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Stolzenbach V, Woods DC, Tilly JL. Non-neutral clonal selection and its potential role in mammalian germline stem cell dysfunction with advancing age. Front Cell Dev Biol 2022; 10:942652. [PMID: 36081905 PMCID: PMC9445274 DOI: 10.3389/fcell.2022.942652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 07/20/2022] [Indexed: 11/13/2022] Open
Abstract
The concept of natural selection, or "survival of the fittest", refers to an evolutionary process in nature whereby traits emerge in individuals of a population through random gene alterations that enable those individuals to better adapt to changing environmental conditions. This genetic variance allows certain members of the population to gain an advantage over others in the same population to survive and reproduce in greater numbers under new environmental pressures, with the perpetuation of those advantageous traits in future progeny. Here we present that the behavior of adult stem cells in a tissue over time can, in many respects, be viewed in the same manner as evolution, with each stem cell clone being representative of an individual within a population. As stem cells divide or are subjected to cumulative oxidative damage over the lifespan of the organism, random genetic alterations are introduced into each clone that create variance in the population. These changes may occur in parallel to, or in response to, aging-associated changes in microenvironmental cues perceived by the stem cell population. While many of these alterations will be neutral or silent in terms of affecting cell function, a small fraction of these changes will enable certain clones to respond differently to shifts in microenvironmental conditions that arise with advancing age. In some cases, the same advantageous genetic changes that support survival and expansion of certain clones over others in the population (viz. non-neutral competition) could be detrimental to the downstream function of the differentiated stem cell descendants. In the context of the germline, such a situation would be devastating to successful propagation of the species across generations. However, even within a single generation, the “evolution” of stem cell lineages in the body over time can manifest into aging-related organ dysfunction and failure, as well as lead to chronic inflammation, hyperplasia, and cancer. Increased research efforts to evaluate stem cells within a population as individual entities will improve our understanding of how organisms age and how certain diseases develop, which in turn may open new opportunities for clinical detection and management of diverse pathologies.
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Kim S, Song E, Park YH, Cho A, Choe K, Kim HJ, Park JY, Kim B, Oh KJ. Association between cesarean section rate and maternal age in twin pregnancies. J Perinat Med 2022; 50:438-445. [PMID: 35106987 DOI: 10.1515/jpm-2021-0337] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 01/07/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the effect of maternal age to the cesarean section rate of twin pregnancies in late preterm and term gestation. METHODS A retrospective study was performed on twin pregnancies delivered at Seoul National University Bundang Hospital from June 2003 to December 2020. Preterm births before 34 weeks of gestation were excluded, and only live births were analyzed. The patients were classified into four groups according to maternal age (<30, 30-34, 35-39, and ≥40 years). The primary outcome was the rate of cesarean section. RESULTS The median value of maternal body mass index, the rate of assisted reproductive technology, dichorionic twin pregnancy, preeclampsia, and gestational diabetes increased significantly according to the maternal age group (all p<0.05). Among a total of 2,075 twin pregnancies, the rates of cesarean section were 65, 74, 80, and 95% for groups with maternal age under 30, 30-34, 35-39, and ≥40 years, respectively (p<0.001). The cesarean section rates after a trial of labor were 22, 22, 28, and 63%, respectively (p=0.032). Maternal old age was an independent risk factor for cesarean section after a trial of labor in both nulliparous and multiparous women after adjusting for confounding factors. CONCLUSIONS The rate of cesarean section in twin pregnancies significantly increased as maternal age increased, even in multiparous women.
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Affiliation(s)
- Seongbeen Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eunjin Song
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ye Hyon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Aeri Cho
- Department of Computer Science and Engineering, Seoul National University, Seoul, Republic of Korea
| | - Kiroong Choe
- Department of Computer Science and Engineering, Seoul National University, Seoul, Republic of Korea
| | - Hyeon Ji Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jee Yoon Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Bohyoung Kim
- Division of Biomedical Engineering, Hankuk University of Foreign Studies, Gyeonggi-do, Republic of Korea
| | - Kyung Joon Oh
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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3
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Bi S, Zhang L, Chen J, Huang M, Huang L, Zeng S, Li Y, Liang Y, Jia J, Wen S, Cao Y, Wang S, Xu X, Feng L, Zhao X, Zhao Y, Zhu Q, Qi H, Zhang L, Li H, Wang Z, Du L, Chen D. Maternal age at first cesarean delivery related to adverse pregnancy outcomes in a second cesarean delivery: a multicenter, historical, cross-sectional cohort study. BMC Pregnancy Childbirth 2021; 21:126. [PMID: 33579220 PMCID: PMC7881558 DOI: 10.1186/s12884-021-03608-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 01/31/2021] [Indexed: 12/18/2022] Open
Abstract
Background To determine the effects of maternal age at first cesarean on maternal complications and adverse outcomes of pregnancy with the second cesarean. Methods This was a multicenter, historical, cross-sectional cohort study involving singleton pregnancies ≥28 gestational weeks, with a history of 1 cesarean delivery, and who underwent a second cesarean between January and December 2017 at 11 public tertiary hospitals in 7 provinces of China. We analyzed the effects of maternal age at first cesarean on adverse outcomes of pregnancy in the second cesarean using multivariate logistic regression analysis. Results The study consisted of 10,206 singleton pregnancies. Women were at first cesarean between 18 and 24, 25–29, 30–34, and ≥ 35 years of age; and numbered 2711, 5524, 1751, and 220 cases, respectively. Maternal age between 18 and 24 years at first cesarean increased the risk of placenta accreta spectrum (aOR, 1.499; 95% CI, 1.12–2.01), placenta previa (aOR, 1.349; 95% CI, 1.07–1.70), intrahepatic cholestasis of pregnancy (aOR, 1.947; 95% CI, 1.24–3.07), postpartum hemorrhage (aOR, 1.505; 95% CI, 1.05–2.16), and blood transfusion (aOR, 1.517; 95% CI, 1.21–1.91) in the second cesarean compared with the reference group (aged 25–29 years). In addition, maternal age ≥ 35 years at first cesarean was a risk factor for premature rupture of membranes (aOR, 1.556; 95% CI, 1.08–2.24), placental abruption (aOR, 6.464, 95% CI, 1.33–31.51), uterine rupture (aOR, 7.952; 95% CI, 1.43–44.10), puerperal infection (aOR, 6.864; 95% CI, 1.95–24.22), neonatal mild asphyxia (aOR, 4.339; 95% CI, 1.53–12.32), severe asphyxia (aOR, 18.439; 95% CI, 1.54–220.95), and admission to a neonatal intensive care unit (aOR, 2.825; 95% CI, 1.54–5.17) compared with the reference group (aged 25–29 years). Conclusions Maternal age between 18 and 24 years or advanced maternal age at first cesarean was an independent risk factor for adverse maternal outcomes with the second cesarean. Advanced maternal age at the first cesarean specifically increased adverse neonatal outcomes with the second. Therefore, decisions as to whether to perform a first cesarean at a young or advanced maternal age must be critically evaluated. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03608-9.
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Affiliation(s)
- Shilei Bi
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, Guangdong, China
| | - Lizi Zhang
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Ave North, Guangzhou, 510515, Guangdong, China
| | - Jingsi Chen
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, Guangdong, China.,Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, People's Republic of China.,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, Guangzhou, People's Republic of China
| | - Minshan Huang
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, Guangdong, China
| | - Lijun Huang
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, Guangdong, China
| | - Shanshan Zeng
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, Guangdong, China
| | - Yulian Li
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, Guangdong, China
| | - Yingyu Liang
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, Guangdong, China
| | - Jinping Jia
- Department of Obstetrics and Gynecology, Guangzhou Huadu District Maternal and Child Health Hospital, Guangzhou, China
| | - Suiwen Wen
- Department of Obstetrics and Gynecology, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Guangzhou, China
| | - Yinli Cao
- Department of Obstetrics and Gynecology, Northwest Women's and Children's Hospital, Xian, China
| | - Shaoshuai Wang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyan Xu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling Feng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xianlan Zhao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yangyu Zhao
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Qiying Zhu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Hongbo Qi
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lanzhen Zhang
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Hongtian Li
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China
| | - Zhijian Wang
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Ave North, Guangzhou, 510515, Guangdong, China.
| | - Lili Du
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, Guangdong, China. .,Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, People's Republic of China. .,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, Guangzhou, People's Republic of China.
| | - Dunjin Chen
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, Guangdong, China. .,Key Laboratory for Major Obstetric Diseases of Guangdong Province, Guangzhou, People's Republic of China. .,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institutes, Guangzhou, People's Republic of China.
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Levenson D, Romero R, Garcia-Flores V, Miller D, Xu Y, Sahi A, Hassan SS, Gomez-Lopez N. The effects of advanced maternal age on T-cell subsets at the maternal-fetal interface prior to term labor and in the offspring: a mouse study. Clin Exp Immunol 2020; 201:58-75. [PMID: 32279324 DOI: 10.1111/cei.13437] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 03/30/2020] [Accepted: 04/02/2020] [Indexed: 12/11/2022] Open
Abstract
Women who conceive at 35 years of age or older, commonly known as advanced maternal age, have a higher risk of facing parturition complications and their children have an increased risk of developing diseases later in life. However, the immunological mechanisms underlying these pathological processes have yet to be established. To fill this gap in knowledge, using a murine model and immunophenotyping, we determined the effect of advanced maternal age on the main cellular branch of adaptive immunity, T cells, at the maternal-fetal interface and in the offspring. We report that advanced maternal age impaired the process of labor at term, inducing dystocia and delaying the timing of delivery. Advanced maternal age diminished the number of specific proinflammatory T-cell subsets [T helper type 1 (Th1): CD4+ IFN-γ+ , CD8+ IFN-γ+ and Th9: CD4+ IL-9+ ], as well as CD4+ regulatory T cells (CD4+ CD25+ FoxP3+ T cells), at the maternal-fetal interface prior to term labor. Advanced maternal age also altered fetal growth and survival of the offspring in early life. In addition, infants born to advanced-age mothers had alterations in the T-cell repertoire but not in CD71+ erythroid cells (CD3- CD71+ TER119+ cells). This study provides insight into the immune alterations observed at the maternal-fetal interface of advanced-age mothers and their offspring.
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Affiliation(s)
- D Levenson
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Detroit, MI, USA.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - R Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Detroit, MI, USA.,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI, USA.,Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI, USA.,Detroit Medical Center, Detroit, MI, USA.,Department of Obstetrics and Gynecology, Florida International University, Miami, FL, USA
| | - V Garcia-Flores
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Detroit, MI, USA.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - D Miller
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Detroit, MI, USA.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Y Xu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Detroit, MI, USA.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - A Sahi
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Detroit, MI, USA.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - S S Hassan
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA.,Office of Women's Health, Integrative Biosciences Center, Wayne State University, Detroit, MI, USA.,Department of Physiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - N Gomez-Lopez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, US Department of Health and Human Services, Detroit, MI, USA.,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA.,Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, MI, USA
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Han MA, Storman D, Al-Rammahy H, Tang S, Hao Q, Leung G, Kandi M, Moradi R, Bartoszko JJ, Arnold C, Rehman N, Guyatt G. Impact of maternal reproductive factors on cancer risks of offspring: A systematic review and meta-analysis of cohort studies. PLoS One 2020; 15:e0230721. [PMID: 32226046 PMCID: PMC7105118 DOI: 10.1371/journal.pone.0230721] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/06/2020] [Indexed: 02/05/2023] Open
Abstract
Background A number of studies have reported on associations between reproductive factors, such as delivery methods, number of birth and breastfeeding, and incidence of cancer in children, but systematic reviews addressing this issue to date have important limitations, and no reviews have addressed the impact of reproductive factors on cancer over the full life course of offspring. Methods We performed a comprehensive search in MEDLINE, and Embase up to January 2020 and Web of Science up to 2018 July, including cohort studies reporting the association between maternal reproductive factors of age at birth, birth order, number of births, delivery methods, and breastfeeding duration and cancer in children. Teams of two reviewers independently extracted data and assessed risk of bias. We conducted random effects meta-analyses to estimate summary relative estimates, calculated absolute differences between those with and without risk factors, and used the GRADE approach to evaluate the certainty of evidence. Results For most exposures and most cancers, we found no suggestion of a causal relation. We found low to very low certainty evidence of the following very small possible impact: higher maternal age at birth with adult multiple myeloma and lifetime uterine cervix cancer incidence; lower maternal age at birth with childhood overall cancer mortality (RR = 1.15, 95% CI = 1.01–1.30; AR/10,000 = 1, 95% CI = 0 to 2), adult leukemia and lifetime uterine cervix cancer incidence; higher birth order with adult melanoma, cervix uteri, corpus uteri, thyroid cancer incidence, lifetime lung, corpus uteri, prostate, testis, sarcoma, thyroid cancer incidence; larger number of birth with childhood brain (RR = 1.27, 95% CI = 1.06–1.52; AR/10,000 = 1, 95% CI = 0 to 2), leukemia (RR = 2.11, 95% CI = 1.62–2.75; AR/10,000 = 9, 95% CI = 5 to 14), lymphoma (RR = 4.66, 95% CI = 1.40–15.57; AR/10,000 = 11, 95% CI = 1 to 44) incidence, adult stomach, corpus uteri cancer incidence and lung cancer mortality, lifetime stomach, lung, uterine cervix, uterine corpus, multiple myeloma, testis cancer incidence; Caesarean delivery with childhood kidney cancer incidence (RR = 1.25, 95% CI = 1.01–1.55; AR/10,000 = 0, 95% CI = 0 to 1); and breastfeeding with adult colorectal cancer incidence. Conclusion Very small impacts existed between a number of reproductive factors and cancer incidence and mortality in children and the certainty of evidence was low to very low primarily due to observational design.
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Affiliation(s)
- Mi Ah Han
- Department of Preventive Medicine, College of Medicine, Chosun University, Gwangju, Republic of Korea
- * E-mail:
| | - Dawid Storman
- Department of Hygiene and Dietetics, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Husam Al-Rammahy
- Life Sciences—Department of Biomedical and Molecular Sciences, Queen's University at Kingston, Kingston, Canada
| | - Shaowen Tang
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Qiukui Hao
- The center of Gerontology and Geriatrics, National Center for Geriatric Clinical Research, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Gareth Leung
- Department of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Maryam Kandi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Romina Moradi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jessica J. Bartoszko
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Callum Arnold
- Division of Infectious Diseases, the Hospital for Sick Children, Toronto, Canada
| | - Nadia Rehman
- Department of Continuing Education, McMaster University, Hamilton, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Yeung EH, Kim K, Purdue-Smithe A, Bell G, Zolton J, Ghassabian A, Vafai Y, Robinson SL, Mumford SL. Child Health: Is It Really Assisted Reproductive Technology that We Need to Be Concerned About? Semin Reprod Med 2019; 36:183-194. [PMID: 30866005 DOI: 10.1055/s-0038-1675778] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Concerns remain about the health of children conceived by infertility treatment. Studies to date have predominantly not identified substantial long-term health effects after accounting for plurality, which is reassuring given the increasing numbers of children conceived by infertility treatment worldwide. However, as technological advances in treatment arise, ongoing studies remain critical for monitoring health effects. To study whether the techniques used in infertility treatment cause health differences, however, remains challenging due to identification of an appropriate comparison group, heterogeneous treatment, and confounding by the underlying causes of infertility. In fact, the factors that are associated with underlying infertility, including parental obesity and other specific male and female factors, may be important independent factors to consider. This review will summarize key methodological considerations in studying children conceived by infertility treatment including the evidence of associations between underlying infertility factors and child health.
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Affiliation(s)
| | | | | | | | | | - Akhgar Ghassabian
- Department of Pediatrics, New York University School of Medicine, New York.,Department of Environmental Medicine, New York University School of Medicine, New York, New York.,Department of Population Health, New York University School of Medicine, New York, New York
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