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Yoon SY, Choi JY, Nam GE, Jung JH, Han K, Kang SH, Kim CK, Kim YW, Koh SB. Association Between Body Mass Index Changes and All-Cause Mortality in Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2024:JPD240181. [PMID: 39331108 DOI: 10.3233/jpd-240181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
Background Whether body weight changes are associated with Parkinson's disease (PD) mortality remains uncertain. Objective To investigate the association between changes in body mass index (BMI) and all-cause mortality in patients with PD. Methods This nationwide cohort study enrolled 20,703 individuals with new-onset PD (ICD-10 code: G20 and a rare intractable disease registration code: V124) who underwent health screening program by the Korean National Health Insurance Service within two years from pre- and post-PD diagnosis. We identified nine BMI change groups based on three BMI status: underweight (BMI < 18.5 kg/m2), normal or overweight (18.5 kg/m2≤BMI < 25 kg/m2), and obese (BMI≥25 kg/m2). Results Of 20,703 individuals, 3,789 (18.0%) died during the follow-up period. Excessive weight loss to underweight in the obese group (hazard ratio [HR] = 3.36, 95% CI:1.60-7.08), weight loss in the normal to overweight group (HR = 2.04, 95% CI:1.75-2.39), sustained underweight status (HR = 2.05, 95% CI:1.67-2.52), and weight gain from underweight to normal or overweight (HR = 1.52, 95% CI:1.15-2.02) were associated with increased mortality. Sustained obese status (HR = 0.80, 95% CI:0.74-0.87) and weight gain in the normal to overweight group (HR = 0.82, 95% CI:0.71-0.95) were associated with reduced mortality. Conclusions We found that BMI change at diagnosis was associated with mortality in patients with PD. Specifically, being underweight either before or after diagnosis as well as experiencing weight loss, were associated with increased mortality. These findings provide valuable insights for weight management planning in PD, highlighting the importance of individualized approach that consider pre-diagnosis BMI.
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Affiliation(s)
- Seo Yeon Yoon
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Ja Young Choi
- Department of Physical and Rehabilitation Medicine, Chungnam National University College of Medicine, Daejeon, South Korea
| | - Ga Eun Nam
- Department of Family Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jin-Hyung Jung
- Samsung Biomedical Research Institute, Sungkyunkwan University School of Medicine, Suwon, South Korea
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea
| | - Sung Hoon Kang
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Yong Wook Kim
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Seong-Beom Koh
- Department of Neurology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
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Canevelli M, Jackson-Tarlton C, Rockwood K. Frailty for neurologists: perspectives on how frailty influences care planning. Lancet Neurol 2024:S1474-4422(24)00291-6. [PMID: 39276779 DOI: 10.1016/s1474-4422(24)00291-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 06/20/2024] [Accepted: 07/03/2024] [Indexed: 09/17/2024]
Abstract
The concept of frailty, now being adopted in most medical disciplines, is attracting growing interest in neurology. Every day, most neurologists care for patients with varying degrees of frailty, from very mild to very severe. Frailty exacerbates patients' health needs, complicates clinical decision making, and negatively affects their health outcomes. Increasing evidence suggests that frailty affects the risk, clinical presentation, and course of common age-related neurological disorders, including dementia, Parkinson's disease, stroke, and multiple sclerosis. Most neurologists should become familiar with assessing and measuring frailty. Doing so can provide information that is crucial for diagnosis, prognostication, and care planning. Consideration of frailty can help to elucidate the pathophysiological underpinnings of age-related neurological disorders, clarify the clinical validity and utility of candidate biomarkers, and identify novel therapeutic targets. Randomised controlled trials investigating late-life neurological diseases that address frailty have the potential to provide insight into these complex disorders.
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Affiliation(s)
- Marco Canevelli
- Department of Human Neuroscience, Sapienza University, Rome, Italy; National Center for Disease Prevention and Health Promotion, Italian National Institute of Health, Rome, Italy; Aging Research Center, Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Caitlin Jackson-Tarlton
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, NS, Canada; Nova Scotia Health, Halifax, NS, Canada
| | - Kenneth Rockwood
- Division of Neurology, Department of Medicine, Dalhousie University, Halifax, NS, Canada; Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, NS, Canada; Frailty and Elder Care Network, Halifax, NS, Canada.
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Komici K, Pansini A, Bencivenga L, Rengo G, Pagano G, Guerra G. Frailty and Parkinson's disease: the role of diabetes mellitus. Front Med (Lausanne) 2024; 11:1377975. [PMID: 38882667 PMCID: PMC11177766 DOI: 10.3389/fmed.2024.1377975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 05/02/2024] [Indexed: 06/18/2024] Open
Abstract
Parkinson's disease (PD) is a chronic neurodegenerative disease associated with a progressive loss of dopaminergic neurons, clinically characterized by motor and non-motor signs. Frailty is a clinical condition of increased vulnerability and negative health outcomes due to the loss of multiple physiological reserves. Chronic hyperglycemia and insulin resistance, which characterize diabetes mellitus (DM), have been reported to alter dopaminergic activity, increase the risk of PD, and influence the development of frailty. Even though diabetes may facilitate the development of frailty in patients with PD, this relationship is not established and a revision of the current knowledge is necessary. Furthermore, the synergy between DM, PD, and frailty may drive clinical complexity, worse outcomes, and under-representation of these populations in the research. In this review, we aimed to discuss the role of diabetes in the development of frailty among patients with PD. We summarized the clinical characteristics and outcomes of patients with concomitant DM, PD, and frailty. Finally, interventions to prevent frailty in this population are discussed.
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Affiliation(s)
- Klara Komici
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | | | - Leonardo Bencivenga
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
| | - Giuseppe Rengo
- Department of Translational Medical Sciences, University of Naples "Federico II", Naples, Italy
- Istituti Clinici Scientifici Maugeri IRCCS-Scientific Institute of Telese Terme, Telese Terme, BN, Italy
| | - Gennaro Pagano
- Roche Pharma Research and Early Development (pRED), Neuroscience and Rare Diseases Discovery and Translational Area, Roche Innovation Center, Basel, Switzerland
- University of Exeter Medical School, London, United Kingdom
| | - Germano Guerra
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
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Yang ZC, Lin H, Jiang GH, Chu YH, Gao JH, Tong ZJ, Wang ZH. Frailty Is a Risk Factor for Falls in the Older Adults: A Systematic Review and Meta-Analysis. J Nutr Health Aging 2023; 27:487-595. [PMID: 37357334 DOI: 10.1007/s12603-023-1935-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/20/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVES There is little evidence in the literature about the relationship between frailty and falls in older adults. Our objective was to explore the relationship between frailty and falls, and to analyze the effect factors (e.g., gender, different frailty assessment tools, areas, level of national economic development, and year of publication) of the association between frailty and falls among older adults. DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS Cohort studies that evaluated the association between frailty and falls in the older adults were included. We excluded any literature outside of cohort studies. METHODS We did a systematic literature search of English databases PubMed, Scopus, Web of Science, EBSCOhost, and SciElO, as well as the Chinese databases CNKI, WANFANG, and VIP from 2001 until October 2022. The eligible studies were evaluated for potential bias using the Newcastle-Ottawa Scale (NOS). Study selection, data extraction and assessment of study quality were each conducted by two investigators. In Stata/MP 17.0 software, we calculated pooled estimates of the prevalence of falls by using a random-effects model, Subgroup analysis was conducted based on gender, different frailty assessment tools, areas, level of economic development, and year of publication. The results are presented using a forest plot. RESULTS Twenty-nine studies were included in this meta-analysis and a total of 1,093,270 participants aged 65 years and above were enrolled. Among the older adults, frailty was significantly associated with a higher risk for falls, compared with those without frailty (combined RR-relative risk = 1.48, 95% CI-confidence interval: 1.27-1.73, I2=98.9%). In addition, the results of subgroup analysis indicated that men had a higher risk for falls than women among the older adults with frailty (RR 1.94, 95% CI: 1.18-3.2 versus RR 1.44, 95% CI: 1.24-1.67). Subgroup analysis by different frailty assessment tools revealed an increased risk of falls in older adults with frailty when assessed using the Frailty Phenotype (combined RR 1.32, 95%CI: 1.17-1.48), FRAIL score (combined RR 1.82, 95%CI: 1.36-2.43), and Study of Osteoporotic Fractures index (combined RR 1.54, 95%CI: 1.10-2.16). Furthermore, subgroup analysis by areas and level of national economic development found the highest fall risk in Oceania (combined RR 2.35, 95%CI: 2.28-2.43) and the lowest in Europe (combined RR 1.20, 95%CI: 1.05-1.38). Developed countries exhibited a lower fall risk compared to developing countries (combined RR 1.44, 95%CI: 1.21-1.71). Analysis by year of publication showed the highest fall risk between 2013-2019 (combined RR 1.79, 95%CI: 1.45-2.20) and the lowest between 2001-2013 (combined RR 1.21, 95%CI: 1.13-1.29). CONCLUSION Frailty represents a significant risk factor for falls in older adults, with the degree of risk varying according to the different frailty assessment tools employed, and notably highest when using the FRAIL scale. Additionally, factors such as gender, areas, level of national economic development, and healthcare managers' understanding of frailty may all impact the correlation between frailty and falls. Thus, it's imperative to select suitable frailty diagnostic tools tailored to the specific characteristics of the population in question. This, in turn, facilitates the accurate identification of frailty in older adults and informs the development of appropriate preventive and therapeutic strategies to mitigate fall risk.
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Affiliation(s)
- Z-C Yang
- Zhi-hao Wang, No.107, Wenhua West Road, Jinan, Shandong, 250012, China, Tel 0531-82166761,
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Sousa-Fraguas MC, Rodríguez-Fuentes G, Conejo NM. Frailty and cognitive impairment in Parkinson’s disease: a systematic review. Neurol Sci 2022; 43:6693-6706. [PMID: 36056182 DOI: 10.1007/s10072-022-06347-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 08/12/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Frailty can lead to increased vulnerability in older people and patients with Parkinson's disease (pwPD) and worsen their health conditions. These patients can also develop cognitive function impairment. The objective is to analyze whether there is a relationship between frailty and cognitive impairment in pwPD, and to find out which instruments to use for its evaluation. METHODS Publications were searched in PubMed, Medline, Web of Science, Cinalh, Cochrane Library, Embase, Phycinfo, and Scopus. The results were measured with the instruments that are used to assess frailty and cognitive impairment, and analyze their relationship. RESULTS Two hundred seventy-one articles were identified, of which 12 met the inclusion criteria. All studies assessed frailty and cognitive function in pwPD. Five studies analyzed the relationship between frailty and cognitive impairment. The most used instruments were the Fried scale followed by the Clinical Frailty Scale (CFS) for frailty. Cognitive impairment was mostly evaluated with the Mini-Mental State Examination and the Montreal Cognitive Assessment. The prevalence data ranged from 20.2 to 51.5% with the Fried scale and from 35.6 to 83.9% with the CFS. Cognitive impairment was present in 15 to 45.2% of the pwPD. CONCLUSION Analysis of the included studies shows a relationship between frailty and cognitive impairment in pwPD. There was significant variability in the application of the scales used, which influences the prevalence data. More observational and experimental studies are needed to provide more evidence on this association and to determine which is the optimal tool to identify frailty in pwPD using multidimensional scales.
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Soh EML, Neo S, Saffari SE, Wong ASY, Ganesan G, Li W, Ng HL, Xu Z, Tay KY, Au WL, Tan KB, Tan LCS. Longitudinal Healthcare Utilization and Costs in Parkinson's Disease: Pre-Diagnosis to 9 Years After. JOURNAL OF PARKINSON'S DISEASE 2022; 12:957-966. [PMID: 34974439 DOI: 10.3233/jpd-212982] [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] [Indexed: 06/14/2023]
Abstract
BACKGROUND There is currently insufficient long-term data on costs of treatment in patients with Parkinson's disease (PD), which is chronic and progressive, and associated with substantial healthcare costs. Identifying patterns in healthcare utilization and cost may illuminate further discussion on early intervention. OBJECTIVE To characterize long-term healthcare utilization and costs of PD in newly diagnosed patients managed by movement disorder specialists. METHODS Using a longitudinal matched-cohort study of linked data from the National Neuroscience Institute Parkinson's disease and Movement Disorder and healthcare administrative databases in Singapore from 2008-2017, we compared healthcare utilization and costs between patients and controls matched on age, sex, race, and Charlson Comorbidity Index score. RESULTS 1,162 patients met study inclusion criteria and 1,157 matched controls were identified. The total mean annual healthcare cost (at 2017 costs) was significantly increased in patients compared to controls from years 1-9 post-diagnosis. The increased cost was observed 2 years before diagnosis (USD2322 vs. 2052; p < 0.001). Mean annual cost attributable to PD increased from USD1854 at 1-year post-diagnosis to USD2652 at 9 years. Over 9 years, average costs were significantly higher across all domains of healthcare utilization except primary care-cost of intermediate and long-term care was increased by a factor of 2.5, specialist care by 2.3, emergency department visits by 1.6, and hospital admissions by 1.3. CONCLUSION PD results in higher healthcare utilization and costs. Pre-diagnosis increase in healthcare utilization observed in patients supports the presence of prodromal PD symptoms and may present an opportunity for early diagnosis.
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Affiliation(s)
| | - Shermyn Neo
- National Neuroscience Institute, Singapore
- Parkinson's Foundation Center of Excellence, Singapore
| | - Seyed Ehsan Saffari
- Duke-NUS Medical School, Singapore
- National Neuroscience Institute, Singapore
- Parkinson's Foundation Center of Excellence, Singapore
| | - Aidan Sheng Yong Wong
- National Neuroscience Institute, Singapore
- Parkinson's Foundation Center of Excellence, Singapore
| | - Ganga Ganesan
- Policy Research and Evaluation Division, Ministry of Health, Singapore
| | - Wei Li
- National Neuroscience Institute, Singapore
- Parkinson's Foundation Center of Excellence, Singapore
| | - Hwee Lan Ng
- National Neuroscience Institute, Singapore
- Parkinson's Foundation Center of Excellence, Singapore
| | - Zheyu Xu
- National Neuroscience Institute, Singapore
- Parkinson's Foundation Center of Excellence, Singapore
| | - Kay Yaw Tay
- National Neuroscience Institute, Singapore
- Parkinson's Foundation Center of Excellence, Singapore
| | - Wing Lok Au
- Duke-NUS Medical School, Singapore
- National Neuroscience Institute, Singapore
- Parkinson's Foundation Center of Excellence, Singapore
| | - Kelvin Bryan Tan
- Policy Research and Evaluation Division, Ministry of Health, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Louis Chew Seng Tan
- Duke-NUS Medical School, Singapore
- National Neuroscience Institute, Singapore
- Parkinson's Foundation Center of Excellence, Singapore
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Fujita T, Babazono A, Kim SA, Jamal A, Li Y. Effects of physician visit frequency for Parkinson's disease treatment on mortality, hospitalization, and costs: a retrospective cohort study. BMC Geriatr 2021; 21:707. [PMID: 34911495 PMCID: PMC8672617 DOI: 10.1186/s12877-021-02685-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 11/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background The number of patients with Parkinson’s disease among older adults is rapidly increasing. Such patients mostly take medication and require regular physician visits. However, the effect of physician visit frequency for the treatment for Parkinson’s disease has not been evaluated. This study aimed to evaluate the impact of physician visit frequency for Parkinson’s disease treatment on mortality, healthcare days, and healthcare and long-term care costs among older adults. Methods This study employed a retrospective cohort design utilizing claims data from the Fukuoka Prefecture Wide-Area Association of Latter-Stage Elderly Healthcare Insurance and Long-Term Care Insurance. Patients aged ≥75 years who were newly diagnosed with Parkinson’s disease in 2014 were included in this study, following the onset of Parkinson’s disease to March 31, 2019. We calculated the restricted mean survival time to evaluate mortality, focusing on the frequency of physician visits for Parkinson’s disease treatment. Inpatient days, outpatient days, and healthcare and long-term care costs per month were calculated using a generalized linear model. Results There were 2224 participants, with 46.5% mortality among those with a higher frequency of physician visits and 56.4% among those with a lower frequency of physician visits. A higher frequency of physician visits was associated with a significant increase in survival time (1.57 months at 24 months and 5.00 months at 60 months) after the onset of Parkinson’s disease and a decrease in inpatient days and healthcare costs compared to a lower frequency of physician visits. Conclusions A higher frequency of physician visits was significantly associated with longer survival time, fewer inpatient days, and lower healthcare costs. Caregivers should support patients with Parkinson’s disease to visit physicians regularly for their treatment.
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Affiliation(s)
- Takako Fujita
- Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Akira Babazono
- Department of Healthcare Administration and Management, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Sung-A Kim
- Department of Healthcare Administration and Management, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Aziz Jamal
- Department of Healthcare Administration and Management, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.,Health Administration Program, Department of International Business and Management, Universiti Teknologi MARA, Selangor Campsus, Shah Alam, Malaysia
| | - Yunfei Li
- Department of Healthcare Administration and Management, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Belvisi D, Canevelli M, Costanzo M, Giangrosso M, Fabbrini A, Borraccino A, Bruno G, Berardelli A, Fabbrini G. The role of frailty in Parkinson's disease: a cross-sectional study. J Neurol 2021; 269:3006-3014. [PMID: 34791518 DOI: 10.1007/s00415-021-10873-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/21/2021] [Accepted: 10/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Frailty is an age-related state of increased risk for health-related adverse outcomes that reflects multisystem physiological changes and likely influences the clinical expression and disease progression of neurodegenerative disorders. The aim of the present study was to assess the potential relationship between frailty, as assessed by a frailty index (FI), and motor symptom severity, motor subtypes, and non-motor domains in Parkinson's disease (PD). METHODS We consecutively enrolled 150 PD patients. We administered an FI specifically designed for PD that included 50 age-related multidimensional biological deficits. Patients underwent a clinical assessment that evaluated motor and non-motor manifestations of PD. Using the FI score, we classified PD patients as relatively fit (FI ≤ 0.10), less fit (0.10 < FI ≤ 0.21), or frail (FI > 0.21). A linear regression model was designed to explore possible associations between frailty level and PD motor and non-motor manifestations. RESULTS Frail patients showed greater motor symptom severity and motor complications than fitter patients. A trend towards a higher prevalence of the postural instability/gait disorder subtype was also observed in frail versus relatively fit and less fit patients. The global burden of non-motor symptoms was higher in frail patients. Increased frailty was associated with more severe motor and non-motor symptoms, as well as with more pronounced cognitive deficits. These associations remained significant even when "traditional" predictors of PD severity (age, disease duration, and levodopa equivalent daily dose) were considered. CONCLUSIONS The present findings indicate that the FI is associated with both motor and non-motor features of PD.
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Affiliation(s)
- Daniele Belvisi
- Department of Human Neuroscience, Sapienza University of Rome, Viale dell'Università 30, 00185, Rome, Italy
- IRCCS Neuromed, via Atinense 18, 86077, Pozzilli, IS, Italy
| | - Marco Canevelli
- Department of Human Neuroscience, Sapienza University of Rome, Viale dell'Università 30, 00185, Rome, Italy
- National Center for Disease Prevention and Health Promotion, Italian National Institute of Health, Viale Regina Elena 299, 00161, Rome, Italy
| | - Matteo Costanzo
- Department of Human Neuroscience, Sapienza University of Rome, Viale dell'Università 30, 00185, Rome, Italy
| | - Margherita Giangrosso
- Department of Human Neuroscience, Sapienza University of Rome, Viale dell'Università 30, 00185, Rome, Italy
| | - Andrea Fabbrini
- Department of Human Neuroscience, Sapienza University of Rome, Viale dell'Università 30, 00185, Rome, Italy
| | - Andrea Borraccino
- Department of Human Neuroscience, Sapienza University of Rome, Viale dell'Università 30, 00185, Rome, Italy
| | - Giuseppe Bruno
- Department of Human Neuroscience, Sapienza University of Rome, Viale dell'Università 30, 00185, Rome, Italy
| | - Alfredo Berardelli
- Department of Human Neuroscience, Sapienza University of Rome, Viale dell'Università 30, 00185, Rome, Italy
- IRCCS Neuromed, via Atinense 18, 86077, Pozzilli, IS, Italy
| | - Giovanni Fabbrini
- Department of Human Neuroscience, Sapienza University of Rome, Viale dell'Università 30, 00185, Rome, Italy.
- IRCCS Neuromed, via Atinense 18, 86077, Pozzilli, IS, Italy.
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