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Huang C, Solis D, Sahoo MK, Pinsky BA. Assessment of an automated Cytomegalovirus nucleic acid amplification test using clinical plasma, bronchoalveolar lavage, and tissue specimens. J Clin Virol 2023; 168:105582. [PMID: 37788527 DOI: 10.1016/j.jcv.2023.105582] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 09/04/2023] [Accepted: 09/08/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Cytomegalovirus (CMV) causes significant morbidity and mortality in immunocompromised patients, particularly transplant recipients. Quantitation of CMV DNA in peripheral blood is used to monitor prophylactic and pre-emptive approaches to prevent CMV disease, whereas CMV DNA testing of non-plasma specimens may aid in the diagnosis of end-organ disease. METHODS The analytical performance of the FDA-approved Aptima CMV Quant Assay was evaluated using reference CMV (SeraCare) diluted in defibrinated human plasma, as well as negative bronchoalveolar lavage fluid and tissue. Agreement was determined using 100 clinical acid-citrate-dextrose (ACD) plasma specimens, 77 bronchoalveolar lavage (BAL) fluids, and 101 tissues previously tested using artus CMV qPCR. RESULTS Aptima CMV lower limit of detection (LLOD) was 169 IU/mL for ACD plasma, 100 IU/mL for BAL, and 50 IU/mL for tissue. Positive percent agreement (PPA) was 100.0% (50/50; 95% CI: 92.9% - 100.0%) and negative percent agreement (NPA) was 94.0% (47/50; 95% CI: 83.5% - 98.8%) for ACD plasma. Bland-Altman analysis revealed a bias of 0.20 log10 IU/mL (Aptima - artus) with 95% limits of agreement of -0.53 to 0.93. For BAL fluids, PPA was 70.0% (14/20; 95% CI: 45.7% - 88.1%) and NPA was 82.4% (43/51; 95% CI: 69.1% - 91.6%). For tissues, PPA was 90.0% (45/50; 95% CI: 78.2% - 96.7%) and NPA was 94.0% (47/50; 95% CI: 83.5% - 98.8%). CONCLUSIONS The Aptima CMV Quant Assay demonstrates high analytical sensitivity and good overall agreement using clinical plasma and tissue specimens.
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Affiliation(s)
- ChunHong Huang
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Daniel Solis
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Malaya K Sahoo
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Benjamin A Pinsky
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA; Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.
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Delgado P, Oshinowo O, Fay ME, Luna CA, Dissanayaka A, Dorbala P, Ravindran A, Shen L, Myers DR. Universal pre-mixing dry-film stickers capable of retrofitting existing microfluidics. BIOMICROFLUIDICS 2023; 17:014104. [PMID: 36687143 PMCID: PMC9848651 DOI: 10.1063/5.0122771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 12/12/2022] [Indexed: 06/17/2023]
Abstract
Integrating microfluidic mixers into lab-on-a-chip devices remains challenging yet important for numerous applications including dilutions, extractions, addition of reagents or drugs, and particle synthesis. High-efficiency mixers utilize large or intricate geometries that are difficult to manufacture and co-implement with lab-on-a-chip processes, leading to cumbersome two-chip solutions. We present a universal dry-film microfluidic mixing sticker that can retrofit pre-existing microfluidics and maintain high mixing performance over a range of Reynolds numbers and input mixing ratios. To attach our pre-mixing sticker module, remove the backing material and press the sticker onto an existing microfluidic/substrate. Our innovation centers around the multilayer use of laser-cut commercially available silicone-adhesive-coated polymer sheets as microfluidic layers to create geometrically complex, easy to assemble designs that can be adhered to a variety of surfaces, namely, existing microfluidic devices. Our approach enabled us to assemble the traditional yet difficult to manufacture "F-mixer" in minutes and conceptually extend this design to create a novel space-saving spiral F-mixer. Computational fluid dynamic simulations and experimental results confirmed that both designs maintained high performance for 0.1 < Re < 10 and disparate input mixing ratios of 1:10. We tested the integration of our system by using the pre-mixer to fluorescently tag proteins encapsulated in an existing microfluidic. When integrated with another microfluidic, our pre-mixing sticker successfully combined primary and secondary antibodies to fluorescently tag micropatterned proteins with high spatial uniformity, unlike a traditional pre-mixing "T-mixer" sticker. Given the ease of this technology, we anticipate numerous applications for point-of-care devices, microphysiological-systems-on-a-chip, and microfluidic-based biomedical research.
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Affiliation(s)
| | | | | | | | | | | | | | | | - D. R. Myers
- Author to whom correspondence should be addressed:
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Tsai HP, Yeh CS, Lin IT, Ko WC, Wang JR. Increasing Cytomegalovirus Detection Rate from Respiratory Tract Specimens by a New Laboratory-Developed Automated Molecular Diagnostic Test. Microorganisms 2020; 8:microorganisms8071063. [PMID: 32708818 PMCID: PMC7409230 DOI: 10.3390/microorganisms8071063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/12/2020] [Accepted: 07/13/2020] [Indexed: 11/16/2022] Open
Abstract
Lots of automated molecular methods for detecting cytomegalovirus (CMV) DNA in the blood are available, but seldom for various clinical specimens. This study was designed to establish a highly sensitive automated assay to detect CMV DNA in non-blood specimens. We designed a new QMT assay using QIAGEN artus CMV RG polymerase chain reaction (Q-CMV PCR) kit applied on the BD MAX system and compared with the other assays, including an RGQ assay (LabTurbo auto-extraction combined Q-CMV PCR kit on Rotor-Gene-Q instrument), and in-house PCR assay. A total of 1067 various clinical samples, including 426 plasma, 293 respiratory tract specimens (RTS), 127 stool, 101 cerebral spinal fluid, 90 vitreous humours were analysed. Examining CMV DNA in simultaneous specimens of the same immunocompromised patient with respiratory symptoms, the detection rate of RTS (93.6%, 88/94) was significant higher than plasma (65.9%, 62/94). The positive rates for plasma samples with a low CMV viral load (<137 IU/mL) and diagnostic sensitivity of QMT, RGQ, and in-house assays were 65% and 99.1%, 45% and 100%, 5% and 65.5%, respectively. The QMT assay performs better, with shorter operational and turnaround time than the other assays, enabling the effective and early detection of CMV infection in various clinical specimens, particularly for RTS.
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Affiliation(s)
- Huey-Pin Tsai
- Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (C.-S.Y.); (I.-T.L.)
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- Correspondence: (H.-P.T.); (J.-R.W.); Tel.: +886-6-2353535 (ext. 2653) (H.-P.T.); Fax: +886-6-2094937 (H.-P.T.); Tel./Fax: +886-6-2760695 (J.-R.W.)
| | - Chun-Sheng Yeh
- Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (C.-S.Y.); (I.-T.L.)
| | - I-Ting Lin
- Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (C.-S.Y.); (I.-T.L.)
| | - Wen-Chien Ko
- Division of Infectious Diseases, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
- Department of Internal Medicine, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
| | - Jen-Ren Wang
- Department of Pathology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (C.-S.Y.); (I.-T.L.)
- Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan
- Center of Infectious Disease and Signaling Research, National Cheng Kung University, Tainan 701, Taiwan
- National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Tainan 704, Taiwan
- Correspondence: (H.-P.T.); (J.-R.W.); Tel.: +886-6-2353535 (ext. 2653) (H.-P.T.); Fax: +886-6-2094937 (H.-P.T.); Tel./Fax: +886-6-2760695 (J.-R.W.)
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Clos-Parals A, Rodríguez-Martínez P, Cañete F, Mañosa M, Ruiz-Cerulla A, José Paúles M, Llaó J, Gordillo J, Fumagalli C, Garcia-Planella E, Ojanguren I, Cabré E, Guardiola J, Domènech E. Prognostic Value of the Burden of Cytomegalovirus Colonic Reactivation Evaluated by Immunohistochemical Staining in Patients with Active Ulcerative Colitis. J Crohns Colitis 2019; 13:385-388. [PMID: 30346606 DOI: 10.1093/ecco-jcc/jjy173] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colonic cytomegalovirus [CMV] reactivation has been involved in steroid refractoriness in patients with active ulcerative colitis [UC]. The benefits of antiviral therapy in this clinical setting are still under debate, but the burden of viral reactivation has been associated with a poorer outcome in some studies. Our aim was to assess whether the burden of CMV reactivation measured by the number of viral inclusions by immunohistochemistry [IHC-CMV] is associated with a risk of colectomy. METHODS Biopsy sets of UC patients with positive IHC-CMV were identified from the Pathology departments of three university hospitals. All biopsies were reviewed by expert pathologists, and the maximum number of IHC-CMV-positive cells in each biopsy set was re-assessed. Epidemiological and clinical features and clinical outcomes were recorded. RESULTS Forty-six positive IHC-CMV cases with UC were included. At the time of CMV reactivation, 70% were receiving corticosteroids, 33% azathioprine, and 24% anti-tumour necrosis factor [TNF] agents. Thirty-two patients [70%] were treated with antiviral therapy. The median number of IHC-CMV-positive cells was 2 cells/biopsy [IQR 1-4]. Fourteen patients [30%] underwent colectomy, and 4 of them [29%] showed persistence of CMV in the surgical specimen. In the multivariate analysis, colectomy was only associated with >2 positive cells/biopsy [p = 0.048] and younger age [p = 0.023]. CONCLUSIONS The burden of CMV colonic reactivation in patients with active UC, as measured by IHC, seems to be related to the risk of colectomy, and more data is needed to understand whether antiviral therapy guided by CMV burden will alter the clinical outcome.
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Affiliation(s)
- Ariadna Clos-Parals
- Department of Gastroenterology, Hospital Germans Trias i Pujol, Badalona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Fiorella Cañete
- Department of Gastroenterology, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Míriam Mañosa
- Department of Gastroenterology, Hospital Germans Trias i Pujol, Badalona, Spain
- Centro de Investigaciones Biomédicas em Red de Enfermedades hepáticas y digestivas [CIBEREHD], Madrid, Spain
| | | | - Mª José Paúles
- Department of Pathology, Hospital Bellvitge [L'Hospitalet], Spain
| | - Jordina Llaó
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Jordi Gordillo
- Department of Gastroenterology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Caterina Fumagalli
- Department of Pathology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Isabel Ojanguren
- Department of Pathology, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Eduard Cabré
- Department of Gastroenterology, Hospital Germans Trias i Pujol, Badalona, Spain
- Centro de Investigaciones Biomédicas em Red de Enfermedades hepáticas y digestivas [CIBEREHD], Madrid, Spain
| | - Jordi Guardiola
- Department of Gastroenterology, Hospital Bellvitge [L'Hospitalet], Spain
| | - Eugeni Domènech
- Department of Gastroenterology, Hospital Germans Trias i Pujol, Badalona, Spain
- Centro de Investigaciones Biomédicas em Red de Enfermedades hepáticas y digestivas [CIBEREHD], Madrid, Spain
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Burgener EB, Waggoner J, Pinsky BA, Chen SF. Clinical characteristics and outcomes of pediatric patients with CMV DNA detection in bronchoalveolar lavage fluid. Pediatr Pulmonol 2017; 52:112-118. [PMID: 27280337 DOI: 10.1002/ppul.23494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 04/01/2016] [Accepted: 05/06/2016] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Cytomegalovirus (CMV) infection can cause severe pulmonary disease in immunocompromised patients. There are no standard diagnostic criteria for CMV pulmonary disease beyond histopathology findings on lung tissue, which is challenging to obtain in pediatric patients. Bronchoalveolar lavage (BAL) fluid is easier to obtain. Since CMV remains latent after primary infection and can potentially reactivate due to any inflammatory response, CMV detection in BAL specimen may not indicate acute CMV pulmonary disease. Thus, we describe the clinical manifestations and outcomes of pediatric patients with CMV detection in BAL fluid. METHODS We reviewed the clinical, radiologic, and laboratory data of patients <19 years old with a BAL specimen positive for CMV during a 5-year period. RESULTS Thirty-four encounters in 29 patients were found with CMV detected in their BAL specimen. Half (17/34) of the encounters were in immunocompromised patients. CMV, polymerase chain reaction (PCR) was the most common positive test. Forty-seven percent of the patients had other infections detected in BAL specimens. The majority of patients were never treated for CMV and resolved their acute respiratory illness. Only one patient had probable CMV pulmonary disease. DISCUSSION CMV is frequently recovered from BAL specimens but does not usually indicate acute CMV pulmonary disease. We would suggest that other diagnoses be considered first, even if CMV is recovered. Pediatr Pulmonol. 2017;52:112-118. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Elizabeth B Burgener
- Department of Pediatrics, Pulmonary Medicine, Stanford University School of Medicine, Palo Alto, 94304, California
| | - Jesse Waggoner
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Benjamin A Pinsky
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Palo Alto, California.,Department of Pathology, Stanford University School of Medicine, Palo Alto, California
| | - Sharon F Chen
- Department of Pediatrics, Infectious Disease, Stanford University School of Medicine, Palo Alto, California
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Choong E, Schulze JJ, Ericsson M, Rane A, Ekström L. Discordant genotyping results using DNA isolated from anti-doping control urine samples. Drug Test Anal 2016; 9:994-1000. [DOI: 10.1002/dta.2103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/21/2016] [Accepted: 10/01/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Eva Choong
- Department Laboratory Medicine; Division of Clinical Pharmacology, Karolinska Institutet; Stockholm Sweden
| | - Jenny J Schulze
- Department Laboratory Medicine; Division of Clinical Pharmacology, Karolinska Institutet; Stockholm Sweden
| | - Magnus Ericsson
- Department Laboratory Medicine; Division of Clinical Pharmacology, Karolinska Institutet; Stockholm Sweden
| | - Anders Rane
- Department Laboratory Medicine; Division of Clinical Pharmacology, Karolinska Institutet; Stockholm Sweden
| | - Lena Ekström
- Department Laboratory Medicine; Division of Clinical Pharmacology, Karolinska Institutet; Stockholm Sweden
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Pillet S, Pozzetto B, Roblin X. Cytomegalovirus and ulcerative colitis: Place of antiviral therapy. World J Gastroenterol 2016; 22:2030-2045. [PMID: 26877608 PMCID: PMC4726676 DOI: 10.3748/wjg.v22.i6.2030] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/19/2015] [Accepted: 12/21/2015] [Indexed: 02/06/2023] Open
Abstract
The link between cytomegalovirus (CMV) infection and inflammatory bowel diseases remains an important subject of debate. CMV infection is frequent in ulcerative colitis (UC) and has been shown to be potentially harmful. CMV reactivation needs to be diagnosed using methods that include in situ detection of viral markers by immunohistochemistry or by nucleic acid amplification techniques. Determination of the density of infection using quantitative tools (numbers of infected cells or copies of the genome) is particularly important. Although CMV reactivation can be considered as an innocent bystander in active flare-ups of refractory UC, an increasing number of studies suggest a deleterious role of CMV in this situation. The presence of colonic CMV infection is possibly linked to a decreased response to steroids and other immunosuppressive agents. Some treatments, notably steroids and cyclosporine A, have been shown to favor CMV reactivation, which seems not to be the case for therapies using anti-tumor necrosis factor drugs. According to these findings, in flare-ups of refractory UC, it is now recommended to look for the presence of CMV reactivation by using quantitative tools in colonic biopsies and to treat them with ganciclovir in cases of high viral load or severe disease.
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Tan SK, Burgener EB, Waggoner JJ, Gajurel K, Gonzalez S, Chen SF, Pinsky BA. Molecular and Culture-Based Bronchoalveolar Lavage Fluid Testing for the Diagnosis of Cytomegalovirus Pneumonitis. Open Forum Infect Dis 2016; 3:ofv212. [PMID: 26885542 PMCID: PMC4752011 DOI: 10.1093/ofid/ofv212] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/24/2015] [Indexed: 11/12/2022] Open
Abstract
Background. Cytomegalovirus (CMV) is a major cause of morbidity and mortality in immunocompromised patients, with CMV pneumonitis among the most severe manifestations of infection. Although bronchoalveolar lavage (BAL) samples are frequently tested for CMV, the clinical utility of such testing remains uncertain. Methods. Retrospective analysis of adult patients undergoing BAL testing via CMV polymerase chain reaction (PCR), shell vial culture, and conventional viral culture between August 2008 and May 2011 was performed. Cytomegalovirus diagnostic methods were compared with a comprehensive definition of CMV pneumonitis that takes into account signs and symptoms, underlying host immunodeficiency, radiographic findings, and laboratory results. Results. Seven hundred five patients underwent 1077 bronchoscopy episodes with 1090 BAL specimens sent for CMV testing. Cytomegalovirus-positive patients were more likely to be hematopoietic cell transplant recipients (26% vs 8%, P < .0001) and less likely to have an underlying condition not typically associated with lung disease (3% vs 20%, P < .0001). Histopathology was performed in only 17.3% of CMV-positive bronchoscopy episodes. When CMV diagnostic methods were evaluated against the comprehensive definition, the sensitivity and specificity of PCR, shell vial culture, and conventional culture were 91.3% and 94.6%, 54.4% and 97.4%, and 28.3% and 96.5%, respectively. Compared with culture, PCR provided significantly higher sensitivity and negative predictive value (P ≤ .001), without significantly lower positive predictive value. Cytomegalovirus quantitation did not improve test performance, resulting in a receiver operating characteristic curve with an area under the curve of 0.53. Conclusions. Cytomegalovirus PCR combined with a comprehensive clinical definition provides a pragmatic approach for the diagnosis of CMV pneumonitis.
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Affiliation(s)
- Susanna K Tan
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine
| | | | - Jesse J Waggoner
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine
| | - Kiran Gajurel
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine
| | - Sarah Gonzalez
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Sharon F Chen
- Department of Pediatrics, Division of Infectious Diseases
| | - Benjamin A Pinsky
- Department of Medicine, Division of Infectious Diseases and Geographic Medicine; Department of Pathology, Stanford University School of Medicine, Stanford, California
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Shi ZF, Aibaidula A, Tang QS, Shen YW, Chen H, Wu JS, Qin ZY, Zhu JH, Mao Y, Zhou LF. Methods of Glioma Sample Processing for Molecular Diagnosis for the Glioma Tissue Bank Project. Biopreserv Biobank 2015; 13:31-6. [PMID: 25686045 DOI: 10.1089/bio.2014.0089] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Zhi-feng Shi
- Glioma Surgery Division, Neurological Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Abudumijiti Aibaidula
- Glioma Surgery Division, Neurological Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Qi-sheng Tang
- Glioma Surgery Division, Neurological Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yi-wen Shen
- Glioma Surgery Division, Neurological Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Hong Chen
- Department of Neuropathology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jin-song Wu
- Glioma Surgery Division, Neurological Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Zhi-yong Qin
- Glioma Surgery Division, Neurological Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jian-hong Zhu
- Glioma Surgery Division, Neurological Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ying Mao
- Glioma Surgery Division, Neurological Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Liang-fu Zhou
- Glioma Surgery Division, Neurological Surgery Department, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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