization of autopsy performance and reporting must be improved.The current minimum number of 50 autopsies should not be reduced until the changes recommended above have been implemented.
View details for DOI 10.1177/2374289518793988
View details for Web of Science ID 000443283600001
View details for PubMedID 30186954
View details for PubMedCentralID PMC6117865
The Evolution of Earned, Transparent, and Quantifiable Faculty Salary Compensation: The Johns Hopkins Pathology Experience
2018; 5: 2374289518777463
Faculty value equitable and transparent policies for determining salaries and expect their compensation to compare favorably to the marketplace. Academic institutions use compensation to recruit and retain talented faculty as well as to reward accomplishment. Institutions are therefore working to decrease salary disparities that appear arbitrary or reflect long-standing biases and to identify metrics for merit-based remuneration. Ours is a large academic pathology department with 97 tenure-track faculty. Faculty salaries are comprised of 3 parts (A + B + C). Part A is determined by the type of appointment and years at rank; part B recognizes defined administrative, educational, or clinical roles; and part C is a bonus to reward and incentivize activities that forward the missions of the department and medical school. A policy for part C allocations was first codified and approved by department faculty in 1993. It rewarded performance using a semiquantitative scale, based on subjective evaluations of the department director (chair) in consultation with deputy directors (vice chairs) and division directors. Faculty could not directly calculate their part C, and distributions data were not widely disclosed. Over the last 2 years (2015-2017), we have implemented a more objective formula for quantifying an earned part C, which is primarily designed to recognize scholarship in the form of research productivity, educational excellence, and clinical quality improvement. Here, we share our experience with this approach, reviewing part C calculations as made for individual faculty members, providing a global view of the resulting allocations, and considering how the process and outcomes reflect our values.
View details for DOI 10.1177/2374289518777463
View details for Web of Science ID 000435829500001
View details for PubMedID 29978019
View details for PubMedCentralID PMC6024278
INSM1 over-expression in CDK4-amplified glioblastoma
OXFORD UNIV PRESS INC. 2018: 492
View details for Web of Science ID 000434064400057
The Association of Departmental Quality Infrastructure and Positive Change: A Pathology Department Illustration
2018; 5: 2374289517744753
A vertically and horizontally well-integrated quality improvement team is essential for effective quality data collection and implementation of improvement measures. We outline the quality structure of a large academic pathology department and describe successful projects across multiple divisions made possible by this tightly integrated structure. The physician vice chair for quality organizes departmental quality efforts and provides representation at the hospital level. The department has an independent continuous quality improvement unit and each laboratory of the department has a staff quality improvement representative. Faculty and staff experts have interacted to produce improvements such as accurate container labeling, efficient triage of specimens, and reduction of unnecessary testing. Specialized task forces such as the Courier Task Force are producing concrete recommendations for process improvement. All phases of pathology patient care are represented by faculty and staff who are trained in quality improvement, and each position touches and communicates actively with levels above and below itself. The key to the department's approach has been the daily attention to quality efforts in all of its activities and the close association of faculty and staff to accomplish the goals of greater efficiency, safety, and cost savings.
View details for DOI 10.1177/2374289517744753
View details for Web of Science ID 000433787300001
View details for PubMedID 29376115
View details for PubMedCentralID PMC5777549
The tumor suppressor phosphatase PP2A-56a regulates stemness and promotes the initiation of malignancies in a novel murine model
2017; 12 (11): e0188910
Protein phosphatase 2A (PP2A) is a ubiquitously expressed Serine-Threonine phosphatase mediating 30-50% of protein phosphatase activity. PP2A functions as a heterotrimeric complex, with the B subunits directing target specificity to regulate the activity of many key pathways that control cellular phenotypes. PP2A-B56α has been shown to play a tumor suppressor role and to negatively control c-MYC stability and activity. Loss of B56α promotes cellular transformation, likely at least in part through its regulation of c-MYC. Here we report generation of a B56α hypomorph mouse with very low B56α expression that we used to study the physiologic activity of the PP2A-B56α phosphatase. The predominant phenotype we observed in mice with B56α deficiency in the whole body was spontaneous skin lesion formation with hyperproliferation of the epidermis, hair follicles and sebaceous glands. Increased levels of c-MYC phosphorylation on Serine62 and c-MYC activity were observed in the skin lesions of the B56αhm/hm mice. B56α deficiency was found to increase the number of skin stem cells, and consistent with this, papilloma initiation was accelerated in a carcinogenesis model. Further analysis of additional tissues revealed increased inflammation in spleen, liver, lung, and intestinal lymph nodes as well as in the skin lesions, resembling elevated extramedullary hematopoiesis phenotypes in the B56αhm/hm mice. We also observed an increase in the clonogenicity of bone marrow stem cells in B56αhm/hm mice. Overall, this model suggests that B56α is important for stem cells to maintain homeostasis and that B56α loss leading to increased activity of important oncogenes, including c-MYC, can result in aberrant cell growth and increased stem cells that can contribute to the initiation of malignancy.
View details for DOI 10.1371/journal.pone.0188910
View details for Web of Science ID 000416841900166
View details for PubMedID 29190822
View details for PubMedCentralID PMC5708644
Fatal Congenital Retroperitoneal Neuroblastoma Diagnosed by Fetal Magnetic Resonance Imaging
JOURNAL OF COMPUTER ASSISTED TOMOGRAPHY
2017; 41 (4): 651-652
Congenital extra-adrenal neuroblastoma is a rare condition, which typically has a favorable prognosis. We present a unique case of extra-adrenal retroperitoneal neuroblastoma diagnosed by fetal magnetic resonance imaging, which ultimately leads to fetal hydrops and neonatal death.
View details for DOI 10.1097/RCT.0000000000000563
View details for Web of Science ID 000405919000023
View details for PubMedID 27997441
Postmortem Assessment of Vector Biodistribution in the First-in-Human Intrathecal scAAV9 Gene Therapy Trial for Giant Axonal Neuropathy
CELL PRESS. 2017: 139
View details for Web of Science ID 000401083600292
A Model for the Departmental Quality Management Infrastructure Within an Academic Health System
2017; 92 (5): 608-613
As quality improvement and patient safety come to play a larger role in health care, academic medical centers and health systems are poised to take a leadership role in addressing these issues. Academic medical centers can leverage their large integrated footprint and have the ability to innovate in this field. However, a robust quality management infrastructure is needed to support these efforts. In this context, quality and safety are often described at the executive level and at the unit level. Yet, the role of individual departments, which are often the dominant functional unit within a hospital, in realizing health system quality and safety goals has not been addressed. Developing a departmental quality management infrastructure is challenging because departments are diverse in composition, size, resources, and needs.In this article, the authors describe the model of departmental quality management infrastructure that has been implemented at the Johns Hopkins Hospital. This model leverages the fractal approach, linking departments horizontally to support peer and organizational learning and connecting departments vertically to support accountability to the hospital, health system, and board of trustees. This model also provides both structure and flexibility to meet individual departmental needs, recognizing that independence and interdependence are needed for large academic medical centers. The authors describe the structure, function, and support system for this model as well as the practical and essential steps for its implementation. They also provide examples of its early success.
View details for DOI 10.1097/ACM.0000000000001380
View details for Web of Science ID 000401145100029
View details for PubMedID 27603038
Uses and limitations of IgG4 positive plasma cells in evaluating ulcerative colitis.
Journal of gastrointestinal and liver diseases : JGLD
2017; 26 (4): 428–29
View details for DOI 10.15403/jgld.2014.1121.264.igg
View details for PubMedID 29253063
PSMA-Targeted F-18-DCFPyL PET/CT Imaging of Clear Cell Renal Cell Carcinoma: Results from a Rapid Autopsy
2017; 71 (1): 145-146
View details for DOI 10.1016/j.eururo.2016.06.019
View details for Web of Science ID 000390564400049
View details for PubMedID 27363386
View details for PubMedCentralID PMC5516900
Increased Mucosal IgG4 Infiltration Is Associated with Poor Clinical Outcomes in Ulcerative Colitis
NATURE PUBLISHING GROUP. 2016: 163A
View details for Web of Science ID 000370302501125
Pulmonary Emboli and the Risk of Mortality in a Diverse Disease Environment
NATURE PUBLISHING GROUP. 2016: 10A
View details for Web of Science ID 000369270700026
Hybrid Capture 2 is as Effective as PCR Testing for High-risk Human Papillomavirus in Head and Neck Cancers
APPLIED IMMUNOHISTOCHEMISTRY & MOLECULAR MORPHOLOGY
2015; 23 (4): 266-272
High-risk human papillomavirus (HPV) infection is a common cause of oropharyngeal squamous cell carcinoma, especially in young male nonsmokers. Accurately diagnosing HPV-associated oral cancers is important, because they have a better prognosis and may be treated differently than smoking-related oral carcinomas. Various methods have been validated to test for high-risk HPV in cervical tissue samples, and they are in routine clinical use to detect dysplasia before it progresses to invasive disease. Similarly, future screening for HPV-mediated oropharyngeal dysplasia may identify patients before it progresses. Our objective was to compare 4 of these methods in a retrospective series of 87 oral and oropharyngeal squamous cell carcinomas that had archived fresh-frozen and paraffin-embedded tissue for evaluation. Patient age, sex, smoking history, and tumor location were also recorded. DNA prepared from fresh-frozen tissue was tested for HPV genotypes by multiplex polymerase chain reaction analysis, and high-risk HPV screening was carried out using Hybrid Capture 2 and Cervista. Histologic sections were immunostained for p16. HPV-positive outcome was defined as agreement between at least 2 of the 3 genetic tests and used for χ analysis and calculations of diagnostic predictive value. As expected, high-risk HPV-positive oral cancers were most common in the tonsil and base of the tongue (oropharynx) of younger male (55 vs. 65 y) (P=0.0002) nonsmokers (P=0.01). Most positive cases were HPV16 (33/36, 92%). Hybrid Capture 2 and Cervista were as sensitive as polymerase chain reaction and had fewer false positives than p16 immunohistochemical staining.
View details for DOI 10.1097/PDM.0000000000000036
View details for Web of Science ID 000352259500004
View details for PubMedID 25839700
View details for PubMedCentralID PMC4116481
A Patient-Derived Xenograft Model of Parameningeal Embryonal Rhabdomyosarcoma for Preclinical Studies.
2015; 2015: 826124
Embryonal rhabdomyosarcoma (eRMS) is one of the most common soft tissue sarcomas in children and adolescents. Parameningeal eRMS is a variant that is often more difficult to treat than eRMS occurring at other sites. A 14-year-old female with persistent headaches and rapid weight loss was diagnosed with parameningeal eRMS. She progressed and died despite chemotherapy with vincristine, actinomycin-D, and cyclophosphamide plus 50.4Gy radiation therapy to the primary tumor site. Tumor specimens were acquired by rapid autopsy and tumor tissue was transplanted into immunodeficient mice to create a patient-derived xenograft (PDX) animal model. As autopsy specimens had an ALK R1181C mutation, PDX tumor bearing animals were treated with the pan-kinase inhibitor lestaurtinib but demonstrated no decrease in tumor growth, suggesting that single agent kinase inhibitor therapy may be insufficient in similar cases. This unique parameningeal eRMS PDX model is publicly available for preclinical study.
View details for DOI 10.1155/2015/826124
View details for PubMedID 26696773
Suprarenal retroperitoneal liposarcoma with intracaval tumor thrombus: an imaging mimic of adrenocortical carcinoma
2014; 38 (1): 75-77
We report a 57-year-old previously healthy man who presented with dull right upper quadrant pain, weight loss, fatigue, and night sweats. Computed tomography demonstrated a large, heterogeneously enhancing, soft tissue mass with no macroscopic fat above the right kidney with tumor thrombus extending into the inferior vena cava and right atrium. Positron Emission Tomography scanning demonstrated intense Fluorodeoxyglucose avidity in the primary tumor and tumor thrombus. The presumptive radiological diagnosis was adrenocortical carcinoma, but surgical pathology revealed a dedifferentiated liposarcoma. We conclude that suprarenal retroperitoneal liposarcoma should be included in the differential diagnosis for an apparent adrenal mass with venous invasion.
View details for DOI 10.1016/j.clinimag.2013.08.016
View details for Web of Science ID 000328314100016
View details for PubMedID 24075490
Overcoming autopsy barriers in pediatric cancer research
PEDIATRIC BLOOD & CANCER
2013; 60 (2): 204-209
More than 13,000 children annually in the United States and Canada under the age of 20 will be diagnosed with cancer at a mortality approaching 20% 1,2. Tumor samples obtained by autopsy provide an innovative way to study tumor progression, potentially aiding in the discovery of new treatments and increased survival rates. The purpose of this study was to identify barriers to autopsies and develop guidelines for requesting autopsies for research purposes.Families of children treated for childhood cancer were referred by patient advocacy groups and surveyed about attitudes and experiences with research autopsies. From 60 interviews, barriers to autopsy and tumor banking were identified. An additional 14 interviews were conducted with medical and scientific experts.Ninety-three percent of parents of deceased children did or would have consented to a research autopsy if presented with the option; however, only half of these families were given the opportunity to donate autopsy tissue for research. The most significant barriers were the physicians' reluctance to ask a grieving family and lack of awareness about research opportunities.The value of donating tumor samples to research via an autopsy should be promoted to all groups managing pediatric cancer patients. Not only does autopsy tumor banking offer a potentially important medical and scientific impact, but the opportunity to contribute this Legacy Gift of autopsy tumor tissue also creates a positive outlet for the grieving family. Taking these findings into account, our multidisciplinary team has developed a curriculum addressing key barriers.
View details for DOI 10.1002/pbc.24320
View details for PubMedID 23015377
MDM2 Amplification and PI3KCA Mutation in a Case of Sclerosing Rhabdomyosarcoma.
2013; 2013: 520858
A rare sclerosing variant of rhabdomyosarcoma characterized by prominent hyalinization and pseudovascular pattern has recently been described as a subtype biologically distinct from embryonal, alveolar, and pleomorphic forms. We present cytogenetic and molecular findings as well as experimental studies of an unusual case of sclerosing rhabdomyosarcoma. The primary lesion arose within the plantar subcutaneous tissue of the left foot of an otherwise healthy 23-year-old male who eventually developed pulmonary nodules despite systemic chemotherapy. Two genetic abnormalities identified in surgical and/or autopsy samples of the tumor were introduced into 10T1/2 murine fibroblasts to determine whether these genetic changes cooperatively facilitated transformation and growth. Cytogenetic analysis revealed a complex abnormal hyperdiploid clone, and MDM2 gene amplification was confirmed by fluorescence in situ hybridization. Cancer gene mutation screening using a combination of multiplexed PCR and mass spectroscopy revealed a PIK3CA exon 20 H1047R mutation in the primary tumor, lung metastasis, and liver metastasis. However, this mutation was not cooperative with MDM2 overexpression in experimental assays for transformation or growth. Nevertheless, MDM2 and PIK3CA are genes worthy of further investigation in patients with sclerosing rhabdomyosarcoma and might be considered in the enrollment of these patients into clinical trials of targeted therapeutics.
View details for DOI 10.1155/2013/520858
View details for PubMedID 23766666
The novel monoclonal antibody HPC2 and N-cadherin distinguish pancreatic ductal adenocarcinoma from cholangiocarcinoma
2012; 43 (10): 1583-1589
Metastatic pancreatic ductal adenocarcinoma and primary cholangiocarcinoma are morphologically very similar and, therefore, challenging to distinguish in liver biopsies. The distinction is important because surgical management and prognosis differ significantly. Several immunohistochemical markers have been evaluated to aid this diagnosis, but aside from N-cadherin, which labels cholangiocarcinoma, few provide the combination of good sensitivity and specificity. Our laboratory recently developed the novel monoclonal antibody human pancreatic cancer fusion #2 (HPC2) that recognizes pancreatic cancer. We hypothesized that the combination of our new marker and N-cadherin can assist in distinguishing metastatic pancreatic cancer from cholangiocarcinoma. We immunostained resections of 60 pancreatic ductal adenocarcinomas and 31 cholangiocarcinomas for the HPC2 and N-cadherin antigens. We also stained 24 gallbladder adenocarcinomas, 11 ampullary adenocarcinomas, and 10 metastatic colonic adenocarcinomas to the liver. Sections were independently scored by 2 pathologists with good agreement using both markers (κ statistics, 0.62-0.64; P < .0001). HPC2 was observed in 80% of pancreatic cancers (48/60), 82% of ampullary (9/11), and 32% (10/31) of cholangiocarcinomas. N-cadherin stained 27% (16/60) of the pancreas cases and 58% (18/31) of the cholangiocarcinomas. Gallbladder and colon cancers were usually double negative (18/24 and 8/10, respectively). Each marker provided significant likelihood ratios to separate pancreatic cancer (HPC2, 2.48 [1.46-4.19]; P < .0001) from cholangiocarcinoma (N-cadherin, 2.17 [1.3-3.64]; P < .01). The combination of both markers provided even better specificity and positive likelihood ratios. We conclude that HPC2 and N-cadherin significantly improve accurate classification of pancreatic cancer and cholangiocarcinoma.
View details for DOI 10.1016/j.humpath.2011.11.012
View details for PubMedID 22406361
Polyoma virus nephropathy-related mass lesion in an apparently immunocompetent patient
INTERNATIONAL UROLOGY AND NEPHROLOGY
2012; 44 (5): 1585-1588
Polyoma virus is a recognized cause of hemorrhagic cystitis, viral nephropathy, and ureteral stricture in renal and stem cell transplant recipients. Rarely, polyoma virus causes native kidney and bladder pathology in heavily immunosuppressed patients. We report a unique case of native kidney polyoma virus nephropathy, urothelial ulceration, and renal pelvic fibrosis presenting as a mass lesion in a non-debilitated, apparently immunocompetent man. Based on radiologic, ureterorenoscopic, and urine cytologic findings, a laparoscopic nephrectomy was performed. However, nephrectomy revealed a hemorrhagic scar-like lesion, with urothelial ulceration, but no neoplasm or malignancy. Histopathologic evaluation and immunostaining revealed polyoma viral infection in the nearby renal medulla. This case adds polyoma virus nephropathy to the differential diagnosis of non-neoplastic and reactive masses, which may mimic renal malignancy.
View details for DOI 10.1007/s11255-011-9985-y
View details for PubMedID 21559788
Disseminated coccidioidomycosis in pregnancy
ARCHIVES OF PATHOLOGY & LABORATORY MEDICINE
2007; 131 (4): 652-655
Coccidioidomycosis is a fungal infection contracted through the inhalation of airborne spores, which are most frequently present in desert areas of the southwestern United States and Mexico. Primary immune response to infection is by T(H)1, a subset of helper T cells. Although pulmonary symptoms are most common, hematogenous systemic spread can also occur. Pregnancy is a well-noted risk factor for disseminated Coccidioides infection. The objective of this review is to provide an overview of coccidioidomycosis and to review immunologic and hormonal factors that increase risk of dissemination in pregnancy. Dissemination may occur more frequently in pregnant patients than in nonpregnant women because of shifts in T-cell immunity, changes in cytokine production, and increased hormone levels. There is disagreement regarding the precise incidence of systemic spread in pregnancy, but most sources agree that risk is substantially increased and vigilance must be high in patients with exposures in endemic areas.
View details for Web of Science ID 000245610500028
View details for PubMedID 17425401
Relevance of the autopsy as a medical tool - A large database of physician attitudes
ARCHIVES OF PATHOLOGY & LABORATORY MEDICINE
2007; 131 (2): 268-274
Autopsy rates for patients dying in hospitals have declined from approximately 50% in the 1950s to 5% or less today.To investigate the nature of physician attitudes about autopsy in a large and varied population and to relate these attitudes to certain physician demographic variables.A 10-question, anonymous, multiple-choice format questionnaire was distributed to all attending physicians at 4 hospitals: 2 that were university-affiliated (1 private and 1 public), 1 military, and 1 private nonuniversity-affiliated medical center. A total of 2608 surveys were distributed.Three hundred eighty-eight (15%) physicians responded to the survey. Respondents agreed (77%) that autopsy results could affect their future medical practice, and disagreed (73%) that the accuracy of modern diagnostic procedures makes autopsy unnecessary. Most respondents (72%) disagreed that litigation concerns play a role in the decision to request autopsy. Spearman correlation coefficients found 9 significant relationships among the survey items, with many correlations reflecting statistically significant relationships between demographic and attitudinal variables.The survey data and statistical analysis confirm that respondents value the autopsy as a relevant clinical tool, in spite of declining requests. One of the most crucial factors influencing attitudes is the physician's level of experience with autopsy in training and practice. Among other interesting results was that strength of belief in autopsy relevancy correlates significantly (P = .003) with greater prior exposure to the autopsy. In a sense, the current low autopsy rates may be self-perpetuating because of the paucity of and decreasing experience with autopsy by succeeding generations of clinicians.
View details for Web of Science ID 000244317700014
View details for PubMedID 17284112