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Tezcan EA, Levendoglu F, Durmaz MS, Batur EB, Gezer IA, Erol K. Utility of shear wave elastography for diagnosing carpal tunnel syndrome with psoriatic arthritis. Ir J Med Sci 2024; 193:977-985. [PMID: 37670102 DOI: 10.1007/s11845-023-03512-5] [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: 07/06/2023] [Accepted: 08/28/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Carpal tunnel syndrome (CTS) is a type of peripheral entrapment neuropathy and common for the patients with psoriatic arthritis (PsA). Shear wave elastography (SWE) is a new ultrasonography technique that can be used for diagnosing CTS, but not studied in PsA patients. AIMS The aim of this study to measure the stiffness of median nerve and hand muscles by quantitative SWE to identify whether SWE can be used for diagnosing CTS in patients with PsA or not. METHODS To diagnose CTS, all patients had electrodiagnostic study. The stiffness values of the median nerve, abductor pollicis brevis, and abductor digiti minimi were determined using SWE. Muscle stiffness ratio was also calculated. RESULTS Consideration is given to 48 patients with PsA (93 wrists) and 29 healthy volunteers (57 wrists). Median nerve stiffness was found to be significantly higher, and abductor pollicis brevis' stiffness and muscle stiffness ratio were significantly lower in PsA patients' wrists compared to control group (p = 0.002, p < 0.001, p = 0.001, respectively) and in CTS wrists compared to others (p < 0.001, p < 0.001, p = 0.001, respectively). Receiver operating characteristic analysis identified 28.2 kPA as the median nerve stiffness cut-off point for differentiating CTS in PsA patients (p = 0.001). CONCLUSIONS We found that SWE has a good diagnostic value for CTS with PsA patients; hence, we can conclude that SWE could diagnose CTS in PsA patients.
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Affiliation(s)
- Ezgi Akyildiz Tezcan
- Department of Physical Medicine and Rehabilitation, Cumra State Hospital, Konya, 42500, Turkey.
| | - Funda Levendoglu
- Department of Physical Medicine and Rehabilitation, Selcuk University Medical Faculty, Konya, Turkey
| | | | - Elif Balevi Batur
- Department of Physical Medicine and Rehabilitation, Selcuk University Medical Faculty, Konya, Turkey
| | - Ilknur Albayrak Gezer
- Department of Physical Medicine and Rehabilitation, Selcuk University Medical Faculty, Konya, Turkey
| | - Kemal Erol
- Division of Rheumatology, Department of Physical Medicine and Rehabilitation, Selcuk University Medical Faculty, Konya, Turkey
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Marklund J, Hanna B, Jin T, Pullerits R. Myositis-associated antibodies predict the severity of lung involvement in adult patients with inflammatory myositis - a cohort study of 70 adult patients with myositis in a single center. Front Med (Lausanne) 2024; 11:1340310. [PMID: 38606156 PMCID: PMC11007204 DOI: 10.3389/fmed.2024.1340310] [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: 11/17/2023] [Accepted: 03/11/2024] [Indexed: 04/13/2024] Open
Abstract
Introduction Idiopathic inflammatory myopathies (IIMs) encompass a diverse group of diseases characterized by considerable variability in clinical manifestations, antibody profiles, and responsiveness to immunosuppressive therapies. This study aimed to investigate the association between organ involvement and distinct myositis autoantibodies in individuals with IIM in a single-center cohort. Methods Patients with ICD diagnoses M33.1, M33.2, M33.9, or M609 who (1) had been tested with Euroline blot assay for myositis autoantibodies and (2) met the classification criteria of definite/probable polymyositis (PM) or dermatomyositis (DM), anti-synthetase syndrome (ASS), or inclusion body myositis (IBM) were included. Medical journals were retrospectively examined with respect to clinical disease features. Results Seventy patients (median age 58 years; 66% females) were included and represented the following diagnosis: PM (n = 23), DM (n = 21), ASS (n = 23), and IBM (n = 3). Most of the patients (87%) presented a muscle biopsy indicative of myositis. The presence of autoantibodies was as follows: myositis-specific antibodies, MSA (n = 53), myositis-associated antibodies, MAA (n = 33), both MSA + MAA (n = 24), MSA only (n = 29), MAA only (n = 9), no MSA, or MAA (n = 8). Anti-Jo-1 was the most common MSA (19%), whereas the most common MAA was anti-Ro/SSA52 (31%). We observed a significant association between antibody patterns and lung disease. In our cohort, 47% of the patients in the whole study group, 86% of patients with anti-SSA52, and 100% with anti-Jo-1 had pulmonary involvement. Patients with both MSA and MAA had a higher incidence of lung disease and decreased CO-diffusion capacity. This was especially prominent in anti-Ro/SSA52-positive patients. Interestingly, none of the patients suffered from lung disease if only antibodies against Mi-2α, Mi-2β, NXP2, HMGCR, and TIF1γ were present or no MSA/MAA were detected. Discussion The simultaneous presence of both MAA and MSA indicates an increased risk of lung involvement in patients with inflammatory myopathies. The presence of any MAA, and especially anti-Ro/SSA52, is associated with more severe pulmonary disease. Our data suggest that MAA antibodies might be relevant markers for early detection and treatment of lung involvement in IIM.
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Affiliation(s)
- Josefin Marklund
- Department of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Balsam Hanna
- Department of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tao Jin
- Department of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Rille Pullerits
- Department of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Immunology and Transfusion Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Nakamura T, Nagira K, Nakagawa N, Takasu Y, Ishida K, Hayashibara M, Hagino H, Nagashima H. Characteristics of patients presenting with concomitant carpal tunnel syndrome at the initial diagnosis with rheumatoid arthritis. Mod Rheumatol 2024:road116. [PMID: 38244590 DOI: 10.1093/mr/road116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/18/2023] [Indexed: 01/22/2024]
Abstract
OBJECTIVE To investigate the clinical characteristics of patients who presented with concomitant carpal tunnel syndrome (CTS) at the initial diagnosis with rheumatoid arthritis (RA). METHODS We analyzed patients with newly diagnosed RA at a single institution between 2012 and 2021. Patient demographic and laboratory data, the 2010 ACR/EULAR classification criteria, and the duration from the initial visit to RA diagnosis were compared between RA patients with concomitant CTS (RA with CTS group) and those without CTS (RA without CTS group). RESULTS The study included 235 patients (157 females), of which 11 patients (4.7%) presented with CTS at the initial diagnosis with RA. In the RA with CTS group, the age was significantly higher (P = .033), all patients were female, and anti-cyclic citrullinated peptide antibody (ACPA) was negative, and the duration to RA diagnosis was longer than in the RA without CTS group. Among all RA with CTS patients, ultrasonography showed power Doppler signal-positive tenosynovitis in the carpal tunnel, which is not usually detected in idiopathic CTS. CONCLUSIONS Patients with concomitant CTS at the initial diagnosis with RA were characterized by old age, female sex, and negative ACPA. Patients with symptoms of CTS should undergo ultrasonography for early diagnosis of RA.
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Affiliation(s)
- Taiki Nakamura
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Yonago, Tottori, Japan
| | - Keita Nagira
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Yonago, Tottori, Japan
| | - Naoki Nakagawa
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Yonago, Tottori, Japan
| | - Yuta Takasu
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Yonago, Tottori, Japan
| | - Koji Ishida
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Yonago, Tottori, Japan
| | - Masako Hayashibara
- Department of Orthopedic Surgery, Yonago Medical Center, Yonago, Tottori, Japan
| | - Hiroshi Hagino
- Department of Rehabilitation, Sanin Rosai Hospital, Yonago, Tottori, Japan
| | - Hideki Nagashima
- Department of Orthopedic Surgery, Faculty of Medicine, Tottori University, Yonago, Tottori, Japan
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Slouma M, Ben Dhia S, Cheour E, Gharsallah I. Acroparesthesias: An Overview. Curr Rheumatol Rev 2024; 20:115-126. [PMID: 37921132 DOI: 10.2174/0115733971254976230927113202] [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: 04/09/2023] [Revised: 08/09/2023] [Accepted: 08/18/2023] [Indexed: 11/04/2023]
Abstract
Acroparesthesia is a symptom characterized by a subjective sensation, such as numbness, tingling, prickling, and reduced sensation, affecting the extremities (fingers and toes). Despite its frequency, data regarding its diagnostic approach and management are scarce. The etiological diagnosis of acroparesthesia is sometimes challenging since it can be due to abnormality anywhere along the sensory pathway from the peripheral nervous system to the cerebral cortex. Acroparesthesia can reveal several diseases. It can be associated with rheumatic complaints such as arthritis or myalgia. Further cautions are required when paresthesia is acute (within days) in onset, rapidly progressive, severe, asymmetric, proximal, multifocal, or associated with predominant motor signs (limb weakness) or severe dysautonomia. Acroparesthesia may reveal Guillain-Barré syndrome or vasculitis, requiring rapid management. Acroparesthesia is a predominant symptom of polyneuropathy, typically distal and symmetric, often due to diabetes. However, it can occur in other diseases such as vitamin B12 deficiency, monoclonal gammopathy of undetermined significance, or Fabry's disease. Mononeuropathy, mainly carpal tunnel syndrome, remains the most common cause of acroparesthesia. Ultrasonography contributes to the diagnosis of nerve entrapment neuropathy by showing nerve enlargement, hypoechogenic nerve, and intraneural vascularity. Besides, it can reveal its cause, such as space-occupying lesions, anatomical nerve variations, or anomalous muscle. Ultrasonography is also helpful for entrapment neuropathy treatment, such as ultrasound-guided steroid injection or carpal tunnel release. The management of acroparesthesia depends on its causes. This article aimed to review and summarize current knowledge on acroparesthesia and its causes. We also propose an algorithm for the management of acroparesthesia.
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Affiliation(s)
- Maroua Slouma
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Siwar Ben Dhia
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
| | - Elhem Cheour
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
- Pain Treatment Center, La Rabta Hospital, Tunis, Tunisia
| | - Imen Gharsallah
- Department of Rheumatology, Military Hospital, Tunis, Tunisia
- Department of Medicine, Tunis El Manar University, Tunis, Tunisia
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Abdullah AY, Yousif RA, Suliman AG, Ibn Idris AA, Hassan SA, Ali SI, Alshoabi SA, Algorashi EM, Mohammed BN, Elzaki M. The Impact of Rheumatoid Arthritis (RA) in Median Nerve Area in the Wrist Joint: A Case-Control Study. Cureus 2023; 15:e38580. [PMID: 37288223 PMCID: PMC10241703 DOI: 10.7759/cureus.38580] [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] [Accepted: 05/05/2023] [Indexed: 06/09/2023] Open
Abstract
Background Rheumatoid arthritis (RA) is one cause of carpal tunnel syndromes (CTS); due to increased intracarpal pressure in the rheumatoid wrist, synovial enlargement, joint erosions, and ligamentous laxity cause the compression of the median nerve (MN). Materials and methods A case-control study was conducted to assess the measurement of median nerve areas in RA using high-frequency ultrasound (US) and to correlate the measurement with the disease duration. Forty patients with rheumatoid arthritis (RA) and 40 with non-rheumatoid arthritis (RA) as a control group were referred to the radiology department of Yastabshiron Hospital, Khartoum, Sudan, from June to August 2022. After assessing the wrist joint by ultrasound scans, median nerve (MN) cross-sectional area (CSA) measurements were performed using a Fukuda Denshi ultrasound machine (Tokyo, Japan) with a linear-array high-frequency transducer (10 MHz), after receiving ethical approval from the research committee of the faculty of radiological science at University of Medical Sciences and Technology (UMST) and the study participants. Results The study demonstrated that the mean measurement of MN cross-sectional area (CSA) in RA patients was 13.60 mm2 for the right and 13.25 mm2 for the left MN. The study found that the MN CSA decreased by increasing the disease duration, with significant differences in the median nerve cross-sectional areas in RA and healthy control (p-value of <0.01). Conclusion The study concluded that rheumatoid arthritis (RA) had a greater influence on the median nerve cross-sectional areas. MN areas significantly decreased with increasing duration of diseases; the MN cross-sectional areas were more in RA than in the healthy control group.
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Affiliation(s)
- Abdulmalek Y Abdullah
- Department of Diagnostic Radiology, University of Medical Sciences and Technology (UMST), Khartoum, SDN
| | - Rihab A Yousif
- Faculty of Radiology Science and Medical Imaging, Alzaiem Alazhari University, Khartoum, SDN
| | - Awadia G Suliman
- Department of Diagnostic Radiology Technology, College of Applied Medical Sciences, Taibah University, Al-Madinah Al-Munawarah, SAU
- Faculty of Radiology Science and Medical Imaging, Alzaiem Alazhari University, Khartoum, SDN
| | | | - Sujood A Hassan
- Department of Diagnostic Radiology, University of Medical Sciences and Technology (UMST), Khartoum, SDN
| | - Shima I Ali
- Faculty of Radiology Science and Medical Imaging, Alzaiem Alazhari University, Khartoum, SDN
| | - Sultan A Alshoabi
- Department of Diagnostic Radiology Technology, College of Applied Medical Sciences, Taibah University, Al-Madinah Al-Munawarah, SAU
| | - Eman M Algorashi
- Department of Diagnostic Radiology, Sudan University of Science and Technology (SUST), Khartoum, SDN
| | - Bassam N Mohammed
- Department of Diagnostic Radiology, Sudan University of Science and Technology (SUST), Khartoum, SDN
| | - Maisa Elzaki
- Department of Diagnostic Radiology Technology, College of Applied Medical Sciences, Taibah University, Al-Madinah Al-Munawarah, SAU
- Faculty of Radiology Science and Medical Imaging, Alzaiem Alazhari University, Khartoum, SDN
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Tezcan EA, Levendoglu F, Durmaz MS, Kara H, Batur EB, Gezer IA, Korez MK. Carpal Tunnel Syndrome in Patients with Psoriatic Arthritis: Ultrasonography and Magnetic Resonance Imaging Findings. JOURNAL OF RHEUMATIC DISEASES 2023; 30:36-44. [PMID: 37476525 PMCID: PMC10351357 DOI: 10.4078/jrd.22.0028] [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: 08/03/2022] [Revised: 11/24/2022] [Accepted: 11/24/2022] [Indexed: 07/22/2023]
Abstract
Objective The aim of the present study is to assess carpal tunnel syndrome's (CTS's) ultrasonography (US) and magnetic resonance imaging (MRI) findings in patients with psoriatic arthritis (PsA) and compare them with healthy controls. Methods Thirty-nine PsA and twenty-eight healthy volunteers were examined in this study. Demographic and clinical features were recorded. CTS-6, a diagnostic algorithm, was used to estimate the probability of CTS. Electrodiagnostic study (EDS) was applied to all wrists included in the report, where the diagnosis of CTS was made by EDS. The cross-sectional area (CSA) of the median nerve was measured at pisiform bone level by US and MRI. Results Regarding to the demographic characteristics, no statistically significant difference was found between the groups. Twelve of 39 (30.76%) PsA patients had CTS, whereas CTS was not detected in the control group (p=0.001). US and MRI showed increased median nerve CSA in PsA patients compared to healthy controls (p=0.005, p<0.001; respectively). Also, US and MRI showed increased median nerve CSA in CTS patients compared to others (p=0.002, p<0.001; respectively). The Pearson correlation coefficient between MRI and US measurements of the CSA was 0.85 (p<0.001). Conclusion CTS frequency in PsA patients is found higher than healthy controls. The relationship between CTS diagnosed by EDS and CSA measured by both US and MRI was observed in PsA patients.
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Affiliation(s)
- Ezgi Akyildiz Tezcan
- Department of Physical Medicine and Rehabilitation, Cumra State Hospital, Konya, Turkey
| | - Funda Levendoglu
- Department of Physical Medicine and Rehabilitation, Konya, Turkey
| | | | - Hasan Kara
- Department of Physical Medicine and Rehabilitation, Erciyes University Medical Faculty, Kayseri, Turkey
| | | | | | - Muslu Kazım Korez
- Department of Biostatistics, Selcuk University Medical Faculty, Konya, Turkey
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Mahmoud W, El-Naby MMH, Awad AA. Carpal tunnel syndrome in rheumatoid arthritis patients: the role of combined ultrasonographic and electrophysiological assessment. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00147-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
Carpal tunnel syndrome (CTS) is known as one of the most common neurological extra-articular manifestations in rheumatoid arthritis (RA) patients. Studies on CTS in RA depend mostly on electrophysiological assessment. Few studies have used ultrasonography for evaluation of the local causes with much focus on wrist arthritis and tenosynovitis as the main cause of entrapment neuropathy of the median nerve in RA. The aim of our study is to assess the local causes of carpal tunnel syndrome in rheumatoid arthritis patients by ultrasonography and whether inflammatory or anomalous variations could affect decision-making and patient management.
Results
Carpal tunnel syndrome was diagnosed in 71 out of 74 examined RA wrists by nerve conduction studies (NCSs) and was categorized from minimal to severe according to Padua et al.’s (Ital J Neurol Sci 18:145–50, 1997) grading criteria. Median nerve CSA at the level of the carpal tunnel inlet and flattening ratio showed statistically significant relation with CTS severity. Bifid MN was found in 20 wrists (10 mild CTS wrists and 10 moderate CTS wrists), a persistent median artery was found in 4 wrists with moderate CTS, and an accessory muscle bundle was present in 3 wrists (2 mild CTS and 1 moderate CTS). The majority of the examined hands (85.1%) showed flexor tendon tenosynovitis at the wrist level and radio-carpal joint synovitis. The US7-joint score using GSUS7 & PDUS7 for synovitis, tenosynovitis and erosions showed significant relation with patients’ disease activity by DAS28 score. Significant relations between CTS severity and the following nerve conduction studies’ parameters, median nerve distal motor latency (DML), motor/sensory NCV, peak sensory latency, amplitude of SNAP, and median-radial latency difference test, were observed.
Conclusion
Synovial inflammation and local causes of median nerve compression such as bifid median nerve, persistent median artery, and accessory muscle bundle are collectively contributing factors in the etiology of carpal tunnel syndrome in rheumatoid arthritis patients. Ultrasonographic visualization of these inflammatory and anomalous variations enables early detection of CTS and highlights the possibility of non-arthritic-related causes. Using the 7-joint ultrasound (US7) score for assessment of synovitis, tenosynovitis, and erosions in rheumatoid arthritis patients is of valuable role in reflecting inflammation and its relation to the development of CTS in RA patients.
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Zaottini F, Picasso R, Pistoia F, Sanguinetti S, Pansecchi M, Tovt L, Viglino U, Cabona C, Garnero M, Benedetti L, Martinoli C. High-resolution ultrasound of peripheral neuropathies in rheumatological patients: An overview of clinical applications and imaging findings. Front Med (Lausanne) 2022; 9:984379. [PMID: 36388946 PMCID: PMC9661426 DOI: 10.3389/fmed.2022.984379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/12/2022] [Indexed: 11/13/2022] Open
Abstract
Peripheral neuropathies are surprisingly common and can be associated with a number of conditions, including rheumatological diseases. Whether the co-existence of peripheral neuropathies with rheumatological disorders is coincidental or related to a common pathogenic mechanism, these disabling conditions can affect the outcome of rheumatological patients and should be targeted with specific treatment. The clinical presentation of peripheral neuropathy can be multifaceted and difficult to recognize in polysymptomatic patients. However, physicians adopting state-of-art diagnostic strategies, including nerve imaging, may improve the detection rate and management of neuropathies. In particular, a diagnostic approach relying exclusively on clinical history and nerve conduction studies may not be sufficient to disclose the etiology of the nerve damage and its anatomical location and thus requires integration with morphological studies. High-Resolution Ultrasound (HRUS) is increasingly adopted to support the diagnosis and follow-up of both joint disorders in rheumatology and peripheral neuropathies of different etiologies. In this review, the different types of nerve disorders associated with the most common syndromes of rheumatological interest are discussed, focusing on the distinctive sonographic features.
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Affiliation(s)
- Federico Zaottini
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Riccardo Picasso
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- *Correspondence: Riccardo Picasso,
| | - Federico Pistoia
- Dipartimento di Medicina Sperimentale, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Sara Sanguinetti
- Dipartimento di Medicina Sperimentale, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Michelle Pansecchi
- Dipartimento di Scienze della Salute, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Luca Tovt
- Dipartimento di Scienze della Salute, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Umberto Viglino
- Dipartimento di Scienze della Salute, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
| | - Corrado Cabona
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- Eye Clinic, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Science, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy
| | - Martina Garnero
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- Eye Clinic, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Science, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy
| | - Luana Benedetti
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- Eye Clinic, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Science, School of Medical and Pharmaceutical Sciences, University of Genoa, Genoa, Italy
| | - Carlo Martinoli
- San Martino Hospital, Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
- Dipartimento di Scienze della Salute, Scuola di Scienze Mediche e Farmaceutiche, Università di Genova, Genoa, Italy
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