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Van Gompel E, Demirdal D, Fernandes-Cerqueira C, Horuluoglu B, Galindo-Feria A, Wigren E, Gräslund S, De Langhe E, Benveniste O, Notarnicola A, Chemin K, Lundberg IE. Autoantibodies against the melanoma differentiation-associated protein 5 in patients with dermatomyositis target the helicase domains. Rheumatology (Oxford) 2024; 63:1466-1473. [PMID: 37572295 PMCID: PMC11065437 DOI: 10.1093/rheumatology/kead400] [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: 04/13/2023] [Revised: 06/30/2023] [Accepted: 07/17/2023] [Indexed: 08/14/2023] Open
Abstract
OBJECTIVES Clinical observations in patients with dermatomyositis (DM) and autoantibodies against the melanoma differentiation-associated protein 5 (MDA5) suggest that the autoantibodies contribute to the pathogenesis of MDA5(+) DM. To gain insight into the role of the anti-MDA5 autoantibodies, we aimed to identify their binding sites on the different domains of the MDA5 protein. METHODS We developed an in-house ELISA to assess the reactivity against the MDA5 domains (conformational epitopes) in plasma (n = 8) and serum (n = 24) samples from MDA5(+) patients with varying clinical manifestations and disease outcomes. The reactivities were also assessed using western blot (linearized epitopes). An ELISA-based depletion assay was developed to assess cross-reactivity among the different MDA5 domains. RESULTS All eight plasma samples consistently showed reactivity towards conformational and linearized epitopes on the helicase domains of the MDA5 protein. The ELISA-based depletion assay suggests that anti-MDA5 autoantibodies specifically target each of the three helicase domains. Twenty-two of the 24 serum samples showed reactivity in the in-house ELISA and all 22 displayed reactivity towards the helicase domains of the MDA5 protein. CONCLUSIONS Our data revealed that the main immunogenic targets of anti-MDA5 autoantibodies from MDA5(+) patients are the helicase domains. Considering that the helicase domains are responsible for the enzymatic activity and subsequent triggering of an inflammatory response, our findings suggest that binding of anti-MDA5 autoantibodies could alter the canonical activity of the MDA5 protein and potentially affect the downstream induction of a pro-inflammatory cascade.
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Affiliation(s)
- Eveline Van Gompel
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Laboratory of Tissue Homeostasis and Disease, Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Deniz Demirdal
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastro, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Catia Fernandes-Cerqueira
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Begum Horuluoglu
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Angeles Galindo-Feria
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Gastro, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Edvard Wigren
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Structural Genomics Consortium, Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Susanne Gräslund
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Structural Genomics Consortium, Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Ellen De Langhe
- Laboratory of Tissue Homeostasis and Disease, Skeletal Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Division of Rheumatology, University Hospitals Leuven, Leuven, Belgium
| | - Olivier Benveniste
- Centre de Recherche en Myologie, Unité Mixte de Recherche Scientifique 974, Sorbonne Université, INSERM, Paris, France
- Département de Médecine Interne et Immunologie Clinique, Centre de Référence Maladies Neuro-Musculaires, Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Antonella Notarnicola
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastro, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Karine Chemin
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ingrid E Lundberg
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Gastro, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
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Chandra T, Aggarwal R. A Narrative Review of Acthar Gel for the Treatment of Myositis. Rheumatol Ther 2023; 10:523-537. [PMID: 36966453 PMCID: PMC10140234 DOI: 10.1007/s40744-023-00545-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/28/2023] [Indexed: 03/27/2023] Open
Abstract
Idiopathic inflammatory myopathies (IIMs) are autoimmune disorders characterized by symmetric proximal muscle weakness and chronic inflammation, with an increased risk of morbidity and mortality. The current standard of care includes traditional immunosuppressive pharmacotherapies; however, some patients cannot tolerate or do not adequately respond to these therapies, highlighting the need for alternative treatments for refractory disease. Acthar® Gel (repository corticotropin injection) is a naturally sourced mixture of adrenocorticotropic hormone analogs and other pituitary peptides that has been approved by the US Food and Drug Administration since 1952 for use in patients with two subgroups of IIMs, dermatomyositis (DM) and polymyositis (PM). However, it has not been routinely used in the treatment of IIMs. While Acthar may induce steroidogenesis, it also has a steroid-independent mechanism of action by exerting immunomodulatory effects through the activation of melanocortin receptors on immune cells, such as macrophages, B cells, and T cells. Recent clinical trials, retrospective analyses, and case reports add to the growing evidence suggesting that Acthar may be effective in patients with DM and PM. Here we review the current evidence supporting the safety and efficacy of Acthar for the treatment of refractory DM and PM.
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Affiliation(s)
| | - Rohit Aggarwal
- University of Pittsburgh, 3601 5th Avenue, Suite 2B, Pittsburgh, PA, 15261, USA.
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Chen TX, Fan YT, Peng BW. Distinct mechanisms underlying therapeutic potentials of CD20 in neurological and neuromuscular disease. Pharmacol Ther 2022; 238:108180. [DOI: 10.1016/j.pharmthera.2022.108180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 03/16/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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Pathophysiological Mechanisms and Treatment of Dermatomyositis and Immune Mediated Necrotizing Myopathies: A Focused Review. Int J Mol Sci 2022; 23:ijms23084301. [PMID: 35457124 PMCID: PMC9030619 DOI: 10.3390/ijms23084301] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/31/2022] [Accepted: 04/05/2022] [Indexed: 12/15/2022] Open
Abstract
Idiopathic inflammatory myopathies (IIM), collectively known as myositis, are a composite group of rare autoimmune diseases affecting mostly skeletal muscle, although other organs or tissues may also be involved. The main clinical feature of myositis is subacute, progressive, symmetrical muscle weakness in the proximal arms and legs, whereas subtypes of myositis may also present with extramuscular features, such as skin involvement, arthritis or interstitial lung disease (ILD). Established subgroups of IIM include dermatomyositis (DM), immune-mediated necrotizing myopathy (IMNM), anti-synthetase syndrome (ASyS), overlap myositis (OM) and inclusion body myositis (IBM). Although these subgroups have overlapping clinical features, the widespread variation in the clinical manifestations of IIM suggests different pathophysiological mechanisms. Various components of the immune system are known to be important immunopathogenic pathways in IIM, although the exact pathophysiological mechanisms causing the muscle damage remain unknown. Current treatment, which consists of glucocorticoids and other immunosuppressive or immunomodulating agents, often fails to achieve a sustained beneficial response and is associated with various adverse effects. New therapeutic targets have been identified that may improve outcomes in patients with IIM. A better understanding of the overlapping and diverging pathophysiological mechanisms of the major subgroups of myositis is needed to optimize treatment. The aim of this review is to report on recent advancements regarding DM and IMNM.
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Gouin A, Ribes D, Colombat M, Chauveau D, Prevot G, Lairez O, Pugnet G, Fremeaux-Bacchi V, Huart A, Belliere J, Faguer S. Role of C5 inhibition in Idiopathic Inflammatory Myopathies and Scleroderma Renal Crisis-Induced Thrombotic Microangiopathies. Kidney Int Rep 2021; 6:1015-1021. [PMID: 33912751 PMCID: PMC8071645 DOI: 10.1016/j.ekir.2021.01.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/11/2021] [Accepted: 01/18/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Connective tissue diseases, including systemic sclerosis and idiopathic inflammatory myopathies (IIMs), are a very rare cause of thrombotic microangiopathies (TMAs). Whether dysregulation of the complement pathways underlies these secondary forms of TMA and may be targeted by complement blocking agents remains elusive. Methods Kidney pathology and outcomes of 18 critically ill patients with TMA related to inflammatory myopathy flare-up (IIM, n=7) or scleroderma renal crisis (SRC, n=11; biopsy n=9) are assessed. Results IIM-TMA is characterized by acute thrombotic lesions only, whereas SRC-TMA patients also harbored chronic vascular lesions and more interstitial fibrosis. C5b9 deposits, a marker of complement component 5 (C5) cleavage, were observed in the 2 subgroups at the junction of media and intima of arterioles, colocalizing with subendothelial edema. Thus, kidney biopsy distinguished between acute and chronic renal phenotypes that may help to individualize treatment. Treatment of IIM-TMA patients with combined full-code organ support, corticosteroids, B-cell depletion, and complement C5 blocking led to 1-year survival of 72%, compared with 19% in historical cohorts. Treatment of SRC-TMA was more heterogenous and relied on conversion enzyme inhibitor only or with eculizumab (n=6) and immunosuppressor (n=5). One-year survival of SRC-TMA patients was 52%, a result similar to historical cohorts. Eculizumab was followed by a rapid dramatic improvement of TMA in all the treated patients. Conclusion C5 blocking may reverse hematologic abnormalities in IIM- and SRC-TMA, and adding an early and aggressive immunosuppressive regimen may improve the survival of IIM-TMA. Underlying chronic vascular and interstitial lesions mitigate renal response in SRC-TMA.
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Affiliation(s)
- Anna Gouin
- Département de Néphrologie et transplantation d'Organes-Unité de Réanimation, Centre de référence des maladies rénales rares, Centre Hospitalier Universitaire, Institut National de la Santé et de la Recherche Médicale U1048 (Institut des Maladies Métaboliques et Cardiovasculaires), Toulouse, France
| | - David Ribes
- Département de Néphrologie et transplantation d'Organes-Unité de Réanimation, Centre de référence des maladies rénales rares, Centre Hospitalier Universitaire, Institut National de la Santé et de la Recherche Médicale U1048 (Institut des Maladies Métaboliques et Cardiovasculaires), Toulouse, France
| | - Magali Colombat
- Service d'anatomopathologie, Institut Universitaire du Cancer de Toulouse - Oncopole, Centre Hospitalier Universitaire, Toulouse, France
| | - Dominique Chauveau
- Département de Néphrologie et transplantation d'Organes-Unité de Réanimation, Centre de référence des maladies rénales rares, Centre Hospitalier Universitaire, Institut National de la Santé et de la Recherche Médicale U1048 (Institut des Maladies Métaboliques et Cardiovasculaires), Toulouse, France
| | - Gregoire Prevot
- Service de Pneumologie, Centre Hospitalier Universitaire, Toulouse, France
| | - Olivier Lairez
- Fédération de Cardiologie, Centre Hospitalier Universitaire, Toulouse, France
| | - Gregory Pugnet
- Service de Médecine Interne, Centre Hospitalier Universitaire, Toulouse, France
| | | | - Antoine Huart
- Département de Néphrologie et transplantation d'Organes-Unité de Réanimation, Centre de référence des maladies rénales rares, Centre Hospitalier Universitaire, Institut National de la Santé et de la Recherche Médicale U1048 (Institut des Maladies Métaboliques et Cardiovasculaires), Toulouse, France
| | - Julie Belliere
- Département de Néphrologie et transplantation d'Organes-Unité de Réanimation, Centre de référence des maladies rénales rares, Centre Hospitalier Universitaire, Institut National de la Santé et de la Recherche Médicale U1048 (Institut des Maladies Métaboliques et Cardiovasculaires), Toulouse, France
| | - Stanislas Faguer
- Département de Néphrologie et transplantation d'Organes-Unité de Réanimation, Centre de référence des maladies rénales rares, Centre Hospitalier Universitaire, Institut National de la Santé et de la Recherche Médicale U1048 (Institut des Maladies Métaboliques et Cardiovasculaires), Toulouse, France
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Dalakas MC, Alexopoulos H, Spaeth PJ. Complement in neurological disorders and emerging complement-targeted therapeutics. Nat Rev Neurol 2020; 16:601-617. [PMID: 33005040 PMCID: PMC7528717 DOI: 10.1038/s41582-020-0400-0] [Citation(s) in RCA: 172] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2020] [Indexed: 12/30/2022]
Abstract
The complement system consists of a network of plasma and membrane proteins that modulate tissue homeostasis and contribute to immune surveillance by interacting with the innate and adaptive immune systems. Dysregulation, impairment or inadvertent activation of complement components contribute to the pathogenesis of some autoimmune neurological disorders and could even contribute to neurodegenerative diseases. In this Review, we summarize current knowledge about the main functions of the complement pathways and the involvement of complement in neurological disorders. We describe the complex network of complement proteins that target muscle, the neuromuscular junction, peripheral nerves, the spinal cord or the brain and discuss the autoimmune mechanisms of complement-mediated myopathies, myasthenia, peripheral neuropathies, neuromyelitis and other CNS disorders. We also consider the emerging role of complement in some neurodegenerative diseases, such as Alzheimer disease, amyotrophic lateral sclerosis and even schizophrenia. Finally, we provide an overview of the latest complement-targeted immunotherapies including monoclonal antibodies, fusion proteins and peptidomimetics that have been approved, that are undergoing phase I–III clinical trials or that show promise for the treatment of neurological conditions that respond poorly to existing immunotherapies. In this Review, Dalakas et al. discuss the complement system, the role it plays in autoimmune neurological disease and neurodegenerative disease, and provide an overview of the latest therapeutics that target complement and that can be used for or have potential in neurological disorders. Complement has an important physiological role in host immune defences and tissue remodelling. The physiological role of complement extends to the regulation of synaptic development. Complement has a key pathophysiological role in autoimmune neurological diseases and mediates the actions of pathogenic autoantibodies, such as acetylcholine receptor antibodies and aquaporin 4 antibodies. For some autoimmune neurological diseases, such as myasthenia gravis and neuromyelitis optica spectrum disorders, approved complement-targeted treatments are now available. Complement also seems to be of pathogenic relevance in neurodegenerative diseases such as Alzheimer disease, in which innate immune-driven inflammation is receiving increasing attention. The field of complement-targeted therapeutics is rapidly expanding, with several FDA-approved agents and others currently in phase II and phase III clinical trials.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA. .,Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter J Spaeth
- Institute of Pharmacology, University of Bern, Bern, Switzerland
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Haviv R, Zehavi T, Pomeranz A, Leibovitch I, Neheman A, Uziel Y. Juvenile polymyositis associated with ureteral necrosis: a diagnostic and therapeutic dilemma-case report and review of the literature. Clin Rheumatol 2019; 38:1925-1929. [PMID: 31098736 DOI: 10.1007/s10067-019-04576-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/16/2019] [Accepted: 04/22/2019] [Indexed: 12/28/2022]
Abstract
We describe an 11-year-old girl, diagnosed with juvenile polymyositis (JPM), who developed right ureteral obstruction secondary to necrosis. We emphasize the dilemmas regarding optimal timing for surgical intervention and medical treatment. Vascular involvement, which could be a part of juvenile dermatomyositis, may also be a feature of JPM. We discuss the association between vasculopathy and ureteral necrosis and review the literature regarding similar conditions. Whether the ureteral necrosis is a specific feature of vasculopathy, or a result of visceral calcinosis, needs to be further explored.
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Affiliation(s)
- Ruby Haviv
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, 59 Tchernichovsky St, 4428164, Kfar Saba, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Tania Zehavi
- Pathology Department, Meir Medical Center, Kfar Saba, Israel
| | - Avishalom Pomeranz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Nephrology Unit, Meir Medical Center, Kfar Saba, Israel
| | - Ilan Leibovitch
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Urology, Meir Medical Center, Kfar Saba, Israel
| | - Amos Neheman
- Pediatric Urology Unit, Assaf Harofeh Medical Center, Zerifin, Be'er Ya'akov, Israel
| | - Yosef Uziel
- Pediatric Rheumatology Unit, Department of Pediatrics, Meir Medical Center, 59 Tchernichovsky St, 4428164, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Sciorati C, Monno A, Doglio MG, Rigamonti E, Ascherman DP, Manfredi AA, Rovere-Querini P. Exacerbation of Murine Experimental Autoimmune Myositis by Toll-Like Receptor 7/8. Arthritis Rheumatol 2018; 70:1276-1287. [PMID: 29569859 DOI: 10.1002/art.40503] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 03/15/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Toll-like receptor 7 (TLR-7), TLR-8, and interferon (IFN)-induced genes are expressed in patients with idiopathic inflammatory myositis. This study was undertaken to investigate whether their activation influences the natural history of the disease. METHODS Experimental autoimmune myositis was induced in mice by injection of the amino-terminal portion of the murine histidyl-transfer RNA synthetase (HisRS). Disease was compared in the presence or the absence of the TLR-7/8 agonist R-848 in wild-type mice and in mice that fail to express the IFNα/β receptor (IFNα/βR-null mice). RESULTS Experimental autoimmune myositis induced by a single intramuscular immunization with HisRS spontaneously abated after 7-8 weeks. In contrast, levels of anti-HisRS autoantibodies, endomysial/perimysial leukocyte infiltration, and myofiber regeneration persisted at the end of the follow-up period (22 weeks after immunization) in mice immunized with HisRS in the presence of R-848. Myofiber major histocompatibility complex (MHC) class I molecules were detectable only in mice immunized with both HisRS and R-848. MHC up-regulation occurred early and in muscles that were not directly injected with HisRS. Muscle MHC expression paralleled with leukocyte infiltration. MHC class I molecules were selectively up-regulated in myotubes challenged with R-848 in vitro. Type I IFN was necessary for the prolonged autoantibody response and for the spreading of the autoimmune response, as demonstrated using IFNα/βR-null mice. Muscle infiltration was maintained in the injected muscle up to the end of the follow-up period. CONCLUSION TLR-7/8 activation is necessary to induce and maintain a systemic autoimmune response targeting the skeletal muscle. This experimental autoimmune myositis model reproduces many characteristics of human idiopathic inflammatory myopathies and may represent a tool for preclinical studies.
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Affiliation(s)
- Clara Sciorati
- IRCCS Ospedale San Raffaele Scientific Institute, Milan, Italy
| | - Antonella Monno
- IRCCS Ospedale San Raffaele Scientific Institute, Milan, Italy
| | | | - Elena Rigamonti
- IRCCS Ospedale San Raffaele Scientific Institute, Milan, Italy
| | | | - Angelo A Manfredi
- IRCCS Ospedale San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Patrizia Rovere-Querini
- IRCCS Ospedale San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
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