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Fan W, Chen X, Xiao P, Wei B, Zhang Y, Huang J, Wu S, Lu L. Protein-A immunoadsorption combined with immunosuppressive treatment in refractory primary Sjögren's syndrome coexisting with NMOSD: a case report and literature review. Front Immunol 2024; 15:1429405. [PMID: 39055718 PMCID: PMC11269126 DOI: 10.3389/fimmu.2024.1429405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 06/19/2024] [Indexed: 07/27/2024] Open
Abstract
The treatment of primary Sjögren's syndrome (pSS) coexisting with neuromyelitis optica spectrum disorder (NMOSD) using protein-A immunoadsorption combined with immunosuppressive therapy has rarely been reported. Herein, we present the case of a 35-year-old female diagnosed with pSS concomitant with NMOSD (pSS-NMOSD) who demonstrated a positive response to protein-A immunoadsorption after failing to respond to therapy comprising high-dose intravenous methylprednisolone (IVMP) and intravenous immunoglobulin (IVIG). Within one week of receiving three sessions of immunoadsorption combined with immunosuppressive treatment, the patient's clinical symptoms (blurred vision, paraparesis, and dysfunctional proprioception) significantly improved. Additionally, a rapid decrease in the circulating levels of Aquaporin-4 immunoglobulin G antibodies (AQP4-IgG), immunoglobulin (Ig) A, IgG, IgM, erythrocyte sedimentation rate (ESR), and rheumatoid factor (RF) were observed. Magnetic resonance imaging (MRI) further revealed a significant reduction in the lesions associated with longitudinal extensive transverse myelitis. During the follow-up period, prednisolone was gradually tapered to a maintenance dose of 5-10 mg/day, whereas mycophenolate mofetil (MMF) was maintained at 1.0-1.5 g/day. The patient's condition has remained stable for four years, with no signs of recurrence or progression observed on imaging examination. Therefore, this case suggests that protein A immunoadsorption may represent a potentially effective therapeutic option for patients with pSS-NMOSD who are refractory to conventional treatments.
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Affiliation(s)
- Wei Fan
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
- Department of Rheumatology, Ren ji Hosptial, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xuyan Chen
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Pingping Xiao
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Bo Wei
- Department of Rheumatology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Yi Zhang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Jinmei Huang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Shufan Wu
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China
| | - Liangjing Lu
- Department of Rheumatology, Ren ji Hosptial, Shanghai Jiaotong University School of Medicine, Shanghai, China
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2
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Heigl F, Hettich R, Fassbender C, Klingel R, Mauch E, Durner J, Kern R, Kleiter I. Immunoadsorption as maintenance therapy for refractory neuromyelitis optica spectrum disorder. Ther Adv Neurol Disord 2023; 16:17562864221150314. [PMID: 36762319 PMCID: PMC9905021 DOI: 10.1177/17562864221150314] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/12/2022] [Indexed: 02/10/2023] Open
Abstract
Background Neuromyelitis optica spectrum disorder (NMOSD) is a rare relapsing autoimmune disease of the central nervous system, affecting mainly optic nerves and spinal cord. NMOSD pathophysiology is associated with anti-aquaporin-4 (AQP4) immunoglobulin G (IgG) autoantibodies. Rapid extracorporeal elimination of autoantibodies with apheresis techniques, such as immunoadsorption (IA), was proven to be an effective treatment of NMOSD attacks. Data on the long-term use of IA to prevent attacks or progression of NMOSD are lacking. Objectives The aim of this study was to evaluate efficacy and safety of maintenance IA for preventing recurrence of NMOSD attacks in patients refractory to other immunotherapies. Design Case study. Methods Retrospective analysis of two female patients with severe NMOSD refractory to conventional immunotherapies was performed. Both patients had responded to tryptophan IA (Tr-IA) as attack therapy and subsequently were treated with biweekly maintenance Tr-IA. Results Patient 1 (AQP4-IgG seropositive, age 42 years) had 1.38 attacks of optic neuritis per year within 10.1 years before commencing regular Tr-IA. With maintenance Tr-IA for 3.1 years, one mild attack occurred, which was responsive to steroid pulse therapy. Expanded Disability Status Scale (EDSS) was stable at 5.0. Visual function score of the last eye improved from 3 to 1. Patient 2 (AQP4-IgG seronegative, age 43 years) experienced 1.7 attacks per year, mainly acute myelitis and optic neuritis, during the period of 10.0 years before the start of Tr-IA. During regular Tr-IA treatment, no further NMOSD attack occurred. The patient was clinically stable without any additional immunosuppressive treatment for 5.3 years. EDSS improved from 6.0 to 5.0, and the ambulation score from 7 to 1. Tolerability of Tr-IA was good in both patients. No serious adverse events occurred during long-term clinical trajectories. Conclusion Tr-IA was well tolerated as maintenance treatment and resulted in clinical stabilization of two patients with highly active NMOSD, who were refractory to standard drug therapy.
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Affiliation(s)
- Franz Heigl
- Medical Care Center Kempten-Allgäu, Kempten, Germany
| | | | | | - Reinhard Klingel
- Apheresis Research Institute, Cologne, Germany; 1st Department of Internal Medicine, University of Mainz, Mainz, Germany
| | - Erich Mauch
- Clinic for Neurology Dietenbronn, Academic Hospital of University of Ulm, Schwendi, Germany
| | - Joachim Durner
- Neurology Department, M&I Fachklinik Ichenhausen, Ichenhausen, Germany
| | - Rolf Kern
- Department of Neurology, Klinikum Worms, Worms, Germany
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3
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Preble JM, Lin X. Plasmapheresis as a viable treatment option for scleritis. Am J Ophthalmol Case Rep 2022; 27:101627. [PMID: 35782168 PMCID: PMC9243044 DOI: 10.1016/j.ajoc.2022.101627] [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: 01/30/2022] [Revised: 05/19/2022] [Accepted: 06/15/2022] [Indexed: 11/12/2022] Open
Abstract
Purpose We describe a case and our experience with using plasmapheresis as a treatment for scleritis. Observations Treating relapsing autoimmune scleritis can be challenging when it inadequately responds to traditional therapy. Our patient could not receive non-steroidal anti-inflammatory therapy for her scleritis due to recent gastrointestinal surgery and previously failed multiple steroid sparing treatments due to intolerance. There was good initial control with high dose oral prednisone, however, the steroid could not be tapered to a safe dosage (<10 mg per day) without relapse. Therefore, we opted to treat our patient with plasmapheresis. Conclusions and Importance After undergoing plasmapheresis, our patient experienced total resolution of symptoms with corresponding clinical resolution of scleritis. Plasmapheresis derives great benefit by filtering circulating immune complexes. Although rarely used, plasmapheresis can be effective in treating non-infectious scleritis.
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4
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Chen B, Qin C, Chen M, Yu HH, Tao R, Chu YH, Bu BT, Tian DS. Dynamic Changes in AQP4-IgG Level and Immunological Markers During Protein-A Immunoadsorption Therapy for NMOSD: A Case Report and Literature Review. Front Immunol 2021; 12:650782. [PMID: 34367127 PMCID: PMC8334553 DOI: 10.3389/fimmu.2021.650782] [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: 01/08/2021] [Accepted: 06/15/2021] [Indexed: 11/13/2022] Open
Abstract
The changes in the serum levels of aquaporin-4-IgG (AQP4-IgG), immunoglobulins, and inflammatory mediators in neuromyelitis optica spectrum disorder (NMOSD) cases treated with immunoadsorption have been rarely described in detail. Here we report a 29-year-old steroid-resistant NMOSD female with a severe disability (bilateral blindness and paraplegia) who received protein-A immunoadsorption as a rescue treatment. During the total 5 sessions, the circulating level of AQP4-IgG, immunoglobulins, and complement proteins (C3 and C4) showed a rapid and sawtooth-like decrease, and the serum AQP4-IgG titer declined from 1:320 to below the detectable limit at the end of the 3rd procedure. Of all the antibodies, IgG had the biggest removal rate (>96.1%), followed by IgM (>66.7%) and IgA (53%), while complement C3 and C4 also dropped by 73% and 65%, respectively. The reduced pro-inflammatory cytokines (interleukin-8 and tumor necrosis factor-α) and marked increased lymphocyte (T and B cell) counts were also observed. The improvement of symptoms initiated after the last session, with a low AQP4-IgG titer (1:32) persisting thereafter. Accordingly, protein-A immunoadsorption treatment could be one of the potential rescue therapies for steroid-resistant NMOSD patients with a severe disability.
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Affiliation(s)
- Bo Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chuan Qin
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Man Chen
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hai-Han Yu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ran Tao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yun-Hui Chu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bi-Tao Bu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dai-Shi Tian
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Li R, Wang J, Li C, Liu X, Chu M, Chang Y, Wang Y, Wang X, Yu B, Ling L, Yang H, Yang H, Hu X, Qiu W. Rescue immunoadsorption treatment for neuromyelitis optica spectrum disorder attacks unresponsive to intravenous methylprednisolone. J Neuroimmunol 2021; 356:577604. [PMID: 33992860 DOI: 10.1016/j.jneuroim.2021.577604] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 02/06/2023]
Abstract
We aimed to evaluate the value of immunoadsorption (IA) treatment after the failure of intravenous methylprednisolone (IVMP) therapy for neuromyelitis optica spectrum disorder (NMOSD). Sixty-one NMOSD attacks unresponsive to IVMP were included: 22 patients received rescue IA (IVMP+IA), 24 underwent rescue plasma exchange (PE) (IVMP+PE), and 21 received no further rescue therapy (IVMP alone). The improvement frequencies were higher in the IVMP+IA and IVMP+PE groups than in the IVMP-alone group (P = 0.024). The effective period for IA treatment may be longer than previously thought. IA treatment for IVMP-resistant NMOSD attacks was effective and comparable to PE treatment.
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Affiliation(s)
- Rui Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Jingqi Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Cong Li
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Xiangfu Liu
- Department of Blood Transfusion, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Muyang Chu
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510060, China
| | - Yanyu Chang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Yuge Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Xia Wang
- Neurology Department, The Sixth People's Hospital of Huizhou, Huizhou 516200, China
| | - Boguang Yu
- Guangdong Provincial Key Laboratory of Hemoadsorption Technology, Guangzhou 510700, China
| | - Li Ling
- Department of Medical Statistics, School of Public Health, Sun Yat-sen University, Guangzhou 510060, China
| | - Hui Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center of Sun Yat-sen University, Guangzhou 510060, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital of Central South University, Changsha 410008, China
| | - Xueqiang Hu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Wei Qiu
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China.
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Restrepo-Aristizábal C, Giraldo LM, Giraldo YM, Pino-Pérez AM, Álvarez-Gómez F, Franco CA, Tobón JV, Ascencio JL, Zuluaga MI. PLEX: the best first-line treatment in nmosd attacks experience at a single center in Colombia. Heliyon 2021; 7:e06811. [PMID: 33948520 PMCID: PMC8080073 DOI: 10.1016/j.heliyon.2021.e06811] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/08/2021] [Accepted: 04/12/2021] [Indexed: 02/09/2023] Open
Abstract
Objective Primary outcome was to evaluate complete improvement at six months after acute treatment in NMOSD relapses. Methods Retrospective observational cohort study of patients with diagnosis of NMOSD admitted for acute attacks. We performed an explanatory analysis using the univariate, bivariate and multivariate logistic regression approach. We compared survival curves using the Kaplan Meier analysis and estimated the median time for the main outcome. Results In the univariate analysis, basal EDSS score, AQP4-IgG positivity, PLEX as a first-line treatment (IVMP + PLEX), less systemic complications related to acute treatment and total attack history were independently associated with complete improvement at six months. After adjusting for confounding variables and using multivariate analysis by Cox Regression, positive AQ4-IgG (HR 0.04, 95% CI: 0.02–0.66) and IVMP + PLEX (HR 5.1, 95% CI: 3.9–66.4), were kept as independent factors associated to time to complete improvement. Time from admission to PLEX initiation and complete improvement at six months had a median of seven days (95% CI: 5.2–8.8). In secondary effects, there were no statistical differences between the groups. Conclusions PLEX + IVMP is the treatment of choice for NMOSD relapses and should be initiated as early as possible.
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Affiliation(s)
- C Restrepo-Aristizábal
- Neurology, Instituto Neurológico de Colombia (INDEC) Medellín, Colombia.,Neurology, CES University Medellín, Colombia
| | - L M Giraldo
- Neurology, Instituto Neurológico de Colombia (INDEC) Medellín, Colombia.,Neurology, CES University Medellín, Colombia
| | - Y M Giraldo
- Epidemiology, Biostatistics CES University; Medellín, Colombia
| | - A M Pino-Pérez
- Neurology, Instituto Neurológico de Colombia (INDEC) Medellín, Colombia.,Neurology, CES University Medellín, Colombia
| | - F Álvarez-Gómez
- Neurology, Instituto Neurológico de Colombia (INDEC) Medellín, Colombia.,Neurology, CES University Medellín, Colombia
| | - C A Franco
- Neurology, Instituto Neurológico de Colombia (INDEC) Medellín, Colombia.,Neurology, CES University Medellín, Colombia
| | - J V Tobón
- Neurology, Instituto Neurológico de Colombia (INDEC) Medellín, Colombia.,Neurology, CES University Medellín, Colombia
| | - J L Ascencio
- Neurorradiology, Instituto Neurológico de Colombia, Medellín, Colombia
| | - M I Zuluaga
- Neurology, Instituto Neurológico de Colombia (INDEC) Medellín, Colombia.,Neurology, CES University Medellín, Colombia
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Carnero Contentti E, Rojas JI, Cristiano E, Marques VD, Flores-Rivera J, Lana-Peixoto M, Navas C, Papais-Alvarenga R, Sato DK, Soto de Castillo I, Correale J. Latin American consensus recommendations for management and treatment of neuromyelitis optica spectrum disorders in clinical practice. Mult Scler Relat Disord 2020; 45:102428. [DOI: 10.1016/j.msard.2020.102428] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 02/06/2023]
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8
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Plasma Exchange or Immunoadsorption in Demyelinating Diseases: A Meta-Analysis. J Clin Med 2020; 9:jcm9051597. [PMID: 32466101 PMCID: PMC7290597 DOI: 10.3390/jcm9051597] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 05/17/2020] [Accepted: 05/18/2020] [Indexed: 12/14/2022] Open
Abstract
Multiple sclerosis (MS) is an inflammatory disease mainly affecting the central nervous system. In MS, abnormal immune mechanisms induce acute inflammation, demyelination, axonal loss, and the formation of central nervous system plaques. The long-term treatment involves options to modify the disease progression, whereas the treatment for the acute relapse has its focus in the administration of high-dose intravenous methylprednisolone (up to 1000 mg daily) over a period of three to five days as a first step. If symptoms of the acute relapse persist, it is defined as glucocorticosteroid-unresponsive, and immunomodulation by apheresis is recommended. However, several national and international guidelines have no uniform recommendations on using plasma exchange (PE) nor immunoadsorption (IA) in this case. A systematic review and meta-analysis was conducted, including observational studies or randomized controlled trials that investigated the effect of PE or IA on different courses of MS and neuromyelitis optica (NMO). One thousand, three hundred and eighty-three patients were included in the evaluation. Therapy response in relapsing-remitting MS and clinically isolated syndrome was 76.6% (95%CI 63.7–89.8%) in PE- and 80.6% (95%CI 69.3–91.8%) in IA-treated patients. Based on the recent literature, PE and IA may be considered as equal treatment possibilities in patients suffering from acute, glucocorticosteroid-unresponsive MS relapses.
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Straube R, Müller G, Voit-Bak K, Tselmin S, Julius U, Schatz U, Rietzsch H, Reichmann H, Chrousos GP, Schürmann A, Jarc L, Ziemssen T, Siepmann T, Bornstein SR. Metabolic and Non-Metabolic Peripheral Neuropathy: Is there a Place for Therapeutic Apheresis? Horm Metab Res 2019; 51:779-784. [PMID: 31826273 DOI: 10.1055/a-1039-1471] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
As the rate of obesity and the incidence of diabetes mellitus have been increasing, diabetic neuropathy has become the most common cause of peripheral neuropathy in developed countries. In addition, a variety of pathogenetically heterogeneous disorders can lead to impairment of the peripheral nervous system including amyloidosis, vitamin deficiencies, uremia and lipid disorders, alcohol abuse, autoimmune and infectious diseases as well as exposure to environmental toxins. We have noted that a combination of these disorders may aggravate the manifestations of peripheral diabetic neuropathy, an effect, which is most pronounced when metabolic and non-metabolic pathologies lead to cumulative damage. Current treatment options are limited and generally have unsatisfactory results in most patients. Therapeutic apheresis (INUSpherese®) allows the removal of metabolic, inflammatory, immunologic and environmental contributors to the disease process and may be an effective treatment option. We reviewed the developments in therapeutic apheresis for metabolic and non-metabolic peripheral neuropathy, including the current literature as well as data from our university diabetes center.
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Affiliation(s)
- Richard Straube
- Zentrum für Apherese- und Hämofiltration am INUS Tagesklinikum - Cham, Germany
| | - Gregor Müller
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany
| | - Karin Voit-Bak
- Zentrum für Apherese- und Hämofiltration am INUS Tagesklinikum - Cham, Germany
| | - Sergey Tselmin
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany
| | - Ulrich Julius
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany
| | - Ulrike Schatz
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany
| | - Hannes Rietzsch
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - George P Chrousos
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany
- University Research Institute of Maternal and Child Health & Precision Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Annette Schürmann
- Department of Experimental Diabetology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Nuthetal, Germany
| | - Luka Jarc
- Center for Regenerative Therapies Dresden, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Tjalf Ziemssen
- Department of Neurology, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - Stefan R Bornstein
- Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Germany
- Division of Diabetes & Nutritional Sciences, Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, University Hospital, Zürich, Switzerland
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