William M Lee

University of Texas Southwestern Medical Center, Dallas, Texas, United States

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Publications (220)1760.49 Total impact

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    ABSTRACT: Hepatitis B virus (HBV) testing and vaccination rates remain low among Asian-American/Pacific Islanders (APIs) despite high rates of HBV infection. The aim of our study was to assess the effectiveness of an outreach campaign to increase HBV knowledge, testing, and vaccination among a cohort of APIs. Vietnamese Americans were invited to participate in a free HBV screening and vaccination outreach program though pubic service announcements. Attendees completed a survey to assess barriers to vaccination and HBV-related knowledge before and after a 30-min education session by a bilingual board-certified gastroenterologist. Among 98 participants, 100 % (22/22) of HBV naïve patients were provided a HBV vaccination series at no cost and over 75 % (14/18) of HBV-infected patients were connected to further medical care. Notable reported barriers to prior testing and/or vaccination were cost of the vaccine, concern about missing work for evaluation, and lack of provider recommendation. Knowledge levels about HBV risk factors, potential consequences, and treatment options were poor at baseline but significantly increased after the education session (49 vs. 64 %, p < 0.001). Outreach campaigns linked with education can successfully address several barriers to HBV testing and offer an approach to improve HBV awareness and prevention among difficult-to-reach populations.
    Journal of Community Health 12/2014; · 1.28 Impact Factor
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    ABSTRACT: Classification of objects into pre-defined groups based on known information is a fundamental problem in the field of statistics. Although approaches for solving this problem exist, finding an accurate classification method can be challenging in an orphan disease setting, where data are minimal and often not normally distributed. The purpose of this paper is to illustrate the application of the random forest (RF) classification procedure in a real clinical setting and discuss typical questions that arise in the general classification framework as well as offer interpretations of RF results. This paper includes methods for assessing predictive performance, importance of predictor variables, and observation-specific information. Copyright © 2014 John Wiley & Sons, Ltd.
    Statistics in Medicine 11/2014; · 2.04 Impact Factor
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    ABSTRACT: Background & Aims We investigated whether antimicrobial prophylaxis alters the incidence of bloodstream infection in patients with acute liver failure (ALF), and whether bloodstream infections affect overall mortality within 21 days after development of ALF. Methods We performed a retrospective cohort analysis of 1551 patients with ALF enrolled by the US Acute Liver Failure Study Group from January 1998 through November 2009. We analyzed data on infections in the first 7 days after admission and the effects of prophylaxis with antimicrobial drugs on development of bloodstream infections and 21-day mortality. Results In our study population, 600 patients (39%) received antimicrobial prophylaxis and 226 (14.6%) developed at least 1 bloodstream infection. Exposure to antimicrobial drugs did not affect the proportion of patients who developed bloodstream infections (12.8% in patients with prophylaxis vs 15.7% non-prophylaxed; P=.12) but a greater percentage who received prophylaxis received liver transplants (28% vs 22%; P=.01). After adjusting for confounding factors, overall mortality within 21 days was independently associated with age (odds ratio [OR]=1.014), model for end-stage liver disease score at admission (OR=1.078), and vasopressor administration at admission (OR=2.499). Low grade of coma (OR=0.47) and liver transplantation (OR=0.101) reduced mortality. Although bloodstream infection was significantly associated with 21-day mortality (P=.004), an interaction between bloodstream infection and etiology was detected: blood stream infection affected mortality to a greater extent in non-acetaminophen ALF patients (OR=2.03) than in acetaminophen ALF patients (OR=1.14). Conclusions Based on a large, observational study, antimicrobial prophylaxis does not reduce incidence of bloodstream infection or mortality within 21 days of ALF. However, bloodstream infections were associated with increased 21-day mortality in patients with ALF—to a greater extent in patients without than with acetaminophen-associated ALF. Our findings do not support routine use of antimicrobial prophylaxis in patients with ALF.
    Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 11/2014; · 5.64 Impact Factor
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    ABSTRACT: IntroductionDrug-induced liver injury [DILI] is often caused by innate and adaptive host immune responses. Characterization of inflammatory infiltrates in the liver may improve understanding of the underlying pathogenesis of DILI.AimsTo characterize leukocytes infiltrating liver tissue from subjects with acute DILI [n = 32] vs. non-DILI causes of acute liver injury [n = 25].Methods Immunostains for CD11b/CD4 (Kupffer and T helper cells), CD3/CD20 (T and B cells), and CD8/CD56 (T cytotoxic and NK cells) were evaluated in biopsies from subjects with acute DILI, either immuno-allergic [IAD] or auto-immune [AID] and idiopathic autoimmune (AIH) and viral hepatitis (VH) and correlated with clinical and pathologic features.ResultsAll biopsies showed numerous CD8+ T cells and macrophages. DILI cases had significantly fewer B-lymphocytes than AIH and VH and significantly fewer NK cells than VH. Prominent plasma cells were unusual in IAD (3/10 cases), but were strongly associated with AIH (8/9) and also observed in most with AID (6/9). They were also found in 5/10 cases with VH.Conclusions Liver biopsies from subjects with DILI were characterized by low counts of mature B cells and NK cells in portal triads in contrast to VH. NK cells were only found in cases of VH, whereas AIH and VH both showed higher counts of B cells than DILI. Plasma cells were most strongly associated with AIH and less so with AID, but were uncommon in IAD.
    Clinical & Experimental Immunology 11/2014; · 3.28 Impact Factor
  • Digestive Diseases and Sciences 10/2014; · 2.26 Impact Factor
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    ABSTRACT: Background: The benefit of therapeutic hypothermia (TH) in Acute Liver Failure (ALF) has not been previously demonstrated in a controlled fashion. This study aimed to determine the impact of TH on 21-day survival and complications in ALF patients at high risk for cerebral edema.Methods: Retrospective cohort study of ALF patients in the US ALFSG with Grade III or IV hepatic encephalopathy. TH (32oC – 35oC) was used in 97 (8%) patients; 1135 (92%) not cooled were controls.Results: Intracranial pressure (ICP) was monitored in 38 (40%) TH ALF patients (vs. 22% controls, p=0.0001). Rates of bleeding (12% in both), bloodstream (17% vs. 18) and tracheal infections (21% vs. 23%, p> 0.5 for all) were similar. Unadjusted 21-day overall (62% vs. 60%) and transplant-free survival (45 vs. 39%, p>0.4 for both) were similar. Multivariable models were created for acetaminophen (APAP) (n= 582) and non-APAP (n=613) patients. For APAP patients, MELD (Odds ratio 0.91 per increment; 95% CI 0.89-0.94, p <0.001) and vasopressors (OR 0.16; 0.11-0.24, p < 0.0001) were associated with decreased 21-day spontaneous survival. Survival was improved with TH in APAP patients aged < 25y (Age 25: OR 2.735; 95% CI 1.001 – 7.467) but worsened in 64y or older APAP patients (Age = 64: OR 0.167; 95%CI 0.028 - 0.999). For non-APAP patients, MELD (OR 0.93 per increment; 0.91-0.95, p < 0.0001) and vasopressors (OR 0.60; 0.40-0.90, p=0.01) were associated with worse outcomes while TH had no impact (p= 0.93).Conclusions: Therapeutic hypothermia in ALF was not associated with increased bleeding or infections. While young APAP-ALF patients may benefit, TH did not consistently impact 21-day survival. A prospective trial is required to clarify the utility of TH in ALF patients. Liver Transpl , 2014. © 2014 AASLD.
    Liver Transplantation 10/2014; · 3.79 Impact Factor
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    ABSTRACT: There have been few reports of acute liver failure (ALF, with encephalopathy and coagulopathy) due to infiltration of the liver by malignant cells. We describe a case series of 27 patients with ALF caused by malignancy. We examined a large, multi-center ALF registry (1910 patients; mean age, 47.1±13.9 years) and found only 27 cases (1.4%) of ALF attributed to malignancy. Twenty cases (74%) presented with abdominal pain and 11 with ascites. The malignancies included lymphoma or leukemia (33%), breast cancer, (30%), and colon cancer (7%); 90% of the patients with lymphoma or leukemia had no history of cancer, compared to 25% of patients with breast cancer. Overall, 44% of the patients had evidence of liver masses by imaging. Diagnosis was confirmed by biopsy in 15 (55%) and autopsy for 6 cases. Twenty-four patients (89%) died within 3 weeks of ALF.
    Clinical Gastroenterology and Hepatology 09/2014; · 6.53 Impact Factor
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    ABSTRACT: Acetaminophen (APAP) - induced acute liver failure (ALF) remains a major clinical problem. While a majority of patients recovers after severe liver injury, a subpopulation of patients proceeds to acute liver failure. Bile acids are generated in the liver and accumulate in blood during liver injury, and as such, have been proposed as biomarkers for liver injury and dysfunction. The goal of this study was to determine if individual bile acid levels could determine outcome in patients with APAP-induced ALF (AALF). Serum bile acid levels were measured in AALF patients using mass spectrometry. Bile acid levels were elevated 5-80 fold above control values in injured patients on day 1 after the overdose and decreased over the course of hospital stay. Interestingly, glycodeoxycholic acid (GDCA) was significantly increased in non-surviving AALF patients compared to survivors. GDCA values obtained at Peak ALT and from Day 1 of admission indicated GDCA could predict survival in these patients by receiver-operating characteristic analysis (AUC=0.70 for Day 1, AUC=0.68 for peak ALT). Of note, AALF patients also had significantly higher levels of serum bile acids than patients with active cholestatic liver injury. These data suggest measurements of GDCA in this patient cohort modestly predicted outcome and may serve as a prognostic biomarker. Furthermore, accumulation of bile acids in serum or plasma may be a result of liver cell dysfunction and not cholestasis, suggesting elevation of circulating bile acid levels may be a consequence and not a cause of liver injury.
    Toxicological Sciences 09/2014; · 4.48 Impact Factor
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    ABSTRACT: Background The complement system is activated in liver diseases including acute liver failure (ALF); however, the role of the lectin pathway of complement has scarcely been investigated in ALF. The pathway is initiated by soluble pattern recognition molecules: mannan-binding lectin (MBL), M-, L- and H-ficolin and collectin-liver-1 (CL-L1), which are predominantly synthesised in the liver.AimWe aimed to study lectin levels in ALF patients and associations with clinical outcome.Methods: Serum samples from 75 patients enrolled by the U.S. ALF Study Group were collected on days 1 and 3. We included 75 healthy blood donors and 20 cirrhosis patients as controls. Analyses were performed using sandwich-type immunoassays (ELISA, TRIFMA).ResultsAt day 1, the MBL level in ALF patients was 40% lower compared with healthy controls ((median(interquartile range) 0.72 μg/ml(0.91) vs. 1.15(1.92)(p=0.02)), and increased significantly by day 3 (0.83 μg/ml(0.94)(p=0.01)). The M-ficolin level was 60% lower (0.54 μg/ml(0.50) vs. 1.48(1.01)(p<0.0001)). The CL-L1 level at day 1 was slightly higher compared with healthy controls (3.20 μg/ml(2.37) vs. 2.64(0.72)(p=0.11)); this was significant at day 3 (3.35(1.84)(p=0.006)). H- and L-ficolin levels were similar to healthy controls. Spontaneous ALF survivors had higher levels of MBL at day 1 (0.96 μg/ml(1.15) vs. 0.60(0.60)(p=0.02)) and lower levels of L-ficolin by day 3 compared with patients who died or were transplanted (1.61 μg/ml(1.19) vs. 2.17(2.19)(p=0.02)).Conclusion We observed significant dynamics in lectin levels in ALF patients, which may suggest they play a role in ALF pathogenesis. High MBL and low L-ficolin levels are associated with survival.This article is protected by copyright. All rights reserved.
    Liver international: official journal of the International Association for the Study of the Liver 09/2014; · 4.41 Impact Factor
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    ABSTRACT: Background The long-term clinical outcomes in initial survivors with acute liver failure (ALF) are not well known.AimsThe aim of the current study is to provide an overview of the 2 year clinical outcomes amongst initial survivors and liver transplant (LT) recipients that were alive 3 weeks after enrollment in the Acute Liver Failure Study Group (ALFSG).Methods Outcomes in adult ALFSG patients that were enrolled between 1998 and 2010 were reviewed.Results2-year patient survival was significantly higher in the 262 LT recipients (92.4%) compared to the 306 acetaminophen (APAP) spontaneous survivors (SS) (89.5%) and 200 non-APAP SS (75.5%) (p < 0.0001). The causes of death were similar in the 3 groups but the time to death was significantly longer in the LT recipients (p< 0.0001). Independent predictors of 2-year mortality in the APAP group were a high serum phosphate level and patient age (c-statistic = 0.65 (0.54, 0.76)), patient age and days from jaundice to ALF onset in the non-APAP group (c-statistic =0.69 (0.60, 0.78)), and patient age, days from jaundice, and higher coma grade in the LT recipients (c-statistic=0.74 (0.61, 0.87)). The LT recipients were significantly more likely to be employed and have a higher educational level (p < 0.05).Conclusions Two-year outcomes in initial survivors of ALF are generally good but non-APAP patients have a significantly lower survival which may relate to pre-existing medical co-morbidities. Spontaneous survivors with APAP overdose experience substantial morbidity during follow-up from ongoing psychiatric and substance abuse issues.This article is protected by copyright. All rights reserved.
    Liver international: official journal of the International Association for the Study of the Liver 07/2014; · 4.41 Impact Factor
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    ABSTRACT: Background & Aims Patients with acute liver failure (ALF) frequently develop renal dysfunction, yet its overall incidence and outcomes have not been fully assessed. We investigated the incidence of acute kidney injury (AKI) among patients with ALF, using defined criteria to identify risk factors and to evaluate its effect on overall outcomes. Methods We performed a retrospective review of data from 1604 patients enrolled in the Acute Liver Failure Study Group, from 1998 through 2010. Patients were classified by the Acute Kidney Injury Network criteria, as well as for etiology of liver failure (acetaminophen-based, ischemic, and all others). Results Seventy percent of patients with ALF developed AKI, and 30% received renal replacement therapy (RRT). Patients with severe AKI had higher international normalized ratio values than those without renal dysfunction (P<.001), and a higher proportion had advanced-grade coma (coma grade 3 or 4, P<.001) or presented with hypotension requiring vasopressor therapy (P<.001). A greater proportion of patients with acetaminophen-induced ALF had severe kidney injury than of patients with other etiologies of ALF; 34% required RRT, compared to 25% of patients with ALF not associated with acetaminophen or ischemia (P<.002). Of the patients with ALF who were alive at 3 weeks after study entry, significantly fewer with AKI survived for 1 year. Although AKI reduced overall survival time, more than 50% of patients with acetaminophen-associated or ischemic ALF survived without liver transplantation (even with RRT), compared to 19% of patients ALF due to other causes (P<.001). Only 4% of patients requiring RRT became dependent on dialysis. Conclusions Based on a retrospective analysis of data from more than 1600 patients, AKI is common in patients with ALF and affects short- and long-term outcomes, but rarely results in chronic kidney disease. Acetaminophen-induced kidney injury is frequent but patients have better outcomes than those with other forms of ALF.
    Clinical Gastroenterology and Hepatology 07/2014; · 6.53 Impact Factor
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    ABSTRACT: Idiosyncratic drug-induced liver injury (DILI) is a rare adverse drug reaction and it can lead to jaundice, liver failure, or even death. Antimicrobials and herbal and dietary supplements are among the most common therapeutic classes to cause DILI in the Western world. DILI is a diagnosis of exclusion and thus careful history taking and thorough work-up for competing etiologies are essential for its timely diagnosis. In this ACG Clinical Guideline, the authors present an evidence-based approach to diagnosis and management of DILI with special emphasis on DILI due to herbal and dietary supplements and DILI occurring in individuals with underlying liver disease.Am J Gastroenterol advance online publication, 17 June 2014; doi:10.1038/ajg.2014.131.
    The American Journal of Gastroenterology 06/2014; · 9.21 Impact Factor
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    ABSTRACT: Acetaminophen (APAP) overdose is a major cause of acute liver failure (ALF). Numerous studies have shown that APAP hepatotoxicity in mice involves mitochondrial dysfunction, and recent data suggest this is also the case in humans. We have previously shown that glutamate dehydrogenase (GDH), mitochondrial DNA (mtDNA) and nuclear DNA (nDNA) fragments can be measured in circulation of overdose patients as mechanistic biomarkers of mitochondrial damage and damage-associated molecular patterns. In the present study, our goal was to determine if these biomarkers are higher in serum from non-survivors of APAP-induced ALF (AALF) compared with survivors. GDH, mtDNA and nDNA fragments were measured in serum from AALF patients who did (n = 34) or did not (n = 35) recover. Importantly, all three were significantly increased in patients who died compared with those who survived (GDH: 450±73 vs. 930±145 U/L; mtDNA: 21±6 vs. 48±13 and 33±10 vs. 43±7 ng/mL for two different genes; nDNA fragments: 148±13 vs. 210±13 % of control). Receiver operating characteristic (ROC) curve analyses revealed that nDNA fragments, GDH and mtDNA were predictive of outcome (AUC, study admission: 0.73, 0.70 and 0.71 or 0.76, respectively, p < 0.05; AUC, time of peak ALT: 0.78, 0.71 and 0.71 or 0.76, respectively, p < 0.05) and the results were similar to those from the model for end-stage liver disease (MELD) (AUC, peak MELD: 0.77, p < 0.05). Conclusions: Our data suggest that patients with more mitochondrial damage are less likely to survive, demonstrating that mitochondria are central in the mechanisms of APAP hepatotoxicity in humans. Clinically, serum nDNA fragments, GDH and mtDNA could be useful as part of a panel of biomarkers to predict patient outcome. (Hepatology 2014;).
    Hepatology 06/2014; · 11.19 Impact Factor
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    ABSTRACT: MicroRNA-122 (miR-122) is the foremost liver-related micro-RNA, but its role in the hepatocyte is not fully understood. To evaluate whether circulating levels of miR-122 are elevated in chronic-HCV for a reason other than hepatic injury, we compared serum level in patients with chronic hepatitis C to other forms of liver injury including patients with acute liver failure and healthy controls. MiR-122 was quantitated using sera from 35 acute liver failure patients (20 acetaminophen-induced, 15 other etiologies), 39 chronic-HCV patients and 12 controls. In parallel, human genomic DNA (hgDNA) levels were measured to reflect quantitatively the extent of hepatic necrosis. Additionally, six HIV–HCV co-infected patients, who achieved viral clearance after undergoing therapy with interferon and ribavirin, had serial sera miR-122 and hgDNA levels measured before and throughout treatment. Serum miR-122 levels were elevated approximately 100-fold in both acute liver failure and chronic-HCV sera as compared to controls (P < 0.001), whereas hgDNA levels were only elevated in acute liver failure patients as compared to both chronic-HCV and controls (P < 0.001). Subgroup analysis showed that chronic-HCV sera with normal aminotransferase levels showed elevated miR-122 despite low levels of hepatocyte necrosis. All successfully treated HCV patients showed a significant Log10 decrease in miR-122 levels ranging from 0.16 to 1.46, after sustained viral response. Chronic-HCV patients have very elevated serum miR-122 levels in the range of most patients with severe hepatic injury leading to acute liver failure. Eradication of HCV was associated with decreased miR-122 but not hgDNA. An additional mechanism besides hepatic injury may be active in chronic-HCV to explain the exaggerated circulating levels of miR-122 observed. J. Med. Virol. © 2014 Wiley Periodicals, Inc.
    Journal of Medical Virology 06/2014; · 2.22 Impact Factor
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    Imir G Metushi, William M Lee, Jack Uetrecht
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    ABSTRACT: Isoniazid (INH) therapy is associated with a significant incidence of idiosyncratic liver failure. We recently reported eight cases of INH-induced liver failure in which patients had anti-drug and anti-cytochrome P450 antibodies. However, it was unclear what role these antibodies play in the mechanism of INH-induced liver injury. Here, we report that the dominant isotype of anti-INH antibodies was IgG, with IgG3 being the dominant subtype. IgG3 antibodies are associated with a Th1-type immune response and fix complement. IgG3 antibodies have been associated with other forms of liver injury and may play a pathogenic role in INH-induced liver injury.
    Chemical Research in Toxicology 04/2014; · 4.19 Impact Factor
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    ABSTRACT: Little is known about the incidence of drug-induced liver injury (DILI) and risk factors for adverse outcomes. We evaluated short-term outcomes of a large cohort of patients with DILI enrolled in an ongoing multicenter prospective study. Data were collected from 660 adults with definite, highly likely, or probable DILI. Regression methods were used to identify risk factors for early liver-related death or liver transplantation and chronic liver injury. The patients' median age was 51.4 years; 59.5% were female and 59.1% required hospitalization. Within 6 months of DILI onset, 30 patients received liver transplants (4.5%; 95% confidence interval (CI), 3.0%-6.1%) and 32 died (5%; 95% CI, 3.2%-6.5%); 53% of the deaths were liver related. Asian race, itching, lung disease, low serum albumin levels, low platelet counts, and high serum levels of alanine aminotransferase and total bilirubin at presentation were independent risk factors for reduced times to liver-related death or liver transplantation (C statistic= 0.87). At 6 months after DILI onset, 18.9% of the 598 evaluable subjects had persistent liver damage. African-American race, higher serum levels of alkaline phosphatase, and prior heart disease or malignancy requiring treatment were independent risk factors for chronic DILI (C statistic = 0.71). Nearly 1 in 10 patients die or undergo liver transplantation within 6 months of DILI onset and nearly 1 in 5 of the remaining patients have evidence of persistent liver injury at 6 months. The profile of liver injury at presentation, initial severity, patient's race, and medical co-morbidities are important determinants of the likelihood of death/ transplant or persistent liver injury within 6 months.
    Gastroenterology 03/2014; · 12.82 Impact Factor
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    Hepatology 03/2014; · 11.19 Impact Factor
  • Hepatology 02/2014; 59(2). · 11.19 Impact Factor
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    ABSTRACT: Acute liver failure (ALF) is a rare clinical syndrome associated with a high case fatality rate. Asymptomatic primary infection with Epstein-Barr virus (EBV) is common in the general population while acute hepatitis and jaundice are much less common and ALF has been rarely reported. We reviewed the presenting features as well as clinical outcomes amongst consecutive adults with EBV-related ALF. Amongst the 1,887 adult ALF patients enrolled into the US ALF Study Group from January 1998 to February 2012, there were four patients (0.21 %) with EBV-related ALF. Diagnostic criteria for acute EBV infection included compatible serologies and/or the detection of EBV-encoded RNA (EBER) in liver tissue. Median patient age was 30 years (range 18-44); 75 % were male, and only 25 % were immunosuppressed. The median presenting ALT was 504 IU/mL (range 156-4,920), median Alk P was 431 (range 136-1,009), and median bilirubin was 17 mg/dL (range 13-22.1). Liver biopsy findings ranged from cholestasis to submassive necrosis with EBER + staining in two of the three samples tested. Although all of the patients were treated with an antiviral agent, two died of ALF, one underwent liver transplantation (LT) and one survived with supportive care and is well at 5 years. A review of the literature identified four additional LT recipients with favorable long-term outcomes. Primary EBV infection accounts for <1 % of consecutive adult ALF cases but is associated with a high case fatality rate. LT is associated with favorable short- and long-term outcomes.
    Digestive Diseases and Sciences 01/2014; · 2.26 Impact Factor
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    ABSTRACT: Drug-induced liver injury (DILI) is the most common cause of acute liver failure in the United-States. The aim of the study was to describe serum immune profiles associated with acute DILI, to investigate whether there are profiles associated with clinical features or types of DILI and/or with prognosis, and to assess temporal changes in levels. Twenty-seven immune analytes were measured in the sera of 78 DILI subjects in the Drug-Induced Liver Injury Network (DILIN) and compared with 40 healthy controls. Immune analytes (14 cytokines, 7 chemokines and 6 growth factors) were measured by BioPlex multiplex ELISA at DILI onset and after 6 months. A modeling process utilizing immune principles was used to select a final set of variables among 27 immune analytes and several additional clinical lab values for prediction of early death (within 6 months of DILI onset). Nineteen of the 27 immune analytes were differentially expressed among healthy control, DILI onset and 6-month cohorts. Disparate patterns of immune responses, especially innate and adaptive cellular (mostly TH17) immunity were evident. Low values of four immune analytes (IL-9, IL-17, PDGF-bb and RANTES) and serum albumin are predictive of early death [PPV = 88% (95% CI, 65%-100%), NPV = 97% (95% CI, 93%-100%), accuracy = 96% (95% CI, 92%-100%)]. Acute DILI is associated with robust and varying immune responses. High levels of expression of cytokines associated with innate immunity are associated with a poor prognosis, whereas high levels of expression of adaptive cytokines are associated with good long-term prognosis and eventual recovery. Serum immune analyte profiles at DILI onset appear to be of prognostic, and perhaps, diagnostic significance.
    PLoS ONE 12/2013; 8(12):e81974. · 3.53 Impact Factor

Publication Stats

11k Citations
1,760.49 Total Impact Points


  • 1994–2014
    • University of Texas Southwestern Medical Center
      • • Division of Digestive and Liver Diseases
      • • Department of Internal Medicine
      Dallas, Texas, United States
  • 2013
    • Stanford University
      • Division of Gastroenterology and Hepatology
      Palo Alto, CA, United States
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
    • University of Miami Miller School of Medicine
      Miami, Florida, United States
  • 2010–2013
    • University of Toronto
      • Department of Pharmacology and Toxicology
      Toronto, Ontario, Canada
    • Johns Hopkins University
      Baltimore, Maryland, United States
    • North Carolina Clinical Research
      Raleigh, North Carolina, United States
    • Medical University of South Carolina
      • Division of Gastroenterology and Hepatology
      Charleston, SC, United States
  • 2004–2013
    • Virginia Commonwealth University
      • Division of Gastroenterology, Hepatology and Nutrition
      Richmond, Virginia, United States
  • 2011–2012
    • Massachusetts General Hospital
      • Department of Medicine
      Boston, Massachusetts, United States
    • University of Kansas
      • Department of Internal Medicine
      Lawrence, KS, United States
  • 2005–2011
    • Washington University in St. Louis
      • Division of Gastroenterology
      Saint Louis, MO, United States
  • 2008–2010
    • National Institutes of Health
      • National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
      Maryland, United States
    • University of Southern California
      • Division of Gastrointestinal and Liver Diseases
      Los Angeles, CA, United States
    • Montefiore Medical Center
      New York City, New York, United States
  • 2005–2010
    • University of Michigan
      • Department of Internal Medicine
      Ann Arbor, MI, United States
  • 2009
    • Arkansas Children's Hospital
      Little Rock, Arkansas, United States
    • University of Pennsylvania
      • Division of Gastroenterology
      Philadelphia, PA, United States
  • 2007
    • Harvard Medical School
      Boston, Massachusetts, United States
    • Aarhus University Hospital
      • Department of Clinical Biochemistry
      Aarhus, Central Jutland, Denmark
  • 2006
    • Mulago Hospital
      Kampala, Central Region, Uganda
    • University of Colorado
      • Division of Gastroenterology and Hepatology
      Denver, CO, United States
  • 2005–2006
    • University of Washington Seattle
      • Department of Laboratory Medicine
      Seattle, WA, United States
  • 2000–2006
    • University of California, San Francisco
      • Division of Hospital Medicine
      San Francisco, California, United States
  • 2003
    • Gold Coast University Hospital
      Southport, Queensland, Australia
    • Northwestern University
      • Department of Medicine
      Evanston, IL, United States