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Dey M, Busby A, Isaac J, Pratt A, Ndosi M, Young A, Lempp H, Nikiphorou E. Personalised care packages for people with rheumatoid arthritis: a mixed-methods study. RMD Open 2024; 10:e003483. [PMID: 38191212 PMCID: PMC10806595 DOI: 10.1136/rmdopen-2023-003483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 11/24/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVES Disease management in rheumatoid arthritis (RA) requires holistic assessment. We aimed to design personalised care packages suitable for people with RA. METHODS This study was conducted using a mixed-methods approach and exploratory sequential design. Consensus workshops were held, involving people with RA and healthcare professionals (HCPs) treating them. Subsequently, an online survey sought views on future care packages for people with RA at relevant disease progression/stages, based on (1) results from previous quantitative data analyses (eg, socioeconomic/clinical factors), and (2) themes identified during workshops. RESULTS Two conceptual care pathways were identified: (1) around the time of RA diagnosis, an early opportunity to influence the disease course; (2) for individuals with established RA, emphasising the importance of 'the right MDT member at the right time'.Three care packages were suggested: (1) early care package (around RA diagnosis): introduction to MDT; (2) continuity of care package (established RA): primary/secondary providers; and (3) personalised holistic care package: integral to packages 1 and 2, implemented alongside allied health professionals.The survey received 41 responses; 82.9% agreed that people with RA need a consistent 'early care package' at diagnosis. 85.4% approved of additional care packages tailored to individuals' clinical, psychological and social needs when moving to different stages of their long-term disease. Fleiss' Kappa calculations demonstrated fair level of agreement among respondents. CONCLUSION Two care pathways, with three tailored care packages, were identified, with potential to improve management of people with RA. Future research will help to determine if such care packages can impact clinical (including patient-reported) outcomes.
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Affiliation(s)
- Mrinalini Dey
- Centre for Rheumatic Diseases, Department of Inflammation Biology, King's College London School of Immunology & Microbial Sciences, London, UK
| | - Amanda Busby
- Centre for Health Services and Clinical Research, Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - John Isaac
- Faculty of Medical Sciences, Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Arthur Pratt
- Faculty of Medical Sciences, Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Musculoskeletal Unit, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mwidimi Ndosi
- School of Health and Social Wellbeing, College of Health Science and Society, University of the West of England, Bristol, UK
- Academic Rheumatology Unit, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Adam Young
- Centre for Health Services and Clinical Research, Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, King's College London School of Immunology & Microbial Sciences, London, UK
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, Department of Inflammation Biology, King's College London School of Immunology & Microbial Sciences, London, UK
- Department of Rheumatology, King's College Hospital, London, UK
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Garg U, Jain N, Kaul S, Nagaich U. Role of Albumin as a Targeted Drug Carrier in the Management of Rheumatoid Arthritis: A Comprehensive Review. Mol Pharm 2023; 20:5345-5358. [PMID: 37870420 DOI: 10.1021/acs.molpharmaceut.3c00581] [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] [Indexed: 10/24/2023]
Abstract
An endogenous transporter protein called albumin interacts with the Fc receptor to provide it with multiple substrate-binding domains, cell membrane receptor activation, and an extended circulating half-life. Albumin has the remarkable ability to bind with receptors viz. secreted protein acidic and rich in cysteine (SPARC) and scavenger protein-A (SR-A) that are overexpressed during rheumatoid arthritis (RA), enabling active targeting of the disease site instead of requiring specialized substrates to be added to the nanocarrier. RA, a chronic autoimmune illness, is characterized by the presence of a severe inflammatory response. RA patients have low serum albumin concentration, which signifies the high uptake of albumin at the inflammatory sites, giving a rationale to use albumin as a drug carrier for RA therapy. Albumin has the capacity for both passive and active targeting. It is an abundantly available protein in the bloodstream showing excellent cellular compatibility, degradability in biological tissues, nonantigenicity, and safety. There are three strategies of albumin mediated drug delivery as encapsulating therapeutics in albumin nanoparticles, chemically conjugating drugs with functional proteins, and albumin itself which is used as a targeting ligand to deliver drugs specifically to cells or tissues that express albumin-binding receptors. In the current review, an attempt has been made to highlight the significant evidence of albumin as a drug delivery carrier for the safe and effective management of RA. Evidence has been provided in the form of recent research advances, clinical trials, and patents. Additionally, this review will outline the prospective for the potential utilization of albumin as a drug vehicle for RA and suggest possible future avenues to provide the perspective for subsequent studies.
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Affiliation(s)
- Unnati Garg
- Department of Pharmaceutics, Amity Institute of Pharmacy, Amity University, Noida, Uttar Pradesh 201303, India
| | - Neha Jain
- Department of Pharmaceutics, Amity Institute of Pharmacy, Amity University, Noida, Uttar Pradesh 201303, India
| | - Shreya Kaul
- Department of Pharmaceutics, Amity Institute of Pharmacy, Amity University, Noida, Uttar Pradesh 201303, India
| | - Upendra Nagaich
- Department of Pharmaceutics, Amity Institute of Pharmacy, Amity University, Noida, Uttar Pradesh 201303, India
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3
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Studenic P, Bond G, Kerschbaumer A, Bécède M, Pavelka K, Karateev D, Stieger J, Puchner R, Mueller RB, Puchhammer-Stöckl E, Durechova M, Loiskandl M, Perkmann T, Olejarova M, Luchikhina E, Steiner CW, Bonelli M, Smolen JS, Aletaha D. Torque Teno Virus Quantification for Monitoring of Immunomodulation with Biological Compounds in the Treatment of Rheumatoid Arthritis. Rheumatology (Oxford) 2021; 61:2815-2825. [PMID: 34792562 DOI: 10.1093/rheumatology/keab839] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 11/02/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Rheumatoid arthritis (RA) patients who fail to respond to methotrexate (MTX) can receive biologic disease-modifying antirheumatic drugs (bDMARDs). The Torque Teno Virus (TTV) is a potential novel candidate for monitoring of immunosuppression. We explore TTV in these patients and association with clinical response to bDMARDs. METHODS The BioBio Study is a multicentre randomized open-label trial, including RA patients with insufficient response to MTX. Patients were randomized to either TNFi (infliximab, INF), anti-IL-6 (tocilizumab, TCZ), CTLA4-Ig (abatacept, ABA) or anti-CD20 (rituximab, RTX) in addition to MTX. PCR was used to quantify TTV in the peripheral blood. RESULTS TTV was measured in 95 patients (INF, n = 23; TCZ, n = 22; ABA, n = 27; RTX; n = 23). TTV increased by a median of 4.5*104 copies/ml (c/ml; inter quartile range [IQR] 0-7.5*105) after 3 months. TTV levels at month 3 were associated with SDAI (p= 0.03) and CDAI response (p= 0.026) at month 6. A TTV cut-off level of 1.2*106 c/ml at month 3 had a positive likelihood ratio of 2.7 for prediction of SDAI85% response at month 6. CONCLUSION Our data suggest that TTV levels increase upon TNF, CD20 and co-stimulation blockade and associate with clinical response to bDMARDs in RA patients. TRIAL REGISTRATION ClinicalTrials.gov; https://clinicaltrials.gov; NCT01638715.
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Affiliation(s)
- Paul Studenic
- Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Austria.,Division of Rheumatology, Department of Medicine (Solna), Karolinska Institutet, Sweden
| | - Gregor Bond
- Division of Nephrology and Dialysis, Medical University of Vienna, Austria
| | - Andreas Kerschbaumer
- Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Austria
| | - Manuel Bécède
- Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Austria
| | - Karel Pavelka
- Institute of Rheumatology, Prague, Czech Republic.,Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Dmitry Karateev
- Department of Rheumatology, Moscow Regional Research and Clinical Institute (MONIKI), Russia
| | - Jutta Stieger
- 2nd Department of Medicine, Hietzing Hospital, Austria
| | | | - Ruediger B Mueller
- Cantonal Hospital Lucerne, Division of Rheumatology, Medical University Department, Rheumazentrum Ostschweiz St. Gallen, Switzerland
| | | | - Martina Durechova
- Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Austria
| | - Michaela Loiskandl
- Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Austria
| | - Thomas Perkmann
- Department of Laboratory Medicine, Medical University of Vienna, Austria
| | - Martina Olejarova
- Institute of Rheumatology, Prague, Czech Republic.,Department of Rheumatology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Elena Luchikhina
- Department of Rheumatology, Moscow Regional Research and Clinical Institute (MONIKI), Russia
| | - Carl-Walter Steiner
- Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Austria
| | - Michael Bonelli
- Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Austria
| | - Josef S Smolen
- Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Austria
| | - Daniel Aletaha
- Department of Internal Medicine 3, Division of Rheumatology, Medical University of Vienna, Austria
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Bugatti S, De Stefano L, Manzo A, Sakellariou G, Xoxi B, Montecucco C. Limiting factors to Boolean remission differ between autoantibody-positive and -negative patients in early rheumatoid arthritis. Ther Adv Musculoskelet Dis 2021; 13:1759720X211011826. [PMID: 34093745 PMCID: PMC8141996 DOI: 10.1177/1759720x211011826] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/31/2021] [Indexed: 12/14/2022] Open
Abstract
Background: The patient global assessment of disease activity (PGA) is the major limiting factor to Boolean remission in patients with established rheumatoid arthritis (RA). Here, we investigated the limiting variables to disease remission in patients with early RA treated with conventional synthetic disease modifying anti-rheumatic drugs, also in relation to autoantibody status. Methods: Data were retrieved from 535 early RA patients (<12 months of symptoms) with an observation period of 6–12 months upon initiation of therapy with methotrexate aimed at the achievement of low disease activity based on the 28-joints disease activity score. Near-remission was defined as any of the four core items of Boolean remission >1 with the remaining three all ⩽1. Reasons for missing Boolean remission and predictors of near-remission subcategories were analyzed in relation to baseline disease variables. Results: After 6 and 12 months, near-remission was two-times more frequent than Boolean remission (25.6% and 26.9% at the two time-points). A 28-swollen joint count (SJC28) >1 was responsible for the majority of near-remission (56.2% and 57.6% at 6 and 12 months, respectively), and PGA > 1 accounted for approximatively 35% of the cases. Autoantibody-positivity independently predicted the risk of missing remission because of SJC28 > 1 [adjusted odds ratio (OR) 95% confidence interval (CI) 2.81 (1.59–4.9) at 6 months and 1.73 (1.01–3.01) at 12 months], whilst autoantibody-negativity was an independent predictor of PGA near-remission [adjusted OR (95% CI) 2.45 (1.25–4.80) at 6 months and 5.71 (2.47–13.2) at 12 months]. Conclusion: In early RA, Boolean remission is more frequently missed because of persistent swollen joints. However, barriers to full-remission vary in relation to the autoantibody status. Autoantibody-positive patients more commonly experience residual swollen joints, whilst PGA more frequently impairs remission in autoantibody-negative patients. Efforts to target full-remission in early RA may thus require different strategies according to autoantibody profile.
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Affiliation(s)
- Serena Bugatti
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation University Hospital, Viale Golgi 19, Pavia, 27100, Italy
| | - Ludovico De Stefano
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Antonio Manzo
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | - Blerina Xoxi
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
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Xiang Y, Wang Q, Li H, Duan X, Fang Y, Yang P, Li Q, Wu R, Huo Y, Shi X, Wu Z, Wang Y, Jiang N, Hsieh E, Li M, Tian X, Zeng X. Chinese registry of rheumatoid arthritis (CREDIT): III. The transition of disease activity during follow-ups and predictors of achieving treatment target. Int J Rheum Dis 2020; 23:1719-1727. [PMID: 33034424 DOI: 10.1111/1756-185x.13996] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/28/2020] [Accepted: 09/16/2020] [Indexed: 12/28/2022]
Abstract
AIM The Chinese Registry of Rheumatoid Arthritis (CREDIT) is the first nationwide multi-center prospective rheumatoid arthritis (RA) registration cohort in China. This study aimed at presenting disease activities transition during follow-ups and identifying predictors to treatment response. METHOD Patients who had baseline, 3- and 6-month follow-up data from November 2016 to April 2018 were recruited. Then, we selected patients who did not reach remission (REM)/low disease activity (LDA) at baseline to investigate the predictors for treatment response. RESULTS There were 979 patients included (83.00% female, mean age 51.8 and median duration 3.84 years). REM/LDA rate at baseline, 3-, and 6-month follow-up were 34.02%, 59.35% and 68.23%. Additionally, early RA has more chance to achieve targets than established RA (6 months: 59.79% vs 48.13%, P = .002). High baseline Disease Activity Score of 28 joints (DAS28) (early RA: odds ratio [OR] 1.319, P = .019; established RA: OR 1.337, P < .001), biologic disease-modifying anti-rheumatic drugs (bDMARD)/targeted synthetic DMARD combined conventional DMARD therapy (early RA: OR 9.023, P = .046) and prednisolone usage (early RA: OR 2.526, P < .001) are positively associated with Clinical Disease Assessment Index (CDAI) decreasing at 3 months. Low baseline DAS28 (REM/LDA: early RA: OR 0.650, P < .001; established RA: OR 0.612, P < .001. REM: early RA: OR 0.743, P = .021; established RA: OR 0.674, P < .001), young age (REM: early RA: OR 0.977, P = .048) and decrease of CDAI at 3 months (REM/LDA: early RA: OR 7.185, P < .001; established RA: OR 8.752, P < .001. REM: early RA: OR 5.602, P < .001; established RA: OR 4.955, P < .001) predict REM/LDA at 6 months. CONCLUSION Disease activity decreased during follow-ups. Disease duration, baseline disease activity, age, treatment strategies, and CDAI decreasing were associated with treatment response.
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Affiliation(s)
- Yirong Xiang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science & Technology, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science & Technology, Beijing, China
| | - Hongbin Li
- Department of Rheumatology, The Affiliated Hospital of Inner Mongolia Medical College, Hohhot, China
| | - Xinwang Duan
- Department of Rheumatology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yongfei Fang
- Department of Rheumatology, Southwest Hospital, Third Military Medical University, Chongqing, China
| | - Pingting Yang
- Department of Rheumatology and Immunology, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Qin Li
- Department of Rheumatology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Rui Wu
- Department of Rheumatology, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yuehong Huo
- Department of Rheumatology, The Fifth People's Hospital of Datong, Datong, China
| | - Xiaofei Shi
- Department of Rheumatology, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Zhenbiao Wu
- Department of Clinical Immunology and Rheumatology, Xijing Hospital affiliated to the Fourth Military Medical University, Xi'an, China
| | - Yanhong Wang
- Department of Epidemiology and Bio-statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Nan Jiang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science & Technology, Beijing, China
| | - Evelyn Hsieh
- Section of Rheumatology, Yale School of Medicine, New Haven, CT, USA
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science & Technology, Beijing, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science & Technology, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, National Clinical Research Center on Rheumatology, Ministry of Science & Technology, Beijing, China
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Prosperini L, Mancinelli CR, Solaro CM, Nociti V, Haggiag S, Cordioli C, De Giglio L, De Rossi N, Galgani S, Rasia S, Ruggieri S, Tortorella C, Capra R, Mirabella M, Gasperini C. Induction Versus Escalation in Multiple Sclerosis: A 10-Year Real World Study. Neurotherapeutics 2020; 17:994-1004. [PMID: 32236822 PMCID: PMC7609676 DOI: 10.1007/s13311-020-00847-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In this independent, multicenter, post-marketing study, we directly compare induction immunosuppression versus escalation strategies on the risk of reaching the disability milestone of Expanded Disability Status Scale (EDSS) ≥ 6.0 over 10 years in previously untreated patients with relapsing-remitting multiple sclerosis. We collected data of patients who started interferon beta (escalation) versus mitoxantrone or cyclophosphamide (induction) as initial treatment. Main eligibility criteria included an EDSS score ≤ 4.0 at treatment start and either ≥ 2 relapses or 1 disabling relapse with evidence of ≥ 1 gadolinium-enhancing lesion at magnetic resonance imaging scan in the pre-treatment year. Since patients were not randomized to treatment group, we performed a propensity score (PS)-based matching procedure to select individuals with homogeneous baseline characteristics. Comparisons were then conducted using Cox models stratified by matched pairs. Overall, 75 and 738 patients started with induction and escalation, respectively. Patients in the induction group were older and more disabled than those in the escalation group (p < 0.05). The PS-matching procedure retained 75 patients per group. In the re-sampled population, a lower proportion of patients reached the outcome after induction (21/75, 28.0%) than escalation (29/75, 38.7%) (hazard ratio = 0.48; p = 0.024). Considering the whole sample, serious adverse events occurred more frequently after induction (8/75, 10.7%) than escalation (18/738, 2.4%) (odds ratio = 3.36, p = 0.015). These findings suggest that, in patients with poor prognostic factors, induction was more effective than escalation in reducing the risk of reaching the disability milestone, albeit with a worse safety profile. Future studies are warranted to explore if newer induction agents may provide a more advantageous long-lasting risk:benefit profile.
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Affiliation(s)
- Luca Prosperini
- Department of Neurosciences, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152 Rome, Italy
| | - Chiara Rosa Mancinelli
- Multiple Sclerosis Centre, ASST Spedali Civili di Brescia, P.O. Montichiari, Via Ciotti 154, 25018 Montichiari, BS Italy
| | - Claudio Marcello Solaro
- Rehabilitation Unit ‘Mons. L. Novarese’ Hospital, Loc. Trompone, 13040 Moncrivello, VC Italy
| | - Viviana Nociti
- Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Shalom Haggiag
- Department of Neurosciences, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152 Rome, Italy
| | - Cinzia Cordioli
- Multiple Sclerosis Centre, ASST Spedali Civili di Brescia, P.O. Montichiari, Via Ciotti 154, 25018 Montichiari, BS Italy
| | - Laura De Giglio
- Neurology Unit, S. Filippo Neri Hospital, Via G. Martinotti 20, 00135 Rome, Italy
- Multiple Sclerosis Centre, S. Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Nicola De Rossi
- Multiple Sclerosis Centre, ASST Spedali Civili di Brescia, P.O. Montichiari, Via Ciotti 154, 25018 Montichiari, BS Italy
| | - Simonetta Galgani
- Department of Neurosciences, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152 Rome, Italy
| | - Sarah Rasia
- Multiple Sclerosis Centre, ASST Spedali Civili di Brescia, P.O. Montichiari, Via Ciotti 154, 25018 Montichiari, BS Italy
| | - Serena Ruggieri
- Department of Neurosciences, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152 Rome, Italy
- Multiple Sclerosis Centre, S. Andrea Hospital, Via di Grottarossa 1035, 00189 Rome, Italy
| | - Carla Tortorella
- Department of Neurosciences, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152 Rome, Italy
| | - Ruggero Capra
- Multiple Sclerosis Centre, ASST Spedali Civili di Brescia, P.O. Montichiari, Via Ciotti 154, 25018 Montichiari, BS Italy
| | - Massimiliano Mirabella
- Fondazione Policlinico Universitario ‘A. Gemelli’ IRCCS, L.go A. Gemelli 8, 00168 Rome, Italy
- Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00168 Rome, Italy
| | - Claudio Gasperini
- Department of Neurosciences, S. Camillo-Forlanini Hospital, C.ne Gianicolense 87, 00152 Rome, Italy
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