David J Libon

Drexel University, Philadelphia, Pennsylvania, United States

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Publications (128)387.34 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Epidemiologic autopsy studies show mixed Alzheimer's disease (AD)/vascular pathology in many patients. Moreover, clinical research shows that it is not uncommon for AD and vascular dementia (VaD) patients to be equally impaired on memory, executive, or other neurocognitive tests. However, this clinical heterogeneity has not been incorporated into the new diagnostic criteria for AD (Dubois et al., 2010; McKhann et al., 2011). Objective: The current research applied Latent Class Analysis (LCA) to a protocol of six neuropsychological parameters to identify phenotypic subtypes from a large group of AD/VaD participants. Follow-up analyses examined difference between groups on neuroradiological parameters and neuropsychological measures of process and errors. Methods: 223 AD/VaD patients were administered a comprehensive neuropsychological protocol. Measures of whole brain and hippocampal volume were available for a portion of the sample (n = 76). Results: LCA identified four distinct groups: moderate/mixed dementia (n = 54; 24.21%), mild/mixed dementia (n = 91; 40.80%); dysexecutive (n = 49, 21.97%), and amnestic (n = 29, 13.00%). Follow-up analyses comparing the groups on neuropsychological process and error scores showed that the dysexecutive group exhibited difficulty sustaining mental set. The moderate/mixed group evidenced pronounced impairment on tests of lexical retrieval/naming along with significant amnesia. Amnestic patients also presented with gross amnesia, but showed relative sparing on other neuropsychological measures. Mild/mixed patients exhibited milder memory deficits that were intermediary between the amnestic and moderate/mixed groups. Conclusions: There are distinct neuropsychological profiles in patients independent of clinical diagnosis, suggesting that the two are not wholly separate and that this information should be integrated into new AD diagnostic paradigms.
    Journal of Alzheimer's disease: JAD 07/2014; · 4.17 Impact Factor
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    ABSTRACT: We compared two methods of diagnosing mild cognitive impairment (MCI): conventional Petersen/Winblad criteria as operationalized by the Alzheimer's Disease Neuroimaging Initiative (ADNI) and an actuarial neuropsychological method put forward by Jak and Bondi designed to balance sensitivity and reliability. 1,150 ADNI participants were diagnosed at baseline as cognitively normal (CN) or MCI via ADNI criteria (MCI: n = 846; CN: n = 304) or Jak/Bondi criteria (MCI: n = 401; CN: n = 749), and the two MCI samples were submitted to cluster and discriminant function analyses. Resulting cluster groups were then compared and further examined for APOE allelic frequencies, cerebrospinal fluid (CSF) Alzheimer's disease (AD) biomarker levels, and clinical outcomes. Results revealed that both criteria produced a mildly impaired Amnestic subtype and a more severely impaired Dysexecutive/Mixed subtype. The neuropsychological Jak/Bondi criteria uniquely yielded a third Impaired Language subtype, whereas conventional Petersen/Winblad ADNI criteria produced a third subtype comprising nearly one-third of the sample that performed within normal limits across the cognitive measures, suggesting this method's susceptibility to false positive diagnoses. MCI participants diagnosed via neuropsychological criteria yielded dissociable cognitive phenotypes, significant CSF AD biomarker associations, more stable diagnoses, and identified greater percentages of participants who progressed to dementia than conventional MCI diagnostic criteria. Importantly, the actuarial neuropsychological method did not produce a subtype that performed within normal limits on the cognitive testing, unlike the conventional diagnostic method. Findings support the need for refinement of MCI diagnoses to incorporate more comprehensive neuropsychological methods, with resulting gains in empirical characterization of specific cognitive phenotypes, biomarker associations, stability of diagnoses, and prediction of progression. Refinement of MCI diagnostic methods may also yield gains in biomarker and clinical trial study findings because of improvements in sample compositions of 'true positive' cases and removal of 'false positive' cases.
    Journal of Alzheimer's disease: JAD 05/2014; · 4.17 Impact Factor
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    ABSTRACT: Total knee arthroplasty improves quality of life but is associated with postoperative cognitive dysfunction in older adults. This prospective longitudinal pilot study with a parallel control group tested the hypotheses that (1) nondemented adults would exhibit primary memory and executive difficulties after total knee arthroplasty, and (2) reduced preoperative hippocampus/entorhinal volume would predict postoperative memory change, whereas preoperative leukoaraiosis and lacunae volumes would predict postoperative executive dysfunction. Surgery (n = 40) and age-education-matched controls with osteoarthritis (n = 15) completed pre- and postoperative (3 weeks, 3 months, and 1 yr) memory and cognitive testing. Hypothesized brain regions of interest were measured in patients completing preoperative magnetic resonance scans (surgery, n = 31; control, n = 12). Analyses used reliable change methods to identify the frequency of cognitive change at each time point. The incidence of postoperative memory difficulties was shown with delay test indices (i.e., story memory test: 3 weeks = 17%, 3 months = 25%, 1 yr = 9%). Postoperative executive difficulty with measures of inhibitory function (i.e., Stroop Color Word: 3 weeks = 21%, 3 months = 22%, 1 yr = 9%). Hierarchical regression analysis assessing the predictive interaction of group (surgery, control) and preoperative neuroanatomical structures on decline showed that greater preoperative volumes of leukoaraiosis/lacunae were significantly contributed to postoperative executive (inhibitory) declines. This pilot study suggests that executive and memory declines occur in nondemented adults undergoing orthopedic surgery. Severity of preoperative cerebrovascular disease may be relevant for understanding executive decline, in particular.
    Anesthesiology 03/2014; 120(3):601-13. · 5.16 Impact Factor
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    ABSTRACT: Background We assessed whether mild cognitive impairment (MCI) subtypes could be empirically derived within the Alzheimer's Disease Neuroimaging Initiative (ADNI) MCI cohort and examined associated biomarkers and clinical outcomes. Methods Cluster analysis was performed on neuropsychological data from 825 MCI ADNI participants. Results Four subtypes emerged: (1) dysnomic (n = 153), (2) dysexecutive (n = 102), (3) amnestic (n = 288), and (4) cluster-derived normal (n = 282) who performed within normal limits on cognitive testing. The cluster-derived normal group had significantly fewer APOE ε4 carriers and fewer who progressed to dementia compared with the other subtypes; they also evidenced cerebrospinal fluid Alzheimer's disease biomarker profiles that did not differ from the normative reference group. Conclusions Identification of empirically derived MCI subtypes demonstrates heterogeneity in MCI cognitive profiles that is not captured by conventional criteria. The large cluster-derived normal group suggests that conventional diagnostic criteria are susceptible to false-positive errors, with the result that prior MCI studies may be diluting important biomarker relationships.
    Alzheimer's & Dementia. 01/2014;
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    ABSTRACT: Cognitive impairment in amyotrophic lateral sclerosis (ALS) is associated with cortical changes beyond the motor cortex. The overall goal of this project is to determine if task induced hemodynamic changes detected by functional near infrared (fNIR) spectroscopy from the anterior prefrontal cortex (PFC) has discriminant validity across ALS (n = 17) patients and matching healthy (n = 17) controls. The experimental protocol was composed of the King-Devick Test, the Number Interference Test and a Continuous Performance Test targeting a range of cognitive domains including sustained attention and executive function. Results indicate that fNIR measures provided significant differences between ALS and healthy controls in all three tasks providing an additional metric for the assessment of cognitive decline. Although this is a pilot study, given the safe, wearable and realworld validity of fNIR, these results may set the foundation for the use of fNIR as a clinical tool in monitoring progression of neurocognitive decline in a simple, less invasive and objective manner than allowed by current imaging technology.
    Journal of Neuroscience and Neuroengineering. 01/2014; 3(1).
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    ABSTRACT: Mild cognitive impairment (MCI) is a dynamic state between normal cognition and dementia, where interventions can be taken to stop or delay the progression to dementia. It is broadly of 2 types-amnestic, where memory loss is the chief concern and nonamnestic, where it is not. One variant of nonamnestic, dysexecutive, being more prevalent is sometimes known as a separate subtype by itself. Diagnosis of MCI is mostly clinical and is aided by various scales and neuropsychological testing. Functional imaging studies help in early detection and is superior to biomarkers or structural magnetic resonance imaging. Although there is no evidence supporting any pharmacological intervention, cognitive rehabilitation, memory training, and caregiver support play a strong role in limiting and sometimes reversing the ongoing cognitive decline. As the spectrum of MCI is heterogeneous, making the right diagnosis can be a challenging; hence, we need a systematic yet cost-effective algorithm for the timely management of MCI.
    American Journal of Alzheimer s Disease and Other Dementias 12/2013; · 1.52 Impact Factor
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    ABSTRACT: Mild functional difficulties have been associated with early cognitive decline in older adults and increased risk for conversion to dementia in mild cognitive impairment, but our understanding of this decline has been limited by a dearth of objective methods. This study evaluated the reliability and validity of a new system to code subtle errors on an established performance-based measure of everyday action and described preliminary findings within the context of a theoretical model of action disruption. Here 45 older adults completed the Naturalistic Action Test (NAT) and neuropsychological measures. NAT performance was coded for overt errors, and subtle action difficulties were scored using a novel coding system. An inter-rater reliability coefficient was calculated. Validity of the coding system was assessed using a repeated-measures ANOVA with NAT task (simple versus complex) and error type (overt versus subtle) as within-group factors. Correlation/regression analyses were conducted among overt NAT errors, subtle NAT errors, and neuropsychological variables. The coding of subtle action errors was reliable and valid, and episodic memory breakdown predicted subtle action disruption. Results suggest that the NAT can be useful in objectively assessing subtle functional decline. Treatments targeting episodic memory may be most effective in addressing early functional impairment in older age.
    The Clinical Neuropsychologist 11/2013; · 1.68 Impact Factor
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    ABSTRACT: The everyday, functional impairments associated with dementia remain poorly understood from a neuropsychological perspective. This study investigated relations between brain structure volumes and two measures of everyday action-caregiver questionnaire and direct assessment-in 57 participants with dementia. Results showed that caregiver ratings reflecting more functional impairment were strongly associated with smaller volumes of deep white matter. Direct assessment of everyday task performance in a subsample revealed relations between unique neurological substrates and discrete everyday action error types. Findings emphasize differences in functional assessment methods and highlight the role of white matter in functional deficits in dementia.
    Journal of Clinical and Experimental Neuropsychology 10/2013; · 2.16 Impact Factor
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    ABSTRACT: This study establishes that sparse canonical correlation analysis (SCCAN) identifies generalizable, structural MRI-derived cortical networks that relate to five distinct categories of cognition. We obtain multivariate psychometrics from the domain-specific sub-scales of the Philadelphia Brief Assessment of Cognition (PBAC). By using a training and separate testing stage, we find that PBAC-defined cognitive domains of language, visuospatial functioning, episodic memory, executive control, and social functioning correlate with unique and distributed areas of gray matter (GM). In contrast, a parallel univariate framework fails to identify, from the training data, regions that are also significant in the left-out test dataset. The cohort includes164 patients with Alzheimer's disease, behavioral-variant frontotemporal dementia, semantic variant primary progressive aphasia, non-fluent/agrammatic primary progressive aphasia, or corticobasal syndrome. The analysis is implemented with open-source software for which we provide examples in the text. In conclusion, we show that multivariate techniques identify biologically-plausible brain regions supporting specific cognitive domains. The findings are identified in training data and confirmedin test data.
    NeuroImage 10/2013; · 6.25 Impact Factor
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    ABSTRACT: The history including some of the intellectual origins of the Boston Process Approach and some misconceptions about the Boston Process Approach are reviewed. The influence of Gestalt psychology and Edith Kaplan's principal collaborators regarding the development of the Boston Process Approach is discussed.
    The Clinical Neuropsychologist 08/2013; · 1.68 Impact Factor
  • Lee Ashendorf, Rod Swenson, David J. Libon
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    ABSTRACT: The Boston Process Approach to neuropsychological assessment, advanced by Edith Kaplan, has a long and well-respected history in the field. However, its theoretical and empirical support has not previously been assembled in an easily accessible format. This volume fills that void by compiling the historical, empirical, and practical teachings of the Process Approach. The reader will find a detailed history of the precursors to this model of thought, its development through its proponents such as Harold Goodglass, Nelson Butters, Laird Cermak, and Norman Geschwind, and its continuing legacy. The second section provides a guide to applying the Boston Process Approach to some of the field's most commonly used measures, such as the various Wechsler Intelligence Scales, the Trail Making Test, the California Verbal Learning Test, and the Boston Naming Test. Here, the reader will find a detailed history of the empirical evidence for test administration and interpretation using Boston Process Approach tenets. The final section of the book provides various perspectives on the implementation of the Boston Process Approach in various clinical and research settings and with specialized populations.
    08/2013; Oxford University Press., ISBN: 978-0199794300
  • 08/2013: pages 355-379;
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    ABSTRACT: Patients with the semantic variant of primary progressive aphasia, also known as semantic dementia, and Alzheimer's disease have deficits in semantic memory. However, few comparative studies have been performed to determine whether these patient groups have distinct semantic memory impairments. We asked 15 patients with semantic variant primary progressive aphasia and 57 patients with Alzheimer's disease to judge semantic category membership of coloured photos and printed words that are members of familiar natural and manufactured categories, and we related performance to grey matter atrophy. We found that both semantic variant primary progressive aphasia and Alzheimer's disease are significantly impaired on this task. Moreover, patients with semantic variant primary progressive aphasia had a significantly more prominent deficit for natural objects than their own deficit judging manufactured objects. Both semantic variant primary progressive aphasia and Alzheimer's disease had atrophy that included portions of the left temporal lobe. Regression analyses related performance in semantic variant primary progressive aphasia to ventral and medial portions of the left temporal lobe, while regression analyses in Alzheimer's disease related performance to these ventral and medial temporal areas as well as lateral temporal-parietal regions in the left hemisphere. We conclude that both semantic variant primary progressive aphasia and Alzheimer's disease are significantly impaired in a simple category membership judgement task and the selective impairment for natural kinds in semantic variant primary progressive aphasia is related in part to disease in visual association cortex in ventral-medial portions of the left temporal lobe. We discuss factors that may contribute to the semantic memory deficit in semantic variant primary progressive aphasia.
    Brain 07/2013; · 9.92 Impact Factor
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    ABSTRACT: Alzheimer's disease (AD) is known to be associated with disruption in semantic networks. Previous studies examining changes in spreading activation in AD have used a lexical decision task paradigm. We have used a paradigm based on average word frequencies obtained from the words generated on the Controlled Oral Word Association Test (COWAT) and the Animal Naming (AN) test. The COWAT and AN tests were administered to a group of 25 patients with AD and 20 control participants. We predicted that the patients with AD would have higher average word frequencies on the COWAT and AN tests than the control participants. The results indicated that the AD group generated words with a higher average word frequency on the AN test but a lower average word frequency on the COWAT. The reasons for the discrepancy in average word frequencies on the AN test and COWAT are discussed.
    American Journal of Alzheimer s Disease and Other Dementias 06/2013; · 1.52 Impact Factor
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    ABSTRACT: BACKGROUND: Vascular risk factors have been associated with cognitive decline; however, it remains unclear whether apolipoprotein E (APOE) genotype modifies this relationship. We aimed to further elucidate these relationships and extend previous findings by examining data from a more comprehensive cognitive assessment than used in prior studies. METHODS: In all, 1436 participants from the prospective Framingham Offspring Cohort Study underwent health examination from 1991 to 1995, followed by a baseline neuropsychological assessment (1999-2003) and a repeat neuropsychological assessment approximately 8 years later (2004-2009). Multivariate linear regression analyses were performed to examine the relationship among midlife vascular risk factors, presence of the APOE ε4 allele, and cognitive change. RESULTS: APOE genotype significantly modified the associations between both midlife hypertension and cardiovascular disease and decline in language abilities and midlife diabetes and decline in verbal memory, attention, and visuospatial abilities. Associations between increased midlife vascular risk burden and greater cognitive decline were observed among APOE ε4 carriers but not noncarriers. CONCLUSIONS: The present findings revealed a subgroup at increased risk for cognitive decline (APOE ε4 carriers with midlife exposure to vascular risk factors) and suggest that treatment of vascular risk factors during midlife may reduce the risk of cognitive impairment later in life, particularly among APOE ε4 carriers.
    Journal of stroke and cerebrovascular diseases: the official journal of National Stroke Association 04/2013;
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    ABSTRACT: Given the importance of identifying dementia prodromes for future treatment efforts, we examined two methods of diagnosing mild cognitive impairment (MCI) and determined whether empirically-derived MCI subtypes of these diagnostic methods were consistent with one another as well as with conventional MCI subtypes (i.e., amnestic, non-amnestic, single-domain, multi-domain). Participants were diagnosed with MCI using either conventional Petersen/Winblad criteria (n = 134; >1.5 SDs below normal on one test within a cognitive domain) or comprehensive neuropsychological criteria developed by Jak et al. (2009) (n = 80; >1 SD below normal on two tests within a domain), and the resulting samples were examined via hierarchical cluster and discriminant function analyses. Results showed that neuropsychological profiles varied depending on the criteria used to define MCI. Both criteria revealed an Amnestic subtype, consistent with prodromal Alzheimer's disease (AD), and a Mixed subtype that may capture individuals in advanced stages of MCI. The comprehensive criteria uniquely yielded Dysexecutive and Visuospatial subtypes, whereas the conventional criteria produced a subtype that performed within normal limits, suggesting its susceptibility to false positive diagnostic errors. Whether these empirically-derived MCI subtypes correspond to dissociable neuropathologic substrates and represent reliable prodromes of dementia will require additional follow-up. (JINS, 2013, 19, 1-11).
    Journal of the International Neuropsychological Society 04/2013; · 2.70 Impact Factor
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    ABSTRACT: OBJECTIVE:: To examine how phenotype affects longitudinal decline on the Mini-Mental State Examination (MMSE) in patients with frontotemporal lobar degeneration (FTLD) and Alzheimer disease (AD). BACKGROUND:: The MMSE is the most commonly administered assessment for dementia severity; however, the effects of phenotype on longitudinal MMSE performance in FTLD and AD have not been extensively studied. METHODS:: Data from 185 patients diagnosed with AD (n=106) and 3 FTLD (n=79) phenotypes [behavioral variant frontotemporal dementia (bvFTD), nonfluent agrammatic variant of primary progressive aphasia (nfaPPA), and semantic variant PPA (svPPA)] were collected for up to 52 months since initial evaluation. RESULTS:: Differential rates of decline were noted in that MMSE scores declined more precipitously for AD and svPPA compared with bvFTD and nfaPPA patients (P=0.001). The absolute 4-year MMSE decline given median baseline MMSE for bvFTD [14.67; 95% confidence interval (CI), 14.63-14.71] and nfaPPA (11.02; 95% CI, 10.98-11.06) were lower than svPPA (22.32; 95% CI, 22.29-22.34) or AD (22.24; 95% CI, 22.22-22.26). CONCLUSIONS:: These data suggest that within-group AD and FTLD phenotypes present distinct patterns of longitudinal decline on the MMSE. MMSE may not be adequately sensitive to track disease progression in some phenotypes of FTLD.
    Alzheimer disease and associated disorders 01/2013; · 2.88 Impact Factor
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    ABSTRACT: It is difficult to longitudinally characterize cognitive impairment in amyotrophic lateral sclerosis (ALS) due to motor deficits, and existing instruments aren't comparable with assessments in other dementias. The ALS Brief Cognitive Assessment (ALS-BCA) was validated in 70 subjects (37 with ALS) who also underwent detailed neuropsychological analysis. Cognitive predictors for poor survival were then analyzed in a longitudinal cohort of 171 ALS patients. The ALS-BCA was highly sensitive (90%) and specific (85%) for ALS-dementia (ALS-D). ALS-D patients had shorter overall survival, primarily due to the poor survival among ALS-D patients with disinhibited or apathetic behaviors after adjusting for demographic variables, ALS site of onset, medications, and supportive measures. ALS-D without behavioral changes was not a predictor of poor survival. ALS-D can present with or without prominent behavioral changes. Cognitive screening in ALS patients should focus on behavioral changes for prognosis, while non-behavioral cognitive impairments may impact quality of life without impacting survival.
    PLoS ONE 01/2013; 8(2):e57584. · 3.73 Impact Factor
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    ABSTRACT: Aging is a complicated process characterized by a progressive loss of homeostasis, which results in an increased vulnerability to multiple diseases. HIV-1-infected patients demonstrate a premature aging phenotype and develop certain age-related diseases earlier in their lifespan than what is seen in the general population. Age-related comorbidities may include the development of bone disease, metabolic disorders, neurologic impairment and immunosenescence. Age also appears to have an effect on traditional markers of HIV-1 disease progression, including CD4(+) T-cell count and viral load. These effects are not only a consequence of HIV-1 infection, but in many cases, are also linked to antiretroviral therapy. This review summarizes the complex interplay between HIV-1 infection and aging, and the impact that aging has on markers of HIV-1 disease.
    Future Virology 01/2013; 8(1):81-101. · 0.96 Impact Factor
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    ABSTRACT: BACKGROUND: Significant heterogeneity in clinical features of frontotemporal lobar degeneration (FTLD) and amyotrophic lateral sclerosis (ALS) cases with the pathogenic C9orf72 expansion (C9P) have been described. To clarify this issue, we compared a large C9P cohort with carefully matched non-expansion (C9N) cases with a known or highly-suspected underlying TAR DNA-binding protein 43 (TDP-43) proteinopathy. METHODS: A retrospective case-control study was carried out using available cross-sectional and longitudinal clinical and neuropsychological data, MRI voxel-based morphometry (VBM) and neuropathological assessment from 64 C9P cases (ALS=31, FTLD=33) and 79 C9N cases (ALS=36, FTLD=43). RESULTS: C9P cases had an earlier age of onset (p=0.047) and, in the subset of patients who were deceased, an earlier age of death (p=0.014) than C9N. C9P had more rapid progression than C9N: C9P ALS cases had a shortened survival (2.6±0.3 years) compared to C9N ALS (3.8±0.4 years; log-rank λ2=4.183, p=0.041), and C9P FTLD showed a significantly greater annualised rate of decline in letter fluency (4.5±1.3 words/year) than C9N FTLD (1.4±0.8 words/year, p=0.023). VBM revealed greater atrophy in the right frontoinsular, thalamus, cerebellum and bilateral parietal regions for C9P FTLD relative to C9N FTLD, and regression analysis related verbal fluency scores to atrophy in frontal and parietal regions. Neuropathological analysis found greater neuronal loss in the mid-frontal cortex in C9P FTLD, and mid-frontal cortex TDP-43 inclusion severity correlated with poor letter fluency performance. CONCLUSIONS: C9P cases may have a shorter survival in ALS and more rapid rate of cognitive decline related to frontal and parietal disease in FTLD. C9orf72 genotyping may provide useful prognostic and diagnostic clinical information for patients with ALS and FTLD.
    Journal of neurology, neurosurgery, and psychiatry 10/2012; · 4.87 Impact Factor

Publication Stats

2k Citations
387.34 Total Impact Points

Institutions

  • 1991–2014
    • Drexel University
      • • Department of Neurology
      • • Department of Psychology
      • • Department of Psychiatry
      Philadelphia, Pennsylvania, United States
  • 2013
    • Middle Tennessee State University
      • Department of Psychology
      Murfreesboro, TN, United States
  • 2009–2013
    • University of California, San Diego
      • • Department of Psychiatry
      • • Department of Medicine
      San Diego, CA, United States
  • 2008–2013
    • Temple University
      • Department of Psychology
      Philadelphia, Pennsylvania, United States
  • 2004–2013
    • Hospital of the University of Pennsylvania
      • • Department of Radiology
      • • Department of Neurology
      Philadelphia, PA, United States
  • 2012
    • VA San Diego Healthcare System
      San Diego, California, United States
  • 2011–2012
    • University of Pennsylvania
      • • Department of Neurology
      • • Department of Psychology
      Philadelphia, PA, United States
  • 2008–2012
    • Drexel University College of Medicine
      • Department of Neurology
      Philadelphia, PA, United States
  • 2005–2012
    • University of Florida
      • Department of Clinical and Health Psychology
      Gainesville, FL, United States
    • Manhattanville College
      Harrison, New York, United States
  • 2007–2010
    • King's College London
      • • Department of Psychology
      • • MRC Centre for Neurodegeneration Research
      London, ENG, United Kingdom
  • 2004–2007
    • Stratford University
      Stratford, Connecticut, United States
  • 2006
    • Columbia University
      • Department of Neuroscience
      New York City, NY, United States
  • 2002–2004
    • National Institute on Aging
      Baltimore, Maryland, United States
  • 1996–2002
    • Crozer Chester Medical Center
      Upland, Pennsylvania, United States
  • 2000
    • Moss Rehabilitation Research Institute
      Elkins, West Virginia, United States
  • 1990
    • Albert Einstein Medical Center
      Philadelphia, Pennsylvania, United States