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Rajani AJ, Raval D, Chitale R, Durvasula R, Oring J, Powers R. A rare case of scedosporium apiospermum osteomyelitis in an immunocompetent patient. IDCases 2024; 35:e01929. [PMID: 38327878 PMCID: PMC10848027 DOI: 10.1016/j.idcr.2024.e01929] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/29/2024] [Indexed: 02/09/2024] Open
Abstract
Scedosporium, a widespread filamentous fungus found in diverse environments, has experienced a rise in cases due to escalating malignancies and chronic immunosuppression. Clinical manifestations span mycetoma, airway involvement, and various infections, with osteomyelitis being a notable complication. We present a case of a 77-year-old female initially displaying cutaneous Scedosporium signs, which progressed to osteomyelitis. The patient, with a history of trauma, chronic low dose steroid use, and underlying conditions, presented with a foot injury caused by her dog. Despite initial management, worsening symptoms led to the identification of Scedosporium. A comprehensive approach involving debridement, antimicrobial therapy, and reduction of immunosuppression resulted in clinical improvement. The rarity of zoonotic transmission, diagnostic challenges, and antifungal efficacy are also discussed. The patient's positive trajectory emphasizes early diagnosis, targeted treatment, and vigilance in managing immunosuppression. An adaptable treatment protocol is proposed based on risk factors. Considering the rising opportunistic fungal infections and delayed culture results, initiating empirical antifungals based on clinical judgment and regional prevalence is vital for favorable outcomes.
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Affiliation(s)
| | | | - Rohit Chitale
- Mayo Clinic Florida, Infectious Disease Department, United States
| | | | - Justin Oring
- Mayo Clinic Florida, Infectious Disease Department, United States
| | - Ross Powers
- Mayo Clinic Florida, Infectious Disease Department, United States
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Rajani AJ, Roach D, Raval D, Amin J, Kempaiah P, Chitale R, Durvasula R, Oring J. A systemic review of Mycobacterium nebraskense case reports up to october 2023, featuring our unique case study. Int J Mycobacteriol 2023; 12:443-447. [PMID: 38149541 DOI: 10.4103/ijmy.ijmy_167_23] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
Background Mycobacterium nebraskense is a rare, slow growing nontuberculous mycobacterium species with limited documented cases. This systematic review aims to comprehensively analyze the clinical characteristics, presentation, and management of M. nebraskense infections by analyzing the available literature, including a newly reported case that we present in this article. Methods A comprehensive search was conducted using PubMed and Google Scholar to identify relevant cases up to October 2023. Only seven reported cases were found, highlighting the scarcity of information on this pathogen. Results Our analysis revealed several key findings. First, gender disparities were observed, with females being more susceptible to M. nebraskense infections. Additionally, a significant portion of patients presented with asymptomatic infections. Most affected individuals were over the age of 60, emphasizing potential age-related susceptibility. Comorbidity profiles varied widely among cases, and patients with preexisting lung comorbidities were at an increased risk of infection. The decision to treat or observe depended on clinical presentation, with even immunosuppressed individuals not always requiring treatment. Regarding treatment, we proposed an empirical approach with amikacin, clarithromycin, or rifabutin, considering the reported resistance to doxycycline and minocycline. Combination therapy was commonly employed to minimize resistance development, consistent with mycobacterial infection management. Conclusion This study underscores the need for further research to validate these findings and enhance our understanding of M. nebraskense infections. As limited data are available, this review aims to provide valuable insights into a rare and emerging pathogen to guide clinical practice and future research endeavors.
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Affiliation(s)
- Aayushi J Rajani
- Department of Infectious Disease, Mayo Clinic, Mayo, Florida, USA
| | - Dawn Roach
- Department of Infectious Disease, Mayo Clinic, Mayo, Florida, USA
| | | | - Juhi Amin
- Department of Obstetrics and Gynecology, Sir Sayajirao Gaekwad Hospital, Vadodara, Gujarat, India
| | - Prakash Kempaiah
- Department of Infectious Disease, Mayo Clinic, Mayo, Florida, USA
| | - Rohit Chitale
- Department of Infectious Disease, Mayo Clinic, Mayo, Florida, USA
| | | | - Justin Oring
- Department of Infectious Disease, Mayo Clinic, Mayo, Florida, USA
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Gupta Y, Savytskyi OV, Coban M, Venugopal A, Pleqi V, Weber CA, Chitale R, Durvasula R, Hopkins C, Kempaiah P, Caulfield TR. Protein structure-based in-silico approaches to drug discovery: Guide to COVID-19 therapeutics. Mol Aspects Med 2023; 91:101151. [PMID: 36371228 PMCID: PMC9613808 DOI: 10.1016/j.mam.2022.101151] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022]
Abstract
With more than 5 million fatalities and close to 300 million reported cases, COVID-19 is the first documented pandemic due to a coronavirus that continues to be a major health challenge. Despite being rapid, uncontrollable, and highly infectious in its spread, it also created incentives for technology development and redefined public health needs and research agendas to fast-track innovations to be translated. Breakthroughs in computational biology peaked during the pandemic with renewed attention to making all cutting-edge technology deliver agents to combat the disease. The demand to develop effective treatments yielded surprising collaborations from previously segregated fields of science and technology. The long-standing pharmaceutical industry's aversion to repurposing existing drugs due to a lack of exponential financial gain was overrun by the health crisis and pressures created by front-line researchers and providers. Effective vaccine development even at an unprecedented pace took more than a year to develop and commence trials. Now the emergence of variants and waning protections during the booster shots is resulting in breakthrough infections that continue to strain health care systems. As of now, every protein of SARS-CoV-2 has been structurally characterized and related host pathways have been extensively mapped out. The research community has addressed the druggability of a multitude of possible targets. This has been made possible due to existing technology for virtual computer-assisted drug development as well as new tools and technologies such as artificial intelligence to deliver new leads. Here in this article, we are discussing advances in the drug discovery field related to target-based drug discovery and exploring the implications of known target-specific agents on COVID-19 therapeutic management. The current scenario calls for more personalized medicine efforts and stratifying patient populations early on for their need for different combinations of prognosis-specific therapeutics. We intend to highlight target hotspots and their potential agents, with the ultimate goal of using rational design of new therapeutics to not only end this pandemic but also uncover a generalizable platform for use in future pandemics.
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Affiliation(s)
- Yash Gupta
- Department of Medicine, Infectious Diseases, Mayo Clinic, Jacksonville, FL, USA
| | - Oleksandr V Savytskyi
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA; In Vivo Biosystems, Eugene, OR, USA
| | - Matt Coban
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA; Department of Cancer Biology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Vasili Pleqi
- Department of Medicine, Infectious Diseases, Mayo Clinic, Jacksonville, FL, USA
| | - Caleb A Weber
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA
| | - Rohit Chitale
- Department of Medicine, Infectious Diseases, Mayo Clinic, Jacksonville, FL, USA; The Council on Strategic Risks, 1025 Connecticut Ave NW, Washington, DC, USA
| | - Ravi Durvasula
- Department of Medicine, Infectious Diseases, Mayo Clinic, Jacksonville, FL, USA
| | | | - Prakasha Kempaiah
- Department of Medicine, Infectious Diseases, Mayo Clinic, Jacksonville, FL, USA
| | - Thomas R Caulfield
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA; Department of QHS Computational Biology, Mayo Clinic, Jacksonville, FL, USA; Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA; Department of Clinical Genomics, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA.
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Cockell CS, Chitale R, Clement B, Davila A, Freeman KH, French KL, Glavin DP, Hays LE, Hummel K, Meyer MA, Pratt LM, Salvo C, Seasly E, Tsang KW. Recommendation on Orbiting Sample Cleanliness. Astrobiology 2022; 22:S238-S241. [PMID: 34904891 DOI: 10.1089/ast.2021.0058] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The National Aeronautics and Space Administration-European Space Agency (NASA-ESA) Mars Sample Return (MSR) campaign involves the collection of samples on Mars by the Perseverance (Mars 2020) rover and their return to Earth. To accomplish this, the Orbiting Sample container (OS) will be sent to Mars to accommodate the collected samples then launched from Mars and returned to Earth, where the samples will be removed for examination in the Sample Return Facility (SRF). Crucial to this entire sequence will be establishment of the required level of cleanliness inside the OS. In February 2021, the NASA Headquarters' Mars Sample Return Program and Office of Planetary Protection assembled an MSR OS Tiger Team (OSTT) to discuss the appropriate cleanliness level options of the interior of the OS. The team's remit was primarily focused on evaluating the trade-offs between Planetary Protection cleanliness levels 4a and 4b. These cleanliness levels are determined by the Committee on Space Research (COSPAR) planetary protection regulations, where 4a requires <300 bacterial spores/m2 and <3 x 105 bacterial spores on the spacecraft (in this case, the interior of the OS) and 4b mandates the more stringent requirement of <30 bacterial spores on the spacecraft. This report documents the consensus opinion submitted by the OSTT that recommended the interior of the OS be cleaned to a 4a requirement with any feasible added effort toward 4b. This report provides, as well, the rationale for that decision.
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Affiliation(s)
- Charles S Cockell
- University of Edinburgh, Centre for Astrobiology, School of Physics and Astronomy, Edinburgh, UK
| | - Rohit Chitale
- Defense Advanced Research Projects Agency, Washington, DC, USA
| | - Brian Clement
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, California, USA
| | - Alfonso Davila
- NASA Ames Research Center, Moffett Field, California, USA
| | - Katherine H Freeman
- Pennsylvania State University, Department of Geosciences University Park, Pennsylvania, USA
| | | | - Daniel P Glavin
- NASA Goddard Space Flight Center, Solar System Exploration Division, Greenbelt, Maryland, USA
| | - Lindsay E Hays
- NASA Headquarters, Mars Sample Return Program, Washington, DC, USA
| | - Kimberly Hummel
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michael A Meyer
- NASA Headquarters, Mars Sample Return Program, Washington, DC, USA
| | - Lisa M Pratt
- NASA Headquarters, Mars Sample Return Program, Washington, DC, USA
| | - Christopher Salvo
- Jet Propulsion Laboratory, California Institute of Technology, Pasadena, California, USA
| | - Elaine Seasly
- NASA Headquarters, Mars Sample Return Program, Washington, DC, USA
| | - Kar Wing Tsang
- US Army Futures Command Combat Capabilities Development Command Chemical Biological Center BioTesting Division, Aberdeen Proving Ground, Maryland, USA
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Wang B, Zhu S, Babigumira J, Furnback W, Chitale R, Yang J, Zhao K, Wasserman M. PIN23 Systematic Review of Economic Evaluations of Pneumococcal Conjugate Vaccines in Mainland China. Value Health Reg Issues 2020. [DOI: 10.1016/j.vhri.2020.07.270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Mistry EA, Mistry AM, Mehta T, Arora N, Starosciak AK, La Rosa FDLR, Siegler JE, Kasner SE, Chitale R, Fusco M, Froehler M, Yaghi S, Schrag M, Khatri P. White Matter Disease and Outcomes of Mechanical Thrombectomy for Acute Ischemic Stroke. AJNR Am J Neuroradiol 2020; 41:639-644. [PMID: 32165366 DOI: 10.3174/ajnr.a6478] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 01/31/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE The increased severity of white matter disease is associated with worse outcomes and an increased rate of intracerebral hemorrhage in patients with ischemic stroke undergoing thrombolytic treatment. However, whether white matter disease is associated with outcomes in patients undergoing endovascular treatment remains unclear. MATERIALS AND METHODS In this prespecified exploratory analysis of our prospective multi-institutional study that enrolled consecutive adult patients with anterior circulation ischemic stroke undergoing endovascular treatment from November 2017 to September 2018, we compared the following outcomes between patients with none-to-minimal (van Swieten score, 0-2) and moderate-to-severe (van Swieten score, 3-4) white matter disease using logistic regression: 90-day mRS 3-6, death, intracerebral hemorrhage, successful recanalization, and early neurologic recovery. RESULTS Of the 485 patients enrolled in the Blood Pressure after Endovascular Stroke Therapy (BEST) study, 389 had white matter disease graded (50% women; median age, 68 years; range, 58-79 years). A van Swieten score of 3-4 (n = 74/389, 19%) was associated with a higher rate of 90-day mRS of 3-6 (45% versus 18%; adjusted OR, 2.73; 95% CI, 1.34-5.93; P = .008). Although the death rate was higher in patients with van Swieten scores of 3-4 (26% versus 15%), the adjusted likelihood was not significantly different (adjusted OR, 1.14; 95% CI, 0.56-2.26; P = .710). Ordered regression revealed a shift toward worse mRS scores with increasing van Swieten scores (adjusted common OR, 3.04; 95% CI, 1.93-4.84; P < .001). No associations between white matter disease severity and intracerebral hemorrhage, successful recanalization, and early neurologic recovery were observed. CONCLUSIONS Moderate-to-severe white matter disease is associated with worse outcomes in patients undergoing endovascular treatment without a significant increase in hemorrhagic complications. Studies comparing patients with and without endovascular treatment are necessary to determine whether the benefit of endovascular treatment is attenuated with greater white matter disease.
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Affiliation(s)
- E A Mistry
- From the Departments of Neurology (E.A.M., M.S.) and
| | - A M Mistry
- Neurosurgery (A.M.M., R.C., M. Fusco), and
| | - T Mehta
- Department of Neurology and Neurosurgery (T.M.), University of Minnesota, Minneapolis, Minnesota
| | - N Arora
- Department of Neurology (N.A.), University of Missouri, Columbia, Missouri
| | - A K Starosciak
- Baptist Health Neuroscience Center (A.K.S., F.D.L.R.L.R.), Miami, Florida
| | - F D L R La Rosa
- Baptist Health Neuroscience Center (A.K.S., F.D.L.R.L.R.), Miami, Florida
| | - J E Siegler
- Department of Neurology (J.E.S., S.E.K.), University of Pennsylvania, Philadelphia, Pennsylvania
| | - S E Kasner
- Department of Neurology (J.E.S., S.E.K.), University of Pennsylvania, Philadelphia, Pennsylvania
| | - R Chitale
- Neurosurgery (A.M.M., R.C., M. Fusco), and
| | - M Fusco
- Neurosurgery (A.M.M., R.C., M. Fusco), and
| | - M Froehler
- Cerebrovascular Program (M. Froehler), Vanderbilt University Medical Center, Nashville, Tennessee
| | - S Yaghi
- New York University Langone Health (S.Y.), Brooklyn, New York
| | - M Schrag
- From the Departments of Neurology (E.A.M., M.S.) and
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Alleman MM, Chitale R, Burns CC, Iber J, Dybdahl-Sissoko N, Chen Q, Van Koko DR, Ewetola R, Riziki Y, Kavunga-Membo H, Dah C, Andriamihantanirina R. Vaccine-Derived Poliovirus Outbreaks and Events - Three Provinces, Democratic Republic of the Congo, 2017. MMWR Morb Mortal Wkly Rep 2018; 67:300-305. [PMID: 29543791 PMCID: PMC5857197 DOI: 10.15585/mmwr.mm6710a4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The last confirmed wild poliovirus (WPV) case in Democratic Republic of the Congo (DRC) had paralysis onset in December 2011 (1). DRC has had cases of vaccine-derived polioviruses (VDPVs) documented since 2004 (Table 1) (1-6). After an outbreak of 30 circulating VDPV type 2 (cVDPV2) cases during 2011-2012, only five VDPV2 cases were reported during 2013-2016 (Table 1) (1-6). VDPVs can emerge from oral poliovirus vaccine (OPV types 1, 2, or 3; Sabin) polioviruses that have genetically mutated resulting in reversion to neurovirulence. This process occurs during extensive person-to-person transmission in populations with low immunity or after extended replication in the intestines of immune-deficient persons following vaccination (1-6). During 2017 (as of March 8, 2018), 25 VDPV cases were reported in three provinces in DRC: in Tanganyika province, an emergence with one VDPV2 case (pending final classification) in Kabalo health zone and an emergence with one ambiguous VDPV type 1 (aVDPV1) case in Ankoro health zone; in Maniema province, an emergence with two cVDPV2 cases; and in Haut Lomami province, an emergence with 20 cVDPV2 cases that originated in Haut Lomami province and later spread to Tanganyika province (hereafter referred to as the Haut Lomami outbreak area) and an emergence with one aVDPV type 2 (aVDPV2) case in Lwamba health zone (Table 1) (Figure) (6). Outbreak response supplementary immunization activities (SIAs) were conducted during June-December 2017 (Table 2) (6). Because of limitations in surveillance and suboptimal SIA quality and geographic scope, cVDPV2 circulation is likely continuing in 2018, requiring additional SIAs. DRC health officials and Global Polio Eradication Initiative (GPEI) partners are increasing human and financial resources to improve all aspects of outbreak response.
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Taha TE, Kumwenda N, Kafulafula G, Kumwenda J, Chitale R, Nkhoma C, Katundu P, Mukiibi J, Chen S, Hoover D, Broadhead R. Haematological changes in African children who received short-term prophylaxis with nevirapine and zidovudine at birth. ACTA ACUST UNITED AC 2013; 24:301-9. [PMID: 15720887 DOI: 10.1179/027249304225019127] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
We assessed the safety of short-term antiretroviral prophylaxis to prevent mother-to-child transmission (MTCT) of HIV by monitoring haematological changes in children up to the age of 18 months. Babies of HIV-infected women were randomised at birth to receive a single dose of nevirapine (NVP) alone or with zidovudine (ZDV) twice daily for a week. Based on the time of presentation to the labour ward, mothers of these babies might or might not have received intrapartum NVP. Complete blood counts were performed at birth and at 1.5, 3, 6, 9, 12, 15 and 18 months. Babies' HIV status was determined by HIV-1 RNA testing. A total of 1755 babies were included in the study. Age-specific mean haemoglobin levels and prevalence of anaemia (haemoglobin < 10 g/dL) were not significantly different in cases where only the babies received a single dose of NVP and cases where NVP was given to mother/infant pairs or additional ZDV to the baby. Among HIV-infected children compared with uninfected children, the age-specific frequency of anaemia was significantly greater, anaemia started earlier and recovery to normal levels was slower and prolonged. A reversible granulocytopenia was observed in all children between 1.5 and 3 months of age. HIV infection significantly increased the children's risk of death. Antiretroviral prophylaxis appeared to protect against anaemia and child death. Short regimens of antiretrovirals to prevent MTCT of HIV are not associated with long-term adverse haematological changes.
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Affiliation(s)
- Taha E Taha
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.
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Gajewski K, Chretien JP, Peterson A, Pavlin J, Chitale R. A Review of Evaluations of Electronic Event-based Biosurveillance Systems. Online J Public Health Inform 2013. [PMCID: PMC3692778] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Objective Introduction Methods Results Conclusions
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Affiliation(s)
| | | | - Amy Peterson
- Division of Integrated Biosurveillance, Silver Spring, MD, USA
| | - Julie Pavlin
- Headquarters, Armed Forces Health Surveillance Center, Silver Spring, MD, USA
| | - Rohit Chitale
- Division of Integrated Biosurveillance, Silver Spring, MD, USA
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Chalouhi N, Tjoumakaris S, Dumont AS, Gonzalez LF, Randazzo C, Gordon D, Chitale R, Rosenwasser R, Jabbour P. Superior hypophyseal artery aneurysms have the lowest recurrence rate with endovascular therapy. AJNR Am J Neuroradiol 2012; 33:1502-6. [PMID: 22403776 DOI: 10.3174/ajnr.a3004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE Given the challenges posed by surgical clipping, endovascular techniques have been increasingly used to treat SHA aneurysms. The purpose of this study was to assess the safety and efficacy of endovascular techniques in the treatment of SHA aneurysms. MATERIALS AND METHODS Medical charts and initial and follow-up angiograms were reviewed retrospectively for all patients treated with endovascular procedures at our institution between January 2006 and February 2011. RESULTS We identified 87 patients with SHA aneurysms who were treated with endovascular techniques. Of these patients, 79 were women and only 8 were men (90.8% female predominance). Thirty-five patients were treated with coil embolization; 45, with stent-assisted coiling; 4, with balloon-assisted coil embolization; and 3, with a flow-diversion technique. Minor complications occurred in 2 patients (2.2%). None of the patients had a major complication. The mortality and permanent morbidity rates related to the procedure were 0%. Imaging follow-up was available for 89.4% of patients (DSA in 65, MRA in 11 patients) at a mean time point of 10.4 months (range, 6-60 months). Of the 76 patients with available follow-up, 3 patients had a recurrence (3.9%) and only 1 required further intervention (1.3%). Stent-assisted coiling was associated with lower recurrence rates than simple coil embolization. CONCLUSIONS SHA aneurysms have the lowest recurrence rate with endovascular treatment compared with aneurysms in other locations by using historical data. Because of its safety and efficacy, endovascular therapy should be considered the procedure of choice for the treatment of SHA aneurysms.
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Affiliation(s)
- N Chalouhi
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA
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