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Gil-Rojas S, Suárez M, Martínez-Blanco P, Torres AM, Martínez-García N, Blasco P, Torralba M, Mateo J. Prognostic Impact of Metabolic Syndrome and Steatotic Liver Disease in Hepatocellular Carcinoma Using Machine Learning Techniques. Metabolites 2024; 14:305. [PMID: 38921441 PMCID: PMC11205954 DOI: 10.3390/metabo14060305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/27/2024] Open
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD) currently represents the predominant cause of chronic liver disease and is closely linked to a significant increase in the risk of hepatocellular carcinoma (HCC), even in the absence of liver cirrhosis. In this retrospective multicenter study, machine learning (ML) methods were employed to investigate the relationship between metabolic profile and prognosis at diagnosis in a total of 219 HCC patients. The eXtreme Gradient Boosting (XGB) method demonstrated superiority in identifying mortality predictors in our patients. Etiology was the most determining prognostic factor followed by Barcelona Clinic Liver Cancer (BCLC) and Eastern Cooperative Oncology Group (ECOG) classifications. Variables related to the development of hepatic steatosis and metabolic syndrome, such as elevated levels of alkaline phosphatase (ALP), uric acid, obesity, alcohol consumption, and high blood pressure (HBP), had a significant impact on mortality prediction. This study underscores the importance of metabolic syndrome as a determining factor in the progression of HCC secondary to MASLD. The use of ML techniques provides an effective tool to improve risk stratification and individualized therapeutic management in these patients.
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Affiliation(s)
- Sergio Gil-Rojas
- Gastroenterology Department, Virgen de la Luz Hospital, 16002 Cuenca, Spain
- Medical Analysis Expert Group, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Medical Analysis Expert Group, Institute of Technology, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
| | - Miguel Suárez
- Gastroenterology Department, Virgen de la Luz Hospital, 16002 Cuenca, Spain
- Medical Analysis Expert Group, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Medical Analysis Expert Group, Institute of Technology, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
| | - Pablo Martínez-Blanco
- Gastroenterology Department, Virgen de la Luz Hospital, 16002 Cuenca, Spain
- Medical Analysis Expert Group, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Medical Analysis Expert Group, Institute of Technology, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
| | - Ana M. Torres
- Medical Analysis Expert Group, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Medical Analysis Expert Group, Institute of Technology, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
| | | | - Pilar Blasco
- Department of Pharmacy, General University Hospital, 46014 Valencia, Spain
| | - Miguel Torralba
- Internal Medicine Unit, University Hospital of Guadalajara, 19002 Guadalajara, Spain
- Faculty of Medicine, Universidad de Alcalá de Henares, 28801 Alcalá de Henares, Spain
- Translational Research Group in Cellular Immunology (GITIC), Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
| | - Jorge Mateo
- Medical Analysis Expert Group, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), 45071 Toledo, Spain
- Medical Analysis Expert Group, Institute of Technology, Universidad de Castilla-La Mancha, 16071 Cuenca, Spain
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Ramachandran L, Abul Rub F, Hajja A, Alodhaibi I, Arai M, Alfuwais M, Makhzoum T, Yaqinuddin A, Al-Kattan K, Assiri AM, Broering DC, Chinnappan R, Mir TA, Mani NK. Biosensing of Alpha-Fetoprotein: A Key Direction toward the Early Detection and Management of Hepatocellular Carcinoma. BIOSENSORS 2024; 14:235. [PMID: 38785709 PMCID: PMC11117836 DOI: 10.3390/bios14050235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/16/2024] [Accepted: 04/25/2024] [Indexed: 05/25/2024]
Abstract
Hepatocellular carcinoma (HCC) is currently one of the most prevalent cancers worldwide. Associated risk factors include, but are not limited to, cirrhosis and underlying liver diseases, including chronic hepatitis B or C infections, excessive alcohol consumption, nonalcoholic fatty liver disease (NAFLD), and exposure to chemical carcinogens. It is crucial to detect this disease early on before it metastasizes to adjoining parts of the body, worsening the prognosis. Serum biomarkers have proven to be a more accurate diagnostic tool compared to imaging. Among various markers such as nucleic acids, circulating genetic material, proteins, enzymes, and other metabolites, alpha-fetoprotein (AFP) is a protein marker primarily used to diagnose HCC. However, current methods need a large sample and carry a high cost, among other challenges, which can be improved using biosensing technology. Early and accurate detection of AFP can prevent severe progression of the disease and ensure better management of HCC patients. This review sheds light on HCC development in the human body. Afterward, we outline various types of biosensors (optical, electrochemical, and mass-based), as well as the most relevant studies of biosensing modalities for non-invasive monitoring of AFP. The review also explains these sensing platforms, detection substrates, surface modification agents, and fluorescent probes used to develop such biosensors. Finally, the challenges and future trends in routine clinical analysis are discussed to motivate further developments.
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Affiliation(s)
- Lohit Ramachandran
- Microfluidics, Sensors and Diagnostics (μSenD) Laboratory, Centre for Microfluidics, Biomarkers, Photoceutics and Sensors (μBioPS), Department of Biotechnology, Manipal Institute of Technology, Manipal Academy of Higher Education, Manipal 576104, India;
| | - Farah Abul Rub
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (F.A.R.); (A.H.); (I.A.); (M.A.); (M.A.); (T.M.); (A.Y.); (K.A.-K.); (A.M.A.); (D.C.B.)
| | - Amro Hajja
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (F.A.R.); (A.H.); (I.A.); (M.A.); (M.A.); (T.M.); (A.Y.); (K.A.-K.); (A.M.A.); (D.C.B.)
| | - Ibrahim Alodhaibi
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (F.A.R.); (A.H.); (I.A.); (M.A.); (M.A.); (T.M.); (A.Y.); (K.A.-K.); (A.M.A.); (D.C.B.)
| | - Momo Arai
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (F.A.R.); (A.H.); (I.A.); (M.A.); (M.A.); (T.M.); (A.Y.); (K.A.-K.); (A.M.A.); (D.C.B.)
| | - Mohammed Alfuwais
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (F.A.R.); (A.H.); (I.A.); (M.A.); (M.A.); (T.M.); (A.Y.); (K.A.-K.); (A.M.A.); (D.C.B.)
| | - Tariq Makhzoum
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (F.A.R.); (A.H.); (I.A.); (M.A.); (M.A.); (T.M.); (A.Y.); (K.A.-K.); (A.M.A.); (D.C.B.)
| | - Ahmed Yaqinuddin
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (F.A.R.); (A.H.); (I.A.); (M.A.); (M.A.); (T.M.); (A.Y.); (K.A.-K.); (A.M.A.); (D.C.B.)
| | - Khaled Al-Kattan
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (F.A.R.); (A.H.); (I.A.); (M.A.); (M.A.); (T.M.); (A.Y.); (K.A.-K.); (A.M.A.); (D.C.B.)
- Lung Health Center Department, Organ Transplant Centre of Excellence, King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Abdullah M. Assiri
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (F.A.R.); (A.H.); (I.A.); (M.A.); (M.A.); (T.M.); (A.Y.); (K.A.-K.); (A.M.A.); (D.C.B.)
- Tissue/Organ Bioengineering & BioMEMS Laboratory, Organ Transplant Centre of Excellence (TR&I-Dpt), King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Dieter C. Broering
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (F.A.R.); (A.H.); (I.A.); (M.A.); (M.A.); (T.M.); (A.Y.); (K.A.-K.); (A.M.A.); (D.C.B.)
- Tissue/Organ Bioengineering & BioMEMS Laboratory, Organ Transplant Centre of Excellence (TR&I-Dpt), King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Raja Chinnappan
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (F.A.R.); (A.H.); (I.A.); (M.A.); (M.A.); (T.M.); (A.Y.); (K.A.-K.); (A.M.A.); (D.C.B.)
- Tissue/Organ Bioengineering & BioMEMS Laboratory, Organ Transplant Centre of Excellence (TR&I-Dpt), King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Tanveer Ahmad Mir
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (F.A.R.); (A.H.); (I.A.); (M.A.); (M.A.); (T.M.); (A.Y.); (K.A.-K.); (A.M.A.); (D.C.B.)
- Tissue/Organ Bioengineering & BioMEMS Laboratory, Organ Transplant Centre of Excellence (TR&I-Dpt), King Faisal Specialist Hospital and Research Centre, Riyadh 11211, Saudi Arabia
| | - Naresh Kumar Mani
- Microfluidics, Sensors and Diagnostics (μSenD) Laboratory, Centre for Microfluidics, Biomarkers, Photoceutics and Sensors (μBioPS), Department of Biotechnology, Manipal Institute of Technology, Manipal Academy of Higher Education, Manipal 576104, India;
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Nair DG, Weiskirchen R. Recent Advances in Liver Tissue Engineering as an Alternative and Complementary Approach for Liver Transplantation. Curr Issues Mol Biol 2023; 46:262-278. [PMID: 38248320 PMCID: PMC10814863 DOI: 10.3390/cimb46010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
Acute and chronic liver diseases cause significant morbidity and mortality worldwide, affecting millions of people. Liver transplantation is the primary intervention method, replacing a non-functional liver with a functional one. However, the field of liver transplantation faces challenges such as donor shortage, postoperative complications, immune rejection, and ethical problems. Consequently, there is an urgent need for alternative therapies that can complement traditional transplantation or serve as an alternative method. In this review, we explore the potential of liver tissue engineering as a supplementary approach to liver transplantation, offering benefits to patients with severe liver dysfunctions.
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Affiliation(s)
- Dileep G. Nair
- Institute of Molecular Pathobiochemistry, Experimental Gene Therapy and Clinical Chemistry (IFMPEGKC), Rheinisch-Westfälische Technische Hochschule (RWTH) University Hospital Aachen, D-52074 Aachen, Germany
| | - Ralf Weiskirchen
- Institute of Molecular Pathobiochemistry, Experimental Gene Therapy and Clinical Chemistry (IFMPEGKC), Rheinisch-Westfälische Technische Hochschule (RWTH) University Hospital Aachen, D-52074 Aachen, Germany
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4
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Abbas E, Fanni SC, Bandini C, Francischello R, Febi M, Aghakhanyan G, Ambrosini I, Faggioni L, Cioni D, Lencioni RA, Neri E. Delta-radiomics in cancer immunotherapy response prediction: A systematic review. Eur J Radiol Open 2023; 11:100511. [PMID: 37520768 PMCID: PMC10371799 DOI: 10.1016/j.ejro.2023.100511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 08/01/2023] Open
Abstract
Background The new immunotherapies have not only changed the oncological therapeutic approach but have also made it necessary to develop new imaging methods for assessing the response to treatment. Delta radiomics consists of the analysis of radiomic features variation between different medical images, usually before and after therapy. Purpose This review aims to evaluate the role of delta radiomics in the immunotherapy response assessment. Methods A systematic search was performed in PubMed, Scopus, and Web Of Science using "delta radiomics AND immunotherapy" as search terms. The included articles' methodological quality was measured using the Radiomics Quality Score (RQS) tool. Results Thirteen articles were finally included in the systematic review. Overall, the RQS of the included studies ranged from 4 to 17, with a mean RQS total of 11,15 ± 4,18 with a corresponding percentage of 30.98 ± 11.61 %. Eleven articles out of 13 performed imaging at multiple time points. All the included articles performed feature reduction. No study carried out prospective validation, decision curve analysis, or cost-effectiveness analysis. Conclusions Delta radiomics has been demonstrated useful in evaluating the response in oncologic patients undergoing immunotherapy. The overall quality was found law, due to the lack of prospective design and external validation. Thus, further efforts are needed to bring delta radiomics a step closer to clinical implementation.
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Affiliation(s)
- Engy Abbas
- The Joint Department of Medical Imaging, University of Toronto, University Health Network, Sinai Health System, Women’s College Hospital, 610 University Ave, Toronto, ON, Canada M5G 2M9
| | | | - Claudio Bandini
- Department of Translational Research, Academic Radiology, University of Pisa, Pisa, Italy
| | - Roberto Francischello
- Department of Translational Research, Academic Radiology, University of Pisa, Pisa, Italy
| | - Maria Febi
- Department of Translational Research, Academic Radiology, University of Pisa, Pisa, Italy
| | - Gayane Aghakhanyan
- Department of Translational Research, Academic Radiology, University of Pisa, Pisa, Italy
| | - Ilaria Ambrosini
- Department of Translational Research, Academic Radiology, University of Pisa, Pisa, Italy
| | - Lorenzo Faggioni
- Department of Translational Research, Academic Radiology, University of Pisa, Pisa, Italy
| | - Dania Cioni
- Department of Translational Research, Academic Radiology, University of Pisa, Pisa, Italy
| | | | - Emanuele Neri
- The Joint Department of Medical Imaging, University of Toronto, University Health Network, Sinai Health System, Women’s College Hospital, 610 University Ave, Toronto, ON, Canada M5G 2M9
- Department of Translational Research, Academic Radiology, University of Pisa, Pisa, Italy
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Wang K, Chen XY, Liu WD, Yue Y, Wen XL, Yang YS, Zhang AG, Zhu HL. Imaging Investigation of Hepatocellular Carcinoma Progress via Monitoring γ-Glutamyltranspeptidase Level with a Near-Infrared Fluorescence/Photoacoustic Bimodal Probe. Anal Chem 2023; 95:14235-14243. [PMID: 37652889 DOI: 10.1021/acs.analchem.3c02270] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Hepatocellular carcinoma (HCC) is one of the main principal causes of cancer death, and the late definite diagnosis limits therapeutic approaches in time. The early diagnosis of HCC is essential, and the previous investigations on the biomarkers inferred that the γ-glutamyltranspeptidase (GGT) level could indicate the HCC process. Herein, a near-infrared fluorescence/photoacoustic (NIRF/PA) bimodal probe, CySO3-GGT, was developed for monitoring the GGT level and thus to image the HCC process. After the in-solution tests, the bimodal response was convinced. The various HCC processes were imaged by CySO3-GGT at the cellular level. Then, the CCl4-induced HCC (both induction and treatment) and the subcutaneous and orthotopic xenograft mice models were selected. All throughout the tests, CySO3-GGT achieved NIRF and PA bimodal imaging of the HCC process. In particular, CySO3-GGT could effectively realize 3D imaging of the HCC nodule by visualizing the boundary between the tumor and the normal tissue. The information here might offer significant guidance for the dynamic monitoring of HCC in the near future.
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Affiliation(s)
- Kai Wang
- Affiliated Children's Hospital of Jiangnan University, Wuxi 214023, China
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing 210023, China
| | - Xu-Yang Chen
- Affiliated Children's Hospital of Jiangnan University, Wuxi 214023, China
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing 210023, China
| | - Wen-Dong Liu
- Jiangxi Nabo Wine Industry Co. Ltd., Hexi Industrial Park, Ji'an, Wan'an County343802, China
| | - Ying Yue
- Affiliated Children's Hospital of Jiangnan University, Wuxi 214023, China
| | - Xiao-Lin Wen
- Affiliated Children's Hospital of Jiangnan University, Wuxi 214023, China
| | - Yu-Shun Yang
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing 210023, China
| | - Ai-Guo Zhang
- Affiliated Children's Hospital of Jiangnan University, Wuxi 214023, China
| | - Hai-Liang Zhu
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing 210023, China
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Fanni SC, Febi M, Francischello R, Caputo FP, Ambrosini I, Sica G, Faggioni L, Masala S, Tonerini M, Scaglione M, Cioni D, Neri E. Radiomics Applications in Spleen Imaging: A Systematic Review and Methodological Quality Assessment. Diagnostics (Basel) 2023; 13:2623. [PMID: 37627882 PMCID: PMC10453085 DOI: 10.3390/diagnostics13162623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/25/2023] [Accepted: 08/05/2023] [Indexed: 08/27/2023] Open
Abstract
The spleen, often referred to as the "forgotten organ", plays numerous important roles in various diseases. Recently, there has been an increased interest in the application of radiomics in different areas of medical imaging. This systematic review aims to assess the current state of the art and evaluate the methodological quality of radiomics applications in spleen imaging. A systematic search was conducted on PubMed, Scopus, and Web of Science. All the studies were analyzed, and several characteristics, such as year of publication, research objectives, and number of patients, were collected. The methodological quality was evaluated using the radiomics quality score (RQS). Fourteen articles were ultimately included in this review. The majority of these articles were published in non-radiological journals (78%), utilized computed tomography (CT) for extracting radiomic features (71%), and involved not only the spleen but also other organs for feature extraction (71%). Overall, the included papers achieved an average RQS total score of 9.71 ± 6.37, corresponding to an RQS percentage of 27.77 ± 16.04. In conclusion, radiomics applications in spleen imaging demonstrate promising results in various clinical scenarios. However, despite all the included papers reporting positive outcomes, there is a lack of consistency in the methodological approaches employed.
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Affiliation(s)
- Salvatore Claudio Fanni
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Maria Febi
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Roberto Francischello
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Francesca Pia Caputo
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Ilaria Ambrosini
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Giacomo Sica
- Radiology Unit, Monaldi Hospital, 80131 Napoli, Italy
| | - Lorenzo Faggioni
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Salvatore Masala
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Michele Tonerini
- Department of Surgical, Medical, Molecular and Critical Area Pathology, University of Pisa, 56124 Pisa, Italy
| | - Mariano Scaglione
- Department of Medicine, Surgery and Pharmacy, University of Sassari, 07100 Sassari, Italy
| | - Dania Cioni
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
| | - Emanuele Neri
- Department of Translational Research, Academic Radiology, University of Pisa, 56126 Pisa, Italy
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Lee S, Ahmed M, Taddei T, Jain D. The role of routine biopsy of the background liver in the management of hepatocellular carcinoma. Hum Pathol 2023; 138:18-23. [PMID: 37236406 DOI: 10.1016/j.humpath.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/19/2023] [Accepted: 05/22/2023] [Indexed: 05/28/2023]
Abstract
We sought to determine the influence of background liver biopsies on hepatocellular carcinoma (HCC) management. The pathology database at a large university hospital was searched between 2013 and 2018 for all instances of when a separate biopsy of the nontumoral liver was performed within 6 months of an HCC biopsy. Patients were evaluated for baseline demographic and clinical characteristics, treatment proposed prior to biopsy, and impact of biopsy results on management. Among the 104 identified cases of paired liver biopsies, 22% were women; the median age was 64 years; and most were of earlier HCC stages at diagnosis (Barcelona Clinic Liver Cancer stages 0-A: 70%). Four patients among 10 in whom cirrhosis status was clinically unclear were confirmed to have cirrhosis on biopsy, and 4 patients did not have cirrhosis despite clinical suspicion. Treatment was altered by the background parenchymal findings for 5 patients (5%): management was less aggressive for 4 patients and more aggressive for 1 patient. A background liver biopsy can significantly impact the management of a small subset of HCC patients, especially those with early disease, and should be considered concurrently with the biopsy of the mass.
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Affiliation(s)
- Seohyuk Lee
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520, USA
| | - Muhammad Ahmed
- Department of Pathology, Yale School of Medicine, New Haven, CT 06520, USA
| | - Tamar Taddei
- Department of Internal Medicine, Section of Digestive Diseases, Yale School of Medicine, New Haven, CT 06520, USA
| | - Dhanpat Jain
- Department of Pathology, Yale School of Medicine, New Haven, CT 06520, USA.
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