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Abstract
BACKGROUND This manuscript is a review of the literature investigating the use of mesenchymal stem cells (MSCs) being applied in the setting of spinal fusion surgery. We mention the rates of pseudarthrosis, discuss current bone grafting options, and examine the preclinical and clinical outcomes of utilizing MSCs to assist in successfully fusing the spine. METHODS A thorough literature review was conducted to look at current and previous preclinical and clinical studies using stem cells for spinal fusion augmentation. Searches for PubMed/MEDLINE and ClinicalTrials.gov through January 2021 were conducted for literature mentioning stem cells and spinal fusion. RESULTS All preclinical and clinical studies investigating MSC use in spinal fusion were examined. We found 19 preclinical and 17 clinical studies. The majority of studies, both preclinical and clinical, were heterogeneous in design due to different osteoconductive scaffolds, cells, and techniques used. Preclinical studies showed promising outcomes in animal models when using appropriate osteoconductive scaffolds and factors for osteogenic differentiation. Similarly, clinical studies have promising outcomes but differ in their methodologies, surgical techniques, and materials used, making it difficult to adequately compare between the studies. CONCLUSION MSCs may be a promising option to use to augment grafting for spinal fusion surgery. MSCs must be used with appropriate osteoconductive scaffolds. Cell-based allografts and the optimization of their use have yet to be fully elucidated. Further studies are necessary to determine the efficacy of MSCs with different osteoconductive scaffolds and growth/osteogenic differentiation factors. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Stephen R Stephan
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Linda E Kanim
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Hyun W Bae
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, California.,Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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2
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Abstract
Spinal fusion surgery is performed all over the world to help patients with cervical and thoracolumbar pathology. As outcomes continue to improve in patients with spine-related pathology, it is important to understand how we got to modern day spinal fusion surgery. Scientific innovations have ranged from the first spinal fusions performed with basic instrumentation in the late nineteenth century to contemporary tools such as pedicle screws, bone grafts, and interbody devices. This article tracks this technological growth so that surgeons may better serve their patients in treating spine-related pain and disability.
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3
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Veronesi F, Maglio M, Brogini S, Fini M. In vivo studies on osteoinduction: A systematic review on animal models, implant site, and type and postimplantation investigation. J Biomed Mater Res A 2020; 108:1834-1866. [PMID: 32297695 DOI: 10.1002/jbm.a.36949] [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: 07/10/2019] [Revised: 03/15/2020] [Accepted: 03/28/2020] [Indexed: 11/10/2022]
Abstract
Musculoskeletal diseases involving loss of tissue usually require management with bone grafts, among which autografts are still the gold standard. To overcome autograft disadvantages, the development of new scaffolds is constantly increasing, as well as the number of in vivo studies evaluating their osteoinductivity in ectopic sites. The aim of the present systematic review is to evaluate the last 10 years of osteoinduction in vivo studies. The review is focused on: (a) which type of animal model is most suitable for osteoinduction evaluation; (b) what are the most used types of scaffolds; (c) what kind of post-explant evaluation is most used. Through three websites (www.pubmed.com, www.webofknowledge.com and www.embase.com), 77 in vivo studies were included. Fifty-eight studies were conducted in small animal models (rodents) and 19 in animals of medium or large size (rabbits, dogs, goats, sheep, and minipigs). Despite the difficulty in establishing the most suitable animal model for osteoinductivity studies, small animals (in particular mice) are the most utilized. Intramuscular implantation is more frequent than subcutis, especially in large animals, and synthetic scaffolds (especially CaP ceramics) are preferred than natural ones, also in combination with cells and growth factors. Paraffin histology and histomorphometric evaluations are usually employed for postimplantation analyses.
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Affiliation(s)
- Francesca Veronesi
- IRCCS-Istituto Ortopedico Rizzoli, Laboratory of Preclinical and Surgical Studies, Bologna, Italy
| | - Melania Maglio
- IRCCS-Istituto Ortopedico Rizzoli, Laboratory of Preclinical and Surgical Studies, Bologna, Italy
| | - Silvia Brogini
- IRCCS-Istituto Ortopedico Rizzoli, Laboratory of Preclinical and Surgical Studies, Bologna, Italy
| | - Milena Fini
- IRCCS-Istituto Ortopedico Rizzoli, Laboratory of Preclinical and Surgical Studies, Bologna, Italy
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4
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Rodríguez-Vázquez M, Ramos-Zúñiga R. Chitosan-Hydroxyapatite Scaffold for Tissue Engineering in Experimental Lumbar Laminectomy and Posterolateral Spinal Fusion in Wistar Rats. Asian Spine J 2019; 14:139-147. [PMID: 31679322 PMCID: PMC7113459 DOI: 10.31616/asj.2019.0091] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 07/04/2019] [Indexed: 12/12/2022] Open
Abstract
Study Design Experimental study with an animal model. Purpose To evaluate the role of a chitosan and hydroxyapatite composite for spinal fusion in a lumbar experimental model based on regenerative tissue engineering principles. Overview of Literature Chitosan and hydroxyapatite represent an alternative biodegradable implant material for tissue engineering and regeneration. The combination of chitosan and hydroxyapatite in a 20:80 ratio could potentiate their individual properties as an implantable composite for experimental laminectomy. Methods Phase I: design and synthesis of a porous composite scaffold composed of chitosan-hydroxyapatite using a freeze drying technique. Phase II: experimental microsurgical lumbar laminectomy at L5. A total of 35 Wistar rats were categorized into three experimental groups: control (laminectomy alone), experimental (laminectomy with implant), and reference (intact spine) (n=5 per group). Postoperative structural and functional evaluations were performed using computed tomography scans. In addition, radiologic, clinical, histological, and immunohistochemical microstructures were evaluated. Results At the laminectomy site, the composite implant induced bone regeneration, which was observed in the axial reconstruction of the rat lumbar spine in all cases. Biomechanical changes in the lumbar spine were observed by radiology in both groups after the surgery. The posterolateral space was covered by a bone structure in the treated spine, a condition not seen in the control group. The range of motion was 7.662°±0.81° in the scaffold group versus 20.72°±3.47° in the control group. Histological findings revealed qualitatively more bone tissue formation in the implant group. Conclusions A composite of chitosan-hydroxyapatite at a 20:80 ratio induced bone formation after experimental laminectomy in rats and led to spinal fusion, which was assessed by radiology and biomechanical tests. No functional complications in posture or walking were observed at 90 days post-surgery, despite biomechanical changes in the spine.
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Affiliation(s)
- Martin Rodríguez-Vázquez
- Department of Neurosciences, Translational Institute of Neuroscience, University Center of Health Sciences, University of Guadalajara, Guadalajara, Mexico
| | - Rodrigo Ramos-Zúñiga
- Department of Neurosciences, Translational Institute of Neuroscience, University Center of Health Sciences, University of Guadalajara, Guadalajara, Mexico
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5
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Branco E, Miranda C, Lima A, Silva K, Cabral R, Miranda M, Ohashi O, Oliveira E, Silva L, Freitas D, Miglino M. Bone marrow mononuclear cells versus mesenchymal stem cells from adipose tissue on bone healing in an Old World primate: can this be extrapolated to humans? ARQ BRAS MED VET ZOO 2019. [DOI: 10.1590/1678-4162-10362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT In veterinary medicine, the cell therapy is still unexplored and there are many unanswered questions that researchers tend to extrapolate to humans in an attempt to treat certain injuries. Investigating this subject in nonhuman primates turns out to be an unparalleled opportunity to better understand the dynamics of stem cells against some diseases. Thus, we aimed to compare the efficiency of bone marrow mononuclear cells (BMMCs) and mesenchymal stem cells (MSCs) from adipose tissue of Chlorocebus aethiops in induced bone injury. Ten animals were used, male adults subjected, to bone injury the iliac crests. The MSCs were isolated by and cultured. In an autologous manner, the BMMCs were infused in the right iliac crest, and MSCs from adipose tissue in the left iliac crest. After 4.8 months, the right iliac crests fully reconstructed, while left iliac crest continued to have obvious bone defects for up to 5.8 months after cell infusion. The best option for treatment of injuries with bone tissue loss in old world primates is to use autologous MSCs from adipose tissue, suggesting we can extrapolate the results to humans, since there is phylogenetic proximity between species.
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Affiliation(s)
- E. Branco
- Universidade Federal Rural da Amazônia, Brazil
| | | | - A.R. Lima
- Universidade Federal Rural da Amazônia, Brazil
| | | | | | | | | | - E.H.C. Oliveira
- Fundação Oswaldo Cruz, Brazil; Universidade Federal do Pará, Brazil
| | - L.S.C. Silva
- Fundação Oswaldo Cruz, Brazil; Universidade Federal do Pará, Brazil
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Axelsen MG, Overgaard S, Jespersen SM, Ding M. Comparison of synthetic bone graft ABM/P-15 and allograft on uninstrumented posterior lumbar spine fusion in sheep. J Orthop Surg Res 2019; 14:2. [PMID: 30606209 PMCID: PMC6318885 DOI: 10.1186/s13018-018-1042-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 12/18/2018] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Spinal fusion is a commonly used procedure in spinal surgery. To ensure stable fusion, bone graft materials are used. ABM/P-15 (commercial name i-Factor™ Flex) is an available synthetic bone graft material that has CE approval in Europe. This peptide has been shown to improve bone formation when used in devices with fixation or on bone defects. However, the lack of external stability and large graft size make posterolateral lumbar fusion (PLF) a most challenging grafting procedure. This prospective randomized study was designed to evaluate early spinal fusion rates using an anorganic bovine-derived hydroxyapatite matrix (ABM) combined with a synthetic 15 amino acid sequence (P-15)-ABM/P-15 bone graft, and compared with allograft in an uninstrumented PLF model in sheep. The objective of this study was to assess fusion rates when using ABM/P-15 in uninstrumented posterolateral fusion in sheep. METHODS Twelve Texas/Gotland mixed breed sheep underwent open PLF at 2 levels L2/L3 and L4/L5 without fixation instruments. The levels were randomized so that sheep received an ABM graft either with or without P15 coating. Sheep were euthanized after 4.5 months and levels were harvested and evaluated with a micro-CT scanner and qualitative histology. Fusion rates were assessed by 2D sections and 3D reconstruction images and fusion was defined as intertransverse bridging. RESULTS There was 68% fusion rate in the allograft group and an extensive migration of graft material was noticed with a fusion rate of just 37% in the ABM/P-15 group. Qualitative histology showed positive osteointegration of the material and good correlation to scanning results. CONCLUSIONS In this PLF fusion model, ABM/P15 demonstrated the ability to migrate when lacking external stability. Due to this migration, reported fusion rates were significantly lower than in the allograft group. The use of ABM/P15 as i-Factor™ Flex may be limited to devices with fixation and bone defects.
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Affiliation(s)
- Martin G Axelsen
- Department of Orthopedic Surgery & Traumatology, Orthopaedic Research Laboratory, Odense University Hospital, J.B. Winsloewsvej 15, 3rd floor, 5000, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark
| | - Søren Overgaard
- Department of Orthopedic Surgery & Traumatology, Orthopaedic Research Laboratory, Odense University Hospital, J.B. Winsloewsvej 15, 3rd floor, 5000, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark
| | - Stig M Jespersen
- Department of Orthopedic Surgery & Traumatology, Orthopaedic Research Laboratory, Odense University Hospital, J.B. Winsloewsvej 15, 3rd floor, 5000, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark
| | - Ming Ding
- Department of Orthopedic Surgery & Traumatology, Orthopaedic Research Laboratory, Odense University Hospital, J.B. Winsloewsvej 15, 3rd floor, 5000, Odense, Denmark. .,Department of Clinical Research, University of Southern Denmark, 5000, Odense, Denmark.
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7
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Duarte RM, Varanda P, Reis RL, Duarte ARC, Correia-Pinto J. Biomaterials and Bioactive Agents in Spinal Fusion. TISSUE ENGINEERING PART B-REVIEWS 2017; 23:540-551. [DOI: 10.1089/ten.teb.2017.0072] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Rui M. Duarte
- School of Medicine, University of Minho, Braga, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's—PT Government Associate Laboratory, Braga/Guimarães, Portugal
- Orthopedic Surgery Department, Hospital de Braga, Braga, Portugal
| | - Pedro Varanda
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's—PT Government Associate Laboratory, Braga/Guimarães, Portugal
- Orthopedic Surgery Department, Hospital de Braga, Braga, Portugal
| | - Rui L. Reis
- ICVS/3B's—PT Government Associate Laboratory, Braga/Guimarães, Portugal
- 3B's Research Group—Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Barco, Portugal
| | - Ana Rita C. Duarte
- ICVS/3B's—PT Government Associate Laboratory, Braga/Guimarães, Portugal
- 3B's Research Group—Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Barco, Portugal
| | - Jorge Correia-Pinto
- School of Medicine, University of Minho, Braga, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's—PT Government Associate Laboratory, Braga/Guimarães, Portugal
- Pediatric Surgery Department, Hospital de Braga, Braga, Portugal
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Abstract
STUDY DESIGN Review of literature. OBJECTIVES This review of literature investigates the application of mesenchymal stem cells (MSCs) in spinal fusion, highlights potential uses in the development of bone grafts, and discusses limitations based on both preclinical and clinical models. METHODS A review of literature was conducted looking at current studies using stem cells for augmentation of spinal fusion in both animal and human models. RESULTS Eleven preclinical studies were found that used various animal models. Average fusion rates across studies were 59.8% for autograft and 73.7% for stem cell-based grafts. Outcomes included manual palpation and stressing of the fusion, radiography, micro-computed tomography (μCT), and histological analysis. Fifteen clinical studies, 7 prospective and 8 retrospective, were found. Fusion rates ranged from 60% to 100%, averaging 87.1% in experimental groups and 87.2% in autograft control groups. CONCLUSIONS It appears that there is minimal clinical difference between commercially available stem cells and bone marrow aspirates indicating that MSCs may be a good choice in a patient with poor marrow quality. Overcoming morbidity and limitations of autograft for spinal fusion, remains a significant problem for spinal surgeons and further studies are needed to determine the efficacy of stem cells in augmenting spinal fusion.
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Affiliation(s)
- Michael A. Robbins
- University of California Davis Medical Center, Sacramento, CA, USA,Michael A. Robbins, Department of Orthopaedic Surgery, Mail Code MP240, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, USA.
| | | | - Adam M. Wegner
- University of California Davis Medical Center, Sacramento, CA, USA
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9
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Mesenchymal Stem Cells for the Treatment of Spinal Arthrodesis: From Preclinical Research to Clinical Scenario. Stem Cells Int 2017; 2017:3537094. [PMID: 28286524 PMCID: PMC5327761 DOI: 10.1155/2017/3537094] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 01/05/2017] [Indexed: 02/07/2023] Open
Abstract
The use of spinal fusion procedures has rapidly augmented over the last decades and although autogenous bone graft is the “gold standard” for these procedures, alternatives to its use have been investigated over many years. A number of emerging strategies as well as tissue engineering with mesenchymal stem cells (MSCs) have been planned to enhance spinal fusion rate. This descriptive systematic literature review summarizes the in vivo studies, dealing with the use of MSCs in spinal arthrodesis surgery and the state of the art in clinical applications. The review has yielded promising evidence supporting the use of MSCs as a cell-based therapy in spinal fusion procedures, thus representing a suitable biological approach able to reduce the high cost of osteoinductive factors as well as the high dose needed to induce bone formation. Nevertheless, despite the fact that MSCs therapy is an interesting and important opportunity of research, in this review it was detected that there are still doubts about the optimal cell concentration and delivery method as well as the ideal implantation techniques and the type of scaffolds for cell delivery. Thus, further inquiry is necessary to carefully evaluate the clinical safety and efficacy of MSCs use in spine fusion.
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10
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Eltorai AEM, Susai CJ, Daniels AH. Mesenchymal stromal cells in spinal fusion: Current and future applications. J Orthop 2016; 14:1-3. [PMID: 27821993 DOI: 10.1016/j.jor.2016.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 10/13/2016] [Indexed: 12/26/2022] Open
Abstract
Mesenchymal stromal cells (MSCs) have been a promising area of study for regenerative medicine. These cells can be harvested from bone marrow, adipose tissue, and other areas allowing for autologous transplantation of these cells into the area of degeneration or injury. With the proper signals, these cells may be able to regenerate healthy tissue. Recent studies have yielded promising evidence supporting translational mesenchymal stromal cell applications particularly in spinal fusion surgery.
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Affiliation(s)
- Adam E M Eltorai
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Cynthia J Susai
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alan H Daniels
- Division of Spine Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Barton VN, D'Amato NC, Gordon MA, Christenson JL, Elias A, Richer JK. Androgen Receptor Biology in Triple Negative Breast Cancer: a Case for Classification as AR+ or Quadruple Negative Disease. Discov Oncol 2015. [PMID: 26201402 DOI: 10.1007/s12672-015-0232-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Triple negative breast cancer (TNBC) is an aggressive breast cancer subtype that lacks estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2) amplification. Due to the absence of these receptors, TNBC does not respond to traditional endocrine or HER2-targeted therapies that improve patient prognosis in other breast cancer subtypes. TNBC has a poor prognosis, and currently, there are no effective targeted therapies. Some TNBC tumors express androgen receptor (AR) and may benefit from AR-targeted therapies. Here, we review the literature on AR in TNBC and propose that TNBC be further sub-classified as either AR+ TNBC or quadruple negative breast cancer since targeting AR may represent a viable therapeutic option for a subset of TNBC.
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Affiliation(s)
- Valerie N Barton
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora CO, RC1 North P18-5127 Mail Stop 8104, 12800 E. 19th Ave, Aurora, CO, 80015, USA
| | - Nicholas C D'Amato
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora CO, RC1 North P18-5127 Mail Stop 8104, 12800 E. 19th Ave, Aurora, CO, 80015, USA
| | - Michael A Gordon
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora CO, RC1 North P18-5127 Mail Stop 8104, 12800 E. 19th Ave, Aurora, CO, 80015, USA
| | - Jessica L Christenson
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora CO, RC1 North P18-5127 Mail Stop 8104, 12800 E. 19th Ave, Aurora, CO, 80015, USA
| | - Anthony Elias
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora CO, RC1 North P18-5127 Mail Stop 8104, 12800 E. 19th Ave, Aurora, CO, 80015, USA
| | - Jennifer K Richer
- Department of Pathology, University of Colorado Anschutz Medical Campus, Aurora CO, RC1 North P18-5127 Mail Stop 8104, 12800 E. 19th Ave, Aurora, CO, 80015, USA.
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