1
|
Matsumura N, Shiro R, Tsunoda I. Critical evaluation on roles of macrophagic myofasciitis and aluminum adjuvants in HPV vaccine-induced adverse events. Cancer Sci 2023; 114:1218-1228. [PMID: 36601818 PMCID: PMC10067403 DOI: 10.1111/cas.15714] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/29/2022] [Accepted: 12/29/2022] [Indexed: 01/06/2023] Open
Abstract
Cervical cancer is caused by human papillomavirus (HPV) infection, which is preventable by HPV vaccines. In Japan, the HPV vaccination rate has remained extremely low due to the concerns for alleged neuropsychological symptoms or "diverse symptoms" following injections of two HPV vaccines, Cervarix and Gardasil, in HPV vaccine lawsuits. In the lawsuits, the attorneys' group has used several manuscripts proposing that aluminum (Al) adjuvant contained in HPV vaccines causes an immune-mediated disease, called macrophagic myofasciitis (MMF), as well as pathology in the central nervous system (CNS). We scientifically evaluated these manuscripts describing the "Al adjuvant-induced pathologies," particularly MMF. Although MMF patients have been reported to develop clinical symptoms/signs in various organs, including the CNS, muscle biopsy of the patients and animal experiments demonstrated that MMF pathology was localized only at the injected muscle. No muscle pathology which characterizes MMF was observed in any other muscles; thus, the systemic and neurological signs of MMF cases were irrelevant to localized MMF pathology. We evaluated that MMF-like pathology was induced as a local inflammatory response following vaccinations; MMF pathology was not the cause of systemic inflammation or "diverse symptoms." Lastly, MMF cases have been reported after vaccinations with Al-hydroxide-containing vaccines exclusively. As Al-hydroxide is a component of Cervarix, but not Gardasil, "diverse symptoms" following two HPV vaccinations in Japan cannot be explained by MMF. Our evaluation would help readers understand the validity of the manuscripts on the role of Al adjuvants or MMF for the alleged "diverse symptoms."
Collapse
Affiliation(s)
- Noriomi Matsumura
- Department of Obstetrics and Gynecology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Reona Shiro
- Department of Obstetrics and Gynecology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Ikuo Tsunoda
- Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
| |
Collapse
|
2
|
Matsumura N, Tsunoda I. Scientific evaluation of alleged findings in HPV vaccines; molecular mimicry and mouse models of vaccine-induced disease. Cancer Sci 2022; 113:3313-3320. [PMID: 35781393 PMCID: PMC9530884 DOI: 10.1111/cas.15482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/19/2022] [Accepted: 06/27/2022] [Indexed: 02/05/2023] Open
Abstract
Cervical cancer is caused by infections of the human papillomavirus (HPV), which can be preventable by vaccinations. In Japan, although about 3,000 people died of cervical cancer annually, the HPV vaccination rate has remained extremely low in the eligible population, since many Japanese have been concerned that "diverse symptoms," such as chronic pain, movement disorders, and cognitive impairment, may occur as adverse reactions after HPV vaccination. The concern has been raised by media coverage of the ongoing HPV vaccine lawsuits, in which the plaintiffs complained of their symptoms caused by HPV vaccination. The claims have been based on the alleged pathogenic findings in research articles on HPV vaccines, summarized in the document prepared by the plaintiffs' attorneys. We critically evaluated these articles, in which the authors proposed the following findings/hypothesis: (i) molecular mimicry between HPV L1 and human proteins leads to the production of cross-reactive antibodies; and (ii) HPV vaccine injection in mice causes damage in the brain, a mouse model for "HPV vaccine associated neuro-immunopathic syndrome (HANS)." We found that they were based mainly on the findings from a few research groups and that all the articles had flaws in the method, result, or discussion sections. Our current evaluation would help better understand the validity of the findings, which have been often misunderstood as the truth by the general public. We propose to accumulate high-quality data on potential adverse events following HPV vaccination and to continue critically evaluating them.
Collapse
Affiliation(s)
- Noriomi Matsumura
- Department of Obstetrics and Gynecology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Ikuo Tsunoda
- Department of Microbiology, Kindai University Faculty of Medicine, Osaka, Japan
| |
Collapse
|
3
|
Nakashima M, Ishikawa K, Fugiwara A, Shu K, Fukushima Y, Okamoto M, Tsukamoto H, Kouwaki T, Oshiumi H. miR-451a levels rather than human papillomavirus vaccine administration is associated with the severity of murine experimental autoimmune encephalomyelitis. Sci Rep 2021; 11:9369. [PMID: 33931700 PMCID: PMC8087664 DOI: 10.1038/s41598-021-88842-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/16/2021] [Indexed: 11/24/2022] Open
Abstract
Human papilloma virus (HPV) vaccine is currently the most effective prophylaxis to prevent cervical cancer. However, concerns regarding its potential severe adverse reactions have limited the vaccination rate. HPV vaccines have been determined to contain adjuvants which induce inflammation by the innate immune system and are crucial for triggering adaptive immunity. MicroRNA-451a (miR-451a) is located within circulating extracellular vesicles (EVs) and regulates the innate immune response. In this study, we examined the effect of HPV vaccines and EV miR-451a on murine experimental autoimmune encephalomyelitis (EAE), which is an autoimmune disorder that affects the central nervous system. Although HPV vaccine induced pro-inflammatory cytokine expression and macrophage cell death, it failed to exacerbate mouse EAE, whereas circulating EV miR-451a levels were associated with the severity of EAE. Since miR-451a knockout exhibited only marginal effect on the murine EAE clinical score, our data suggest that miR-451a levels reflect an unknown condition associated with EAE severity. Interestingly, excessive uptake of glucose increased EV miR-451a levels both in vitro and in vivo and also exacerbated mouse EAE. Therefore, environmental factors that increase EV miR-451a levels exacerbate the autoimmune disorder more than the HPV vaccine. These observations provide evidence for the safety of HPV vaccines.
Collapse
Affiliation(s)
- Momoka Nakashima
- Department of Immunology, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Kana Ishikawa
- Department of Immunology, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Aika Fugiwara
- Department of Immunology, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Kaiin Shu
- Department of Immunology, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Yoshimi Fukushima
- Department of Immunology, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Masaaki Okamoto
- Department of Immunology, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Hirotake Tsukamoto
- Department of Immunology, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Takahisa Kouwaki
- Department of Immunology, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan
| | - Hiroyuki Oshiumi
- Department of Immunology, Graduate School of Medical Sciences, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto, 860-8556, Japan.
| |
Collapse
|
4
|
Wiyeh AB, Cooper S, Nnaji CA, Wiysonge CS. Vaccine hesitancy ‘outbreaks’: using epidemiological modeling of the spread of ideas to understand the effects of vaccine related events on vaccine hesitancy. Expert Rev Vaccines 2018; 17:1063-1070. [DOI: 10.1080/14760584.2018.1549994] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Alison B. Wiyeh
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Chukwudi A. Nnaji
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Charles S. Wiysonge
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
5
|
Ozawa K, Hineno A, Kinoshita T, Ishihara S, Ikeda SI. Suspected Adverse Effects After Human Papillomavirus Vaccination: A Temporal Relationship Between Vaccine Administration and the Appearance of Symptoms in Japan. Drug Saf 2018; 40:1219-1229. [PMID: 28744844 PMCID: PMC5688202 DOI: 10.1007/s40264-017-0574-6] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction In Japan, after receiving human papillomavirus vaccination, a significant number of adolescent girls experienced various symptoms, the vast majority of which have been ascribed to chronic regional pain syndrome, orthostatic intolerance, and/or cognitive dysfunction. However, a causal link has not been established between human papillomavirus vaccination and the development of these symptoms. Objective The aim of this study was to clarify the temporal relationship between human papillomavirus vaccination and the appearance of post-vaccination symptoms. Methods Between June 2013 and December 2016, we examined symptoms and objective findings in 163 female patients who had received human papillomavirus vaccination. We used newly defined diagnostic criteria for accurate inclusion of patients who experienced adverse symptoms after human papillomavirus vaccination; these diagnostic criteria were created for this study, and thus their validity and reliability have not been established. Results Overall, 43 female patients were excluded. Among the remaining 120 patients, 30 were diagnosed as having definite vaccine-related symptoms, and 42 were diagnosed as probable. Among these 72 patients, the age at initial vaccination ranged from 11 to 19 years (average 13.6 ± 1.6 years), and the age at appearance of symptoms ranged from 12 to 20 years (average 14.4 ± 1.7 years). The patients received the initial human papillomavirus vaccine injection between May 2010 and April 2013. The first affected girl developed symptoms in October 2010, and the last two affected girls developed symptoms in October 2015. The time to onset after the first vaccine dose ranged from 1 to 1532 days (average 319.7 ± 349.3 days). Conclusions The period of human papillomavirus vaccination considerably overlapped with that of unique post-vaccination symptom development. Based on these sequential events, it is suggested that human papillomavirus vaccination is related to the transiently high prevalence of the previously mentioned symptoms including chronic regional pain syndrome and autonomic and cognitive dysfunctions in the vaccinated patients. Electronic supplementary material The online version of this article (doi:10.1007/s40264-017-0574-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Kazuki Ozawa
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Akiyo Hineno
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan.,Intractable Disease Care Center, Shinshu University Hospital, Matsumoto, 390-0802, Japan
| | - Tomomi Kinoshita
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Sakiko Ishihara
- Department of Rehabilitation, Shinshu University Hospital, Matsumoto, Japan
| | - Shu-Ichi Ikeda
- Intractable Disease Care Center, Shinshu University Hospital, Matsumoto, 390-0802, Japan.
| |
Collapse
|
6
|
Ameratunga R, Langguth D, Hawkes D. Perspective: Scientific and ethical concerns pertaining to animal models of autoimmune/autoinflammatory syndrome induced by adjuvants (ASIA). Autoimmun Rev 2018. [DOI: 10.1016/j.autrev.2017.11.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
7
|
The value of Autoimmune Syndrome Induced by Adjuvant (ASIA) - Shedding light on orphan diseases in autoimmunity. Autoimmun Rev 2018. [DOI: 10.1016/j.autrev.2017.11.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
8
|
Dahan S, Segal Y, Watad A, Azrielant S, Shemer A, Maymon D, Stroev YI, Sobolevskaya PA, Korneva EA, Blank M, Gilburd B, Shovman O, Amital H, Ehrenfeld M, Tanay A, Kivity S, Pras E, Chapman J, Damoiseaux J, Cervera R, Putterman C, Shapiro I, Mouthon L, Perricone R, Bizzaro N, Koren O, Riemekasten G, Chereshnev VA, Mazurov VI, Goloviznin M, Gurevich V, Churilov LP, Shoenfeld Y. Novelties in the field of autoimmunity – 1st Saint Petersburg congress of autoimmunity, the bridge between east and west. Autoimmun Rev 2017; 16:1175-1184. [DOI: 10.1016/j.autrev.2017.10.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 07/30/2017] [Indexed: 12/16/2022]
|
9
|
Bragazzi NL, Watad A, Amital H, Shoenfeld Y. Debate on vaccines and autoimmunity: Do not attack the author, yet discuss it methodologically. Vaccine 2017; 35:5522-5526. [DOI: 10.1016/j.vaccine.2017.08.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 01/31/2023]
|
10
|
Poddighe D. 2-Dose Schedule of AS04-Adjuvanted Human Papillomavirus Types 16/18 Vaccine. J Infect Dis 2017; 216:782-783. [PMID: 28934441 DOI: 10.1093/infdis/jix364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 08/14/2017] [Indexed: 09/21/2023] Open
Affiliation(s)
- Dimitri Poddighe
- Department of Pediatrics, ASST Melegnano e Martesana, Vizzolo Predabissi, Milano
- Department of Pediatrics, Università degli Studi di Pavia, Pavia, Italy
| |
Collapse
|
11
|
Feiring B, Laake I, Bakken IJ, Greve-Isdahl M, Wyller VB, Håberg SE, Magnus P, Trogstad L. HPV vaccination and risk of chronic fatigue syndrome/myalgic encephalomyelitis: A nationwide register-based study from Norway. Vaccine 2017. [PMID: 28648542 DOI: 10.1016/j.vaccine.2017.06.031] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Vaccination has been suggested to be involved in the aetiology of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). HPV vaccine was introduced in the Norwegian Childhood Immunisation Programme and offered 12year old girls from 2009. We studied the association between HPV vaccination and risk of CFS/ME and also assessed medical history in relation to both risk of CFS/ME and HPV vaccine uptake. METHODS Individual data from national registries, including the Norwegian Population Registry, the Norwegian Patient Registry and the Norwegian Immunisation Registry were linked using the unique personal identification number. Yearly incidence rates of CFS/ME for 2009-2014 were calculated among the 824,133 boys and girls, aged 10-17 living in Norway during these 6years. A total of 176,453 girls born 1997-2002 were eligible for HPV vaccination and included in further analyses. Hazard ratios (HRs) of CFS/ME were estimated using Cox regression. Risk differences (RDs) of vaccine uptake were estimated with binomial regression. RESULTS A similar yearly increase in incidence rate of CFS/ME was observed among girls and boys, IRR=1.15 (95% confidence interval (CI) 1.10-1.19) and 1.15 (95% CI 1.09-1.22), respectively. HPV vaccination was not associated with CFS/ME, HR=0.86 (95% CI 0.69-1.08) for the entire follow-up period and 0.96 (95% CI 0.64-1.43) for the first two years after vaccination. The risk of CFS/ME increased with increasing number of previous hospital contacts, HR=5.23 (95% CI 3.66-7.49) for 7 or more contacts as compared to no contacts. Girls with 7 or more hospital contacts were less likely to be vaccinated than girls with no previous hospital contacts, RD=-5.5% (95% CI -6.7% to -4.2%). CONCLUSIONS No indication of increased risk of CFS/ME following HPV vaccination was observed among girls in the first 6 birth cohorts offered HPV vaccine through the national immunisation programme in Norway.
Collapse
Affiliation(s)
- Berit Feiring
- Department of Infectious Disease Epidemiology and Modelling, Norwegian Institute of Public Health, PO Box 4404 Nydalen, 0403 Oslo, Norway.
| | - Ida Laake
- Department of Infectious Disease Epidemiology and Modelling, Norwegian Institute of Public Health, PO Box 4404 Nydalen, 0403 Oslo, Norway.
| | - Inger Johanne Bakken
- Department of Child Health, Norwegian Institute of Public Health, PO Box 4404 Nydalen, 0403 Oslo, Norway.
| | - Margrethe Greve-Isdahl
- Department of Vaccine Preventable Diseases, Norwegian Institute of Public Health, PO Box 4404 Nydalen, 0403 Oslo, Norway.
| | - Vegard Bruun Wyller
- Department of Paediatrics and Adolescent Health, Akershus University Hospital, 1478 Lørenskog, Norway.
| | - Siri E Håberg
- Division of Physical and Mental Health, Norwegian Institute of Public Health, PO Box 4404 Nydalen, 0403 Oslo, Norway.
| | - Per Magnus
- Division of Health Data and Digitalisation, Norwegian Institute of Public Health, PO Box 4404 Nydalen, 0403 Oslo, Norway.
| | - Lill Trogstad
- Department of Infectious Disease Epidemiology and Modelling, Norwegian Institute of Public Health, PO Box 4404 Nydalen, 0403 Oslo, Norway.
| |
Collapse
|
12
|
Poddighe D, Vadalà M, Laurino C, Palmieri B. Somatoform and neurocognitive syndromes after HPV immunization are not associated to cell-mediated hypersensitivity to aluminum. Toxicol In Vitro 2017; 43:58-61. [PMID: 28599844 DOI: 10.1016/j.tiv.2017.06.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 04/25/2017] [Accepted: 06/04/2017] [Indexed: 01/09/2023]
Abstract
Vaccines against human papilloma virus (HPV) have been demonstrated to be very effective to prevent infection-related neoplasms. However, several reports describing heterogeneous post-vaccination phenomena have been published in last few years. The spectrum of these disorders includes both immune-mediated neurological diseases and neuropsychiatric functional disorders. Some researchers speculated about a genetic predisposition, but others hypothesized a role of adjuvants, including some metals and, particularly, aluminum. Here, we tested sixteen young girls developing somatoform and neurocognitive syndromes after the HPV immunization, through MELISA® test, detecting cell-mediated hypersensitivity to several metals. We found no association between these neurocognitive disorders and the results provided by this test; importantly, no patients showed hypersensitivity to aluminum, which is the inorganic adjuvant included in HPV vaccines. Thus, if aluminum played a role in the pathophysiology of musculoskeletal and neurocognitive disturbances occurring in some young girls after HPV immunization, that should recognize other mechanisms than the activation of aluminum-specific lymphocytes.
Collapse
Affiliation(s)
- Dimitri Poddighe
- Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Maria Vadalà
- Department of General Surgery and Surgical Specialties, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy
| | - Carmen Laurino
- Department of General Surgery and Surgical Specialties, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy
| | - Beniaminoi Palmieri
- Department of General Surgery and Surgical Specialties, University of Modena and Reggio Emilia Medical School, Surgical Clinic, Modena, Italy
| |
Collapse
|
13
|
Carnovale C, Tabaee Damavandi P, Gentili M, Pozzi M, Antoniazzi S, Radice S, Clementi E. On the association between human papillomavirus vaccine and sleep disorders: Evaluation based on vaccine adverse events reporting systems. J Neurol Sci 2017; 373:179-181. [PMID: 28131183 DOI: 10.1016/j.jns.2016.12.067] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 12/23/2016] [Accepted: 12/28/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Carla Carnovale
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, University Hospital "Luigi Sacco", Università di Milano, Milan, Italy
| | - Payam Tabaee Damavandi
- Department of Biomedical and Clinical Sciences, University Hospital "Luigi Sacco", Università di Milano, Milan, Italy
| | - Marta Gentili
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, University Hospital "Luigi Sacco", Università di Milano, Milan, Italy
| | - Marco Pozzi
- Scientific Institute, IRCCS E. Medea, Bosisio Parini, Lecco, Italy
| | - Stefania Antoniazzi
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, University Hospital "Luigi Sacco", Università di Milano, Milan, Italy; Scientific Direction, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sonia Radice
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, University Hospital "Luigi Sacco", Università di Milano, Milan, Italy.
| | - Emilio Clementi
- Scientific Institute, IRCCS E. Medea, Bosisio Parini, Lecco, Italy; Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, Consiglio Nazionale delle Ricerche Institute of Neuroscience, University Hospital "Luigi Sacco", Milan, Italy
| |
Collapse
|