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Zedde M, Romani I, Scaravilli A, Cocozza S, Trojano L, Ragno M, Rifino N, Bersano A, Gerevini S, Pantoni L, Valzania F, Pascarella R. Expanding the Neurological Phenotype of Anderson-Fabry Disease: Proof of Concept for an Extrapyramidal Neurodegenerative Pattern and Comparison with Monogenic Vascular Parkinsonism. Cells 2024; 13:1131. [PMID: 38994983 PMCID: PMC11240674 DOI: 10.3390/cells13131131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Revised: 06/18/2024] [Accepted: 06/25/2024] [Indexed: 07/13/2024] Open
Abstract
Anderson-Fabry disease (AFD) is a genetic sphingolipidosis involving virtually the entire body. Among its manifestation, the involvement of the central and peripheral nervous system is frequent. In recent decades, it has become evident that, besides cerebrovascular damage, a pure neuronal phenotype of AFD exists in the central nervous system, which is supported by clinical, pathological, and neuroimaging data. This neurodegenerative phenotype is often clinically characterized by an extrapyramidal component similar to the one seen in prodromal Parkinson's disease (PD). We analyzed the biological, clinical pathological, and neuroimaging data supporting this phenotype recently proposed in the literature. Moreover, we compared the neurodegenerative PD phenotype of AFD with a classical monogenic vascular disease responsible for vascular parkinsonism and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). A substantial difference in the clinical and neuroimaging features of neurodegenerative and vascular parkinsonism phenotypes emerged, with AFD being potentially responsible for both forms of the extrapyramidal involvement, and CADASIL mainly associated with the vascular subtype. The available studies share some limitations regarding both patients' information and neurological and genetic investigations. Further studies are needed to clarify the potential association between AFD and extrapyramidal manifestations.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy
| | - Ilaria Romani
- Department of Neurosciences, Psychology, Pharmacology and Child Health, University of Florence, 50139 Firenze, Italy
| | - Alessandra Scaravilli
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", 80133 Napoli, Italy
| | - Sirio Cocozza
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", 80133 Napoli, Italy
| | - Luigi Trojano
- Dipartimento di Psicologia, Università della Campania 'Luigi Vanvitelli', viale Ellittico 31, 81100 Caserta, Italy
| | - Michele Ragno
- Centro Medico Salute 23, Via O. Licini 5, 63066 Grottammare (AP), Italy
| | - Nicola Rifino
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milano, Italy
| | - Anna Bersano
- Cerebrovascular Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, 20133 Milano, Italy
| | - Simonetta Gerevini
- Head Diagnostic Dept and Neuroradiology Unit, ASST Papa Giovanni XXIII, 24127 Bergamo, Italy
| | - Leonardo Pantoni
- Neuroscience Research Center, Department of Biomedical and Clinical Science, University of Milan, 20122 Milano, Italy
| | - Franco Valzania
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy
| | - Rosario Pascarella
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123 Reggio Emilia, Italy
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Montella A, Tranfa M, Scaravilli A, Barkhof F, Brunetti A, Cole J, Gravina M, Marrone S, Riccio D, Riccio E, Sansone C, Spinelli L, Petracca M, Pisani A, Cocozza S, Pontillo G. Assessing brain involvement in Fabry disease with deep learning and the brain-age paradigm. Hum Brain Mapp 2024; 45:e26599. [PMID: 38520360 PMCID: PMC10960551 DOI: 10.1002/hbm.26599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 12/23/2023] [Accepted: 01/07/2024] [Indexed: 03/25/2024] Open
Abstract
While neurological manifestations are core features of Fabry disease (FD), quantitative neuroimaging biomarkers allowing to measure brain involvement are lacking. We used deep learning and the brain-age paradigm to assess whether FD patients' brains appear older than normal and to validate brain-predicted age difference (brain-PAD) as a possible disease severity biomarker. MRI scans of FD patients and healthy controls (HCs) from a single Institution were, retrospectively, studied. The Fabry stabilization index (FASTEX) was recorded as a measure of disease severity. Using minimally preprocessed 3D T1-weighted brain scans of healthy subjects from eight publicly available sources (N = 2160; mean age = 33 years [range 4-86]), we trained a model predicting chronological age based on a DenseNet architecture and used it to generate brain-age predictions in the internal cohort. Within a linear modeling framework, brain-PAD was tested for age/sex-adjusted associations with diagnostic group (FD vs. HC), FASTEX score, and both global and voxel-level neuroimaging measures. We studied 52 FD patients (40.6 ± 12.6 years; 28F) and 58 HC (38.4 ± 13.4 years; 28F). The brain-age model achieved accurate out-of-sample performance (mean absolute error = 4.01 years, R2 = .90). FD patients had significantly higher brain-PAD than HC (estimated marginal means: 3.1 vs. -0.1, p = .01). Brain-PAD was associated with FASTEX score (B = 0.10, p = .02), brain parenchymal fraction (B = -153.50, p = .001), white matter hyperintensities load (B = 0.85, p = .01), and tissue volume reduction throughout the brain. We demonstrated that FD patients' brains appear older than normal. Brain-PAD correlates with FD-related multi-organ damage and is influenced by both global brain volume and white matter hyperintensities, offering a comprehensive biomarker of (neurological) disease severity.
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Affiliation(s)
- Alfredo Montella
- Department of Advanced Biomedical SciencesUniversity “Federico II”NaplesItaly
| | - Mario Tranfa
- Department of Advanced Biomedical SciencesUniversity “Federico II”NaplesItaly
| | | | - Frederik Barkhof
- NMR Research Unit, Queen Square MS Centre, Department of NeuroinflammationUCL Institute of NeurologyLondonUK
- Department of Radiology and Nuclear MedicineMS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Centre for Medical Image ComputingUniversity College LondonLondonUK
- Dementia Research CentreUCL Queen Square Institute of Neurology, University College LondonLondonUK
| | - Arturo Brunetti
- Department of Advanced Biomedical SciencesUniversity “Federico II”NaplesItaly
| | - James Cole
- Centre for Medical Image ComputingUniversity College LondonLondonUK
- Dementia Research CentreUCL Queen Square Institute of Neurology, University College LondonLondonUK
| | - Michela Gravina
- Department of Electrical Engineering and Information Technology (DIETI)University “Federico II”NaplesItaly
| | - Stefano Marrone
- Department of Electrical Engineering and Information Technology (DIETI)University “Federico II”NaplesItaly
| | - Daniele Riccio
- Department of Electrical Engineering and Information Technology (DIETI)University “Federico II”NaplesItaly
| | - Eleonora Riccio
- Department of Public Health, Nephrology UnitUniversity “Federico II”NaplesItaly
| | - Carlo Sansone
- Department of Electrical Engineering and Information Technology (DIETI)University “Federico II”NaplesItaly
| | - Letizia Spinelli
- Department of Advanced Biomedical SciencesUniversity “Federico II”NaplesItaly
| | - Maria Petracca
- Department of Neurosciences and Reproductive and Odontostomatological SciencesUniversity “Federico II”NaplesItaly
- Department of Human NeurosciencesSapienza University of RomeRomeItaly
| | - Antonio Pisani
- Department of Public Health, Nephrology UnitUniversity “Federico II”NaplesItaly
| | - Sirio Cocozza
- Department of Advanced Biomedical SciencesUniversity “Federico II”NaplesItaly
| | - Giuseppe Pontillo
- Department of Advanced Biomedical SciencesUniversity “Federico II”NaplesItaly
- NMR Research Unit, Queen Square MS Centre, Department of NeuroinflammationUCL Institute of NeurologyLondonUK
- Department of Radiology and Nuclear MedicineMS Center Amsterdam, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit AmsterdamAmsterdamThe Netherlands
- Department of Electrical Engineering and Information Technology (DIETI)University “Federico II”NaplesItaly
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Fabry Disease and Central Nervous System Involvement: From Big to Small, from Brain to Synapse. Int J Mol Sci 2023; 24:ijms24065246. [PMID: 36982318 PMCID: PMC10049671 DOI: 10.3390/ijms24065246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/05/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023] Open
Abstract
Fabry disease (FD) is an X-linked lysosomal storage disorder (LSD) secondary to mutations in the GLA gene that causes dysfunctional activity of lysosomal hydrolase α-galactosidase A and results in the accumulation of globotriaosylceramide (Gb3) and globotriaosylsphingosine (lyso-Gb3). The endothelial accumulation of these substrates results in injury to multiple organs, mainly the kidney, heart, brain and peripheral nervous system. The literature on FD and central nervous system involvement is scarce when focusing on alterations beyond cerebrovascular disease and is nearly absent in regard to synaptic dysfunction. In spite of that, reports have provided evidence for the CNS’ clinical implications in FD, including Parkinson’s disease, neuropsychiatric disorders and executive dysfunction. We aim to review these topics based on the current available scientific literature.
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Zedde M, Pascarella R, Cavallieri F, Pezzella FR, Grisanti S, Di Fonzo A, Valzania F. Anderson-Fabry Disease: A New Piece of the Lysosomal Puzzle in Parkinson Disease? Biomedicines 2022; 10:biomedicines10123132. [PMID: 36551888 PMCID: PMC9776280 DOI: 10.3390/biomedicines10123132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 12/09/2022] Open
Abstract
Anderson-Fabry disease (AFD) is an inherited lysosomal storage disorder characterized by a composite and multisystemic clinical phenotype and frequent involvement of the central nervous system (CNS). Research in this area has largely focused on the cerebrovascular manifestations of the disease, and very little has been described about further neurological manifestations, which are known in other lysosomal diseases, such as Gaucher disease. In particular, a clinical and neuroimaging phenotype suggesting neurodegeneration as a putative mechanism has never been fully described for AFD, but the increased survival of affected patients with early diagnosis and the possibility of treatment have given rise to some isolated reports in the literature on the association of AFD with a clinical phenotype of Parkinson disease (PD). The data are currently scarce, but it is possible to hypothesize the molecular mechanisms of cell damage that support this association; this topic is worthy of further study in particular in relation to the therapeutic possibilities, which have significantly modified the natural history of the disease but which are not specifically dedicated to the CNS. In this review, the molecular mechanisms underlying this association will be proposed, and the available data with implications for future research and treatment will be rewritten.
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Affiliation(s)
- Marialuisa Zedde
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
- Correspondence: or
| | - Rosario Pascarella
- Neuroradiology Unit, Radiology Department, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Francesco Cavallieri
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Francesca Romana Pezzella
- Neurology Unit, Stroke Unit, Dipartimento di Neuroscienze, AO San Camillo Forlanini, 00152 Rome, Italy
| | - Sara Grisanti
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41121 Modena, Italy
| | - Alessio Di Fonzo
- Neurology Unit, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Franco Valzania
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy
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Gabusi I, Pontillo G, Petracca M, Battocchio M, Bosticardo S, Costabile T, Daducci A, Pane C, Riccio E, Pisani A, Brunetti A, Schiavi S, Cocozza S. Structural disconnection and functional reorganization in Fabry disease: a multimodal MRI study. Brain Commun 2022; 4:fcac187. [PMID: 35912136 PMCID: PMC9327118 DOI: 10.1093/braincomms/fcac187] [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: 01/03/2022] [Revised: 05/17/2022] [Accepted: 07/20/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
Central nervous system involvement in Fabry disease, a rare systemic X-linked lysosomal storage disorder, is characterized by the presence of heterogeneous but consistent functional and microstructural changes. Nevertheless, knowledge about the degree and extension of macro-scale brain connectivity modifications is to date missing. In this work, we performed connectomic analyses of diffusion and resting-state functional MRI to investigate changes of both structural and functional brain organization in Fabry disease, as well as to explore the relationship between the two and their clinical correlates. In this retrospective cross-sectional study, 46 patients with Fabry disease (28F, 42.2 ± 13.2years) and 49 healthy controls (21F, 42.3 ± 16.3years) were included. All subjects underwent an MRI examination including anatomical, diffusion and resting-state functional sequences. Images were processed to obtain quantitative structural and functional connectomes, where the connections between regions of interest were weighted by the total intra-axonal signal contribution of the corresponding bundle and by the correlation between blood-oxygen level–dependent time series, respectively. We explored between-group differences in terms of both global network properties, expressed with graph measures and specific connected subnetworks, identified using a network-based statistics approach. As exploratory analyses, we also investigated the possible association between cognitive performance and structural and functional connectome modifications at both global and subnetwork level in a subgroup of patients (n = 11). Compared with healthy controls, patients with Fabry disease showed a significantly reduced global efficiency (P = 0.005) and mean strength (P < 0.001) in structural connectomes, together with an increased modularity (P = 0.005) in functional networks. As for the network-based statistics analysis, a subnetwork with decreased structural connectivity in patients with Fabry disease compared with healthy controls emerged, with eight nodes mainly located at the level of frontal or deep grey-matter areas. When probing the relation between altered global network metrics and neuropsychological tests, correlations emerged between the structural and functional disruption with results at verbal and working memory tests, respectively. Furthermore, structural disruption at subnetwork level was associated with worse executive functioning, with a significant moderation effect of functional changes suggesting a compensation mechanism. Taken together, these results further expand the current knowledge about brain involvement in Fabry disease, showing widespread structural disconnection and functional reorganization, primarily sustained by loss in axonal integrity and correlating with cognitive performance.
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Affiliation(s)
- Ilaria Gabusi
- Department of Computer Science, Diffusion Imaging and Connectivity Estimation (DICE) Lab, University of Verona , Verona 37134 , Italy
- Department of Advanced Biomedical Sciences, University “Federico II” , Naples 80131 , Italy
| | - Giuseppe Pontillo
- Department of Advanced Biomedical Sciences, University “Federico II” , Naples 80131 , Italy
- Department of Electrical Engineering and Information Technology (DIETI), University “Federico II” , Naples 80125 , Italy
| | - Maria Petracca
- Department of Human Neuroscience, Sapienza University of Rome , Rome 00189 , Italy
| | - Matteo Battocchio
- Department of Computer Science, Diffusion Imaging and Connectivity Estimation (DICE) Lab, University of Verona , Verona 37134 , Italy
- Department of Computer Science, University of Sherbrooke , Sherbrooke, QC J1K 2R1 , Canada
| | - Sara Bosticardo
- Department of Computer Science, Diffusion Imaging and Connectivity Estimation (DICE) Lab, University of Verona , Verona 37134 , Italy
- Department of Biomedical Engineering, Translational Imaging in Neurology (ThINk), University Hospital Basel and University of Basel , Basel 4001 , Switzerland
| | - Teresa Costabile
- Department of Clinical and Experimental Medicine, Multiple Sclerosis Centre, II Division of Neurology, ‘'Luigi Vanvitelli” University , Naples 80138 , Italy
| | - Alessandro Daducci
- Department of Computer Science, Diffusion Imaging and Connectivity Estimation (DICE) Lab, University of Verona , Verona 37134 , Italy
| | - Chiara Pane
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, University “Federico II” , Naples 80131 , Italy
| | - Eleonora Riccio
- Department of Public Health, Nephrology Unit, University “Federico II” , Naples 80131 , Italy
| | - Antonio Pisani
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, University “Federico II” , Naples 80131 , Italy
| | - Arturo Brunetti
- Department of Advanced Biomedical Sciences, University “Federico II” , Naples 80131 , Italy
| | - Simona Schiavi
- Department of Computer Science, Diffusion Imaging and Connectivity Estimation (DICE) Lab, University of Verona , Verona 37134 , Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa , Genoa 16132 , Italy
| | - Sirio Cocozza
- Department of Advanced Biomedical Sciences, University “Federico II” , Naples 80131 , Italy
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The central vein sign helps in differentiating multiple sclerosis from its mimickers: lessons from Fabry disease. Eur Radiol 2022; 32:3846-3854. [PMID: 35029733 DOI: 10.1007/s00330-021-08487-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/26/2021] [Accepted: 11/28/2021] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Although the use of specific MRI criteria has significantly increased the diagnostic accuracy of multiple sclerosis (MS), reaching a correct neuroradiological diagnosis remains a challenging task, and therefore the search for new imaging biomarkers is crucial. This study aims to evaluate the incidence of one of the emerging neuroradiological signs highly suggestive of MS, the central vein sign (CVS), using data from Fabry disease (FD) patients as an index of microvascular disorder that could mimic MS. METHODS In this retrospective study, after the application of inclusion and exclusion criteria, MRI scans of 36 FD patients and 73 relapsing-remitting (RR) MS patients were evaluated. Among the RRMS participants, 32 subjects with a disease duration inferior to 5 years (early MS) were also analyzed. For all subjects, a Fazekas score (FS) was recorded, excluding patients with FS = 0. Different neuroradiological signs, including CVS, were evaluated on FLAIR T2-weighted and spoiled gradient recalled echo sequences. RESULTS Among all the recorded neuroradiological signs, the most striking difference was found for the CVS, with a detectable prevalence of 78.1% (57/73) in RRMS and of 71.4% (25/32) in early MS patients, while this sign was absent in FD (0/36). CONCLUSIONS Our results confirm the high incidence of CVS in MS, also in the early phases of the disease, while it seems to be absent in conditions with a different etiology. These results corroborate the possible role of CVS as a useful neuroradiological sign highly suggestive of MS. KEY POINTS • The search for new imaging biomarkers is crucial to achieve a correct neuroradiological diagnosis of MS. • The CVS shows an incidence superior to 70% in MS patients, even in the early phases of the disease, while it appears to be absent in FD. • These findings further corroborate the possible future central role of CVS in distinguishing between MS and its mimickers.
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Cennamo G, Montorio D, Santoro C, Cocozza S, Spinelli L, Di Risi T, Riccio E, Russo C, Pontillo G, Esposito R, Imbriaco M, Pisani A. The Retinal Vessel Density as a New Vascular Biomarker in Multisystem Involvement in Fabry Disease: An Optical Coherence Tomography Angiography Study. J Clin Med 2020; 9:jcm9124087. [PMID: 33352849 PMCID: PMC7766384 DOI: 10.3390/jcm9124087] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/11/2020] [Accepted: 12/16/2020] [Indexed: 12/13/2022] Open
Abstract
In this study, we evaluated the possible relationship between the changes in retinal vessel density (VD) by optical coherence tomography angiography (OCTA) and the vascular alterations involving renal, cardiovascular and central nervous systems in patients affected by Fabry disease (FD). In 50 FD patients, the retinal superficial capillary plexus (SCP) and deep capillary plexus (DCP) in macular region were evaluated by OCTA examination. The patients also underwent a brain magnetic resonance imaging scan, renal and echocardiographic examinations with quantification of systolic pulmonary arterial pressure (PAPs) and left atrial volume index (LAVi). The VD of SCP and DCP was inversely related with E/e’ ratio, LAVi, interventricular septal thickness, global longitudinal strain (GLS) and PAPs (p < 0.05). No relationship was found, with a multivariate analysis, between OCTA parameters and kidney function and neuroradiological signs of central nervous system involvement. OCTA could be a new vascular biomarker in FD, revealing a strong correlation between retinal capillary damage and myocardial impairment, possibly preceding both renal dysfunction and cerebrovascular involvement.
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Affiliation(s)
- Gilda Cennamo
- Eye Clinic, Public Health Department, University of Naples “Federico II”, 80131 Naples, Italy
- Correspondence:
| | - Daniela Montorio
- Department of Neurosciences, Reproductive Sciences and Dentistry, University of Naples “Federico II”, 80131 Naples, Italy;
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
| | - Sirio Cocozza
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
| | - Letizia Spinelli
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
| | - Teodolinda Di Risi
- CEINGE—Advanced Biotechnologies, 80145 Naples, Italy;
- Department of Public Medicine, University Federico II, 80131 Naples, Italy; (E.R.); (A.P.)
| | - Eleonora Riccio
- Department of Public Medicine, University Federico II, 80131 Naples, Italy; (E.R.); (A.P.)
| | - Camilla Russo
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
| | - Giuseppe Pontillo
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
- Department of Electrical Engineering and Information Technology, University of Naples “Federico II”, 80125 Naples, Italy
| | - Roberta Esposito
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
| | - Massimo Imbriaco
- Department of Advanced Biomedical Sciences, Federico II University Hospital, 80131 Naples, Italy; (C.S.); (S.C.); (L.S.); (C.R.); (G.P.); (R.E.); (M.I.)
| | - Antonio Pisani
- Department of Public Medicine, University Federico II, 80131 Naples, Italy; (E.R.); (A.P.)
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