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Yoshimatsu Y, Thomas H, Thompson T, Smithard DG. Prognostic factors of poor outcomes in pneumonia in older adults: aspiration or frailty? Eur Geriatr Med 2024; 15:481-488. [PMID: 38310191 PMCID: PMC10997696 DOI: 10.1007/s41999-023-00929-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/26/2023] [Indexed: 02/05/2024]
Abstract
PURPOSE Little is known about the long-term and functional prognoses of older adults with pneumonia, which complicates their management. There is a common belief that aspiration is a poor prognostic factor; however, the diagnosis of aspiration pneumonia (AP) lacks consensus criteria and is mainly based on clinical characteristics typical of the frailty syndrome. Therefore, the poor prognosis of AP may also be a result of frailty rather than aspiration. This study investigated the impact of AP and other prognostic factors in older patients with pneumonia. METHODS We performed a retrospective cohort study of patients aged 75 years and older, admitted with pneumonia in 2021. We divided patients according to their initial diagnosis (AP or non-AP), compared outcomes using Kaplan-Meier curves, and used logistic regression to identify independent prognostic factors. RESULTS 803 patients were included, with a median age of 84 years and 52.7% were male. 17.3% were initially diagnosed with AP. Mortality was significantly higher in those diagnosed with AP than non-AP during admission (27.6% vs 19.0%, p = 0.024) and at 1 year (64.2% vs 53.1%, p = 0.018), with survival analysis showing a median survival time of 62 days and 274 days in AP and non-AP, respectively (χ2 = 9.2, p = 0.002). However, the initial diagnosis of AP was not an independent risk factor for poor prognosis in multivariable analysis. Old age, frailty and cardio-respiratory comorbidities were the main factors associated with death. CONCLUSION The greater mortality in AP may be a result of increased frailty rather than the diagnosis of aspiration itself. This supports our proposal for a paradigm shift from making predictions based on the potentially futile labelling of AP or non-AP, to considering frailty and overall condition of the patient.
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Affiliation(s)
- Yuki Yoshimatsu
- Elderly Care, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, Stadium Rd, London, SE18 4QH, UK.
- Centre for Exercise Activity and Rehabilitation, School of Human Sciences, University of Greenwich, London, UK.
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan.
| | - Heledd Thomas
- Elderly Care, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, Stadium Rd, London, SE18 4QH, UK
| | - Trevor Thompson
- Centre for Chronic Illness and Ageing, University of Greenwich, London, UK
| | - David G Smithard
- Elderly Care, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, Stadium Rd, London, SE18 4QH, UK
- Centre for Exercise Activity and Rehabilitation, School of Human Sciences, University of Greenwich, London, UK
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Yoshimatsu Y, Kragholm K, Clemmensen SZ, Melgaard D, Torp-Pedersen C, Smithard DG, Riis J. The predictive value of anticholinergic drug exposure and the outcome of pneumonia: a Danish database study. Age Ageing 2024; 53:afae012. [PMID: 38337045 DOI: 10.1093/ageing/afae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Indexed: 02/12/2024] Open
Abstract
INTRODUCTION Older adults are susceptible to anticholinergic effects. Dysphagia and pneumonia are associated with anticholinergic usage, though a definitive causative relationship has not been established. There is no effective way to predict the prognosis of older adults with pneumonia; therefore, this study investigates the predictive value of anticholinergic burden. METHODS Patients aged 65 years and above admitted for community-acquired pneumonia from 2011 to 2018 in Denmark were included through Danish registries. We calculated anticholinergic drug exposure using the CRIDECO Anticholinergic Load Scale (CALS). The primary outcome was in-hospital mortality, and other outcomes included intensive care unit admission, ventilator usage, length of stay, 30-day/90-day/1-year mortality, institutionalisation, home care utilisation and readmission. RESULTS 186,735 patients were included in the in-hospital outcome analyses, 165,181 in the readmission analysis, 150,791 in the institutionalisation analysis, and 95,197 and 73,461 patients in the home care analysis at follow-up. Higher CALS score was associated with higher in-hospital mortality, with a mean risk increasing from 9.9% (CALS 0) to 16.4% (CALS >10), though the risk plateaued above a CALS score of 8. A higher CALS score was also associated with greater mortality after discharge, more home health care, more institutionalizations and higher readmission rates. CONCLUSIONS High anticholinergic burden levels were associated with poor patient outcomes including short-/long-term mortality, dependence and readmission. It may be useful to calculate the CALS score on admission of older patients with pneumonia to predict their prognosis. This also highlights the importance of avoiding the use of drugs with a high anticholinergic burden in older patients.
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Affiliation(s)
- Yuki Yoshimatsu
- Geriatric Medicine, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, London, UK
- Centre for Exercise Activity and Rehabilitation, School of Human Sciences, University of Greenwich, London, UK
| | - Kristian Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
- Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Dorte Melgaard
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - David G Smithard
- Geriatric Medicine, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, London, UK
- Centre for Exercise Activity and Rehabilitation, School of Human Sciences, University of Greenwich, London, UK
| | - Johannes Riis
- Department of Geriatric Medicine, Aalborg University Hospital, Aalborg, Denmark
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Yoshimatsu Y, Ohtake Y, Ukai M, Miyagami T, Morikawa T, Shimamura Y, Kataoka Y, Hashimoto T. "Diagnose, Treat, and SUPPORT". Clinical competencies in the management of older adults with aspiration pneumonia: a scoping review. Eur Geriatr Med 2024; 15:57-66. [PMID: 38060164 PMCID: PMC10876713 DOI: 10.1007/s41999-023-00898-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 10/31/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Aspiration pneumonia in older adults is increasingly common, with a high care burden and morbidity. However, clinical competencies in its management have not been developed, and healthcare professionals struggle on how to care for these patients with multimodal treatment needs. Therefore, we conducted a scoping review to investigate what is known about the desired clinical competencies for the management of older adults with aspiration pneumonia, to utilise in clinical practice, education, and future research. METHODS First, we defined aspiration pneumonia according to a preliminary search. We then searched the literature on MEDLINE and CINAHL, focusing on studies involving patients aged 65 years old and older diagnosed with aspiration pneumonia. All settings were included, with the exception of intensive care units. Publication dates were limited to January 2011 to July 2022 and languages to English and Japanese. The extracted data were used to refine the preliminary competency framework developed by the Japan Aspiration pneumonia inter-Professional team Educational Program (JAPEP) in preparation of this study. RESULTS Ninety-nine studies were included. Following data extraction from these studies, 3 competencies were renamed, and 3 new competencies were added, to create a list of 12 competencies. These were Diagnosis, Treatment, Swallow Assessment, Underlying condition management, Nutrition, Oral management, Rehabilitation, Multidisciplinary team, Decision making, Prevention, Prognosis, and Palliative care. CONCLUSIONS Our scoping review identified 12 clinical competencies required in the management of older adults with aspiration pneumonia, outlined in the phrase 'Diagnose, Treat and SUPPORT'. We encourage healthcare professionals to share these competencies as a team to identify areas of unmet need and improve their patient care, with an emphasis on supportive care.
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Affiliation(s)
- Yuki Yoshimatsu
- Elderly Care, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, Stadium Rd, London, SE18 4QH, UK.
- Centre for Exercise Activity and Rehabilitation, School of Human Sciences, University of Greenwich, London, UK.
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan.
| | - Yoichi Ohtake
- Department of Internal Medicine, Imai Hospital, Hyogo, Japan
| | - Mamiko Ukai
- Department of Family Medicine, Kameda Family Clinic, Tateyama, Japan
- Department of Health Data Science, Yokohama City University, Kanagawa, Japan
| | - Taiju Miyagami
- Faculty of Medicine, Department of General Medicine, Juntendo University, Bunkyo City, Japan
| | - Toru Morikawa
- Department of General Medicine, Nara City Hospital, 1-50-1, Higashikideracho, Nara, 630-8305, Japan
| | - Yoshinosuke Shimamura
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Nephrology, Teine Keijinkai Medical Center, 1-40, Maeda 1-12, Teine, Sapporo, Hokkaido, 006-8555, Japan
| | - Yuki Kataoka
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Tanaka Asukai-cho 89, Sakyo-ku, Kyoto, 606-8226, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
- Department of Healthcare Epidemiology, Graduate School of Medicine/Public Health, Kyoto University, Yoshida Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Tadayuki Hashimoto
- Department of General Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
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Kong R, Patel AS, Sato T, Jiang F, Yoo S, Bao L, Sinha A, Tian Y, Fridrikh M, Liu S, Feng J, He X, Jiang J, Ma Y, Grullon K, Yang D, Powell CA, Beasley MB, Zhu J, Snyder EL, Li S, Watanabe H. Transcriptional Circuitry of NKX2-1 and SOX1 Defines an Unrecognized Lineage Subtype of Small-Cell Lung Cancer. Am J Respir Crit Care Med 2022; 206:1480-1494. [PMID: 35848993 PMCID: PMC9757094 DOI: 10.1164/rccm.202110-2358oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 07/18/2022] [Indexed: 12/24/2022] Open
Abstract
Rationale: The current molecular classification of small-cell lung cancer (SCLC) on the basis of the expression of four lineage transcription factors still leaves its major subtype SCLC-A as a heterogeneous group, necessitating more precise characterization of lineage subclasses. Objectives: To refine the current SCLC classification with epigenomic profiles and to identify features of the redefined SCLC subtypes. Methods: We performed unsupervised clustering of epigenomic profiles on 25 SCLC cell lines. Functional significance of NKX2-1 (NK2 homeobox 1) was evaluated by cell growth, apoptosis, and xenograft using clustered regularly interspaced short palindromic repeats-Cas9 (CRISPR-associated protein 9)-mediated deletion. NKX2-1-specific cistromic profiles were determined using chromatin immunoprecipitation followed by sequencing, and its functional transcriptional partners were determined using coimmunoprecipitation followed by mass spectrometry. Rb1flox/flox; Trp53flox/flox and Rb1flox/flox; Trp53flox/flox; Nkx2-1flox/flox mouse models were engineered to explore the function of Nkx2-1 in SCLC tumorigenesis. Epigenomic landscapes of six human SCLC specimens and 20 tumors from two mouse models were characterized. Measurements and Main Results: We identified two epigenomic subclusters of the major SCLC-A subtype: SCLC-Aα and SCLC-Aσ. SCLC-Aα was characterized by the presence of a super-enhancer at the NKX2-1 locus, which was observed in human SCLC specimens and a murine SCLC model. We found that NKX2-1, a dual lung and neural lineage factor, is uniquely relevant in SCLC-Aα. In addition, we found that maintenance of this neural identity in SCLC-Aα is mediated by collaborative transcriptional activity with another neuronal transcriptional factor, SOX1 (SRY-box transcription factor 1). Conclusions: We comprehensively describe additional epigenomic heterogeneity of the major SCLC-A subtype and define the SCLC-Aα subtype by the core regulatory circuitry of NKX2-1 and SOX1 super-enhancers and their functional collaborations to maintain neuronal linage state.
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Affiliation(s)
- Ranran Kong
- Department of Thoracic Surgery and
- Division of Pulmonary, Critical Care and Sleep Medicine
- Tisch Cancer Institute
| | - Ayushi S. Patel
- Division of Pulmonary, Critical Care and Sleep Medicine
- Tisch Cancer Institute
- Division of Hematology and Medical Oncology, Laura and Isaac Perlmutter Cancer Center, Langone Medical Center, New York University, New York, New York
| | - Takashi Sato
- Division of Pulmonary, Critical Care and Sleep Medicine
- Tisch Cancer Institute
- Department of Respiratory Medicine, School of Medicine, Kitasato University, Sagamihara, Japan
- Division of Pulmonary Medicine, Department of Medicine, School of Medicine, Keio University, Tokyo, Japan
| | - Feng Jiang
- Division of Pulmonary, Critical Care and Sleep Medicine
- Tisch Cancer Institute
| | - Seungyeul Yoo
- Department of Genetics and Genomic Sciences, and
- Sema4, Stamford, Connecticut
| | - Li Bao
- People’s Hospital of Ningxia Hui Autonomous Region, Yinchuan, China
| | - Abhilasha Sinha
- Division of Pulmonary, Critical Care and Sleep Medicine
- Tisch Cancer Institute
| | - Yang Tian
- Division of Pulmonary, Critical Care and Sleep Medicine
- Tisch Cancer Institute
| | - Maya Fridrikh
- Division of Pulmonary, Critical Care and Sleep Medicine
- Tisch Cancer Institute
| | - Shuhui Liu
- Division of Infectious Diseases, Department of Medicine
| | - Jie Feng
- Department of Nephrology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Xijing He
- Department of Orthopedics, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Xi’an International Medical Center, Xi’an, China
| | | | | | - Karina Grullon
- Division of Pulmonary, Critical Care and Sleep Medicine
- Tisch Cancer Institute
| | - Dawei Yang
- Division of Pulmonary, Critical Care and Sleep Medicine
- Tisch Cancer Institute
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital Fudan University, Shanghai, China; and
| | - Charles A. Powell
- Division of Pulmonary, Critical Care and Sleep Medicine
- Tisch Cancer Institute
| | - Mary Beth Beasley
- Department of Pathology and Laboratory Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jun Zhu
- Tisch Cancer Institute
- Department of Genetics and Genomic Sciences, and
- Sema4, Stamford, Connecticut
| | - Eric L. Snyder
- Department of Pathology
- Department of Oncological Sciences, and
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | | | - Hideo Watanabe
- Division of Pulmonary, Critical Care and Sleep Medicine
- Tisch Cancer Institute
- Department of Genetics and Genomic Sciences, and
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Yoshimatsu Y, Melgaard D, Westergren A, Skrubbeltrang C, Smithard DG. The diagnosis of aspiration pneumonia in older persons: a systematic review. Eur Geriatr Med 2022; 13:1071-1080. [PMID: 36008745 PMCID: PMC9409622 DOI: 10.1007/s41999-022-00689-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/09/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE Community-acquired pneumonia (CAP) is highly common across the world. It is reported that over 90% of CAP in older adults may be due to aspiration. However, the diagnostic criteria for aspiration pneumonia (AP) have not been widely agreed. Is there a consensus on how to diagnose AP? What are the clinical features of patients being diagnosed with AP? We conducted a systematic review to answer these questions. METHODS We performed a literature search in MEDLINE®, EMBASE, CINHAL, and Cochrane to review the steps taken toward diagnosing AP. Search terms for "aspiration pneumonia" and "aged" were used. Inclusion criteria were: original research, community-acquired AP, age ≥ 75 years old, acute hospital admission. RESULTS A total of 10,716 reports were found. Following the removal of duplicates, 7601 were screened, 95 underwent full-text review, and 9 reports were included in the final analysis. Pneumonia was diagnosed using a combination of symptoms, inflammatory markers, and chest imaging findings in most studies. AP was defined as pneumonia with some relation to aspiration or dysphagia. Aspiration was inferred if there was witnessed or prior presumed aspiration, episodes of coughing on food or liquids, relevant underlying conditions, abnormalities on videofluoroscopy or water swallow test, and gravity-dependent distribution of shadows on chest imaging. Patients with AP were older, more frailer, and had more comorbidities than in non-AP. CONCLUSION There is a broad consensus on the clinical criteria to diagnose AP. It is a presumptive diagnosis with regards to patients' general frailty rather than in relation to swallowing function itself.
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Affiliation(s)
- Yuki Yoshimatsu
- Elderly Care, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, Stadium Rd, London, SE18 4QH, UK.
- Centre for Exercise Activity and Rehabilitation, School of Human Sciences, University of Greenwich, London, UK.
| | - Dorte Melgaard
- Centre for Clinical Research, North Denmark Regional Hospital, Hjoerring, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Albert Westergren
- The Research Platform for Collaboration for Health, Faculty of Health Sciences, Kristianstad University, Kristianstad, Sweden
| | | | - David G Smithard
- Elderly Care, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, Stadium Rd, London, SE18 4QH, UK
- Centre for Exercise Activity and Rehabilitation, School of Human Sciences, University of Greenwich, London, UK
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Patel AS, Yoo S, Kong R, Sato T, Sinha A, Karam S, Bao L, Fridrikh M, Emoto K, Nudelman G, Powell CA, Beasley MB, Zhu J, Watanabe H. Prototypical oncogene family Myc defines unappreciated distinct lineage states of small cell lung cancer. Sci Adv 2021; 7:7/5/eabc2578. [PMID: 33514539 PMCID: PMC7846160 DOI: 10.1126/sciadv.abc2578] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 12/10/2020] [Indexed: 05/11/2023]
Abstract
Comprehensive genomic analyses of small cell lung cancer (SCLC) have revealed frequent mutually exclusive genomic amplification of MYC family members. Hence, it has been long suggested that they are functionally equivalent; however, more recently, their expression has been associated with specific neuroendocrine markers and distinct histopathology. Here, we explored a previously undescribed role of L-Myc and c-Myc as lineage-determining factors contributing to SCLC molecular subtypes and histology. Integrated transcriptomic and epigenomic analyses showed that L-Myc and c-Myc impart neuronal and non-neuroendocrine-associated transcriptional programs, respectively, both associated with distinct SCLC lineage. Genetic replacement of c-Myc with L-Myc in c-Myc-SCLC induced a neuronal state but was insufficient to induce ASCL1-SCLC. In contrast, c-Myc induced transition from ASCL1-SCLC to NEUROD1-SCLC characterized by distinct large-cell neuroendocrine carcinoma-like histopathology. Collectively, we characterize a role of historically defined general oncogenes, c-Myc and L-Myc, for regulating lineage plasticity across molecular and histological subtypes.
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Affiliation(s)
- Ayushi S Patel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Seungyeul Yoo
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Sema4, a Mount Sinai venture, Stamford, CT 06902, USA
| | - Ranran Kong
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Thoracic Surgery, The Second Affiliated Hospital of Medical School, Xi'an Jiaotong University, Xi'an, Shaanxi 710004, China
| | - Takashi Sato
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Abhilasha Sinha
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Sarah Karam
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Li Bao
- Ningxia People's Hospital, Yinchuan, Ningxia Province 750001, China
| | - Maya Fridrikh
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Katsura Emoto
- Department of Diagnostic Pathology, Keio University Hospital, Tokyo 160-8582, Japan
| | - German Nudelman
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Charles A Powell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Mary Beth Beasley
- Department of Pathology and Laboratory Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jun Zhu
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Sema4, a Mount Sinai venture, Stamford, CT 06902, USA
| | - Hideo Watanabe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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