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Riley C, Venkatesh S, Dhand A, Doshi N, Kavak K, Levit E, Perrone C, Weinstock-Guttman B, Longbrake E, De Jager P, Xia Z. Impact of the COVID-19 Pandemic on the Personal Networks and Neurological Outcomes of People With Multiple Sclerosis: Cross-Sectional and Longitudinal Case-Control Study. JMIR Public Health Surveill 2024; 10:e45429. [PMID: 38319703 PMCID: PMC10879979 DOI: 10.2196/45429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 08/05/2023] [Accepted: 08/31/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic has negatively affected the social fabric. OBJECTIVE We evaluated the associations between personal social networks and neurological function in people with multiple sclerosis (pwMS) and controls in the prepandemic and pandemic periods. METHODS During the early pandemic (March-December 2020), 8 cohorts of pwMS and controls completed a questionnaire quantifying the structure and composition of their personal social networks, including the health behaviors of network members. Participants from 3 of the 8 cohorts had additionally completed the questionnaire before the pandemic (2017-2019). We assessed neurological function using 3 interrelated patient-reported outcomes: Patient Determined Disease Steps (PDDS), Multiple Sclerosis Rating Scale-Revised (MSRS-R), and Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function. We identified the network features associated with neurological function using paired 2-tailed t tests and covariate-adjusted regressions. RESULTS In the cross-sectional analysis of the pandemic data from 1130 pwMS and 1250 controls during the pandemic, having a higher percentage of network members with a perceived negative health influence was associated with worse disability in pwMS (MSRS-R: β=2.181, 95% CI 1.082-3.279; P<.001) and poor physical function in controls (PROMIS Physical Function: β=-5.707, 95% CI -7.405 to -4.010; P<.001). In the longitudinal analysis of 230 pwMS and 136 controls, the networks of all participants contracted, given an increase in constraint (pwMS-prepandemic: mean 52.24, SD 15.81; pwMS-pandemic: mean 56.77, SD 18.91; P=.006. Controls-prepandemic: mean 48.07, SD 13.36; controls-pandemic: mean 53.99, SD 16.31; P=.001) and a decrease in network size (pwMS-prepandemic: mean 8.02, SD 5.70; pwMS-pandemic: mean 6.63, SD 4.16; P=.003. Controls-prepandemic: mean 8.18, SD 4.05; controls-pandemic: mean 6.44, SD 3.92; P<.001), effective size (pwMS-prepandemic: mean 3.30, SD 1.59; pwMS-pandemic: mean 2.90, SD 1.50; P=.007. Controls-prepandemic: mean 3.85, SD 1.56; controls-pandemic: mean 3.40, SD 1.55; P=.01), and maximum degree (pwMS-prepandemic: mean 4.78, SD 1.86; pwMS-pandemic: mean 4.32, SD 1.92; P=.01. Controls-prepandemic: mean 5.38, SD 1.94; controls-pandemic: mean 4.55, SD 2.06; P<.001). These network changes were not associated with worsening function. The percentage of kin in the networks of pwMS increased (mean 46.06%, SD 29.34% to mean 54.36%, SD 30.16%; P=.003) during the pandemic, a change that was not seen in controls. CONCLUSIONS Our findings suggest that high perceived negative health influence in the network was associated with worse function in all participants during the pandemic. The networks of all participants became tighter knit, and the percentage of kin in the networks of pwMS increased during the pandemic. Despite these perturbations in social connections, network changes from the prepandemic to the pandemic period were not associated with worsening function in all participants, suggesting possible resilience.
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Affiliation(s)
- Claire Riley
- Columbia University Irving Medical Center, New York, NY, United States
| | | | - Amar Dhand
- Brigham and Women's Hospital, Boston, MA, United States
| | - Nandini Doshi
- University of Pittsburgh, Pittsburgh, PA, United States
| | | | - Elle Levit
- Yale University, New Haven, CT, United States
| | | | | | | | - Philip De Jager
- Columbia University Irving Medical Center, New York, NY, United States
| | - Zongqi Xia
- University of Pittsburgh, Pittsburgh, PA, United States
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Tsilioni I, Theoharides TC. Recombinant SARS-CoV-2 Spike Protein and Its Receptor Binding Domain Stimulate Release of Different Pro-Inflammatory Mediators via Activation of Distinct Receptors on Human Microglia Cells. Mol Neurobiol 2023; 60:6704-6714. [PMID: 37477768 DOI: 10.1007/s12035-023-03493-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/10/2023] [Indexed: 07/22/2023]
Abstract
SARS-CoV-2 infects cells via its spike (S) protein binding to its surface receptor angiotensin converting enzyme 2 (ACE2) on target cells and results in acute symptoms involving especially the lungs known as COVID-19. However, increasing evidence indicates that SARS-CoV-2 infection produces neuroinflammation associated with neurological, neuropsychiatric, and cognitive symptoms persists well past the resolution of the infection, known as post-COVID-19 sequalae or long-COVID. The neuroimmune mechanism(s) involved in long-COVID have not been adequately characterized. In this study, we show that recombinant SARS-CoV-2 full-length S protein stimulates release of pro-inflammatory IL-1b, CXCL8, IL-6, and MMP-9 from cultured human microglia via TLR4 receptor activation. Instead, recombinant receptor-binding domain (RBD) stimulates release of TNF-α, IL-18, and S100B via ACE2 signaling. These results provide evidence that SARS-CoV-2 spike protein contributes to neuroinflammation through different mechanisms that may be involved in CNS pathologies associated with long-COVID.
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Affiliation(s)
- Irene Tsilioni
- Laboratory of Molecular Immunopharmacology and Drug Discovery, Department of Immunology, Tufts University School of Medicine, 136 Harrison Avenue, Suite 304, Boston, MA, 02111, USA.
| | - Theoharis C Theoharides
- Laboratory of Molecular Immunopharmacology and Drug Discovery, Department of Immunology, Tufts University School of Medicine, 136 Harrison Avenue, Suite 304, Boston, MA, 02111, USA
- Institute of Neuro-Immune Medicine, Nova Southeastern University, Clearwater, FL, 33759, USA
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Bloom O, Bryce TN, Botticello AL, Galea M, Delgado AD, Dyson-Hudson TA, Zanca JM, Spungen A. Health impacts reported in the Spinal Cord Injury COVID-19 Pandemic Experience Survey (SCI-CPES). J Spinal Cord Med 2023:1-10. [PMID: 37769141 DOI: 10.1080/10790268.2023.2260959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/30/2023] Open
Abstract
CONTEXT In people with spinal cord injury (SCI), infections are a leading cause of death, and there is a high prevalence of diabetes mellitus, obesity, and hypertension, which are all comorbidities associated with worse outcomes after COVID-19 infection. OBJECTIVE To characterize self-reported health impacts of COVID-19 on people with SCI related to exposure to virus, diagnosis, symptoms, complications of infection, and vaccination. METHODS The Spinal Cord Injury COVID-19 Pandemic Experience Survey (SCI-CPES) study was administered to ask people with SCI about their health and other experiences during the COVID-19 pandemic. RESULTS 223 community-living people with SCI (male = 71%; age = 52±15 years [mean±SD]; paraplegia = 55%) completed the SCI-CPES. Comorbidities first identified in the general population as associated with poor outcomes after COVID-19 infection were commonly reported in this SCI sample: hypertension (30%) and diabetes (13%). 23.5% of respondents reported a known infection exposure from someone who visited (13.5%) or lived in their home (10%). During the study, which included a timeframe when testing was either unavailable or scarce, 61% of respondents were tested for COVID-19; 14% tested or were presumed positive. Fever, fatigue, and chills were the most common symptoms reported. Of the 152 respondents surveyed after COVID-19 vaccines became available, 82% reported being vaccinated. Race and age were significantly associated with positive vaccination status: most (78%) individuals who were vaccinated identified as Non-Hispanic White and were older than those who reported being unvaccinated (57±14 vs. 43±13 years, mean±SD). CONCLUSIONS Self-reported COVID-19 symptoms were relatively uncommon and not severe in this sample of people with SCI. Potential confounders and limitations include responder, recruitment and self-reporting biases and changing pandemic conditions. Future studies on this topic should query social distancing and other behavioral strategies. Large retrospective chart review studies may provide additional data on incidence and prevalence of COVID-19 infections, symptoms, and severities in the SCI population.
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Affiliation(s)
- Ona Bloom
- The Feinstein Institutes for Medical Research, Manhasset, New York, USA
- Department of Physical Medicine and Rehabilitation, Northwell Health, Manhasset, New York, USA
| | - Thomas N Bryce
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Amanda L Botticello
- Kessler Foundation, West Orange, New Jersey, USA
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Marinella Galea
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Spinal Cord Injury and Disorders Service and Spinal Cord Damage Research Center, James J Peters VA Medical Center, Bronx, New York, USA
| | - Andrew D Delgado
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Trevor A Dyson-Hudson
- Kessler Foundation, West Orange, New Jersey, USA
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Jeanne M Zanca
- Kessler Foundation, West Orange, New Jersey, USA
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Ann Spungen
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Spinal Cord Injury and Disorders Service and Spinal Cord Damage Research Center, James J Peters VA Medical Center, Bronx, New York, USA
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Gombolay G, Hallman-Cooper J. COVID-19 and the Pandemic-Related Aspects in Pediatric Demyelinating Disorders. Semin Pediatr Neurol 2023; 46:101055. [PMID: 37451752 PMCID: PMC10169322 DOI: 10.1016/j.spen.2023.101055] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 05/05/2023] [Accepted: 05/07/2023] [Indexed: 07/05/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), also known as Coronavirus-19 (COVID-19) infection, has been associated with several neurological symptoms, including acute demyelinating syndromes (ADS). There is a growing body of literature discussing COVID-19 and demyelinating conditions in adults; however, there is less published about COVID-19 demyelinating conditions in the pediatric population. This review aims to discuss the impact of COVID-19 in pediatric patients with central nervous system ADS (cADS) and chronic demyelinating conditions. We reviewed PubMed, Google Scholar, and Medline for articles published between December 1, 2019 and October 25, 2022 related to COVID-19 and pediatric demyelinating conditions. Of 56 articles reviewed, 20 cases of initial presentation of ADS associated with COVID-19 were described. The most commonly described cADS associated with COVID-19 infection in children was Acute Disseminated Encephalomyelitis followed by Transverse Myelitis. Cases of Myelin Oligodendrocyte Glycoprotein Antibody Disease, Neuromyelitis Optica Spectrum Disorder, and Multiple Sclerosis are also described. The risk of severe COVID-19 in pediatric patients with demyelinating conditions appears low, including in patients on disease modifying therapies, but studies are limited. The pandemic did affect disease modifying therapies in ADS, whether related to changes in prescriber practice or access to medications. COVID-19 is associated with ADS in children and the COVID-19 pandemic has impacted pediatric patients with demyelinating conditions in various ways.
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Affiliation(s)
- Grace Gombolay
- Department of Pediatrics, Division of Pediatric Neurology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA.
| | - Jamika Hallman-Cooper
- Department of Pediatrics, Division of Pediatric Neurology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
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Jakimovski D, Kavak KS, Longbrake EE, Levit E, Perrone CM, Bar-Or A, Benedict RHB, Riley CS, De Jager PL, Venkatesh S, Walker EL, Xia Z, Weinstock-Guttman B. Impact of resilience, social support, and personality traits in patients with neuroinflammatory diseases during the COVID-19 pandemic. Mult Scler Relat Disord 2022; 68:104235. [PMID: 36283322 PMCID: PMC9548342 DOI: 10.1016/j.msard.2022.104235] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 08/30/2022] [Accepted: 10/08/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND AND OBJECTIVE The COVID-19 pandemic negatively impacted the well-being of persons with neuroinflammatory diseases (pwNID). Identifying factors that influence the response to challenging conditions could guide supportive care. METHODS 2185 pwNID and 1079 healthy controls (HCs) from five US centers completed an online survey regarding the effects of the COVID-19 pandemic on physical and psychological well-being. Survey instruments included resilience (Connor-Davidson Resilience Scale, CD-RISC), loneliness (UCLA Loneliness Scale), social support (modified social support survey, MSSS-5), personality traits (NEO-Five Factor Inventory, NEO-FFI), and disability (Patient-Determined Disability Steps (PDDS). Step-wise regression models and mediation analyses assessed whether the level of self-reported resilience, size of the social support, and specific personality traits (study predictors) were associated with self-reported disability and/or loneliness (study outcomes). RESULTS The response rate varied significantly between the questionnaires. While, all pwNID completed the demographic questionnaire, 78.8% completed the loneliness questionnaire and 49.7% completed the NEO-FFI. Based on 787 responses, greater neuroticism (standardized β = 0.312, p < 0.001), less social support (standardized β = -0.242, p < 0.001), lower extraversion (standardized β = -0.083, p=0.017), lower agreeableness (standardized β = -0.119, p < 0.001), and lower resilience (standardized β = -0.125, p = 0.002) were associated with the feeling of loneliness. Social support and resilience modestly but significantly mediated the association between personality traits and loneliness. Older age (standardized β = 0.165, p < 0.001) and lower conscientiousness (standardized β = -0.094, p = 0.007) were associated with worse disability (higher PDDS scores). There were no differences in outcomes between pwNID and HCs. CONCLUSION Greater social support potentially attenuates the association between neuroticism and the feeling of loneliness in pwNID during the COVID-19 pandemic. Assessment of personality traits may identify pwNID that are in greater need of social support and guide targeted interventions.
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Affiliation(s)
- Dejan Jakimovski
- Buffalo Neuroimaging Analysis Center, Department of Neurology, University at Buffalo, State University of New York, Buffalo, NY, United States,Department of Neurology, Jacobs School of Medicine and Biomedical Science Center, University of Buffalo, State University of New York, 1010 Main Street, Buffalo, NY 14202, United States
| | - Katelyn S Kavak
- Department of Neurology, Jacobs School of Medicine and Biomedical Science Center, University of Buffalo, State University of New York, 1010 Main Street, Buffalo, NY 14202, United States
| | - Erin E. Longbrake
- Department of Neurology, Yale University, New Haven, CT, United States
| | - Elle Levit
- Department of Neurology, Yale University, New Haven, CT, United States
| | - Christopher M Perrone
- Center for Neuroinflammation and Experimental Therapeutics and Division of MS and Related Disorders, University of Pennsylvania, Philadelphia, PA, United States
| | - Amit Bar-Or
- Center for Neuroinflammation and Experimental Therapeutics and Division of MS and Related Disorders, University of Pennsylvania, Philadelphia, PA, United States
| | - Ralph HB Benedict
- Department of Neurology, Jacobs School of Medicine and Biomedical Science Center, University of Buffalo, State University of New York, 1010 Main Street, Buffalo, NY 14202, United States
| | - Claire S Riley
- Center for Translational & Computational Neuroimmunology, Department of Neurology, Columbia Multiple Sclerosis Center, New York NY, United States
| | - Philip L De Jager
- Center for Translational & Computational Neuroimmunology, Department of Neurology, Columbia Multiple Sclerosis Center, New York NY, United States
| | - Shruthi Venkatesh
- Department of Neurology, University of Pittsburgh, Pittsburgh PA, United States
| | | | - Zongqi Xia
- Department of Neurology, University of Pittsburgh, Pittsburgh PA, United States
| | - Bianca Weinstock-Guttman
- Department of Neurology, Jacobs School of Medicine and Biomedical Science Center, University of Buffalo, State University of New York, 1010 Main Street, Buffalo, NY 14202, United States.
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Thompson CM, Pulido MD, Babu S, Zenzola N, Chiu C. Communication between persons with multiple sclerosis and their health care providers: A scoping review. PATIENT EDUCATION AND COUNSELING 2022; 105:3341-3368. [PMID: 35927111 DOI: 10.1016/j.pec.2022.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/30/2022] [Accepted: 07/19/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES This study undertakes a scoping review of research about communication between persons with MS and their health care providers. DESIGN PubMed, PsycInfo, Communication Source, Socindex, Sociological Abstracts, Cinahl, and Proquest Dissertations and Theses were used to identify studies since each database's inception. Research team members engaged in study selection, coding for communication issues, and data extraction for descriptive information. RESULTS Of the 419 empirical articles identified, 175 were included. Codes represented all elements of ecological and pathway models, emphasizing emerging technologies for facilitating communication, uncertainty and anxiety for persons with MS, and communication issues surrounding diagnosis, information seeking, and decision making. CONCLUSION This review synthesizes and organizes influences on communication, communication processes, and health outcomes of communication for persons with MS and their providers. Findings extend the ecological model with illness context and the pathway model with communication breakdowns and provider outcomes. PRACTICE IMPLICATIONS Health care providers should consider the complexity of communication when interacting with persons with MS, including the larger context in which it occurs, communication processes and their purposes, and short-term and long-term consequences of interactions. Ecological and pathway models can be frameworks for developing educational materials, as they succinctly capture key communication issues and outcomes.
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Affiliation(s)
- Charee M Thompson
- Department of Communication, University of Illinois, Urbana-Champaign, Urbana, USA.
| | - Manuel D Pulido
- Department of Communication, University of Illinois, Urbana-Champaign, Urbana, USA
| | - Sara Babu
- Department of Communication, University of Illinois, Urbana-Champaign, Urbana, USA
| | - Nicole Zenzola
- Department of Communication, University of Illinois, Urbana-Champaign, Urbana, USA
| | - Chungyi Chiu
- Department of Kinesiology and Community Health, University of Illinois, Urbana-Champaign, Urbana, USA
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7
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Riley CS, Venkatesh S, Dhand A, Doshi N, Kavak K, Levit EE, Perrone C, Weinstock-Guttman B, Longbrake EE, De Jager PL, Xia Z. Impact of the COVID-19 Pandemic on Personal Networks and Neurological Outcomes of People with Multiple Sclerosis: A Case-Control Cross-sectional and Longitudinal Analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.08.17.22278896. [PMID: 36203554 PMCID: PMC9536025 DOI: 10.1101/2022.08.17.22278896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background The COVID-19 pandemic has negatively impacted the social fabric of people with multiple sclerosis (pwMS). Objective To evaluate the associations between personal social network environment and neurological function in pwMS and controls during the COVID-19 pandemic and compare with the pre-pandemic baseline. Methods We first analyzed data collected from 8 cohorts of pwMS and control participants during the COVID-19 pandemic (March-December 2020). We then leveraged data collected between 2017-2019 in 3 of the 8 cohorts for longitudinal comparison. Participants completed a questionnaire that quantified the structure and composition of their personal social network, including the health behaviors of network members. We assessed neurological disability using three interrelated patient-reported outcomes: Patient Determined Disease Steps (PDDS), Multiple Sclerosis Rating Scale â€" Revised (MSRS-R), and Patient Reported Outcomes Measurement Information System (PROMIS)-Physical Function. We identified the network features associated with neurologic disability using paired t-tests and covariate-adjusted regressions. Results In the cross-sectional analysis of the pandemic data from 1130 pwMS and 1250 control participants, higher percent of network members with a perceived negative health influence was associated with greater neurological symptom burden in pwMS (MSRS-R: Beta[95% CI]=2.181[1.082, 3.279], p<.001) and worse physical function in controls (PROMIS-Physical Function: Beta[95% CI]=-5.707[-7.405, -4.010], p<.001). In the longitudinal analysis of 230 pwMS and 136 control participants, the networks of both pwMS and controls experienced an increase in constraint (pwMS p=.006, control p=.001) as well as a decrease in network size (pwMS p=.003, control p<.001), effective size (pwMS p=.007, control p=.013), maximum degree (pwMS p=.01, control p<.001), and percent contacted weekly or less (pwMS p<.001, control p<.001), suggesting overall network contraction during the COVID-19 pandemic. There was also an increase in percentage of kin (p=.003) in the networks of pwMS but not controls during the COVID-19 pandemic when compared to the pre-pandemic baseline. These changes in personal social network due to the pandemic were not associated with worsening neurological disability during the pandemic. Conclusions Our findings suggest that perceived negative health influences in personal social networks are associated with worse disability in all participants during the COVID-19 pandemic. Despite the perturbation in social environment and connections during the pandemic, the stability in neurological function among pwMS suggests potential resilience.
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Tziastoudi M, Cholevas C, Stefanidis I, Theoharides TC. Genetics of COVID-19 and myalgic encephalomyelitis/chronic fatigue syndrome: a systematic review. Ann Clin Transl Neurol 2022; 9:1838-1857. [PMID: 36204816 PMCID: PMC9639636 DOI: 10.1002/acn3.51631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 01/08/2023] Open
Abstract
COVID‐19 and ME/CFS present with some similar symptoms, especially physical and mental fatigue. In order to understand the basis of these similarities and the possibility of underlying common genetic components, we performed a systematic review of all published genetic association and cohort studies regarding COVID‐19 and ME/CFS and extracted the genes along with the genetic variants investigated. We then performed gene ontology and pathway analysis of those genes that gave significant results in the individual studies to yield functional annotations of the studied genes using protein analysis through evolutionary relationships (PANTHER) VERSION 17.0 software. Finally, we identified the common genetic components of these two conditions. Seventy‐one studies for COVID‐19 and 26 studies for ME/CFS were included in the systematic review in which the expression of 97 genes for COVID‐19 and 429 genes for ME/CFS were significantly affected. We found that ACE, HLA‐A, HLA‐C, HLA‐DQA1, HLA‐DRB1, and TYK2 are the common genes that gave significant results. The findings of the pathway analysis highlight the contribution of inflammation mediated by chemokine and cytokine signaling pathways, and the T cell activation and Toll receptor signaling pathways. Protein class analysis revealed the contribution of defense/immunity proteins, as well as protein‐modifying enzymes. Our results suggest that the pathogenesis of both syndromes could involve some immune dysfunction.
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Affiliation(s)
- Maria Tziastoudi
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Christos Cholevas
- First Department of Ophthalmology, Faculty of Health Sciences, Aristotle University, AHEPA Hospital, Thessaloniki, Greece
| | - Ioannis Stefanidis
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Theoharis C Theoharides
- Institute of Neuro-Immune Medicine, Nova Southeastern University, Clearwater, FL, USA.,Laboratory of Molecular Immunopharmacology and Drug Discovery, Department of Immunology, Tufts University School of Medicine, Boston, Massachusetts, USA.,School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, Massachusetts, USA.,Departments of Internal Medicine and Psychiatry, Tufts University School of Medicine and Tufts Medical Center, Boston, Massachusetts, USA
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Association of Disease-Modifying Therapies with COVID-19 Susceptibility and Severity in Patients with Multiple Sclerosis: A Systematic Review and Network Meta-Analysis. Mult Scler Int 2022; 2022:9388813. [PMID: 36187599 PMCID: PMC9519336 DOI: 10.1155/2022/9388813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/03/2022] [Indexed: 12/24/2022] Open
Abstract
Background We conducted this study to assess the effect of disease-modifying therapies (DMTs) on coronavirus disease (COVID-19) susceptibility and severity in people with multiple sclerosis (MS). Methods Available studies from PubMed, Scopus, EMBASE, Web of Science, and gray literature, including reference lists and conference abstracts, were searched from December 1, 2019, to July 26, 2021. We included cross-sectional, case-control, and cohort studies assessing the association of DMTs with risk of contracting COVID-19 or its outcomes in MS patients on univariate or multivariate regression analyses. We conducted a network meta-analysis (NMA) to compare the risk of COVID-19 and developing severe infection across DMTs. Results Out of the initial 3893 records and 1883 conference abstracts, a total of 10 studies were included. Pairwise comparisons showed that none of the DMTs meaningfully affect the risk of acquiring infection. There was significant total heterogeneity and inconsistency across this NMA. In comparison with no DMT, dimethyl fumarate (0.62 (0.42, 0.93)), fingolimod (0.55 (0.32, 0.94)), natalizumab (0.50 (0.31, 0.81)), and interferon (0.42 (0.22, 0.79)) were associated with a decreased risk of severe COVID-19; but, rituximab was observed to increase the risk (1.94 (1.20, 3.12)). Compared to rituximab or ocrelizumab, all DMTs were associated with a decreased risk. Pairwise comparisons showed no differences across other DMTs. Interferon and rituximab were associated with the lowest and highest risks of severe COVID-19. Conclusion Our study showed an increased risk of severe COVID-19 in patients on rituximab and ocrelizumab. No association with COVID-19 severity across other DMTs was observed.
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Boorgu DSSK, Venkatesh S, Lakhani CM, Walker E, Aguerre IM, Riley C, Patel CJ, De Jager PL, Xia Z. The impact of socioeconomic status on subsequent neurological outcomes in multiple sclerosis. Mult Scler Relat Disord 2022; 65:103994. [DOI: 10.1016/j.msard.2022.103994] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/04/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
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Chikersal P, Venkatesh S, Masown K, Walker E, Quraishi D, Dey A, Goel M, Xia Z. Predicting Multiple Sclerosis Outcomes During the COVID-19 Stay-at-home Period: Observational Study Using Passively Sensed Behaviors and Digital Phenotyping. JMIR Ment Health 2022; 9:e38495. [PMID: 35849686 PMCID: PMC9407162 DOI: 10.2196/38495] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/15/2022] [Accepted: 07/16/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has broad negative impact on the physical and mental health of people with chronic neurological disorders such as multiple sclerosis (MS). OBJECTIVE We presented a machine learning approach leveraging passive sensor data from smartphones and fitness trackers of people with MS to predict their health outcomes in a natural experiment during a state-mandated stay-at-home period due to a global pandemic. METHODS First, we extracted features that capture behavior changes due to the stay-at-home order. Then, we adapted and applied an existing algorithm to these behavior-change features to predict the presence of depression, high global MS symptom burden, severe fatigue, and poor sleep quality during the stay-at-home period. RESULTS Using data collected between November 2019 and May 2020, the algorithm detected depression with an accuracy of 82.5% (65% improvement over baseline; F1-score: 0.84), high global MS symptom burden with an accuracy of 90% (39% improvement over baseline; F1-score: 0.93), severe fatigue with an accuracy of 75.5% (22% improvement over baseline; F1-score: 0.80), and poor sleep quality with an accuracy of 84% (28% improvement over baseline; F1-score: 0.84). CONCLUSIONS Our approach could help clinicians better triage patients with MS and potentially other chronic neurological disorders for interventions and aid patient self-monitoring in their own environment, particularly during extraordinarily stressful circumstances such as pandemics, which would cause drastic behavior changes.
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Affiliation(s)
- Prerna Chikersal
- School of Computer Science, Carnegie Mellon University, Pittsburgh, PA, United States
| | - Shruthi Venkatesh
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Karman Masown
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Elizabeth Walker
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Danyal Quraishi
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Anind Dey
- Information School, University of Washington, Seattle, Seattle, WA, United States
| | - Mayank Goel
- School of Computer Science, Carnegie Mellon University, Pittsburgh, PA, United States
| | - Zongqi Xia
- Department of Neurology, University of Pittsburgh, Pittsburgh, PA, United States
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12
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Ghadiri F, Naser Moghadasi A, Sahraian MA. Telemedicine as a strategic intervention for cognitive rehabilitation in MS patients during COVID-19. Acta Neurol Belg 2022; 122:23-29. [PMID: 35094365 PMCID: PMC8801040 DOI: 10.1007/s13760-022-01875-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/17/2022] [Indexed: 12/27/2022]
Abstract
The recent COVID-19 pandemic has taken the lives of nearly 5.2 million up to now. With no definite treatment and considering close contact as the primary mode of transmission, telemedicine has emerged as an essential medical care platform. Virtual medical communications have offered clinicians the opportunity to visit and follow up on patients more efficiently during the lockdown. Not only has telemedicine improved multiple sclerosis (MS) patients’ health and quality of life during the pandemic, but it could also be used as a cost-effective platform for physical and cognitive MS rehabilitation programs. Cognitive impairment is a common problem among MS patients even at the initial phases of the disease. Rehabilitation training programs such as RehaCom, BrainHQ, Speed of Processing Training (PST), and COGNI-TRAcK have made great strides in improving a wide range of cognitive functions that MS patients are challenged with. Regarding the impact of COVID-19 on the cognitive aspects of MS patients, efforts to implement rehabilitation training applications have been increased. Web-based mobile applications, virtual visits, and telephone follow-ups are examples of such efforts. Having said that, limitations such as privacy, socioeconomic disparities, e-health literacy, study settings, and challenges of neurologic examinationss have been raised. Since most MS patients are young, all the beneficiaries are encouraged to embrace the research in the field to pave the road for more feasible and efficient ways of cognitive enhancement in MS patients.
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13
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Theoharides TC. Could SARS-CoV-2 Spike Protein Be Responsible for Long-COVID Syndrome? Mol Neurobiol 2022; 59:1850-1861. [PMID: 35028901 PMCID: PMC8757925 DOI: 10.1007/s12035-021-02696-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 12/10/2021] [Indexed: 02/06/2023]
Abstract
SARS-CoV-2 infects cells via its spike protein binding to its surface receptor on target cells and results in acute symptoms involving especially the lungs known as COVID-19. However, increasing evidence indicates that many patients develop a chronic condition characterized by fatigue and neuropsychiatric symptoms, termed long-COVID. Most of the vaccines produced so far for COVID-19 direct mammalian cells via either mRNA or an adenovirus vector to express the spike protein, or administer recombinant spike protein, which is recognized by the immune system leading to the production of neutralizing antibodies. Recent publications provide new findings that may help decipher the pathogenesis of long-COVID. One paper reported perivascular inflammation in brains of deceased patients with COVID-19, while others showed that the spike protein could damage the endothelium in an animal model, that it could disrupt an in vitro model of the blood-brain barrier (BBB), and that it can cross the BBB resulting in perivascular inflammation. Moreover, the spike protein appears to share antigenic epitopes with human molecular chaperons resulting in autoimmunity and can activate toll-like receptors (TLRs), leading to release of inflammatory cytokines. Moreover, some antibodies produced against the spike protein may not be neutralizing, but may change its conformation rendering it more likely to bind to its receptor. As a result, one wonders whether the spike protein entering the brain or being expressed by brain cells could activate microglia, alone or together with inflammatory cytokines, since protective antibodies could not cross the BBB, leading to neuro-inflammation and contributing to long-COVID. Hence, there is urgent need to better understand the neurotoxic effects of the spike protein and to consider possible interventions to mitigate spike protein-related detrimental effects to the brain, possibly via use of small natural molecules, especially the flavonoids luteolin and quercetin.
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Affiliation(s)
- Theoharis C Theoharides
- Laboratory of Molecular Immunopharmacology and Drug Discovery, Department of Immunology, Tufts University School of Medicine, 136 Harrison Avenue, Suite 304, Boston, MA, 02111, USA.
- School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, 02111, USA.
- Departments of Internal Medicine and Psychiatry, Tufts University School of Medicine and Tufts Medical Center, Boston, MA, 02111, USA.
- Institute of Neuro-Immune Medicine, Nova Southeastern University, Clearwater, FL, 33759, USA.
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14
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Worsening physical functioning in patients with neuroinflammatory disease during the COVID-19 pandemic. Mult Scler Relat Disord 2022; 58:103482. [PMID: 35016114 PMCID: PMC8742609 DOI: 10.1016/j.msard.2021.103482] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/08/2021] [Accepted: 12/31/2021] [Indexed: 12/21/2022]
Abstract
Objective To quantify changes in psychological wellbeing and physical function as reported by people with neurological inflammatory disease (PwNID) during the COVID-19 pandemic. Methods 1134 PwNID and 868 control participants were recruited through five major academic medical centers in the Northeast/Mid-Atlantic U.S. beginning in April 2020. Participants completed serial surveys throughout the COVID-19 pandemic that aimed to quantify mood symptoms and physical function, analyzed cross-sectionally with a smaller cohort analyzed longitudinally. Results Throughout the pandemic, depression scores were not significantly different between PwNID and controls, although a higher proportion of PwNID reported clinically significant depression at study entry. Depression scores did not worsen over time for either group. Loneliness was the strongest predictor of worse depression, along with older age, male gender in both PwNID and controls, as well as lack of disease modifying therapy use, and disease duration in PwNID only. In contrast, physical disability worsened significantly over time for both PwNID and controls. Age, DMT status and comorbid health conditions emerged as significant predictors of physical function. Conclusions Depressive symptoms remained consistent for both PwNID and controls throughout the COVID-19 pandemic, but physical function worsened significantly over time for both groups. This is particularly impactful for PwNID, who have higher baseline levels of physical disability, and underscores the importance of reinstituting services and interventions that facilitate exercise and reconditioning for this population.
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15
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Roth EG, Minden SL, Maloni HW, Miles ZJ, Wallin MT. A Qualitative, Multiperspective Inquiry of Multiple Sclerosis Telemedicine in the United States. Int J MS Care 2022; 24:275-281. [PMID: 36545645 PMCID: PMC9749833 DOI: 10.7224/1537-2073.2021-117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Telemedicine has expanded access to high-quality, appropriate, and affordable health care for people with multiple sclerosis (MS). This study explored how the expansion of MS telemedicine is perceived and experienced by people with MS, health care providers (HCPs), and payers and policy experts (PYs). METHODS Forty-five semistructured interviews with 20 individuals with MS, 15 HCPs, and 10 PYs were conducted between September 2020 and January 2021. The interviews were recorded on a televideo platform, transcribed, and analyzed for themes using qualitative data software. RESULTS Interviews revealed the following 4 themes. Technology: Telemedicine increases access and convenience. Technical challenges were the most cited downside to telemedicine. Clinical encounters: Confidence in MS care via telemedicine varies. Virtual "house calls" have clinical benefits. Financing and infrastructure: Reimbursement parity is critical to utilization and expansion of telemedicine. Stakeholders are hopeful and fearful as infrastructure and business models begin to shift. Shifting expectations: The familiar structure of the office visit is currently absent in telemedicine. Telemedicine visits need more intentionality from both providers and patients. CONCLUSIONS Telemedicine is an efficient, convenient way to deliver and receive many aspects of MS care. To expand telemedicine care, many HCPs need more training and experience, people with MS need guidance to optimize their care, and PYs in the United States need to pass legislation and adjust business models to incorporate benefits and reimbursement for telemedicine health in insurance plans. The future is promising for the ongoing use of telemedicine to improve MS care, and stakeholders should work to preserve and expand the policy changes made during the COVID-19 pandemic.
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Affiliation(s)
- Erin G. Roth
- From The Department of Sociology, Anthropology, & Public Health, University of Maryland Baltimore County (UMBC), Baltimore, MD, USA (EGR)
| | | | - Heidi W. Maloni
- Department of Veterans Affairs Multiple Sclerosis Center of Excellence, Washington, DC, USA (HWM, MTW)
| | | | - Mitchell T. Wallin
- Department of Veterans Affairs Multiple Sclerosis Center of Excellence, Washington, DC, USA (HWM, MTW),George Washington University School of Medicine, Washington, DC, USA (MTW)
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16
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Epstein S, Xia Z, Lee AJ, Dahl M, Edwards K, Levit E, Longbrake EE, Perrone C, Kavak K, Weinstock-Guttman B, Diallo F, Ricci A, Riley CS, De Jager PL, Farber R, Wesley SF. Vaccination Against SARS-CoV-2 in Neuroinflammatory Disease: Early Safety/Tolerability Data. Mult Scler Relat Disord 2021; 57:103433. [PMID: 34923427 PMCID: PMC8638239 DOI: 10.1016/j.msard.2021.103433] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/26/2021] [Accepted: 11/27/2021] [Indexed: 01/10/2023]
Abstract
Background Patients with autoimmune disease and on immunotherapy were largely excluded from seminal anti-SARS-CoV-2 vaccine trials. This has led to significant vaccine hesitancy in patients with neuroinflammatory diseases (NID); including, but not limited to: multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD), neurosarcoidosis and myelin oligodendrocyte antibody-mediated disease (MOG-AD). Data is urgently needed to help guide clinical care in the NID population. Methods This was a cross-sectional observational study evaluating adults with a neurologist-confirmed diagnosis of a neuroinflammatory disease (NID) and a neurologically asymptomatic control population. Participants were recruited from multiple academic centers participating in the MS Resilience to COVID-19 Collaborative study. We analyzed participant responses from a vaccine-specific questionnaire collected between February and May 2021. Results 1164 participants with NID and 595 controls completed the vaccine survey. Hesitancy rates were similar between NID and control groups (n = 134, 32.7% NID vs. n = 56, 30.6% control; p = 0.82). The most common reasons for hesitancy in NID participants were lack of testing in the autoimmune population and fear of demyelinating/neurologic events. Unvaccinated patients who had discussed vaccination with their doctor were less likely to be hesitant (n=184, 73.6% vs. n=83, 59.7%; p = 0.007). 634 NID patients and 332 controls had received at least one dose of a vaccine against SARS-CoV-2 at the time of survey completion. After adjusting for age, BMI, and comorbidities, there was no difference in self-reported side effects (SE) between groups with the first dose (n = 256, 42.2% NID vs. 141, 45.3% control; p = 0.20) or second dose (n = 246, 67.0% NID vs. n = 114, 64.8% control, p = 0.85) of the mRNA vaccines nor with the viral-vector vaccines (n = 6, 46% NID vs. n = 8, 66% control; p = 0.39). All reported SEs fell into the expected SE profile. There was no difference in report of new/recurrent neurologic symptoms (n = 110, 16.2% vaccinated vs. 71, 18.2% unvaccinated; p = 0.44) nor radiologic disease activity (n = 40, 5.9% vaccinated vs. n = 30, 7.6% unvaccinated) between vaccinated and unvaccinated NID participants. Conclusions We found no difference in patient-reported vaccine side effects and no evidence of NID worsening after vaccination. Large-scale real-world evidence is needed for further validation.
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Affiliation(s)
- Samantha Epstein
- Multiple Sclerosis Center and the Center For Translational & Computational Neuroimmunology, Columbia University Irving Medical Center; Department of Neurology. New York, NY, USA.
| | - Zongqi Xia
- University of Pittsburgh; Department of Neurology; Pittsburgh, PA, USA
| | - Annie J Lee
- Multiple Sclerosis Center and the Center For Translational & Computational Neuroimmunology, Columbia University Irving Medical Center; Department of Neurology. New York, NY, USA
| | - Megan Dahl
- University of Pittsburgh; Department of Neurology; Pittsburgh, PA, USA
| | - Keith Edwards
- The Multiple Sclerosis Center of Northeastern New York; Latham, NY, USA
| | - Elle Levit
- Yale University School of Medicine; Department of Neurology; New Haven, CT, USA
| | - Erin E Longbrake
- Yale University School of Medicine; Department of Neurology; New Haven, CT, USA
| | - Christopher Perrone
- University of Pennsylvania School of Medicine; Department of Neurology; Philadelphia, PA, USA
| | - Katelyn Kavak
- State University of New York at Buffalo; Department of Neurology; Buffalo, NY, USA
| | | | - Fatoumata Diallo
- Multiple Sclerosis Center and the Center For Translational & Computational Neuroimmunology, Columbia University Irving Medical Center; Department of Neurology. New York, NY, USA
| | - Adelle Ricci
- Multiple Sclerosis Center and the Center For Translational & Computational Neuroimmunology, Columbia University Irving Medical Center; Department of Neurology. New York, NY, USA
| | - Claire S Riley
- Multiple Sclerosis Center and the Center For Translational & Computational Neuroimmunology, Columbia University Irving Medical Center; Department of Neurology. New York, NY, USA
| | - Philip L De Jager
- Multiple Sclerosis Center and the Center For Translational & Computational Neuroimmunology, Columbia University Irving Medical Center; Department of Neurology. New York, NY, USA
| | - Rebecca Farber
- Multiple Sclerosis Center and the Center For Translational & Computational Neuroimmunology, Columbia University Irving Medical Center; Department of Neurology. New York, NY, USA
| | - Sarah F Wesley
- Multiple Sclerosis Center and the Center For Translational & Computational Neuroimmunology, Columbia University Irving Medical Center; Department of Neurology. New York, NY, USA
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17
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Alborghetti M, Bellucci G, Gentile A, Calderoni C, Nicoletti F, Capra R, Salvetti M, Centonze D. Drugs used in the treatment of multiple sclerosis during COVID-19 pandemic: a critical viewpoint. Curr Neuropharmacol 2021; 20:107-125. [PMID: 33784961 PMCID: PMC9199540 DOI: 10.2174/1570159x19666210330094017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/15/2021] [Accepted: 03/24/2021] [Indexed: 11/22/2022] Open
Abstract
Since COVID-19 has emerged as a word public health problem, attention has been focused on how immune-suppressive drugs used for the treatment of autoimmune disorders influence the risk for SARS-CoV-2 infection and the development of acute respiratory distress syndrome (ARDS). Here, we discuss the disease-modifying agents approved for the treatment of multiple sclerosis (MS) within this context. Interferon (IFN)-β1a and -1b, which display antiviral activity, could be protective in the early stage of COVID-19 infection, although SARS-CoV-2 may have developed resistance to IFNs. However, in the hyperinflammation stage, IFNs may become detrimental by facilitating macrophage invasion in the lung and other organs. Glatiramer acetate and its analogues should not interfere with the development of COVID-19 and may be considered safe. Teriflunomide, a first-line oral drug used in the treatment of relapsing-remitting MS (RRMS), may display antiviral activity by depleting cellular nucleotides necessary for viral replication. The other first-line drug, dimethyl fumarate, may afford protection against SARS-CoV-2 by activating the Nrf-2 pathway and reinforcing the cellular defenses against oxidative stress. Concern has been raised regarding the use of second-line treatments for MS during the COVID-19 pandemic. However, this concern is not always justified. For example, fingolimod might be highly beneficial during the hyperinflammatory stage of COVID-19 for a number of mechanisms, including the reinforcement of the endothelial barrier. Caution is suggested for the use of natalizumab, cladribine, alemtuzumab, and ocrelizumab, although MS disease recurrence after discontinuation of these drugs may overcome a potential risk for COVID-19 infection.
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Affiliation(s)
- Marika Alborghetti
- Departments of Neuroscience Mental Health and Sensory Organs (NESMOS), University Sapienza of Rome. Italy
| | - Gianmarco Bellucci
- Departments of Neuroscience Mental Health and Sensory Organs (NESMOS), University Sapienza of Rome. Italy
| | - Antonietta Gentile
- Synaptic Immunopathology Lab, IRCCS San Raffaele Pisana, 00166 Rome. Italy
| | - Chiara Calderoni
- Departments of Physiology and Pharmacology, University Sapienza of Rome. Italy
| | | | - Ruggero Capra
- Multiple Sclerosis Center, ASST Ospedali Civili, Brescia. Italy
| | - Marco Salvetti
- Departments of Neuroscience Mental Health and Sensory Organs (NESMOS),University Sapienza of Rome. Italy
| | - Diego Centonze
- Department of Systems Medicine, Tor Vergata University, 00133 Rome. Italy
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