CEST MRI Research Articles

In Vivo Imaging of Allografted Glial-Restricted Progenitor Cell Survival and Hydrogel Scaffold Biodegradation

Transplanted glial-restricted progenitor (GRP) cells have potential to focally replace defunct astrocytes and produce remyelinating oligodendrocytes to avert neuronal death and dysfunction. However, most central nervous system cell therapeutic paradigms are hampered by high initial cell death and a host anti-graft immune response. We show here that composite hyaluronic acid-based hydrogels of tunable mechanical strengths can significantly improve transplanted GRP survival and differentiation. Allogeneic GRPs expressing green fluorescent protein and firefly luciferase were scaffolded in optimized hydrogel formulations and transplanted intracerebrally into immunocompetent BALB/c mice followed by serial in vivo bioluminescent imaging and chemical exchange saturation transfer magnetic resonance imaging (CEST MRI). We demonstrate that gelatin-sensitive CEST MRI can be exploited to monitor hydrogel scaffold degradation in vivo for ∼5 weeks post transplantation without necessitating exogenous labeling. Hydrogel scaffolding of GRPs resulted in a 4.5-fold increase in transplanted cell survival at day 32 post transplantation compared to naked cells. Histological analysis showed significant enhancement of cell proliferation as well as Olig2+ and GFAP+ cell differentiation for scaffolded cells compared to naked cells, with reduced host immunoreactivity. Hence, hydrogel scaffolding of transplanted GRPs in conjunction with serial in vivo imaging of cell survival and hydrogel degradation has potential for further advances in glial cell therapy.

AcidoCEST MRI Evaluates the Bone Microenvironment in Multiple Myeloma.

Multiple myeloma (MM) is an incurable disease of malignant plasma cells in the bone marrow (BM). Adaptive responses to hypoxia may be an essential element in MM progression and drug resistance. This metabolic adaptation involves a decrease in extracellular pH (pHe), and it depends on the upregulation of glucose transporters (GLUTs) that is common in hypoxia and in cancer cells. CEST MRI is an imaging technique that assesses pHe indirectly by the exchange rate of magnetic saturation transfer between labile protons on a solute and water. Thus, this study aimed to determine the feasibility of acidoCEST MRI for pHe measurement using an orthotopic mouse model of MM compared with GLUT1 immunofluorescence staining as a reference. Orthotopic BM engrafted MM xenografts were established in NSG/NOD mice using the human RPMI8226 myeloma cell line. AcidoCEST MRI was performed approximately 6 weeks after intravenous challenge, before and after intravenous administration of iopamidol. BM pHe values were generated via fitting the CEST spectrum with the Bloch-McConnell equations. Samples were decalcified, sectioned, and immunostained for GLUT1 expression. Pearson's correlation was used to assess the relationship between pHe and [H3O+] versus GLUT1 expression. Ten mice underwent acidoCEST MRI followed by immunofluorescent histologic analysis. A strong negative correlation was seen between pHe versus GLUT1 expression (r = - 0.75, p < 0.001). After transformation of pH to [H3O+], a strong positive correlation between [H3O+] and GLUT1 expression was observed (r = 0.8, p < 0.001). AcidoCEST MRI can measure the extracellular pH of bone marrow affected by multiple myeloma. In this MM orthotopic mouse model, pHe measured by acidoCEST MRI showed strong correlations with the metabolic phenotype of BM tumor assessed by immunofluorescent histological assessment of GLUT1 overexpression.

Simultaneous proteoglycans and hypoxia mapping of chondrosarcoma environment by frequency selective CEST MRI

To evaluate the relevance of CEST frequency selectivity in simultaneous in vivo imaging of both of chondrosarcoma's phenotypic features, that are, its high proteoglycan concentration and its hypoxic core. Swarm rat chondrosarcomas were implanted subcutaneously in NMRI nude mice. When tumors were measurable (12-16 days postoperative), mice were submitted to GAG, guanidyl, and APT CEST imaging. Proteoglycans and hypoxia were assessed in parallel by nuclear imaging exploiting 99m Tc-NTP 15-5 and 18 F-FMISO, respectively. Data were completed by ex vivo analysis of proteoglycans (histology and biochemical assay) and hypoxia (immunofluorescence). Quantitative analysis of GAG CEST evidenced a significantly higher signal for tumor tissues than for muscles. These results were in agreement with nuclear imaging and ex vivo data. For imaging tumoral pH in vivo, the CEST ratio of APT/guanidyl was studied. This highlighted an important heterogeneity inside the tumor. The hypoxic status was confirmed by 18 F-FMISO PET imaging and ex vivo immunofluorescence. CEST MRI simultaneously imaged both chondrosarcoma properties during a single experimental run and without the injection of any contrast agent. Both MR and nuclear imaging as well as ex vivo data were in agreement and showed that this chondrosarcoma animal model was rich in proteoglycans. However, even if tumors were lightly hypoxic at the stage studied, acidic areas were highlighted and mapped inside the tumor.

Quasi-steady-state CEST (QUASS CEST) solution improves the accuracy of CEST quantification: QUASS CEST MRI-based omega plot analysis.

CEST MRI omega plot quantifies the labile proton fraction ratio (fr ) and exchange rate (ksw ), yet it assumes long RF saturation time (Ts) and relaxation delay (Td). Our study aimed to test if a quasi-steady-state (QUASS) CEST analysis that accounts for the effect of finite Ts and Td could improve the accuracy of CEST MRI quantification. We modeled the MRI signal evolution using a typical CEST EPI sequence. The signal relaxes toward its thermal equilibrium following the bulk water relaxation rate during Td, and then toward its CEST steady state following the spin-lock relaxation rate during Ts from which the QUASS CEST effect is derived. Both fr and ksw were solved from simulated conventional apparent CEST and QUASS CEST MRI. We also performed MRI experiments from a Cr-gel phantom under serially varied Ts and Td times from 1.5 to 7.5 s. Simulation showed that, although ksw could be slightly overestimated (3%-15%) for the range of Ts and Td, fr could be substantially underestimated by as much as 67%. In contrast, the QUASS solution provided accurate ksw and fr determination within 2%. The CEST MRI experiments confirmed that the QUASS solution enabled robust quantification of ksw and fr , superior over the omega plot analysis based on the conventional apparent CEST MRI measurements. The QUASS CEST MRI algorithm corrects the effect of finite Ts and Td times on CEST measurements, thereby allowing robust and accurate CEST quantification.

CEST MRI pH Mapping of Tumor Acidity as a Predictor of Breast Cancer Metastatic Potential.

CEST MRI pH Mapping of Tumor Acidity as a Predictor of Breast Cancer Metastatic Potential.

Whole-brain quantitative CEST MRI at 7T using parallel transmission methods and correction.

To enable whole-brain quantitative CEST MRI at ultra-high magnetic field strengths (B0 ≥ 7T) within short acquisition times. Multiple interleaved mode saturation (MIMOSA) was combined with fast online-customized (FOCUS) parallel transmission (pTx) excitation pulses and correction to achieve homogenous whole-brain coverage. Examinations of 13 volunteers were performed on a 7T MRI system with 3 different types of pulse sequences: (1) saturation in circular polarized (CP) mode and CP mode readout, (2) MIMOSA and CP readout, and (3) MIMOSA and FOCUS readout. For comparison, the inverse magnetic transfer ratio metric for relayed nuclear Overhauser effect and amide proton transfer were calculated. To investigate the number of required acquisitions for a good correction, 4 volunteers were measured with 6 different B1 amplitudes. Finally, time point repeatability was investigated for 6 volunteers. MIMOSA FOCUS sequence using correction, with both single and multiple points, reduced inhomogeneity of the CEST contrasts around the occipital lobe and cerebellum. Results indicate that the most stable inter-subject coefficient of variation was achieved using the MIMOSA FOCUS sequence. Time point repeatability of MIMOSA FOCUS with single-point correction showed a maximum coefficient of variation below 8% for 3 measurements in a single volunteer. A combination of MIMOSA FOCUS with a single-point correction can be used to achieve quantitative CEST measurements at ultra-high magnetic field strengths. Compared to previous correction methods, acquisition time can be reduced as additional scans required for correction can be omitted.

Furin‐Mediated Self‐Assembly of Olsalazine Nanoparticles for Targeted Raman Imaging of Tumors

AbstractOlsalazine (Olsa) is a broad‐spectrum anti‐cancer agent acting as a DNA‐methylation inhibitor. When conjugated to 2‐cyano‐6‐aminobenzothiazole and a peptide substrate specific for the tumor‐overexpressed enzyme furin, it can self‐assemble into nanoparticles that can be detected by chemical‐exchange saturation‐transfer magnetic‐resonance imaging (CEST MRI). We report here that these nano‐assemblies can also be detected with high specificity in furin‐overexpressing tumor cells by Raman spectroscopy with a distinct scattering signature and demonstrate the utility of this sensing mechanism in vitro and in vivo. Our findings suggest that Raman spectroscopy could be used for high‐resolution image‐guided surgery to precisely delineate tumor margins during and after resection in real‐time as well as to determine microscopic tumor invasion and multifocal locoregional tumor spread, which are currently impossible to visualize with available imaging technologies, including CEST MRI.

Furin-Mediated Self-Assembly of Olsalazine Nanoparticles for Targeted Raman Imaging of Tumors.

Olsalazine (Olsa) is a broad-spectrum anti-cancer agent acting as a DNA-methylation inhibitor. When conjugated to 2-cyano-6-aminobenzothiazole and a peptide substrate specific for the tumor-overexpressed enzyme furin, it can self-assemble into nanoparticles that can be detected by chemical-exchange saturation-transfer magnetic-resonance imaging (CEST MRI). We report here that these nano-assemblies can also be detected with high specificity in furin-overexpressing tumor cells by Raman spectroscopy with a distinct scattering signature and demonstrate the utility of this sensing mechanism in vitro and in vivo. Our findings suggest that Raman spectroscopy could be used for high-resolution image-guided surgery to precisely delineate tumor margins during and after resection in real-time as well as to determine microscopic tumor invasion and multifocal locoregional tumor spread, which are currently impossible to visualize with available imaging technologies, including CEST MRI.

Quasi-steady state chemical exchange saturation transfer (QUASS CEST) analysis-correction of the finite relaxation delay and saturation time for robust CEST measurement.

CEST provides a MR contrast mechanism sensitizing to the exchange between dilute labile and bulk water protons. However, the CEST effect depends on the RF saturation duration and relaxation delay, which need to be long to reach its steady state. Our study aims to estimate the QUAsi-Steady State (QUASS) CEST signal from experiments with shorter saturation and relaxation delay times. The evolution of the CEST signal was modeled as a function of the bulk water longitudinal relaxation rate during the relaxation delay (Td) and spin-lock relaxation rate during the RF saturation (Ts), from which the QUASS CEST effect is solved. Numeric simulations were programmed to compare the apparent CEST and QUASS CEST effects as a function of Ts and Td times. We also performed CEST MRI experiments from a creatine-gel pH phantom under serially varied Ts and Td times. The numeric simulation showed that although the apparent CEST effect depends on Td and Ts, the QUASS CEST solution has little dependence. Phantom results showed that the routine CEST pH contrast could be described by a nonlinear regression model (ie, ). We had = (P < 5e-8) and (P < 5e-6). For the QUASS CEST analysis, we modeled the pH contrast as , using a linear regression model. We had (P < 5e-9) and (P < 0.01), the slope of which is minimal. The QUASS CEST algorithm provides a post-processing solution that facilitates robust CEST measurement.

Paracetamol and other acetanilide analogs as inter-molecular hydrogen bonding assisted diamagnetic CEST MRI contrast agents.

Paracetamol and a few other acetanilide derivatives are reported as a special class of diamagnetic Chemical Exchange Saturation Transfer (diaCEST) MRI contrast agents, that exhibit contrast only when the molecules form inter-molecular hydrogen bonding mediated molecular chains or sheets. Without the protection of the hydrogen bonding their contrast producing labile proton exchanges too quickly with the solvent to produce any appreciable contrast. Through a number of variable temperature experiments we demonstrate that under the conditions when the hydrogen bond network breaks and the high exchange returns back, the contrast drops quickly. The well-known analgesic drug paracetamol shows 12% contrast at a concentration of 15 mM at physiological conditions. With the proven safety track-record for human consumption and appreciable physiological contrast, paracetamol shows promise as a diaCEST agent for in vivo studies.

Renal pH Mapping Using Chemical Exchange Saturation Transfer (CEST) MRI: Experimental Protocol.

Chemical exchange saturation transfer (CEST) is recognized as one of the premier methods for measuring pH with this environmental variable expected to be an excellent biomarker for kidney diseases. Here we describe step-by-step CEST MRI experimental protocols for producing pH and perfusion maps for monitoring kidney pH homeostasis in rodents after administering iopamidol as contrast agent. Several CEST techniques, acquisition protocols and ratiometric approaches are described. The impact of length of acquisition time on the quality of the maps is detailed. These methods may be useful for investigating progression in kidney disease in vivo for rodent models.This chapter is based upon work from the COST Action PARENCHIMA, a community-driven network funded by the European Cooperation in Science and Technology (COST) program of the European Union, which aims to improve the reproducibility and standardization of renal MRI biomarkers. This experimental protocol is complemented by two separate chapters describing the basic concepts and data analysis.

Mapping the Alterations of Glutamate Using Glu-Weighted CEST MRI in a Rat Model of Fatigue.

Objective: Glutamate dysregulation may play an important role in the pathophysiology of fatigue. Glutamate weighted chemical exchange saturation transfer (Glu-weighted CEST) MRI is a recently developed technology which enables measuring glutamate in vivo with high sensitivity and spatial resolution. The purpose of this study is to map the alternations of brain glutamate in a rat model of fatigue.Methods: Rats were subjected to 10 days fatigue loading procedure (fatigue group) or reared without any fatigue loading (control group). Spontaneous activities of rats in the fatigue group were recorded from 3 days before fatigue loading to 4 days after the end of fatigue loading. Glu-weighted CEST were performed following 10-day fatigue loading.Results: Rats in the fatigue group exhibited significant reduced spontaneous activities after 10-day fatigue loading. The glutamate level in the whole brain increased significantly in the fatigue group compared to that in the control group. Further analysis of glutamate in the sub-regions of brain including the prefrontal cortex, hippocampus, and striatum revealed a trend of increment, although statistical significance was not reached.Significance: The increase of glutamate level in the brain may be a crucial process involved in the pathophysiology of fatigue.

Chemical exchange sensitive MRI of glucose uptake using xylose as a contrast agent.

Glucose and its analogs can be detected by CEST and chemical exchange spin-lock (CESL) MRI techniques, but sensitivity is still a bottleneck for human applications. Here, CESL and CEST sensitivity and the effect of injection on baseline physiology were evaluated for a glucose analog, xylose. The CEST and CESL sensitivity were evaluated at 9.4 T in phantoms and by in vivo rat experiments with 0.5 and 1 g/kg xylose injections. Arterial blood glucose level was sampled before and after 1g/kg xylose injection. The effect of injection on baseline neuronal activity was measured by electrophysiology data during injections of saline, xylose, and 2-deoxy-D-glucose. In phantoms, xylose shows similar chemical exchange sensitivity and pH-dependence with that of glucose. In rat experiments with a bolus injection, CESL shows higher sensitivity in the detection of xylose than CEST, and the sensitivity of xylose is much higher than glucose. Injection of xylose does not significantly affect blood glucose level and baseline neural activity for 1-g/kg and 0.6-g/kg doses, respectively. Due to its relatively high sensitivity and safety, xylose is a promising contrast agent for the study of glucose uptake.

Mechanism and quantitative assessment of saturation transfer for water-based detection of the aliphatic protons in carbohydrate polymers.

CEST MRI experiments of mobile macromolecules, for example, proteins, carbohydrates, and phospholipids, often show signals due to saturation transfer from aliphatic protons to water. Currently, the mechanism of this nuclear Overhauser effect (NOE)-based transfer pathway is not completely understood and could be due either to NOEs directly to bound water or NOEs relayed intramolecularly via exchangeable protons. We used glycogen as a model system to investigate this saturation transfer pathway in sugar polymer solution. To determine whether proton exchange affected saturation transfer, saturation spectra (Z-spectra) were measured for glycogen solutions of different pH, D2 O/H2 O ratio, and glycogen particle size. A theoretical model was derived to analytically describe the NOE-based signals in these spectra. Numerical simulations were performed to verify this theory, which was further tested by fitting experimental data for different exchange regimes. Signal intensities of aliphatic NOEs in Z-spectra of glycogen in D2 O solution were influenced by hydroxyl proton exchange rates, whereas those in H2 O were not. This indicates that the primary transfer pathway is an exchange-relayed NOE from these aliphatic protons to neighboring hydroxyl protons, followed by the exchange to water protons. Experimental data for glycogen solutions in D2 O and H2 O could be analyzed successfully using an analytical theory derived for such relayed NOE transfer, which was further validated using numerical simulations with the Bloch equations. The predominant mechanism underlying aliphatic signals in Z-spectra of mobile carbohydrate polymers is intramolecular relayed NOE transfer followed by proton exchange.

Whole brain snapshot CEST at 3T using 3D-EPI: Aiming for speed, volume, and homogeneity.

CEST MRI enables imaging of distributions of low-concentrated metabolites as well as proteins and peptides and their alterations in diseases. CEST examinations often suffer from low spatial resolution, long acquisition times, and concomitant motion artifacts. This work aims to maximize both resolution and volume coverage with a 3D-EPI snapshot CEST approach at 3T, allowing for fast and robust whole-brain CEST MRI. Resolution and temporal SNR of 3D-EPI examinations with nonselective excitation were optimized at a clinical 3T MR scanner in five healthy subjects using a clinical head/neck coil. A CEST presaturation module for low power relayed nuclear Overhauser enhancement and amide proton transfer contrast was applied as an example. The suggested postprocessing included motion correction, dynamic B0 correction, denoising, and B1 correction and was compared to an established 3D-gradient echo-based sequence. CEST examinations were performed at 1.8mm nominal isotropic resolution in 4.3s per presaturation offset. In contrast to slab-selective 3D or multislice approaches, the whole brain was covered. Repeated examinations at three different B1 values took 13 minutes for 58 presaturation offsets with temporal SNR around 75. The resulting CEST effects revealed significant gray and white matter contrast and were of similar quality across the whole brain. Coefficient of variation across three healthy subjects was below 9%. The suggested protocol enables whole brain coverage at 1.8mm isotropic resolution and fast acquisition of 4.3s per presaturation offset. For the fitted CEST amplitudes, high reproducibility was proven, increasing the opportunities of quantitative CEST investigations at 3T significantly.

In vitro characterization of the serotonin biosynthesis pathway by CEST MRI.

The diagnosis of monoamine-related psychiatric disorders is based on the phenomenological evaluation of symptoms and behavior by trained clinicians. The CEST technique can be sensitive to monoamines such as serotonin. This study quantifies the CEST properties of the compounds in the serotonin biosynthesis pathway with the goal of developing noninvasive techniques aimed at advancing the diagnostic assessment of serotonin dysfunction. Saturation transfer-weighted images of L-tryptophan, 5-hydroxytryptophan, serotonin, 5-hydroxyindoleacetic acid, and melatonin phantoms were acquired over a range of saturation amplitudes and frequency offsets along with observed T1 , T2 , and B1 efficiency maps at physiological temperature and pH of 5.5, 6.7, and 7.4. The CEST and MT data were fitted to a three-pool Bloch-McConnell model of exchange to estimate the model parameters. At apH of 5.5, tryptophan, 5-hydroxytryptophan and serotonin exhibited significant CEST contrast at resonance frequency offset, Δω between 2.64 ppm and 2.71 ppm, and magnetization transfer ratio asymmetry amplitudes up to 20% per 30 mM. At apH of 7.4, all molecules exhibited significant CEST contrast between 5.11 ppm and 5.47 ppm, and magnetization transfer ratio asymmetry amplitudes up to 9.5%per 30 mM. At apH of 6.7, all studied compounds except melatonin exhibited a CEST peak from each of the preceding two pHs. At apH of 5.5, tryptophan, 5-hydroxytryptophan, and serotonin CEST contrast originates from the side chain, whereas at apH of 7.4, CEST contrast is due to the chemical exchange between water and the NH proton on the indole ring. The data in this study could be used to inform future investigations aimed at detecting and measuring in vivo serotonin.

Co(II) and Fe(II) triazole-appended 4,10-diaza-15-crown-5-ether Macrocyclic complexes for CEST MRI applications

Transition metal ion complexes have several advantages as MRI contrast agents including low cost, biological relevance, rich coordination chemistry, tunable magnetic properties, and the potential for smart agents that are responsive to temperature, pH, and redox environment. Here we present triazole-appended azamacrocyclic ligands for Co(II) and Fe(II) complexes towards paraCEST and lipoCEST applications. The triazole pendants are synthesized using ‘click’ chemistry, in particular the azide-alkyne Huisgen cycloaddition reaction. The versatility and specificity of these reactions are particularly useful in synthesizing a variety of analogs and derivatives of triazole-containing ligands. The triazole-NH proton in our Co(II) complex is unsuitable for paraCEST applications at biological pH, but the carboxylic acid derivative produced exceptionally large paramagnetically shifted bulk water 1H resonances which are important towards the development of lipoCEST agents.

CEST MRI detectable liposomal hydrogels for multiparametric monitoring in the brain at 3T.

Adjuvant treatment using local drug delivery is applied in treating glioblastoma multiforme (GBM) after tumor resection. However, there are no non-invasive imaging techniques available for tracking the compositional changes of hydrogel-based drug treatment.Methods: We developed Chemical Exchange Saturation Transfer Magnetic Resonance Imaging (CEST MRI) detectable and injectable liposomal hydrogel to monitor these events in vivo at 3T clinical field. Mechanical attributes of these hydrogels and their in vitro and in vivo CEST imaging properties were systematically studied.Results: The MRI detectable hydrogels were capable of generating multiparametric readouts for monitoring specific components of the hydrogel matrix simultaneously and independently. Herein, we report, for the first time, CEST contrast at -3.4 ppm provides an estimated number of liposomes and CEST contrast at 5 ppm provides an estimated amount of encapsulated drug. CEST contrast decreased by 1.57% at 5 ppm, while the contrast at -3.4 ppm remained constant over 3 d in vivo, demonstrating different release kinetics of these components from the hydrogel matrix. Furthermore, histology analysis confirmed that the CEST contrast at -3.4 ppm was associated with liposome concentrations.Conclusion: This multiparametric CEST imaging of individual compositional changes in liposomal hydrogels, formulated with clinical-grade materials at 3T and described in this study, has the potential to facilitate the refinement of adjuvant treatment for GBM.

DeepCEST 3T: Robust MRI parameter determination and uncertainty quantification with neural networks-application to CEST imaging of the human brain at 3T.

Calculation of sophisticated MR contrasts often requires complex mathematical modeling. Data evaluation is computationally expensive, vulnerable to artifacts, and often sensitive to fit algorithm parameters. In this work, we investigate whether neural networks can provide not only fast model fitting results, but also a quality metric for the predicted values, so called uncertainty quantification, investigated here in the context of multi-pool Lorentzian fitting of CEST MRI spectra at 3T. A deep feed-forward neural network including a probabilistic output layer allowing for uncertainty quantification was set up to take uncorrected CEST-spectra as input and predict 3T Lorentzian parameters of a 4-pool model (water, semisolid MT, amide CEST, NOE CEST), including the B0 inhomogeneity. Networks were trained on data from 3 subjects with and without data augmentation, and applied to untrained data from 1 additional subject and 1 brain tumor patient. Comparison to conventional Lorentzian fitting was performed on different perturbations of input data. The deepCEST 3T networks provided fast and accurate predictions of all Lorentzian parameters and were robust to input perturbations because of noise or B0 artifacts. The uncertainty quantification detected fluctuations in input data by increase of the uncertainty intervals. The method generalized to unseen brain tumor patient CEST data. The deepCEST 3T neural network provides fast and robust estimation of CEST parameters, enabling online reconstruction of sophisticated CEST contrast images without the typical computational cost. Moreover, the uncertainty quantification indicates if the predictions are trustworthy, enabling confident interpretation of contrast changes.

A novel normalization for amide proton transfer CEST MRI to correct for fat signal–induced artifacts: application to human breast cancer imaging

Magnetic Resonance in MedicineVolume 83, Issue 3 p. C1-C1 COVER IMAGEFree Access A novel normalization for amide proton transfer CEST MRI to correct for fat signal–induced artifacts: application to human breast cancer imaging First published: 25 November 2019 https://doi.org/10.1002/mrm.28098AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume83, Issue3March 2020Pages C1-C1 RelatedInformation