Jeffrey L Myers

University of Michigan, Ann Arbor, Michigan, United States

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Publications (93)494.3 Total impact

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    ABSTRACT: Idiopathic pulmonary fibrosis is a progressive fibrotic lung disease that distorts pulmonary architecture, leading to hypoxia, respiratory failure, and death. Diagnosis is difficult because other interstitial lung diseases have similar radiological and histopathological characteristics. A usual interstitial pneumonia pattern is a hallmark of idiopathic pulmonary fibrosis and is essential for its diagnosis. We aimed to develop a molecular test that distinguishes usual interstitial pneumonia from other interstitial lung diseases in surgical lung biopsy samples. The eventual goal of this research is to develop a method to diagnose idiopathic pulmonary fibrosis without the patient having to undergo surgery. We collected surgical lung biopsy samples from patients with various interstitial lung diseases at 11 hospitals in North America. Pathology diagnoses were confirmed by an expert panel. We measured RNA expression levels for 33 297 transcripts on microarrays in all samples. A classifier algorithm was trained on one set of samples and tested in a second set. We subjected a subset of samples to next-generation RNA sequencing (RNAseq) generating expression levels on 55 097 transcripts, and assessed a classifier trained on RNAseq data by cross-validation. We took 125 surgical lung biopsies from 86 patients. 58 samples were identified by the expert panel as usual interstitial pneumonia, 23 as non-specific interstitial pneumonia, 16 as hypersensitivity pneumonitis, four as sarcoidosis, four as respiratory bronchiolitis, two as organising pneumonia, and 18 as subtypes other than usual interstitial pneumonia. The microarray classifier was trained on 77 samples and was assessed in a test set of 48 samples, for which it had a specificity of 92% (95% CI 81-100) and a sensitivity of 82% (64-95). Based on a subset of 36 samples, the RNAseq classifier had a specificity of 95% (84-100) and a sensitivity of 59% (35-82). Our results show that the development of a genomic signature that predicts usual interstitial pneumonia is feasible. These findings are an important first step towards the development of a molecular test that could be applied to bronchoscopy samples, thus avoiding surgery in the diagnosis of idiopathic pulmonary fibrosis. Veracyte. Copyright © 2015 Elsevier Ltd. All rights reserved.
    05/2015; 3(6). DOI:10.1016/S2213-2600(15)00140-X
  • Joel K Greenson, Jeffrey L Myers
    Archives of pathology & laboratory medicine 10/2014; 138(10):1266-1267. DOI:10.5858/arpa.2014-0362-ED · 2.88 Impact Factor
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    ABSTRACT: Objective: A panel of immunohistochemical (IHC) stains frequently used to subclassify non-small cell lung cancers (NSCLCs) includes napsin A, TTF-1, CK5/6, p40, and p63. The expression profiles of these stains in neuroendocrine tumors have not been systematically evaluated. Method: Sixty-eight resected pulmonary neuroendocrine tumors, including 52 typical carcinoids (TCs), eight atypical carcinoids (ACs), seven small cell carcinomas (SCLCs) and one large cell neuroendocrine carcinoma (LCNEC), were stained for napsin A, TTF-1, p63, p40, and CK5/6. Tumors were scored as positive (>1% tumor cells reactive) or negative, and percentage of reactive tumor cells was recorded. Results: Napsin A, p63, p40, and CK5/6 were consistently negative in neuro endocrine tumors. TTF-1 was positive in 17 of 52 TCs, 4 of 8 ACs, 5 of 7 SCLCs, and 0 of 1 LCNECs. Conclusion: Pulmonary neuroendocrine tumors have a distinct but nonspecific profile on IHC panel commonly applied to subclassify) NSCLCs. They are napsin A-/p40-/p63-/CK5/6-TTF-1 +/-. Recognizing this profile may have value in separating neuroendocrine tumors from NSCLCs.
    American Journal of Clinical Pathology 09/2014; 142(3):320-4. DOI:10.1309/AJCPGA0IUA8BHQEZ · 3.01 Impact Factor
  • USCAP 2014 Annual Meeting, San Diego; 03/2014
  • Article: Response.
    Chest 02/2014; 145(2):434. DOI:10.1378/chest.13-2763 · 7.13 Impact Factor
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    ABSTRACT: Twin recent reports identify a novel entity, primary pulmonary myxoid sarcoma (PPMS)(1) and an endobronchial presentation of angiomatoid fibrous histiocytoma (AFH)(2) . PPMS was described as 2-4cm lesions occurring in young patients (mean age 45 years), as endobronchial, lobulated neoplasms of polygonal to spindled cells within a myxoid stroma evocative of extraskeletal myxoid chondrosaroma (EMC)(1,3) . In contrast to EMC, seven of nine testable cases harbored EWSR1-CREB1 gene fusions. Nine of ten showed remarkable associated inflammation, focal to follicular to lymphoplasmacytic. This article is protected by copyright. All rights reserved.
    Histopathology 12/2013; 65(1). DOI:10.1111/his.12354 · 3.30 Impact Factor
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    ABSTRACT: Pulmonary nodules, both solid and subsolid, are common incidental findings on computed tomography (CT) studies. Subsolid nodules (SSNs) may be further classified as either pure ground-glass nodules or part-solid nodules. The differential diagnosis for an SSN is broad, including infection, organizing pneumonia, inflammation, hemorrhage, focal fibrosis, and neoplasm. Adenocarcinomas of the lung are currently the most common type of lung cancer, representing 30-35% of all primary lung tumors, and the subtype of bronchioloalveolar cell carcinoma (BAC) commonly presents as an SSN. In 2011, a new classification system for lung adenocarcinomas was proposed by the International Association for the Study of Lung Cancer, the American Thoracic Society, and the European Respiratory Society. An important feature of the new system is the relinquishment of the term BAC in favor of more specific histologic subtypes. It has been reported that these subtypes are associated with characteristic CT findings. This article reviews the new classification system of lung adenocarcinomas, discusses and illustrates the associated CT findings, and outlines the current recommendations for further diagnosis, treatment, and follow-up of SSNs based on computed tomography findings.
    Cancer Imaging 09/2013; 13(3):365-73. DOI:10.1102/1470-7330.2013.9025 · 1.29 Impact Factor
  • Chen Zhang, Jeffrey L Myers
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    ABSTRACT: Crystal-storing histiocytosis is an uncommon form of nonneoplastic histiocytic proliferation that in most patients complicates an underlying lymphoproliferative or plasma cell disorder. Lung is a common site of involvement in patients with localized disease. We present an illustrative example from a 54-year-old woman with an asymptomatic solitary lung nodule. The tumor was characterized by sheets of histiocytes with abundant cytoplasm expanded by distinctive eosinophilic inclusions. Focal necrosis was present. Aggregates of monocytoid lymphocytes and clusters of peribronchiolar plasma cells were overshadowed by the histiocytic infiltrate. Immunohistochemical stains showed CD68 staining in nonneoplastic histiocytes and CD20 staining in monocytoid lymphocytes. In situ hybridization studies showed κ light-chain restriction in plasma cells. These results, combined with the histologic findings, supported the diagnosis of crystal-storing histiocytosis complicating marginal zone lymphoma of mucosa-associated lymphoid tissue. We review the literature pertaining to pulmonary crystal-storing histiocytosis, highlighting the differential diagnosis for this rare phenomenon.
    Archives of pathology & laboratory medicine 09/2013; 137(9):1199-204. DOI:10.5858/arpa.2013-0252-CR · 2.88 Impact Factor
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    ABSTRACT: Context.-In 2006, the department of pathology at our institution established an intramural research funding mechanism to support anatomic pathology research projects for faculty and trainee development. A review committee consisting of faculty members with diverse academic interests evaluated applications; proposals were eligible for a maximum award amount of $30 000 per project with a maximum program cost of $150 000 annually. Objective.-To report our experience based on a retrospective review of the research proposals submitted to the committee since the inception of the Anatomic Pathology Research Fund and evaluate the outcomes of the funded projects. Design.-We retrospectively analyzed all project applications that were received by the committee. Outcome data were collected by reviewing progress reports, abstracts for national and international meetings, PubMed search results, and/or direct communication with investigators. Results.-To date, a total of 59 individual projects have been awarded funding, for a total amount of $349 792, with an average award amount of $5381 per project. A total of 26 faculty members have secured funding for projects through this mechanism, and 27 resident and fellow trainees have been engaged in the funded projects. Spanning 11 subspecialty disciplines in anatomic pathology, 32 abstracts (54%) have been presented at national meetings and 26 (44%) have been published in the peer-reviewed literature to date. One project generated data used to secure an extramural (R01) grant. Conclusions.-Our funding mechanism could serve as a model used by other academic departments to support research activities, thereby fostering faculty development through scholarly activities.
    Archives of pathology & laboratory medicine 09/2013; 137(9):1270-3. DOI:10.5858/arpa.2012-0546-OA · 2.88 Impact Factor
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    ABSTRACT: Rheumatoid arthritis (RA) is a systemic autoimmune disorder with a variety of extra-articular manifestations. The lung is a common target and diffuse parenchymal lung disease can appear as any of the patterns found with idiopathic interstitial pneumonia. Controversy exists as to the prognostic significance of these patterns among patients with RA-ILD. We retrospectively identified 48 patients with a diagnosis of RA-ILD confirmed by surgical lung biopsy. The pathology was reviewed by four expert pulmonary pathologists. We examined survival after stratifying on the presence or absence of fibrotic ILD, and contrasted it with a matched idiopathic pulmonary fibrosis (IPF) population. The Cox proportional hazards model was used to identify independent predictors of survival. The majority of subjects were male smokers with physiologic restriction. A usual interstitial pneumonia (UIP)-pattern was identified in 31% of subjects. Median survival time for the entire cohort was 1360 days. Subjects with fibrotic ILD had worse survival than subjects with non-fibrotic ILD (log rank p = 0.02). There was no difference in survival between UIP-pattern RA-ILD subjects and IPF controls (log rank p = 0.94). Multivariable analysis revealed that age (hazard ratio [HR] = 1.04, p = 0.01) and fibrosis (HR = 2.1, p = 0.02) were independent predictors of mortality. Both cellular and fibrosing ILD patterns are common among RA-ILD patients who undergo surgical lung biopsy. These patients have a shortened survival when compared to the general population and all-comers with RA. Age and the presence of a fibrosing interstitial pneumonia predict shortened survival in these patients. Survival in UIP is similar to matched IPF patients.
    Respiratory medicine 06/2013; 107(8). DOI:10.1016/j.rmed.2013.05.002 · 2.92 Impact Factor
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    ABSTRACT: ABSTRACT BACKGROUND: The etiology of pulmonary necrotizing granulomas is often unclear even after histologic examination. Our aim was to determine the clinical significance of histologically unexplained necrotizing granulomas. METHODS: Pulmonary necrotizing granulomas surgically resected at Mayo Clinic (1994-2004) were retrieved and reviewed retrospectively. Cases in which an etiology was evident at the time of initial histologic examination were excluded. The analysis cohort comprised 131 completely resected histologically unexplained pulmonary necrotizing granulomas. Clinical and laboratory information was abstracted from medical records, chest CT scans reviewed, histologic slides re-examined and additional ancillary studies performed in selected cases. RESULTS: An etiology was determined on review in more than half of histologically unexplained necrotizing granulomas (79/131, 60%) by re-examining histologic slides (47), incorporating results of cultures (26), fungal serologies (14) and other laboratory studies (8) and correlating histologic findings with clinical and radiologic information (13). Infections accounted for the majority (64/79), the most common being histoplasmosis (37) and non-tuberculous mycobacterial infections (18). Non-infectious diagnoses (15/79) were rheumatoid nodule (5), granulomatosis with polyangiitis (Wegener's granulomatosis) (5), sarcoidosis (4), and chronic granulomatous disease (1). Many cases remained unexplained even after extensive review (52/131, 40%). Most of these patients received no medical therapy, and did not progress clinically or develop new nodules (median follow-up 84 months). CONCLUSION: An etiology can be established in many surgically resected pulmonary necrotizing granulomas that appear unexplained at the time of initial histologic diagnosis, the most common being infection. Patients whose granulomas remain unexplained after a rigorous review have a favorable outcome. Most do not develop new nodules or progress clinically, even without medical therapy.
    Chest 04/2013; 144(3). DOI:10.1378/chest.12-2113 · 7.13 Impact Factor
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    ABSTRACT: Context.-Sclerosing hemangiomas (SH) are lung tumors characterized by surface cuboidal cells and round stromal cells. The cell of origin remains controversial, though immunohistochemical and ultrastructural studies suggest primitive respiratory epithelium. Napsin A, a human aspartic proteinase found primarily in type II pneumocytes and alveolar macrophages, is emerging as a helpful immunohistochemical marker in characterizing the origin of lung neoplasms, and may be of use in evaluating SH. Objective.-To evaluate napsin A immunohistochemical staining in SH to further characterize the cell of origin. Design.-Six cases of SH were stained for napsin A, as well as thyroid transcription factor 1 and cytokeratin in selected cases. Results.-Surface and round cells were positive for thyroid transcription factor 1 in all cases stained with this marker. Cytokeratins were positive in surface cells in all cases stained with this marker; 2 cases had focal cytokeratin staining in round cells. Round cells had focal napsin A staining in 1 case (17%); surface cells were napsin positive in all cases. Conclusions.-The observation of thyroid transcription factor 1 positivity in both surface and round cells in all SH suggests primitive respiratory epithelium as the cell of origin of SH. Our napsin A findings support this, with positivity in surface cells of all tumors (100%), and focal round cell staining in only 1 (17%). In fact, surface cells may represent entrapped type II pneumocytes, which normally express napsin A in a granular cytoplasmic pattern, similar to surface cells. The coexpression of thyroid transcription factor 1 and napsin A also introduces a caveat in differentiating primary pulmonary adenocarcinomas from SH in small biopsy specimens.
    Archives of pathology & laboratory medicine 12/2012; 136(12):1580-4. DOI:10.5858/arpa.2011-0486-OA · 2.88 Impact Factor
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    ABSTRACT: Intraoperative frozen section (FS) margin evaluation is not common practice for patients undergoing breast conservation therapy (BCT), but offers a significant reduction in reoperation. In this study, a technique to allow for more effective freezing of breast tissue was developed to perform FS evaluation of lumpectomy margins (FSM) for all patients undergoing BCT at an ambulatory surgery center. FS evaluation of sentinel lymph node biopsy specimens was performed concurrently. One hundred eighty-one study and 188 control patients, with and without FS evaluation, were compared. Reexcision was reduced 34% (from 48.9% to 14.9%) and reoperation was reduced 36% (from 55.3% to 19.3%) with FS evaluation. Most of the decrease in reoperative rate was because of a decrease in the need for margin reexcision. The number of patients requiring 1, 2, or 3 operations to complete therapy was 84, 92, and 12, respectively, in the control group, and 146, 33, and 2, respectively, in the study group. Lobular subtype, multifocal disease, and larger tumor size (≥2 cm) were significantly associated with failure of FSM to prevent reoperation, but reoperation rates were still significantly decreased in this subgroup of patients (from 75.5% to 43.8%) with FSM. This study highlights an innovative yet simple and adaptable FS approach that resulted in a nearly 3-fold reduction in reoperation for patients undergoing BCT.
    American Journal of Clinical Pathology 11/2012; 138(5):657-69. DOI:10.1309/AJCP4IEMXCJ1GDTS · 3.01 Impact Factor
  • Jonathon B Herbst, Jeffrey L Myers
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    ABSTRACT: Lung biopsy often plays a key role in identifying patients with hypersensitivity pneumonia, especially in the absence of a typical history. A 69-year-old woman with a 2-year history of unexplained dyspnea on exertion underwent surgical lung biopsy for diagnosis of diffuse lung disease thought to represent idiopathic pulmonary fibrosis. Her biopsy showed honeycomb change and fibroblast foci suggestive of usual interstitial pneumonia, but also showed areas of cellular interstitial pneumonia with chronic bronchiolitis and a pattern of granulomatous inflammation typical of hypersensitivity pneumonia. The classic features of hypersensitivity pneumonia in surgical lung biopsy are emphasized, including a bronchiolocentric cellular interstitial pneumonia, chronic bronchiolitis, and poorly formed nonnecrotizing granulomas. As illustrated in our patient, sometimes subtle histologic clues are key in separating hypersensitivity pneumonia from usual interstitial pneumonia and other forms of idiopathic interstitial pneumonia. Making the distinction is important given differences in treatment strategies and natural history.
    Archives of pathology & laboratory medicine 08/2012; 136(8):889-95. DOI:10.5858/arpa.2012-0201-CR · 2.88 Impact Factor
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    Jeffrey L Myers, Joel K Greenson
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    ABSTRACT: New Frontiers in Pathology is a unique educational event intended to meet the ongoing educational needs of practicing pathologists. Continuous medical education (CME) is required for maintenance of licensure by virtually all state licensing bodies. Satisfying CME requirements hinges on earning a minimum number of American Medical Association Physician Recognition Award category 1 credits through various activities, including courses like New Frontiers in Pathology that are accredited by the Accreditation Council for Continuing Medical Education. Self-assessment modules (SAMs) are a key component of the American Board of Pathology expectations for maintenance of board certification. Beginning in 2006, the American Board of Pathology granted only time-limited certificates as part of an American Board of Medical Specialties-wide process for maintenance of board certification. Maintenance of board certification has requirements in 4 categories: professional standing, life-long learning and self-assessment, cognitive expertise, and evaluation of performance in practice. Life-long learning and self-assessment includes not only the traditional elements of CME but also the SAMs that are defined as educational products comprising self-administered examinations with a predetermined minimum performance level and a mechanism for receiving feedback. New Frontiers in Pathology will offer SAMs, in addition to the American Medical Association Physician Recognition Award category 1 credits, which it has been accredited to do since its inception, at its 2012 conference scheduled for August 3 through August 5 at The Homestead Resort, Michigan's largest waterfront resort on beautiful Lake Michigan.
    Archives of pathology & laboratory medicine 08/2012; 136(8):851-3. DOI:10.5858/arpa.2012-0234-ED · 2.88 Impact Factor
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    ABSTRACT: A survey completed by 366 pathology residents and fellows examined preferences for 3 fellowship application systems: keeping the current system, a National Resident Matching Program (NRMP)-style match, and a unified time line. All groups showed a strong preference for a time line, accounting for 62.1% of first choices vs the current system (17.3%) or a match (20.6%). When asked for a second choice after time line was ranked first, 60.5% of respondents whose fellowship of choice was available at their residency institution and 63.5% who had accepted fellowship positions at their residency institution preferred the current system; 51.4% whose fellowship of choice was not available at their residency institution and 50.6% of those who had accepted fellowship positions elsewhere preferred a match. Location and family/personal reasons were more important than subspecialty competitiveness and program prestige when accepting fellowship positions. Pressure to choose and apply early for fellowship persists and is greatest for anatomic pathology-only and clinical pathology-only residents.
    American Journal of Clinical Pathology 04/2012; 137(4):543-52. DOI:10.1309/AJCP2YNIJ0ZPMJNE · 3.01 Impact Factor
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    ABSTRACT: Critical values in anatomic pathology are rare occurrences and difficult to define with precision. Nevertheless, accrediting institutions require effective and timely communication of all critical values generated by clinical and anatomic laboratories. Provisional gating criteria for potentially critical anatomic diagnoses have been proposed, with some success in their implementation reported in the literature. Ensuring effective communication is challenging, however, making the case for programmatic implementation of a turnkey-style integrated information technology solution. To address this need, we developed a generically deployable laboratory information system-based tool, using a tiered natural language processing predicate calculus inference engine to identify qualifying cases that meet criteria for critical diagnoses but lack an indication in the electronic medical record for an appropriate clinical discussion with the ordering physician of record. Using this tool, we identified an initial cohort of 13,790 cases over a 49-month period, which were further explored by reviewing the available electronic medical record for each patient. Of these cases, 35 (0.3%) were judged to require intervention in the form of direct communication between the attending pathologist and the clinical physician of record. In 8 of the 35 cases, this intervention resulted in the conveyance of new information to the requesting physician and/or a change in the patient's clinical plan. The very low percentage of such cases (0.058%) illustrates their rarity in daily practice, making it unlikely that manual identification/notification approaches alone can reliably manage them. The automated turnkey system was useful in avoiding missed handoffs of significant, clinically actionable diagnoses.
    The American journal of surgical pathology 03/2012; 36(3):376-80. DOI:10.1097/PAS.0b013e318245c9a4 · 4.59 Impact Factor
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    ABSTRACT: Recognizing the difficulty in applying the concept of critical values to anatomic pathology diagnoses, the College of American Pathologists and the Association of Directors of Anatomic and Surgical Pathology have chosen to reevaluate the concept of critical diagnoses. To promote effective communication of urgent and significant, unexpected diagnoses in surgical pathology and cytology. A comprehensive literature search was conducted and reviewed by an expert panel. A policy of effective communication of important results in surgical pathology and cytology is desirable to enhance patient safety and to address multiple regulatory requirements. Each institution should create its own policy regarding urgent diagnoses and significant, unexpected diagnoses in anatomic pathology. This policy should be separate from critical results or panic-value policies in clinical pathology, with the expectation of a different time frame for communication. Urgent diagnosis is defined as a medical condition that, in most cases, should be addressed as soon as possible. Significant, unexpected diagnosis is defined as a medical condition that is clinically unusual or unforeseen and should be addressed at some point in the patient's course. Further details of this statement are provided.
    Archives of pathology & laboratory medicine 02/2012; 136(2):148-54. DOI:10.5858/arpa.2011-0400-SA · 2.88 Impact Factor
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    Jeffrey L Myers
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    ABSTRACT: Hypersensitivity pneumonia is a form of diffuse interstitial lung disease resulting from sensitization to an inhaled antigen. Clinical and radiological features are relatively nonspecific, overlapping significantly with other forms of diffuse interstitial lung disease. Establishing the diagnosis in the absence of lung biopsy is challenging and is heavily dependent on being able to identify a specific antigenic exposure. Lung biopsy is especially important in diagnosing hypersensitivity pneumonia in patients for whom no incriminating exposure has been elucidated. Surgical lung biopsies show a classical combination of findings in the majority of patients, which include an airway-centered, variably cellular chronic interstitial pneumonia, a lymphocyte-rich chronic bronchiolitis, and poorly formed non-necrotizing granulomas distributed mainly within the peribronchiolar interstitium. The bronchiolitis may include variable degrees of peribronchiolar fibrosis and hyperplasia of the bronchiolar epithelium ('peribronchiolar metaplasia'), a characteristic but a nonspecific finding. In some patients, granulomatous inflammation may be lacking, resulting in a histological appearance resembling nonspecific interstitial pneumonia. Late-stage fibrotic hypersensitivity pneumonia results in clinical, radiological, and histological findings that closely mimic usual interstitial pneumonia. The presence of established collagen fibrosis, especially when associated with architectural distortion in the form of honeycomb change, is associated with shorter survivals.
    Modern Pathology 01/2012; 25 Suppl 1:S58-67. DOI:10.1038/modpathol.2011.152 · 6.36 Impact Factor
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    ABSTRACT: Plastic bronchitis (PB) is a rare disease that often occurs in patients with congenital heart disease (CHD) who have undergone staged single-ventricle palliation. It is characterized by the formation of rubbery "casts" in the airways. PB treatment frequently includes inhaled tissue plasminogen activator (tPA). However, the efficacy of tPA to reduce cast burden is unknown. This is further complicated by our lack of knowledge of cast composition. We obtained spontaneously expectorated PB casts from children (n = 4) with CHD and one adult patient with idiopathic PB. Pathological assessment was made from paraffin-preserved samples. Casts were treated with phosphate-buffered saline (PBS) or tPA. Cast response to tPA was assessed by changes in cast weight and the production of fibrin D-dimer. Independent of dose, tPA reduced cast weight compared with PBS-treatment (P = 0.001) and increased D-dimer levels. Histological staining showed that PB casts from all patients were composed of fibrin and contained notable numbers of lymphocytes. Cast composition did not change over time. Collectively, these data support that in our PB patients, casts are composed of fibrin and are responsive to tPA treatment. This makes inhaled tPA a potentially viable option for symptomatic relief of PB while we work to unravel the complexity of PB pathogenesis.
    Pediatric Cardiology 07/2011; 32(8):1182-9. DOI:10.1007/s00246-011-0058-x · 1.55 Impact Factor

Publication Stats

3k Citations
494.30 Total Impact Points


  • 2006–2015
    • University of Michigan
      • Department of Pathology
      Ann Arbor, Michigan, United States
  • 2008–2014
    • Concordia University–Ann Arbor
      Ann Arbor, Michigan, United States
  • 1993–2013
    • Mayo Clinic - Rochester
      • • Department of Laboratory Medicine & Pathology
      • • Department of Pulmonary and Critical Care Medicine
      Рочестер, Minnesota, United States
  • 2006–2007
    • Mayo Foundation for Medical Education and Research
      Rochester, Michigan, United States
  • 2004
    • Instituto Nacional de Enfermedades Respiratorias
      Ciudad de México, Mexico City, Mexico