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Grigoropoulos I, Tsioulos G, Kastrissianakis A, Shapira S, Green O, Rapti V, Tsakona M, Konstantinos T, Savva A, Kavatha D, Boumpas D, Syrigos K, Xynogalas I, Leontis K, Ntousopoulos V, Sakka V, Sardelis Z, Fotiadis A, Vlassi L, Kontogianni C, Levounets A, Poulakou G, Gaga M, MacLoughlin R, Stebbing J, Arber N, Antoniadou A, Tsiodras S. The safety and potential efficacy of exosomes overexpressing CD24 (EXO-CD24) in mild-moderate COVID-19 related ARDS. Respir Res 2024; 25:151. [PMID: 38561798 PMCID: PMC10983648 DOI: 10.1186/s12931-024-02759-5] [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: 09/30/2023] [Accepted: 03/06/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION EXO-CD24 are exosomes genetically manipulated to over-express Cluster of Differentiation (CD) 24. It consists of two breakthrough technologies: CD24, the drug, as a novel immunomodulator that is smarter than steroids without any side effects, and exosomes as the ideal natural drug carrier. METHODS A randomized, single blind, dose-finding phase IIb trial in hospitalized patients with mild to moderate Coronavirus disease 2019 (COVID-19) related Acute Respiratory Distress Syndrome (ARDS) was carried out in two medical centers in Athens. Patients received either 109 or 1010 exosome particles of EXO-CD24, daily, for five consecutive days and monitored for 28 days. Efficacy was assessed at day 7 among 91 patients who underwent randomization. The outcome was also compared in a post-hoc analysis with an income control group (n = 202) that fit the inclusion and exclusion criteria. RESULTS The mean age was 49.4 (± 13.2) years and 74.4% were male. By day 7, 83.7% showed improved respiratory signs and 64% had better oxygen saturation (SpO2) (p < 0.05). There were significant reductions in all inflammatory markers, most notably in C-reactive protein (CRP), lactate dehydrogenase (LDH), ferritin, fibrinogen and an array of cytokines. Conversely, levels of the anti-inflammatory cytokine Interleukin-10 (IL-10) were increased (p < 0.05). Of all the documented adverse events, none were considered treatment related. No drug-drug interactions were noted. Two patients succumbed to COVID-19. Post-hoc analysis revealed that EXO-CD24 patients exhibited greater improvements in clinical and laboratory outcomes compared to an observational income control group. CONCLUSIONS EXO-CD24 presents a promising therapeutic approach for hyper-inflammatory state and in particular ARDS. Its unique combination of exosomes, as a drug carrier, and CD24, as an immunomodulator, coupled with inhalation administration, warrants further investigation in a larger, international, randomized, quadri-blind trial against a placebo.
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Affiliation(s)
- Ioannis Grigoropoulos
- 4, Department of Internal Medicine, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Georgios Tsioulos
- 4, Department of Internal Medicine, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Artemis Kastrissianakis
- 4, Department of Internal Medicine, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Shiran Shapira
- Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, 6 Weizmann St., 6423906, Tel Aviv, Israel
- Department of Molecular Genetic and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orr Green
- Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, 6 Weizmann St., 6423906, Tel Aviv, Israel
| | - Vasiliki Rapti
- 3, Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, "Sotiria" General Hospital, 11527, Athens, Greece
| | - Maria Tsakona
- 4, Department of Internal Medicine, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Thomas Konstantinos
- 4, Department of Internal Medicine, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Athina Savva
- 4, Department of Internal Medicine, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Dimitra Kavatha
- 4, Department of Internal Medicine, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Dimitrios Boumpas
- 4, Department of Internal Medicine, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Konstantinos Syrigos
- 3, Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, "Sotiria" General Hospital, 11527, Athens, Greece
| | - Ioannis Xynogalas
- 3, Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, "Sotiria" General Hospital, 11527, Athens, Greece
| | - Konstantinos Leontis
- 3, Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, "Sotiria" General Hospital, 11527, Athens, Greece
| | - Vasileios Ntousopoulos
- 3, Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, "Sotiria" General Hospital, 11527, Athens, Greece
| | - Vissaria Sakka
- 3, Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, "Sotiria" General Hospital, 11527, Athens, Greece
| | - Zafeiris Sardelis
- 7, Respiratory Medicine Department "Sotiria" General Hospital, 11527, Athens, Greece
| | - Andreas Fotiadis
- 7, Respiratory Medicine Department "Sotiria" General Hospital, 11527, Athens, Greece
| | - Lamprini Vlassi
- 7, Respiratory Medicine Department "Sotiria" General Hospital, 11527, Athens, Greece
| | - Chrysoula Kontogianni
- 7, Respiratory Medicine Department "Sotiria" General Hospital, 11527, Athens, Greece
| | - Anastasia Levounets
- 7, Respiratory Medicine Department "Sotiria" General Hospital, 11527, Athens, Greece
| | - Garyfalia Poulakou
- 3, Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, "Sotiria" General Hospital, 11527, Athens, Greece
| | - Mina Gaga
- 7, Respiratory Medicine Department "Sotiria" General Hospital, 11527, Athens, Greece
| | - Ronan MacLoughlin
- R&D Science & Emerging Technologies, Aerogen Ltd., IDA Business Park, Dangan, Galway, Ireland
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, Dublin, Ireland
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, Dublin, Ireland
| | - Justin Stebbing
- Department of Surgery and Cancer, Anglia Ruskin University, London, UK
- Department of Life Sciences, ARU, Cambridge, UK
| | - Nadir Arber
- Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, 6 Weizmann St., 6423906, Tel Aviv, Israel.
- Department of Molecular Genetic and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Anastasia Antoniadou
- 4, Department of Internal Medicine, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Sotirios Tsiodras
- 4, Department of Internal Medicine, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, 12462, Athens, Greece
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Tan F, Li X, Wang Z, Li J, Shahzad K, Zheng J. Clinical applications of stem cell-derived exosomes. Signal Transduct Target Ther 2024; 9:17. [PMID: 38212307 PMCID: PMC10784577 DOI: 10.1038/s41392-023-01704-0] [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: 07/23/2023] [Revised: 10/15/2023] [Accepted: 11/12/2023] [Indexed: 01/13/2024] Open
Abstract
Although stem cell-based therapy has demonstrated considerable potential to manage certain diseases more successfully than conventional surgery, it nevertheless comes with inescapable drawbacks that might limit its clinical translation. Compared to stem cells, stem cell-derived exosomes possess numerous advantages, such as non-immunogenicity, non-infusion toxicity, easy access, effortless preservation, and freedom from tumorigenic potential and ethical issues. Exosomes can inherit similar therapeutic effects from their parental cells such as embryonic stem cells and adult stem cells through vertical delivery of their pluripotency or multipotency. After a thorough search and meticulous dissection of relevant literature from the last five years, we present this comprehensive, up-to-date, specialty-specific and disease-oriented review to highlight the surgical application and potential of stem cell-derived exosomes. Exosomes derived from stem cells (e.g., embryonic, induced pluripotent, hematopoietic, mesenchymal, neural, and endothelial stem cells) are capable of treating numerous diseases encountered in orthopedic surgery, neurosurgery, plastic surgery, general surgery, cardiothoracic surgery, urology, head and neck surgery, ophthalmology, and obstetrics and gynecology. The diverse therapeutic effects of stem cells-derived exosomes are a hierarchical translation through tissue-specific responses, and cell-specific molecular signaling pathways. In this review, we highlight stem cell-derived exosomes as a viable and potent alternative to stem cell-based therapy in managing various surgical conditions. We recommend that future research combines wisdoms from surgeons, nanomedicine practitioners, and stem cell researchers in this relevant and intriguing research area.
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Affiliation(s)
- Fei Tan
- Department of ORL-HNS, Shanghai Fourth People's Hospital, and School of Medicine, Tongji University, Shanghai, China.
- Plasma Medicine and Surgical Implants Center, Tongji University, Shanghai, China.
- The Royal College of Surgeons in Ireland, Dublin, Ireland.
- The Royal College of Surgeons of England, London, UK.
| | - Xuran Li
- Department of ORL-HNS, Shanghai Fourth People's Hospital, and School of Medicine, Tongji University, Shanghai, China
- Plasma Medicine and Surgical Implants Center, Tongji University, Shanghai, China
| | - Zhao Wang
- Department of ORL-HNS, Shanghai Fourth People's Hospital, and School of Medicine, Tongji University, Shanghai, China
| | - Jiaojiao Li
- Department of ORL-HNS, Shanghai Fourth People's Hospital, and School of Medicine, Tongji University, Shanghai, China
- Plasma Medicine and Surgical Implants Center, Tongji University, Shanghai, China
| | - Khawar Shahzad
- Department of ORL-HNS, Shanghai Fourth People's Hospital, and School of Medicine, Tongji University, Shanghai, China
- Plasma Medicine and Surgical Implants Center, Tongji University, Shanghai, China
| | - Jialin Zheng
- Center for Translational Neurodegeneration and Regenerative Therapy, Tongji Hospital affiliated to Tongji University School of Medicine, Shanghai, China
- Shanghai Frontiers Science Center of Nanocatalytic Medicine, Tongji University, Shanghai, China
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Shapira S, Schwartz R, Tsiodras S, Bar-Shai A, Melloul A, Borsekofsky S, Peer M, Adi N, MacLoughlin R, Arber N. Inhaled CD24-Enriched Exosomes (EXO-CD24) as a Novel Immune Modulator in Respiratory Disease. Int J Mol Sci 2023; 25:77. [PMID: 38203250 PMCID: PMC10779124 DOI: 10.3390/ijms25010077] [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: 10/29/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Acute Respiratory Distress Syndrome (ARDS) is a major health concern with urgent unmet need for treatment options. There are three million new ARDS cases annually, and the disease's mortality rate is high (35-46%). Cluster of differentiation 24 (CD24), a long-known protein with multifaceted functions, is a small, heavily glycosylated, membrane-anchored protein which functions as an immune checkpoint control. CD24 allows for immune discrimination between Damage-Associated Molecular Patterns and Pathogen-Associated Molecular Patterns derived from pathogens. Exosomes are intraluminal vesicles which play an important role in intercellular communication. Exosomes offer the advantage of targeted delivery, which improves safety and efficacy. The safety and efficacy of EXO-CD24 is promising, as was shown in >180 ARDS patients in phase 1b/2a, phase 2b, and compassionate use. CD24 binds Damage-associated molecular patterns (DAMPs) and inhibits the activation of the NF-ĸB pathway, a pivotal mediator of inflammatory responses. In contrast to anti-inflammatory therapies that are cytokine-specific or steroids that shut down the entire immune system, EXO-CD24 acts upstream, reverting the immune system back to normal activity. Herein, the safety and efficacy of mEXO-CD24 is shown in murine models of several pulmonary diseases (sepsis, allergic asthma, Chronic Obstructive Pulmonary Disease(COPD), fibrosis). EXO CD24 can suppress the hyperinflammatory response in the lungs in several pulmonary diseases with a significant unmet need for treatment options.
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Affiliation(s)
- Shiran Shapira
- Health Promotion Center and Integrated Cancer Prevention Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (S.S.); (A.B.-S.); (A.M.)
- Department of Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Reut Schwartz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (R.S.); (N.A.)
- Anesthesia and Intensive Care Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Sotirios Tsiodras
- 4th Department of Internal Medicine, University General Hospital Attikon, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Amir Bar-Shai
- Health Promotion Center and Integrated Cancer Prevention Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (S.S.); (A.B.-S.); (A.M.)
| | - Ariel Melloul
- Health Promotion Center and Integrated Cancer Prevention Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (S.S.); (A.B.-S.); (A.M.)
| | - Sarah Borsekofsky
- Department of Pathology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel;
| | - Michael Peer
- Department of Chest Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel;
| | - Nimrod Adi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (R.S.); (N.A.)
- Anesthesia and Intensive Care Unit, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Ronan MacLoughlin
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, D02 YN77 Dublin, Ireland;
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
| | - Nadir Arber
- Health Promotion Center and Integrated Cancer Prevention Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (S.S.); (A.B.-S.); (A.M.)
- Department of Molecular Genetics and Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; (R.S.); (N.A.)
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Roerig J, Schulz-Siegmund M. Standardization Approaches for Extracellular Vesicle Loading with Oligonucleotides and Biologics. Small 2023; 19:e2301763. [PMID: 37287374 DOI: 10.1002/smll.202301763] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/13/2023] [Indexed: 06/09/2023]
Abstract
Extracellular vesicles (EVs) are widely recognized for their potential as drug delivery systems. EVs are membranous nanoparticles shed from cells. Among their natural features are their ability to shield cargo molecules against degradation and enable their functional internalization into target cells. Especially biological or bio-inspired large molecules (LMs), like nucleic acids, proteins, peptides, and others, may profit from encapsulation in EVs for drug delivery purposes. In the last years, a variety of loading protocols are explored for different LMs. The lack of standardization in the EV drug delivery field has impeded their comparability so far. Currently, the first reporting frameworks and workflows for EV drug loading are proposed. The aim of this review is to summarize these evolving standardization approaches and set recently developed methods into context. This will allow for enhanced comparability of future work on EV drug loading with LMs.
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Affiliation(s)
- Josepha Roerig
- Pharmaceutical Technology, Institute of Pharmacy, Medical Faculty, Leipzig University, 04317, Leipzig, Germany
| | - Michaela Schulz-Siegmund
- Pharmaceutical Technology, Institute of Pharmacy, Medical Faculty, Leipzig University, 04317, Leipzig, Germany
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Green O, Shenberg G, Baruch R, Argaman L, Levin T, Michelson I, Hadary R, Isakovich B, Golos M, Schwartz R, MacLoughlin R, Adi N, Arber N, Shapira S. Inhaled Exosomes Genetically Manipulated to Overexpress CD24 (EXO-CD24) as a Compassionate Use in Severe ARDS Patients. Biomedicines 2023; 11:2523. [PMID: 37760963 PMCID: PMC10525844 DOI: 10.3390/biomedicines11092523] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/01/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
RATIONALE Acute respiratory distress syndrome (ARDS) is a major global health concern with a significant unmet need. EXO-CD24 is delivered via inhalation-reduced cytokines and chemokine secretion and lung injury in ARDS and improved survival in mice models of ARDS, influenza, and sepsis. OBJECTIVES This clinical paper aims to evaluate the potential of EXO-CD24, a novel immunomodulatory treatment, in the compassionate care of critically ill, intubated patients with post-infection-induced acute respiratory distress syndrome (ARDS). METHODS Eleven critically ill patients diagnosed with post-infection ARDS (10 with COVID-19 and one with an adenovirus-associated infection) were administered EXO-CD24 in four medical centers across Israel. The patients had multiple co-morbidities, including cancer, hypertension, diabetes, and ischemic heart disease, and met the criteria for severe ARDS according to the Berlin classification. EXO-CD24 was administered via inhalation, and adverse events related to its use were carefully monitored. MEASUREMENTS AND MAIN RESULTS The administration of EXO-CD24 did not result in any recorded adverse events. The median hospitalization duration was 11.5 days, and the overall mortality rate was 36%. Notably, patients treated at the Tel Aviv Medical Center (TASMC) showed a lower mortality rate of 12.5%. The WBC and CRP levels decreased in comparison to baseline levels at hospitalization, and rapid responses occurred even in patients with kidney transplants who were off the ventilator within a few days and discharged shortly thereafter. The production of cytokines and chemokines was significantly suppressed in all patients, including those who died. Among the patients at TASMC, four had kidney transplants and were on immunosuppressive drugs, and all of them fully recovered and were discharged from the hospital. CONCLUSIONS EXO-CD24 holds promise as a potential therapeutic agent for all stages of ARDS, even in severe intubated cases. Importantly, EXO-CD24 demonstrated a favorable safety profile without any apparent side effects with promising efficacy. Furthermore, the potential of EXO-CD24 as a platform for addressing hyper-inflammatory states warrants exploration. Further research and larger-scale clinical trials are warranted to validate these preliminary findings.
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Affiliation(s)
- Orr Green
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
| | - Gil Shenberg
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
| | - Roni Baruch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
- Department of Kidney Transplantation, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Lihi Argaman
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
| | - Talya Levin
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
| | - Ian Michelson
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
| | - Ruthy Hadary
- Department of Internal Medicine C, Meir Medical Center, Kefar-Saba 4428164, Israel;
| | - Boris Isakovich
- Intensive Care Unit, Hillel Yaffe Medical Center, Hadera 3820302, Israel;
| | - Miri Golos
- Carmel Medical Center, Haifa 3436212, Israel;
| | - Reut Schwartz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
- Anesthesia and Intensive Care Unit, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Ronan MacLoughlin
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons, D02 YN77 Dublin, Ireland;
- School of Pharmacy and Pharmaceutical Sciences, Trinity College, D02 PN40 Dublin, Ireland
| | - Nimrod Adi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
- Anesthesia and Intensive Care Unit, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Nadir Arber
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
| | - Shiran Shapira
- Health Promotion Center and Integrated Cancer Prevention Center, Tel-Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel; (O.G.); (G.S.); (L.A.); (I.M.); (N.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6423906, Israel; (R.B.); (R.S.); (N.A.)
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