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Kalderon L, Kaplan A, Wolfovitz A, Levy-Tzedek S, Gimmon Y. Barriers and Facilitators of Vestibular Rehabilitation: Patients and Physiotherapists' Perspectives. J Neurol Phys Ther 2024; 48:140-150. [PMID: 38426842 PMCID: PMC11208053 DOI: 10.1097/npt.0000000000000470] [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: 03/02/2024]
Abstract
BACKGROUND AND PURPOSE Poor adherence to vestibular rehabilitation protocols is a known barrier to optimal care. Vestibular clinicians' comprehensive understanding of the barriers and facilitators to vestibular home exercise programs (VHEP) is a key element to achieving optimal care in the context of vestibular rehabilitation. The aims of this study are as follows: (1) to identify primary barriers and facilitators to VHEP from the perspective of patients with vestibular dysfunction and vestibular physical therapists (PTs); and (2) to provide strategies for clinicians to improve adherence and outcomes of VHEP. METHODS A qualitative research with single-session focus groups conducted separately for: (1) patients with vestibular disorders and (2) vestibular PTs. Six focus groups were conducted, 3 for each population, with a total of 39 participants. An online survey was conducted to evaluate the estimates of adherence rates, followed by a structured discussion over barriers and facilitators to VHEP as perceived by patients and PTs. Thematic data analyses were performed using a mixed deductive-inductive approach. RESULTS Eighteen patients with vestibular disorders and 21 experienced vestibular PTs participated in this study. Six barrier categories and 5 facilitator categories were identified. Barriers included motivation aspects, provocation of symptoms, time management, associated impairments, missing guidance and feedback, and psychosocial factors. Facilitators included motivation aspects, time management, patient education and exercise instructions, exercise setting, and associated symptom management. DISCUSSION AND CONCLUSIONS Clinicians who prescribe home exercise to patients with vestibular disorders can use this information about common barriers and facilitators for patient education and to provide optimal care and improve rehabilitation outcomes. VIDEO ABSTRACT AVAILABLE for more insights from the authors (see the video, Supplemental Digital Content, available at: http://links.lww.com/JNPT/A467 ).
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Affiliation(s)
- Liran Kalderon
- Recanati School for Community Health Professions, Department of Physical Therapy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (L.K., A.K., S.L.-T.); Department of Otolaryngology—Head and Neck Surgery, Sheba Medical Center, Tel-Hashomer, Israel (A.W., Y.G.); Zelman Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel (S.L.-T.); Freiburg Institute for Advanced Studies (FRIAS), University of Freiburg, Freiburg, Germany (S.L.-T.); Department of Physical Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel (Y.G.)
| | - Azriel Kaplan
- Recanati School for Community Health Professions, Department of Physical Therapy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (L.K., A.K., S.L.-T.); Department of Otolaryngology—Head and Neck Surgery, Sheba Medical Center, Tel-Hashomer, Israel (A.W., Y.G.); Zelman Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel (S.L.-T.); Freiburg Institute for Advanced Studies (FRIAS), University of Freiburg, Freiburg, Germany (S.L.-T.); Department of Physical Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel (Y.G.)
| | - Amit Wolfovitz
- Recanati School for Community Health Professions, Department of Physical Therapy, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel (L.K., A.K., S.L.-T.); Department of Otolaryngology—Head and Neck Surgery, Sheba Medical Center, Tel-Hashomer, Israel (A.W., Y.G.); Zelman Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel (S.L.-T.); Freiburg Institute for Advanced Studies (FRIAS), University of Freiburg, Freiburg, Germany (S.L.-T.); Department of Physical Therapy, Faculty of Social Welfare & Health Sciences, University of Haifa, Haifa, Israel (Y.G.)
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Jenkins AR, Burtin C, Camp PG, Lindenauer P, Carlin B, Alison JA, Rochester C, Holland AE. Do pulmonary rehabilitation programmes improve outcomes in patients with COPD posthospital discharge for exacerbation: a systematic review and meta-analysis. Thorax 2024; 79:438-447. [PMID: 38350731 DOI: 10.1136/thorax-2023-220333] [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: 04/04/2023] [Accepted: 01/23/2024] [Indexed: 02/15/2024]
Abstract
INTRODUCTION Previous systematic reviews have provided heterogeneous and differing estimates for the efficacy of pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease (COPD). The aim of this review was to examine the efficacy of pulmonary rehabilitation programmes initiated within 3 weeks of hospital discharge following an exacerbation of COPD. METHODS An update of a previous Cochrane review was undertaken using the Cochrane Airways Review Group Specialised Register. Searches were conducted from October 2015 to August 2023 for studies that initiated pulmonary rehabilitation within 3 weeks of hospital discharge. Studies assessing the impact of solely inpatient pulmonary rehabilitation were excluded. Forest plots were generated using a generic inverse variance random effects method. RESULTS Seventeen studies were included. Posthospital discharge pulmonary rehabilitation reduced hospital re-admissions (OR 0.48, 95% CI 0.30 to 0.77, I2=67%), improved exercise capacity (6 min walk test, mean difference (MD) 57 m, 95% CI 29 to 86, I2=89%; incremental shuttle walk test, MD 43 m, 95% CI 6 to 79, I2=81%), health-related quality of life (St. George's Respiratory Questionnaire, MD -8.7 points, 95% CI -12.5 to -4.9, I2=59%; Chronic Respiratory Disease Questionnaire (CRQ)-emotion, MD 1.0 points, 95% CI 0.4 to 1.6, I2=74%; CRQ-fatigue, MD 0.9 points, 95% CI 0.1 to 1.6, I2=91%), and dyspnoea (CRQ-dyspnoea, MD 1.0 points, 95% CI 0.3 to 1.7, I2=87%; modified Medical Research Council Dyspnoea Scale, MD -0.3 points, 95% CI -0.5 to -0.1, I2=60%). Significant effects were not observed for CRQ-mastery, COPD assessment test, EuroQol-5 Dimension-5 Level and mortality. No intervention-related adverse events were reported. DISCUSSION Pulmonary rehabilitation delivered posthospital discharge for exacerbation of COPD results in a reduction in hospital re-admissions and improvements in exercise capacity, health-related quality of life and dyspnoea in the absence of any intervention-related adverse events. TRIAL REGISTRATION NUMBER CRD42023406397.
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Affiliation(s)
- Alex R Jenkins
- Clinical Exercise and Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, Faculty of Education, McGill University, Montreal, QC, Canada
| | - Chris Burtin
- REVAL-Rehabilitation Research Center, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
- BIOMED-Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Pat G Camp
- Centre for Heart Lung Innovation, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Peter Lindenauer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School - Baystate, Springfield, MA, USA
| | - Brian Carlin
- Sleep Medicine and Lung Health Consultants, Pittsburgh, Pennsylvania, USA
| | - Jennifer A Alison
- Sydney School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Allied Health, Sydney Local Health District, Sydney, NSW, Australia
| | - Carolyn Rochester
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Anne E Holland
- Respiratory Research@Alfred, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Department of Physiotherapy, Alfred Health, Melbourne, VIC, Australia
- Institute for Breathing and Sleep, Heidelberg, VIC, Australia
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Paixão C, Rocha V, Brooks D, Marques A. Unsupervised physical activity interventions for people with COPD: A systematic review and meta-analysis. Pulmonology 2024; 30:53-67. [PMID: 35151622 DOI: 10.1016/j.pulmoe.2022.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Unsupervised PA interventions might have a role in the management of chronic obstructive pulmonary disease (COPD) but their effectiveness is largely unknown. Thus, we aimed to identify and synthesise data on the effects of unsupervised PA interventions in people with COPD. MATERIAL AND METHODS Databases were systematically searched in April 2020, with weekly updates until September 2021. Randomised controlled trials and quasi-experimental studies comparing unsupervised PA with usual care, were included. Primary outcomes were dyspnoea, exercise capacity and physical activity. The effect direction plot was performed to synthesise results. Meta-analysis with forest plots were conducted for the Chronic Respiratory Disease questionnaire - dyspnoea domain (CRQ-D), 6-minute walk distance (6MWD) and incremental shuttle walk distance (ISWD). RESULTS Eleven studies with 900 participants with COPD (68±10 years; 58.8% male, FEV1 63.7±15.8% predicted) were included. All interventions were conducted at home, most with daily sessions, for 8-12 weeks. Walking was the most common component. The effect direction plot showed that unsupervised PA interventions improved emotional function, fatigue, health-related quality of life, muscle strength and symptoms of anxiety and depression. Meta-analysis showed statistical, but not clinical, significant improvements in dyspnoea (CRQ-D, MD=0.12, 95% CI 0.09-0.15) and exercise capacity, measured with 6MWD (MD=13.70, 95% CI 3.58-23.83). Statistical and clinical significant improvements were observed in exercise capacity, measured with ISWD (MD=58.59, 95% CI 5.79-111.39). None to minor adverse events and a high adherence rate were found. CONCLUSIONS Unsupervised PA interventions benefits dyspnoea and exercise capacity of people with COPD, are safe and present a high adherence rate. Unsupervised PA interventions should be considered for people with COPD who cannot or do not want to engage in supervised PA interventions or as a maintenance strategy of PA levels.
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Affiliation(s)
- C Paixão
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences (ESSUA), University of Aveiro, Aveiro, Portugal; iBiMED - Institute of Biomedicine, University of Aveiro, Aveiro, Portugal; Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - V Rocha
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences (ESSUA), University of Aveiro, Aveiro, Portugal; iBiMED - Institute of Biomedicine, University of Aveiro, Aveiro, Portugal
| | - D Brooks
- School of Rehabilitation Sciences, McMaster University, Hamilton, Canada; West Park Healthcare Centre, Toronto, Canada
| | - A Marques
- Lab3R - Respiratory Research and Rehabilitation Laboratory, School of Health Sciences (ESSUA), University of Aveiro, Aveiro, Portugal; iBiMED - Institute of Biomedicine, University of Aveiro, Aveiro, Portugal.
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Ward T, Jha A, Daynes E, Ackland J, Chalmers JD. Review of the British Thoracic Society Winter Meeting 23 November 2022 23-25 November 2022. Thorax 2023; 78:e1. [PMID: 36717241 DOI: 10.1136/thorax-2022-219941] [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: 01/06/2023] [Indexed: 02/01/2023]
Abstract
The British Thoracic Society Winter Meeting at the QEII Centre in London provided the first opportunity for the respiratory community to meet and disseminate research findings face to face since the start of the COVID-19 pandemic. World-leading researchers from the UK and abroad presented their latest findings across a range of respiratory diseases. This article aims to represent the range of the conference and as such is written from the perspective of a basic scientist, a physiotherapist and two doctors. The authors reviewed showcase sessions plus a selection of symposia based on their personal highlights. Content ranged from exciting new developments in basic science to new and unpublished results from clinical trials, delivered by leading scientists from their fields including former deputy chief medical officer Professor Sir Jonathan Van-Tam and former WHO chief scientist Dr Soumya Swaminathan.
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Affiliation(s)
- Tom Ward
- Department Respiratory Sciences, College of Life Sciences, University of Leicester, Leicester, UK
| | - Akhilesh Jha
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Enya Daynes
- Department of Respiratory Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Jodie Ackland
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James D Chalmers
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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Zanaboni P, Dinesen B, Hoaas H, Wootton R, Burge AT, Philp R, Oliveira CC, Bondarenko J, Tranborg Jensen T, Miller BR, Holland AE. Long-term Telerehabilitation or Unsupervised Training at Home for Patients with Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial. Am J Respir Crit Care Med 2023; 207:865-875. [PMID: 36480957 PMCID: PMC10111997 DOI: 10.1164/rccm.202204-0643oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
Rationale: Despite the benefits of pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD), many patients do not access or complete pulmonary rehabilitation, and long-term maintenance of exercise is difficult. Objectives: To compare long-term telerehabilitation or unsupervised treadmill training at home with standard care. Methods: In an international randomized controlled trial, patients with COPD were assigned to three groups (telerehabilitation, unsupervised training, or control) and followed up for 2 years. Telerehabilitation consisted of individualized treadmill training at home supervised by a physiotherapist and self-management. The unsupervised training group performed unsupervised treadmill exercise at home. The control group received standard care. The primary outcome was the combined number of hospitalizations and emergency department presentations. Secondary outcomes included time free from the first event; exercise capacity; dyspnea; health status; quality of life; anxiety; depression; self-efficacy; and subjective impression of change. Measurements and Main Results: A total of 120 participants were randomized. The incidence rate of hospitalizations and emergency department presentations was lower in telerehabilitation (1.18 events per person-year; 95% confidence interval [CI], 0.94-1.46) and unsupervised training group (1.14; 95% CI, 0.92-1.41) than in the control group (1.88; 95% CI, 1.58-2.21; P < 0.001 compared with intervention groups). Telerehabilitation and unsupervised training groups experienced better health status for 1 year. Intervention participants reached and maintained clinically significant improvements in exercise capacity. Conclusions: Long-term telerehabilitation and unsupervised training at home in COPD are both successful in reducing hospital readmissions and can broaden the availability of pulmonary rehabilitation and maintenance strategies.
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Affiliation(s)
- Paolo Zanaboni
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Birthe Dinesen
- Laboratory of Welfare Technologies-Digital Health & Rehabilitation, Sports Science, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Hanne Hoaas
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway
| | - Richard Wootton
- Norwegian Centre for E-health Research, University Hospital of North Norway, Tromsø, Norway
| | - Angela T. Burge
- Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Physiotherapy Department and
- Institute for Breathing and Sleep, Melbourne, Victoria, Australia
| | | | | | - Janet Bondarenko
- Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Physiotherapy Department and
| | | | | | - Anne E. Holland
- Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Physiotherapy Department and
- Respiratory Medicine, Alfred Health, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Melbourne, Victoria, Australia
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Neder JA, O'Donnell DE. The severe asthma-obesity conundrum: Consequences for exertional dyspnoea and exercise tolerance in men and women. Respirology 2022; 27:1002-1005. [PMID: 35977722 DOI: 10.1111/resp.14346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/08/2022] [Indexed: 12/13/2022]
Affiliation(s)
- J Alberto Neder
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen's University & Kingston General Hospital, Kingston, Ontario, Canada
| | - Denis E O'Donnell
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen's University & Kingston General Hospital, Kingston, Ontario, Canada
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Nigro E, Polito R, Elce A, Signoriello G, Iacotucci P, Carnovale V, Gelzo M, Zarrilli F, Castaldo G, Daniele A. Physical Activity Regulates TNFα and IL-6 Expression to Counteract Inflammation in Cystic Fibrosis Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18094691. [PMID: 33924887 PMCID: PMC8125516 DOI: 10.3390/ijerph18094691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 12/21/2022]
Abstract
Background: Cystic fibrosis (CF) is one of the most common inherited diseases. It is characterised by a severe decline in pulmonary function associated with metabolic perturbations and an increased production of inflammatory cytokines. The key role of physical activity (PA) in improving the health status of CF patients and reducing lung function decline has recently been demonstrated. This study evaluated interleukin-6 (IL-6) and tumour necrosis factor α (TNFα) expression in two subgroups of CF patients classified based on PA. Methods: We selected 85 CF patients; half of them regularly undertook supervised PA in the three years leading up to the study and half of them were not physically active. Patients were analysed for serum IL-6 and TNFα levels using enzyme-linked immunosorbent assays. Results: We found that the expression levels of IL-6 and TNFα differed in terms of their regulation by PA. In particular, TNFα levels negatively correlated with FEV1% decrease/year and FEV1% decrease (p = 0.023 and p = 0.02, respectively), and positively correlated with serum fasting glucose (p = 0.019) in PA CF patients. In contrast, in the NPA subgroup, TNFα levels were positively correlated with IL-6 (p = 0.001) and negatively correlated with adiponectin (p = 0.000). In addition, multiple logistic regression analysis confirmed that PA is an independent modulator of the inflammatory state. Conclusions: PA modulates inflammatory processes in CF patients by regulating the secretion of pro-inflammatory cytokines and thus ameliorating lung function. Our data show that PA is a useful complementary strategy in the management of CF and that TNFα may be a marker of these effects of PA.
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Affiliation(s)
- Ersilia Nigro
- Dipartimento di Scienze e Tecnologie Ambientali, Biologiche, Farmaceutiche, Università della Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (E.N.); (R.P.)
- CEINGE-Biotecnologie Avanzate Scarl, Via G. Salvatore 486, 80145 Napoli, Italy; (A.E.); (M.G.); (F.Z.); (G.C.)
| | - Rita Polito
- Dipartimento di Scienze e Tecnologie Ambientali, Biologiche, Farmaceutiche, Università della Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (E.N.); (R.P.)
- Dipartimento di Sanità Pubblica, Università degli Studi di Napoli “Federico II”, 80131 Napoli, Italy
| | - Ausilia Elce
- CEINGE-Biotecnologie Avanzate Scarl, Via G. Salvatore 486, 80145 Napoli, Italy; (A.E.); (M.G.); (F.Z.); (G.C.)
- Dipartimento di Scienze Umanistiche, Università Telematica Pegaso, 80132 Napoli, Italy
| | - Giuseppe Signoriello
- Dipartimento di Salute Mentale e Fisica e Medicina Preventiva dell’Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Paola Iacotucci
- Centro Regionale Fibrosi Cistica Adulti, Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli Federico II, 80131 Napoli, Italy; (P.I.); (V.C.)
| | - Vincenzo Carnovale
- Centro Regionale Fibrosi Cistica Adulti, Dipartimento di Scienze Mediche Traslazionali, Università degli Studi di Napoli Federico II, 80131 Napoli, Italy; (P.I.); (V.C.)
| | - Monica Gelzo
- CEINGE-Biotecnologie Avanzate Scarl, Via G. Salvatore 486, 80145 Napoli, Italy; (A.E.); (M.G.); (F.Z.); (G.C.)
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, 80131 Napoli, Italy
| | - Federica Zarrilli
- CEINGE-Biotecnologie Avanzate Scarl, Via G. Salvatore 486, 80145 Napoli, Italy; (A.E.); (M.G.); (F.Z.); (G.C.)
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, 80131 Napoli, Italy
| | - Giuseppe Castaldo
- CEINGE-Biotecnologie Avanzate Scarl, Via G. Salvatore 486, 80145 Napoli, Italy; (A.E.); (M.G.); (F.Z.); (G.C.)
- Dipartimento di Medicina Molecolare e Biotecnologie Mediche, Università degli Studi di Napoli Federico II, 80131 Napoli, Italy
| | - Aurora Daniele
- Dipartimento di Scienze e Tecnologie Ambientali, Biologiche, Farmaceutiche, Università della Campania “Luigi Vanvitelli”, 81100 Caserta, Italy; (E.N.); (R.P.)
- CEINGE-Biotecnologie Avanzate Scarl, Via G. Salvatore 486, 80145 Napoli, Italy; (A.E.); (M.G.); (F.Z.); (G.C.)
- Correspondence: ; Tel.: +39-0813-737-856
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