1
|
Bajaj JS, Garcia-Tsao G, Reddy KR, O’Leary JG, Vargas HE, Lai JC, Kamath PS, Tandon P, Subramanian RM, Thuluvath P, Fagan A, Sehrawat T, de la Rosa Rodriguez R, Thacker LR, Wong F. Admission Urinary and Serum Metabolites Predict Renal Outcomes in Hospitalized Patients With Cirrhosis. Hepatology 2021; 74:2699-2713. [PMID: 34002868 PMCID: PMC9338693 DOI: 10.1002/hep.31907] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Acute kidney injury (AKI) has a poor prognosis in cirrhosis. Given the variability of creatinine, the prediction of AKI and dialysis by other markers is needed. The aim of this study is to determine the role of serum and urine metabolomics in the prediction of AKI and dialysis in an inpatient cirrhosis cohort. APPROACH AND RESULTS Inpatients with cirrhosis from 11 North American Consortium of End-stage Liver Disease centers who provided admission serum/urine when they were AKI and dialysis-free were included. Analysis of covariance adjusted for demographics, infection, and cirrhosis severity was performed to identify metabolites that differed among patients (1) who developed AKI or not; (2) required dialysis or not; and/pr (3) within AKI subgroups who needed dialysis or not. We performed random forest and AUC analyses to identify specific metabolite(s) associated with outcomes. Logistic regression with clinical variables with/without metabolites was performed. A total of 602 patients gave serum (218 developed AKI, 80 needed dialysis) and 435 gave urine (164 developed AKI, 61 needed dialysis). For AKI prediction, clinical factor-adjusted AUC was 0.91 for serum and 0.88 for urine. Major metabolites such as uremic toxins (2,3-dihydroxy-5-methylthio-4-pentenoic acid [DMTPA], N2N2dimethylguanosine, uridine/pseudouridine) and tryptophan/tyrosine metabolites (kynunerate, 8-methoxykyunerate, quinolinate) were higher in patients who developed AKI. For dialysis prediction, clinical factor-adjusted AUC was 0.93 for serum and 0.91 for urine. Similar metabolites as AKI were altered here. For dialysis prediction in those with AKI, the AUC was 0.81 and 0.79 for serum/urine. Lower branched-chain amino-acid (BCAA) metabolites but higher cysteine, tryptophan, glutamate, and DMTPA were seen in patients with AKI needing dialysis. Serum/urine metabolites were additive to clinical variables for all outcomes. CONCLUSIONS Specific admission urinary and serum metabolites were significantly additive to clinical variables to predict AKI development and dialysis initiation in inpatients with cirrhosis. These observations can potentially facilitate earlier initiation of renoprotective measures.
Collapse
Affiliation(s)
- Jasmohan S. Bajaj
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
| | | | | | | | | | | | | | | | | | | | - Andrew Fagan
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
| | | | | | - Leroy R. Thacker
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, VA
| | | |
Collapse
|
2
|
Bajaj JS, Garcia-Tsao G, Wong F, Biggins SW, Kamath PS, McGeorge S, Chew M, Pearson M, Shaw J, Kalluri A, Fagan A, Olofson A, Moini M, de la Rosa Rodriguez R, Reddy KR. Cirrhosis Is Associated With High Mortality and Readmissions Over 90 Days Regardless of COVID-19: A Multicenter Cohort. Liver Transpl 2021; 27:1343-1347. [PMID: 33427401 PMCID: PMC8014819 DOI: 10.1002/lt.25981] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/22/2020] [Accepted: 12/28/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Jasmohan S Bajaj
- Department of Medicine, Virginia Commonwealth University, Richmond, VA.,Department of Medicine, Central Virginia Veterans Healthcare System, Richmond, VA
| | | | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Scott W Biggins
- Department of Medicine, University of Washington, Seattle, WA
| | - Patrick S Kamath
- Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Sara McGeorge
- Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Michael Chew
- Department of Medicine, Yale University Medical Center, New Haven, CT
| | | | - Jawaid Shaw
- Department of Medicine, Virginia Commonwealth University, Richmond, VA.,Department of Medicine, Central Virginia Veterans Healthcare System, Richmond, VA
| | - Anita Kalluri
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andrew Fagan
- Department of Medicine, Central Virginia Veterans Healthcare System, Richmond, VA
| | - Amy Olofson
- Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Maryam Moini
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
3
|
Takeuchi M, Vidigal PT, Guerra MT, Hundt MA, Robert ME, Olave-Martinez M, Aoki S, Khamphaya T, Kersten R, Kruglov E, de la Rosa Rodriguez R, Banales JM, Nathanson MH, Weerachayaphorn J. Neutrophils interact with cholangiocytes to cause cholestatic changes in alcoholic hepatitis. Gut 2021; 70:342-356. [PMID: 33214166 PMCID: PMC7906004 DOI: 10.1136/gutjnl-2020-322540] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/17/2020] [Accepted: 10/29/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND & OBJECTIVES Alcoholic hepatitis (AH) is a common but life-threatening disease with limited treatment options. It is thought to result from hepatocellular damage, but the presence of cholestasis worsens prognosis, so we examined whether bile ducts participate in the pathogenesis of this disease. DESIGN Cholangiocytes derived from human bile ducts were co-cultured with neutrophils from patients with AH or controls. Loss of type 3 inositol 1,4,5-trisphosphate receptor (ITPR3), an apical intracellular calcium channel necessary for cholangiocyte secretion, was used to reflect cholestatic changes. Neutrophils in contact with bile ducts were quantified in liver biopsies from patients with AH and controls and correlated with clinical and pathological findings. RESULTS Liver biopsies from patients with AH revealed neutrophils in contact with bile ducts, which correlated with biochemical and histological parameters of cholestasis. Cholangiocytes co-cultured with neutrophils lost ITPR3, and neutrophils from patients with AH were more potent than control neutrophils. Biochemical and histological findings were recapitulated in an AH animal model. Loss of ITPR3 was attenuated by neutrophils in which surface membrane proteins were removed. RNA-seq analysis implicated integrin β1 (ITGB1) in neutrophil-cholangiocyte interactions and interference with ITGB1 on cholangiocytes blocked the ability of neutrophils to reduce cholangiocyte ITPR3 expression. Cell adhesion molecules on neutrophils interacted with ITGB1 to trigger RAC1-induced JNK activation, causing a c-Jun-mediated decrease in ITPR3 in cholangiocytes. CONCLUSIONS Neutrophils bind to ITGB1 on cholangiocytes to contribute to cholestasis in AH. This previously unrecognised role for cholangiocytes in this disease alters our understanding of its pathogenesis and identifies new therapeutic targets.
Collapse
Affiliation(s)
- Masahiro Takeuchi
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Paula T Vidigal
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Pathological Anatomy and Forensic Medicine, School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Mateus T Guerra
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Melanie A Hundt
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Marie E Robert
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Maria Olave-Martinez
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Satoshi Aoki
- Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Tanaporn Khamphaya
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Remco Kersten
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Emma Kruglov
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Randolph de la Rosa Rodriguez
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jesus M Banales
- Department of Liver and Gastrointestinal Diseases, Biodonostia Research Institute-Donostia University Hospital, University of Basque Country (UPV/EHU), CIBERehd, Ikerbasque, San Sebastián, Spain
| | - Michael H Nathanson
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jittima Weerachayaphorn
- Department of Internal Medicine, Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Physiology, Faculty of Science, Mahidol University, Bangkok, Thailand
| |
Collapse
|
4
|
Bajaj JS, Reddy KR, O’Leary JG, Vargas HE, Lai JC, Kamath PS, Tandon P, Wong F, Subramanian RM, Thuluvath P, Fagan A, White MB, Gavis EA, Sehrawat T, de la Rosa Rodriguez R, Thacker LR, Sikaroodi M, Garcia-Tsao G, Gillevet PM. Serum Levels of Metabolites Produced by Intestinal Microbes and Lipid Moieties Independently Associated With Acute-on-Chronic Liver Failure and Death in Patients With Cirrhosis. Gastroenterology 2020; 159:1715-1730.e12. [PMID: 32687928 PMCID: PMC7680282 DOI: 10.1053/j.gastro.2020.07.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 07/02/2020] [Accepted: 07/13/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Inpatients with cirrhosis have high rates of acute-on-chronic failure (ACLF) development and high mortality within 30 days of admission to the hospital. Better biomarkers are needed to predict these outcomes. We performed metabolomic analyses of serum samples from patients with cirrhosis at multiple centers to determine whether metabolite profiles might identify patients at high risk for ACLF and death. METHODS We performed metabolomic analyses, using liquid chromatography, of serum samples collected at time of admission to 12 North American tertiary hepatology centers from 602 patients in the North American Consortium for the Study of End-Stage Liver Disease sites from 2015 through 2017 (mean age, 56 years; 61% men; mean model for end-stage liver disease score, 19.5). We performed analysis of covariance, adjusted for model for end-stage liver disease at time of hospital admission, serum levels of albumin and sodium, and white blood cell count, to identify metabolites that differed between patients who did vs did not develop ACLF and patients who did vs did not die during hospitalization and within 30 days. We performed random forest analysis to identify specific metabolite(s) that were associated with outcomes and area under the curve (AUC) analyses to analyze them in context of clinical parameters. We analyzed microbiomes of stool samples collected from 133 patients collected at the same time and examined associations with serum metabolites. RESULTS Of the 602 patients analyzed, 88 developed ACLF (15%), 43 died in the hospital (7%), and 72 died within 30 days (12%). Increased levels of compounds of microbial origin (aromatic compounds, secondary or sulfated bile acids, and benzoate) and estrogen metabolites, as well as decreased levels of phospholipids, were associated with development of ACLF, inpatient, and 30-day mortality and were also associated with fecal microbiomes. Random forest analysis and logistic regression showed that levels of specific microbially produced metabolites identified patients who developed ACLF with an AUC of 0.84 (95% confidence interval [CI] 0.78-0.88; P = .001), patients who died while in the hospital with an AUC of 0.81 (95% CI 0.74-0.85; P = .002), and patients who died within 30 days with an AUC of 0.77 (95% CI 0.73-0.81; P = .02). The metabolites were significantly additive to clinical parameters for predicting these outcomes. Metabolites associated with outcomes were also correlated with microbiomes of stool samples. CONCLUSIONS In an analysis of serum metabolites and fecal microbiomes of patients hospitalized with cirrhosis at multiple centers, we associated metabolites of microbial origin and lipid moieties with development of ACLF and death as an inpatient or within 30 days, after controlling for clinical features.
Collapse
Affiliation(s)
- Jasmohan S Bajaj
- Department of Medicine, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia.
| | | | | | | | | | | | | | | | | | | | - Andrew Fagan
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, USA
| | - Melanie B White
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, USA
| | - Edith A Gavis
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, USA
| | | | | | - Leroy R Thacker
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, USA
| | | | | | | |
Collapse
|
5
|
Ghonem NS, Auclair AM, Hemme CL, Gallucci GM, de la Rosa Rodriguez R, Boyer JL, Assis DN. Fenofibrate Improves Liver Function and Reduces the Toxicity of the Bile Acid Pool in Patients With Primary Biliary Cholangitis and Primary Sclerosing Cholangitis Who Are Partial Responders to Ursodiol. Clin Pharmacol Ther 2020; 108:1213-1223. [PMID: 32480421 DOI: 10.1002/cpt.1930] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 05/07/2020] [Indexed: 12/12/2022]
Abstract
Cholestatic liver diseases result in the hepatic retention of bile acids, causing subsequent liver toxicity. Peroxisome proliferator-activated receptor alpha (PPARα) regulates bile acid metabolism. In this retrospective observational study, we assessed the effects of fenofibrate (a PPARα agonist) therapy on bile acid metabolism when given to patients with primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC) who have had an incomplete response to Ursodiol monotherapy. When fenofibrate was added to Ursodiol therapy there was a significant reduction and in some cases normalization of serum alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase abnormalities, as well as pro-inflammatory cytokines. Combination fenofibrate treatment also reduced 7α-hydroxy-4-cholesten-3-one (C4), the bile acid precursor, as well as total, primary, and conjugated bile acids. In addition, principal components analysis and heatmap analysis show that bile acid metabolites trended closer to that of healthy control subjects. These favorable effects of fenofibrate on bile acid metabolism may contribute to its beneficial clinical effects in patients with PBC and PSC experiencing a subtherapeutic response to Ursodiol monotherapy.
Collapse
Affiliation(s)
- Nisanne S Ghonem
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Adam M Auclair
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Christopher L Hemme
- RI-INBRE Bioinformatics Core, University of Rhode Island, Kingston, Rhode Island, USA
| | - Gina M Gallucci
- Department of Biomedical and Pharmaceutical Sciences, College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | | | - James L Boyer
- Liver Center, Yale University School of Medicine, New Haven, Connecticut, USA
| | - David N Assis
- Liver Center, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
6
|
Bajaj JS, Garcia-Tsao G, Biggins S, Kamath PS, Wong F, McGeorge S, Shaw J, Pearson M, Chew M, Fagan A, de la Rosa Rodriguez R, Worthington J, Olofson A, Weir V, Trisolini C, Dwyer S, Reddy KR. Comparison of mortality risk in patients with cirrhosis and COVID-19 compared with patients with cirrhosis alone and COVID-19 alone: multicentre matched cohort. Gut 2020; 70:531-536. [PMID: 32660964 PMCID: PMC7371484 DOI: 10.1136/gutjnl-2020-322118] [Citation(s) in RCA: 157] [Impact Index Per Article: 39.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/18/2020] [Accepted: 06/24/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Comorbid conditions are associated with poor prognosis in COVID-19. Registry data show that patients with cirrhosis may be at high risk. However, outcome comparisons among patients with cirrhosis+COVID-19 versus patients with COVID-19 alone and cirrhosis alone are lacking. The aim of this study was to perform these comparisons. DESIGN A multicentre study of inpatients with cirrhosis+COVID-19 compared with age/gender-matched patients with COVID-19 alone and cirrhosis alone was performed. COVID-19 and cirrhosis characteristics, development of organ failures and acute-on-chronic liver failure (ACLF) and mortality (inpatient death+hospice) were compared. RESULTS 37 patients with cirrhosis+COVID-19 were matched with 108 patients with COVID-19 and 127 patients with cirrhosis from seven sites. Race/ethnicity were similar. Patients with cirrhosis+COVID-19 had higher mortality compared with patients with COVID-19 (30% vs 13%, p=0.03) but not between patients with cirrhosis+COVID-19 and patients with cirrhosis (30% vs 20%, p=0.16). Patients with cirrhosis+COVID-19 versus patients with COVID-19 alone had equivalent respiratory symptoms, chest findings and rates of intensive care unit transfer and ventilation. However, patients with cirrhosis+COVID-19 had worse Charlson Comorbidity Index (CCI 6.5±3.1 vs 3.3±2.5, p<0.001), lower presenting GI symptoms and higher lactate. Patients with cirrhosis alone had higher cirrhosis-related complications, maximum model for end-stage liver disease (MELD) score and lower BiPAP/ventilation requirement compared with patients with cirrhosis+COVID-19, but CCI and ACLF rates were similar. In the entire group, CCI (OR 1.23, 95% CI 1.11 to 1.37, p<0.0001) was the only variable predictive of mortality on multivariable regression. CONCLUSIONS In this multicentre North American contemporaneously enrolled study, age/gender-matched patients with cirrhosis+COVID-19 had similar mortality compared with patients with cirrhosis alone but higher than patients with COVID-19 alone. CCI was the only independent mortality predictor in the entire matched cohort.
Collapse
Affiliation(s)
- Jasmohan S Bajaj
- Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University Health System, Richmond, Virginia, USA .,Department of Medicine, Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Health Care System, Richmond, Virginia, USA
| | - Guadalupe Garcia-Tsao
- Department of Medicine, Internal Medicine, Yale University, New Haven, Connecticut, USA
| | | | - Patrick S Kamath
- Department of Medicine, Gastroenterology and Hepatology, Mayo Medical School, Rochester, Minnesota, USA
| | | | - Sara McGeorge
- Department of Medicine, Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Health Care System, Richmond, Virginia, USA
| | - Jawaid Shaw
- Department of Medicine, Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Health Care System, Richmond, Virginia, USA
| | | | - Micheal Chew
- Department of Medicine, Internal Medicine, Yale University, New Haven, Connecticut, USA
| | - Andrew Fagan
- Department of Medicine, Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Health Care System, Richmond, Virginia, USA
| | | | - Janelle Worthington
- Department of Medicine, Gastroenterology and Hepatology, Mayo Medical School, Rochester, Minnesota, USA
| | - Amy Olofson
- Department of Medicine, Gastroenterology and Hepatology, Mayo Medical School, Rochester, Minnesota, USA
| | - Vanessa Weir
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Calvin Trisolini
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah Dwyer
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA,Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
7
|
de la Rosa Rodriguez R, Fogarty A, Israel GM, Sanchez MJ. Annular pancreas in a 24-year-old woman with persistent abdominal pain. BMJ Case Rep 2019; 12:e229223. [PMID: 31227569 PMCID: PMC6605914 DOI: 10.1136/bcr-2019-229223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2019] [Indexed: 12/20/2022] Open
Abstract
Annular pancreas (AP) is a rare diagnosis in the adult population but can cause significant morbidity if not correctly identified. In adults, the most common symptoms are abdominal pain, nausea and vomiting. While these are not specific to AP, they are important clues to this diagnosis in the right clinical context. We present the case of a 24-year-old woman presenting with a 6-year history of progressive abdominal pain and dyspepsia in the context of an extensive negative workup. Upper gastrointestinal (GI) series and MRI revealed partial duodenal obstruction, concerning for AP. While patients with chronic abdominal pain and vague GI complaints may be diagnosed with functional bowel disorders, it is important to appropriately address the possibility of an underlying structural lesion such as AP. This strategy is not only cost-effective but also saves the patient discomfort associated with unnecessary procedures and allows a timely intervention.
Collapse
Affiliation(s)
| | - Alexandra Fogarty
- Neurology, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Gary M Israel
- Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mayra J Sanchez
- Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|