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Alqudah AM, Elwali A, Kupiak B, Hajipour F, Jacobson N, Moussavi Z. Obstructive sleep apnea detection during wakefulness: a comprehensive methodological review. Med Biol Eng Comput 2024; 62:1277-1311. [PMID: 38279078 PMCID: PMC11021303 DOI: 10.1007/s11517-024-03020-3] [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: 06/25/2023] [Accepted: 01/11/2024] [Indexed: 01/28/2024]
Abstract
Obstructive sleep apnea (OSA) is a chronic condition affecting up to 1 billion people, globally. Despite this spread, OSA is still thought to be underdiagnosed. Lack of diagnosis is largely attributed to the high cost, resource-intensive, and time-consuming nature of existing diagnostic technologies during sleep. As individuals with OSA do not show many symptoms other than daytime sleepiness, predicting OSA while the individual is awake (wakefulness) is quite challenging. However, research especially in the last decade has shown promising results for quick and accurate methodologies to predict OSA during wakefulness. Furthermore, advances in machine learning algorithms offer new ways to analyze the measured data with more precision. With a widening research outlook, the present review compares methodologies for OSA screening during wakefulness, and recommendations are made for avenues of future research and study designs.
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Affiliation(s)
- Ali Mohammad Alqudah
- Biomedical Engineering Program, University of Manitoba, 66 Chancellors Cir, Winnipeg, MB, R3T 2N2, Canada
| | - Ahmed Elwali
- Biomedical Engineering Program, Marian University, 3200 Cold Sprint Road, Indianapolis, IN, 46222-1997, USA
| | - Brendan Kupiak
- Electrical and Computer Engineering Department, University of Manitoba, 66 Chancellors Cir, Winnipeg, MB, R3T 2N2, Canada
| | | | - Natasha Jacobson
- Biosystems Engineering Department, University of Manitoba, 66 Chancellors Cir, Winnipeg, MB, R3T 2N2, Canada
| | - Zahra Moussavi
- Biomedical Engineering Program, University of Manitoba, 66 Chancellors Cir, Winnipeg, MB, R3T 2N2, Canada.
- Electrical and Computer Engineering Department, University of Manitoba, 66 Chancellors Cir, Winnipeg, MB, R3T 2N2, Canada.
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Cohen O, Kundel V, Robson P, Al-Taie Z, Suárez-Fariñas M, Shah NA. Achieving Better Understanding of Obstructive Sleep Apnea Treatment Effects on Cardiovascular Disease Outcomes through Machine Learning Approaches: A Narrative Review. J Clin Med 2024; 13:1415. [PMID: 38592223 PMCID: PMC10932326 DOI: 10.3390/jcm13051415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 02/13/2024] [Accepted: 02/17/2024] [Indexed: 04/10/2024] Open
Abstract
Obstructive sleep apnea (OSA) affects almost a billion people worldwide and is associated with a myriad of adverse health outcomes. Among the most prevalent and morbid are cardiovascular diseases (CVDs). Nonetheless, randomized controlled trials (RCTs) of OSA treatment have failed to show improvements in CVD outcomes. A major limitation in our field is the lack of precision in defining OSA and specifically subgroups with the potential to benefit from therapy. Further, this has called into question the validity of using the time-honored apnea-hypopnea index as the ultimate defining criteria for OSA. Recent applications of advanced statistical methods and machine learning have brought to light a variety of OSA endotypes and phenotypes. These methods also provide an opportunity to understand the interaction between OSA and comorbid diseases for better CVD risk stratification. Lastly, machine learning and specifically heterogeneous treatment effects modeling can help uncover subgroups with differential outcomes after treatment initiation. In an era of data sharing and big data, these techniques will be at the forefront of OSA research. Advanced data science methods, such as machine-learning analyses and artificial intelligence, will improve our ability to determine the unique influence of OSA on CVD outcomes and ultimately allow us to better determine precision medicine approaches in OSA patients for CVD risk reduction. In this narrative review, we will highlight how team science via machine learning and artificial intelligence applied to existing clinical data, polysomnography, proteomics, and imaging can do just that.
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Affiliation(s)
- Oren Cohen
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (O.C.); (V.K.)
| | - Vaishnavi Kundel
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (O.C.); (V.K.)
| | - Philip Robson
- Biomedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA;
| | - Zainab Al-Taie
- Center for Biostatistics, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (Z.A.-T.); (M.S.-F.)
| | - Mayte Suárez-Fariñas
- Center for Biostatistics, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (Z.A.-T.); (M.S.-F.)
| | - Neomi A. Shah
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (O.C.); (V.K.)
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Chen B, Cao R, Song D, Qiu P, Liao C, Li Y. Predicting obstructive sleep apnea hypopnea syndrome using three-dimensional optical devices: A systematic review. Digit Health 2024; 10:20552076241271749. [PMID: 39119554 PMCID: PMC11307370 DOI: 10.1177/20552076241271749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 07/01/2024] [Indexed: 08/10/2024] Open
Abstract
Purpose As a global health concern, the diagnosis of obstructive sleep apnea hypopnea syndrome (OSAHS), characterized by partial reductions and complete pauses in ventilation, has garnered significant scientific and public attention. With the advancement of digital technology, the utilization of three-dimensional (3D) optical devices demonstrates unparalleled potential in diagnosing OSAHS. This study aimed to review the current literature to assess the accuracy of 3D optical devices in identifying the prevalence and severity of OSAHS. Methods A systematic literature search was conducted in the Web of Science, Scopus, PubMed/MEDLINE, and Cochrane Library databases for English studies published up to April 2024. Peer-reviewed researches assessing the diagnostic utility of 3D optical devices for OSAHS were included. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) guideline was employed to appraise the risk of bias. Results The search yielded 3216 results, with 10 articles meeting the inclusion criteria for this study. Selected studies utilized structured light scanners, stereophotogrammetry, and red, green, blue-depth (RGB-D) cameras. Stereophotogrammetry-based 3D optical devices exhibited promising potential in OSAHS prediction. Conclusions The utilization of 3D optical devices holds considerable promise for OSAHS diagnosis, offering potential improvements in accuracy, cost reduction, and time efficiency. However, further clinical data are essential to assist clinicians in the early detection of OSAHS using 3D optical devices.
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Affiliation(s)
| | | | - Danni Song
- Shanghai Engineering Research Center of Tooth Restoration and Regeneration & Tongji Research Institute of Stomatology & Department of Orthodontics, Stomatological Hospital and Dental School, Tongji University, Shanghai, China
| | - Piaopiao Qiu
- Shanghai Engineering Research Center of Tooth Restoration and Regeneration & Tongji Research Institute of Stomatology & Department of Orthodontics, Stomatological Hospital and Dental School, Tongji University, Shanghai, China
| | - Chongshan Liao
- Shanghai Engineering Research Center of Tooth Restoration and Regeneration & Tongji Research Institute of Stomatology & Department of Orthodontics, Stomatological Hospital and Dental School, Tongji University, Shanghai, China
| | - Yongming Li
- Yongming Li, Shanghai Engineering Research Center of Tooth Restoration and Regeneration & Tongji Research Institute of Stomatology & Department of Orthodontics, Stomatological Hospital and Dental School, Tongji University, Shanghai, China.
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He S, Li Y, Zhang C, Li Z, Ren Y, Li T, Wang J. Deep learning technique to detect craniofacial anatomical abnormalities concentrated on middle and anterior of face in patients with sleep apnea. Sleep Med 2023; 112:12-20. [PMID: 37801860 DOI: 10.1016/j.sleep.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 09/17/2023] [Accepted: 09/23/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVES The aim of this study is to propose a deep learning-based model using craniofacial photographs for automatic obstructive sleep apnea (OSA) detection and to perform design explainability tests to investigate important craniofacial regions as well as the reliability of the method. METHODS Five hundred and thirty participants with suspected OSA are subjected to polysomnography. Front and profile craniofacial photographs are captured and randomly segregated into training, validation, and test sets for model development and evaluation. Photographic occlusion tests and visual observations are performed to determine regions at risk of OSA. The number of positive regions in each participant is identified and their associations with OSA is assessed. RESULTS The model using craniofacial photographs alone yields an accuracy of 0.884 and an area under the receiver operating characteristic curve of 0.881 (95% confidence interval, 0.839-0.922). Using the cutoff point with the maximum sum of sensitivity and specificity, the model exhibits a sensitivity of 0.905 and a specificity of 0.941. The bilateral eyes, nose, mouth and chin, pre-auricular area, and ears contribute the most to disease detection. When photographs that increase the weights of these regions are used, the performance of the model improved. Additionally, different severities of OSA become more prevalent as the number of positive craniofacial regions increases. CONCLUSIONS The results suggest that the deep learning-based model can extract meaningful features that are primarily concentrated in the middle and anterior regions of the face.
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Affiliation(s)
- Shuai He
- Department of Otolaryngology Head and Neck Surgery, Beijing Chaoyang Hospital, Capital Medical University, China
| | - Yingjie Li
- School of Computer Science and Engineering, Beijing Technology and Business University, China
| | - Chong Zhang
- Department of Big Data Management and Application, School of International Economics and Management, Beijing Technology and Business University, China
| | - Zufei Li
- Department of Otolaryngology Head and Neck Surgery, Beijing Chaoyang Hospital, Capital Medical University, China
| | - Yuanyuan Ren
- Department of Otolaryngology Head and Neck Surgery, Beijing Chaoyang Hospital, Capital Medical University, China
| | - Tiancheng Li
- Department of Otolaryngology Head and Neck Surgery, Beijing Chaoyang Hospital, Capital Medical University, China.
| | - Jianting Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing Chaoyang Hospital, Capital Medical University, China.
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Chen Q, Liang Z, Wang Q, Ma C, Lei Y, Sanderson JE, Hu X, Lin W, Liu H, Xie F, Jiang H, Fang F. Self-helped detection of obstructive sleep apnea based on automated facial recognition and machine learning. Sleep Breath 2023; 27:2379-2388. [PMID: 37278870 DOI: 10.1007/s11325-023-02846-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/16/2023] [Accepted: 05/01/2023] [Indexed: 06/07/2023]
Abstract
PURPOSE The diagnosis of obstructive sleep apnea (OSA) relies on time-consuming and complicated procedures which are not always readily available and may delay diagnosis. With the widespread use of artificial intelligence, we presumed that the combination of simple clinical information and imaging recognition based on facial photos may be a useful tool to screen for OSA. METHODS We recruited consecutive subjects suspected of OSA who had received sleep examination and photographing. Sixty-eight points from 2-dimensional facial photos were labelled by automated identification. An optimized model with facial features and basic clinical information was established and tenfold cross-validation was performed. Area under the receiver operating characteristic curve (AUC) indicated the model's performance using sleep monitoring as the reference standard. RESULTS A total of 653 subjects (77.2% males, 55.3% OSA) were analyzed. CATBOOST was the most suitable algorithm for OSA classification with a sensitivity, specificity, accuracy, and AUC of 0.75, 0.66, 0.71, and 0.76 respectively (P < 0.05), which was better than STOP-Bang questionnaire, NoSAS scores, and Epworth scale. Witnessed apnea by sleep partner was the most powerful variable, followed by body mass index, neck circumference, facial parameters, and hypertension. The model's performance became more robust with a sensitivity of 0.94, for patients with frequent supine sleep apnea. CONCLUSION The findings suggest that craniofacial features extracted from 2-dimensional frontal photos, especially in the mandibular segment, have the potential to become predictors of OSA in the Chinese population. Machine learning-derived automatic recognition may facilitate the self-help screening for OSA in a quick, radiation-free, and repeatable manner.
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Affiliation(s)
- Qi Chen
- Sleep Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhe Liang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Qing Wang
- Department of Automation, Tsinghua University, Beijing, China
- Pharmacovigilance Research Center for Information Technology and Data Science, Cross-Strait Tsinghua Research Institute, Xiamen, China
| | - Chenyao Ma
- Sleep Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi Lei
- School of Software Engineering, Faculty of Information Technology, Beijing University of Technology, Beijing, China
| | - John E Sanderson
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xu Hu
- Automation School, Beijing University of Posts and Telecommunications, Beijing, China
| | - Weihao Lin
- Automation School, Beijing University of Posts and Telecommunications, Beijing, China
| | - Hu Liu
- Sleep Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fei Xie
- Sleep Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongfeng Jiang
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Fang Fang
- Sleep Medical Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
- Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Fazlıoğlu N, Uysal P, Durmus S, Yurt S, Gelisgen R, Uzun H. Significance of Plasma Irisin, Adiponectin, and Retinol Binding Protein-4 Levels as Biomarkers for Obstructive Sleep Apnea Syndrome Severity. Biomolecules 2023; 13:1440. [PMID: 37892122 PMCID: PMC10604585 DOI: 10.3390/biom13101440] [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: 08/15/2023] [Revised: 09/22/2023] [Accepted: 09/22/2023] [Indexed: 10/29/2023] Open
Abstract
OBJECTIVE Obstructive sleep apnea syndrome (OSAS) is a common sleep disorder that is caused by the reduction or cessation of airflow in the upper airway. Irisin, retinol-binding protein-4 (RBP-4), and adiponectin are the three significant factors in the metabolic process of the human body. The objective of this study was to investigate whether plasma irisin, RBP-4, and adiponectin levels are associated with the severity of OSAS. METHODS According to inclusion and exclusion criteria, 125 patients with OSAS and 46 healthy, gender-matched controls were included in this study. The patients were classified according to the apnea hypopnea index (AHI) as 14 mild cases (5 < AHI < 15), 23 moderate OSAS cases (15 < AHI < 30), and 88 severe OSAS cases (AHI > 30). The plasma irisin, RBP-4, and adiponectin levels were measured and compared between groups. RESULTS RBP-4 levels were higher in severe OSAS compared to other groups, and irisin levels were significantly lower in severe OSAS compared to other groups. There was a negative correlation between irisin and RBP-4 (r = -0.421; p < 0.001), and irisin and AHI (r = -0.834; p < 0.001), and a positive correlation between irisin and adiponectin (r = 0.240; p = 0.002). There was a negative correlation between RBP-4 and adiponectin (r = -0.507; p < 0.001) and a positive correlation between RBP-4 and AHI (r = 0.473; p < 0.001). As a predictor of OSAS, adiponectin showed the highest specificity (84.8%) and RBP-4 the highest sensitivity (92.0%). CONCLUSION Circulating adiponectin, irisin, and RBP-4 may be new biomarkers in OSAS patients in addition to risk factors such as diabetes, obesity, and hypertension. When polysomnography is not available, these parameters and clinical data can be used to diagnose the disease. As a result, patients with an AHI score greater than thirty should be closely monitored for metabolic abnormalities.
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Affiliation(s)
- Nevin Fazlıoğlu
- Department of Pulmonary Medicine, Namık Kemal University, 59010 Tekirdag, Turkey;
| | - Pelin Uysal
- Maslak Hospital, Faculty of Medicine, Department of Pulmonary Medicine, Acibadem Mehmet Ali Aydinlar University, 34752 Istanbul, Turkey;
| | - Sinem Durmus
- Department of Biochemistry, School of Medicine, Istanbul University-Cerrahpasa, 34320 Istanbul, Turkey; (S.D.); (R.G.)
| | - Sibel Yurt
- Basaksehir Cam and Sakura State Hospital, Department of Pulmonary Medicine, University of Health Sciences, 34480 Istanbul, Turkey;
| | - Remise Gelisgen
- Department of Biochemistry, School of Medicine, Istanbul University-Cerrahpasa, 34320 Istanbul, Turkey; (S.D.); (R.G.)
| | - Hafize Uzun
- Department of Biochemistry, Faculty of Medicine, İstanbul Atlas University, 34403 Istanbul, Turkey
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Pei B, Jin C, Cao S, Ji N, Xia M, Jiang H. Geometric morphometrics and machine learning from three-dimensional facial scans for difficult mask ventilation prediction. Front Med (Lausanne) 2023; 10:1203023. [PMID: 37636580 PMCID: PMC10447910 DOI: 10.3389/fmed.2023.1203023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 07/31/2023] [Indexed: 08/29/2023] Open
Abstract
Background Unanticipated difficult mask ventilation (DMV) is a potentially life-threatening event in anesthesia. Nevertheless, predicting DMV currently remains a challenge. This study aimed to verify whether three dimensional (3D) facial scans could predict DMV in patients scheduled for general anesthesia. Methods The 3D facial scans were taken on 669 adult patients scheduled for elective surgery under general anesthesia. Clinical variables currently used as predictors of DMV were also collected. The DMV was defined as the inability to provide adequate and stable ventilation. Spatially dense landmarks were digitized on 3D scans to describe sufficient details for facial features and then processed by 3D geometric morphometrics. Ten different machine learning (ML) algorithms, varying from simple to more advanced, were introduced. The performance of ML models for DMV prediction was compared with that of the DIFFMASK score. The area under the receiver operating characteristic curves (AUC) with its 95% confidence interval (95% CI) as well as the specificity and sensitivity were used to evaluate the predictive value of the model. Results The incidence of DMV was 35/669 (5.23%). The logistic regression (LR) model performed best among the 10 ML models. The AUC of the LR model was 0.825 (95% CI, 0.765-0.885). The sensitivity and specificity of the model were 0.829 (95% CI, 0.629-0.914) and 0.733 (95% CI, 0.532-0.819), respectively. The LR model demonstrated better predictive performance than the DIFFMASK score, which obtained an AUC of 0.785 (95% CI, 0.710-0.860) and a sensitivity of 0.686 (95% CI, 0.578-0.847). Notably, we identified a significant morphological difference in the mandibular region between the DMV group and the easy mask ventilation group. Conclusion Our study indicated a distinct morphological difference in the mandibular region between the DMV group and the easy mask ventilation group. 3D geometric morphometrics with ML could be a rapid, efficient, and non-invasive tool for DMV prediction to improve anesthesia safety.
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Daboul A, Krüger M, Ivanonvka T, Obst A, Ewert R, Stubbe B, Fietze I, Penzel T, Hosten N, Biffar R, Cardini A. Do brachycephaly and nose size predict the severity of obstructive sleep apnea (OSA)? A sample-based geometric morphometric analysis of craniofacial variation in relation to OSA syndrome and the role of confounding factors. J Sleep Res 2022; 32:e13801. [PMID: 36579627 DOI: 10.1111/jsr.13801] [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: 09/14/2022] [Revised: 10/27/2022] [Accepted: 11/25/2022] [Indexed: 12/30/2022]
Abstract
Obstructive sleep apnea is a common disorder that leads to sleep fragmentation and is potentially bidirectionally related to a variety of comorbidities, including an increased risk of heart failure and stroke. It is often considered a consequence of anatomical abnormalities, especially in the head and neck, but its pathophysiology is likely to be multifactorial in origin. With geometric morphometrics, and a large sample of adults from the Study for Health in Pomerania, we explore the association of craniofacial morphology to the apnea-hypopnea index used as an estimate of obstructive sleep apnea severity. We show that craniofacial size and asymmetry, an aspect of morphological variation seldom analysed in obstructive sleep apnea research, are both uncorrelated to apnea-hypopnea index. In contrast, as in previous analyses, we find evidence that brachycephaly and larger nasal proportions might be associated to obstructive sleep apnea severity. However, this correlational signal is weak and completely disappears when age-related shape variation is statistically controlled for. Our findings suggest that previous work might need to be re-evaluated, and urge researchers to take into account the role of confounders to avoid potentially spurious findings in association studies.
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Affiliation(s)
- Amro Daboul
- Department of Prosthodontics, Gerodontology and Biomaterials, University Medicine Greifswald, Greifswald, Germany
| | - Markus Krüger
- Department of Prosthodontics, Gerodontology and Biomaterials, University Medicine Greifswald, Greifswald, Germany
| | - Tatyana Ivanonvka
- Department of Electrical Engineering, Media and Computer Science East Bavarian Technical University of Applied Sciences Amberg-Weiden, Amberg, Germany
| | - Anne Obst
- Department of Prosthodontics, Gerodontology and Biomaterials, University Medicine Greifswald, Greifswald, Germany
| | - Ralf Ewert
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
| | - Beate Stubbe
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany
| | - Ingo Fietze
- Interdisciplinary Sleep Medicine Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Penzel
- Interdisciplinary Sleep Medicine Center, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Norbert Hosten
- Institute of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Reiner Biffar
- Department of Prosthodontics, Gerodontology and Biomaterials, University Medicine Greifswald, Greifswald, Germany
| | - Andrea Cardini
- Dipartimento di Scienze Chimiche e Geologiche, Università di Modena e Reggio Emilia, Modena, Italy.,School of Anatomy, Physiology and Human Biology, The University of Western Australia, Crawley, Western Australia, Australia
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