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Souza R, Stanley EAM, Camacho M, Camicioli R, Monchi O, Ismail Z, Wilms M, Forkert ND. A multi-center distributed learning approach for Parkinson's disease classification using the traveling model paradigm. Front Artif Intell 2024; 7:1301997. [PMID: 38384277 PMCID: PMC10879577 DOI: 10.3389/frai.2024.1301997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/23/2024] [Indexed: 02/23/2024] Open
Abstract
Distributed learning is a promising alternative to central learning for machine learning (ML) model training, overcoming data-sharing problems in healthcare. Previous studies exploring federated learning (FL) or the traveling model (TM) setup for medical image-based disease classification often relied on large databases with a limited number of centers or simulated artificial centers, raising doubts about real-world applicability. This study develops and evaluates a convolution neural network (CNN) for Parkinson's disease classification using data acquired by 83 diverse real centers around the world, mostly contributing small training samples. Our approach specifically makes use of the TM setup, which has proven effective in scenarios with limited data availability but has never been used for image-based disease classification. Our findings reveal that TM is effective for training CNN models, even in complex real-world scenarios with variable data distributions. After sufficient training cycles, the TM-trained CNN matches or slightly surpasses the performance of the centrally trained counterpart (AUROC of 83% vs. 80%). Our study highlights, for the first time, the effectiveness of TM in 3D medical image classification, especially in scenarios with limited training samples and heterogeneous distributed data. These insights are relevant for situations where ML models are supposed to be trained using data from small or remote medical centers, and rare diseases with sparse cases. The simplicity of this approach enables a broad application to many deep learning tasks, enhancing its clinical utility across various contexts and medical facilities.
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Affiliation(s)
- Raissa Souza
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Emma A. M. Stanley
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Milton Camacho
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Richard Camicioli
- Department of Medicine (Neurology), Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Oury Monchi
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Radiology, Radio-oncology and Nuclear Medicine, Université de Montréal, Montréal, QC, Canada
- Centre de Recherche, Institut Universitaire de Gériatrie de Montréal, Montréal, QC, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Zahinoor Ismail
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
- Clinical and Biomedical Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, United Kingdom
| | - Matthias Wilms
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Nils D. Forkert
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Hsieh TC, Lesmann H, Krawitz PM. Facilitating the Molecular Diagnosis of Rare Genetic Disorders Through Facial Phenotypic Scores. Curr Protoc 2023; 3:e906. [PMID: 37812136 DOI: 10.1002/cpz1.906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
With recent advances in computer vision, many applications based on artificial intelligence have been developed to facilitate the diagnosis of rare genetic disorders through the analysis of patients' two-dimensional frontal images. Some of these have been implemented on online platforms with user-friendly interfaces and provide facial analysis services, such as Face2Gene. However, users cannot run the facial analysis processes in house because the training data and the trained models are unavailable. This article therefore provides an introduction, designed for users with programming backgrounds, to the use of the open-source GestaltMatcher approach to run facial analysis in their local environment. The Basic Protocol provides detailed instructions for applying for access to the trained models and then performing facial analysis to obtain a prediction score for each of the 595 genes in the GestaltMatcher Database. The prediction results can then be used to narrow down the search space of disease-causing mutations or further connect with a variant-prioritization pipeline. © 2023 The Authors. Current Protocols published by Wiley Periodicals LLC. Basic Protocol: Using the open-source GestaltMatcher approach to perform facial analysis.
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Affiliation(s)
- Tzung-Chien Hsieh
- Institut für Genomische Statistik und Bioinformatik, Universitätsklinikum Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Hellen Lesmann
- Institut für Genomische Statistik und Bioinformatik, Universitätsklinikum Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
- Institut für Humangenetik, Universitätsklinikum Bonn, Universität Bonn, Bonn, Germany
| | - Peter M Krawitz
- Institut für Genomische Statistik und Bioinformatik, Universitätsklinikum Bonn, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
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Barbalho IMP, Fonseca ALA, Fernandes F, Henriques J, Gil P, Nagem D, Lindquist R, Lima T, dos Santos JPQ, Paiva J, Morais AHF, Dourado Júnior MET, Valentim RAM. Digital health solution for monitoring and surveillance of Amyotrophic Lateral Sclerosis in Brazil. Front Public Health 2023; 11:1209633. [PMID: 37693725 PMCID: PMC10485256 DOI: 10.3389/fpubh.2023.1209633] [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: 04/21/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Amyotrophic Lateral Sclerosis (ALS) is a complex and rare neurodegenerative disease given its heterogeneity. Despite being known for many years, few countries have accurate information about the characteristics of people diagnosed with ALS, such as data regarding diagnosis and clinical features of the disease. In Brazil, the lack of information about ALS limits data for the research progress and public policy development that benefits people affected by this health condition. In this context, this article aims to show a digital health solution development and application for research, intervention, and strengthening of the response to ALS in the Brazilian Health System. The proposed solution is composed of two platforms: the Brazilian National ALS Registry, responsible for the data collection in a structured way from ALS patients all over Brazil; and the Brazilian National ALS Observatory, responsible for processing the data collected in the National Registry and for providing a monitoring room with indicators on people diagnosed with ALS in Brazil. The development of this solution was supported by the Brazilian Ministry of Health (MoH) and was carried out by a multidisciplinary team with expertise in ALS. This solution represents a tool with great potential for strengthening public policies and stands out for being the only public database on the disease, besides containing innovations that allow data collection by health professionals and/or patients. By using both platforms, it is believed that it will be possible to understand the demographic and epidemiological data of ALS in Brazil, since the data will be able to be analyzed by care teams and also by public health managers, both in the individual and collective monitoring of people living with ALS in Brazil.
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Affiliation(s)
- Ingridy M. P. Barbalho
- Laboratory of Technological Innovation in Health (LAIS), Federal University of Rio Grande do Norte (UFRN), Natal, Brazil
| | - Aleika L. A. Fonseca
- Laboratory of Technological Innovation in Health (LAIS), Federal University of Rio Grande do Norte (UFRN), Natal, Brazil
| | - Felipe Fernandes
- Laboratory of Technological Innovation in Health (LAIS), Federal University of Rio Grande do Norte (UFRN), Natal, Brazil
| | - Jorge Henriques
- Department of Informatics Engineering, Center for Informatics and Systems of the University of Coimbra, Universidade de Coimbra, Coimbra, Portugal
| | - Paulo Gil
- Department of Informatics Engineering, Center for Informatics and Systems of the University of Coimbra, Universidade de Coimbra, Coimbra, Portugal
| | - Danilo Nagem
- Laboratory of Technological Innovation in Health (LAIS), Federal University of Rio Grande do Norte (UFRN), Natal, Brazil
| | - Raquel Lindquist
- Department of Physical Therapy, Rio Grande do Norte Federal University, Natal, Brazil
| | - Thaisa Lima
- Brazilian Ministry of Health, Brasília, Brazil
| | - João Paulo Queiroz dos Santos
- Advanced Nucleus of Technological Innovation (NAVI), Federal Institute of Education Science and Technology, Natal, Brazil
| | - Jailton Paiva
- Laboratory of Technological Innovation in Health (LAIS), Federal University of Rio Grande do Norte (UFRN), Natal, Brazil
| | - Antonio H. F. Morais
- Laboratory of Technological Innovation in Health (LAIS), Federal University of Rio Grande do Norte (UFRN), Natal, Brazil
| | | | - Ricardo A. M. Valentim
- Laboratory of Technological Innovation in Health (LAIS), Federal University of Rio Grande do Norte (UFRN), Natal, Brazil
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Tröster TS, von Wyl V, Beeler PE, Dressel H. Frequency-based rare diagnoses as a novel and accessible approach for studying rare diseases in large datasets: a cross-sectional study. BMC Med Res Methodol 2023; 23:143. [PMID: 37330464 PMCID: PMC10276905 DOI: 10.1186/s12874-023-01972-y] [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: 09/27/2022] [Accepted: 06/09/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Up to 8% of the general population have a rare disease, however, for lack of ICD-10 codes for many rare diseases, this population cannot be generically identified in large medical datasets. We aimed to explore frequency-based rare diagnoses (FB-RDx) as a novel method exploring rare diseases by comparing characteristics and outcomes of inpatient populations with FB-RDx to those with rare diseases based on a previously published reference list. METHODS Retrospective, cross-sectional, nationwide, multicenter study including 830,114 adult inpatients. We used the national inpatient cohort dataset of the year 2018 provided by the Swiss Federal Statistical Office, which routinely collects data from all inpatients treated in any Swiss hospital. Exposure: FB-RDx, according to 10% of inpatients with the least frequent diagnoses (i.e.1.decile) vs. those with more frequent diagnoses (deciles 2-10). Results were compared to patients having 1 of 628 ICD-10 coded rare diseases. PRIMARY OUTCOME In-hospital death. SECONDARY OUTCOMES 30-day readmission, admission to intensive care unit (ICU), length of stay, and ICU length of stay. Multivariable regression analyzed associations of FB-RDx and rare diseases with these outcomes. RESULTS 464,968 (56%) of patients were female, median age was 59 years (IQR: 40-74). Compared with patients in deciles 2-10, patients in the 1. were at increased risk of in-hospital death (OR 1.44; 95% CI: 1.38, 1.50), 30-day readmission (OR 1.29; 95% CI 1.25, 1.34), ICU admission (OR 1.50; 95% CI 1.46, 1.54), increased length of stay (Exp(B) 1.03; 95% CI 1.03, 1.04) and ICU length of stay (1.15; 95% CI 1.12, 1.18). ICD-10 based rare diseases groups showed similar results: in-hospital death (OR 1.82; 95% CI 1.75, 1.89), 30-day readmission (OR 1.37; 95% CI 1.32, 1.42), ICU admission (OR 1.40; 95% CI 1.36, 1.44) and increased length of stay (OR 1.07; 95% CI 1.07, 1.08) and ICU length of stay (OR 1.19; 95% CI 1.16, 1.22). CONCLUSION(S) This study suggests that FB-RDx may not only act as a surrogate for rare diseases but may also help to identify patients with rare disease more comprehensively. FB-RDx associate with in-hospital death, 30-day readmission, intensive care unit admission, and increased length of stay and intensive care unit length of stay, as has been reported for rare diseases.
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Affiliation(s)
- Thomas S. Tröster
- Division of Occupational and Environmental Medicine, Epidemiology, Biostatistics and Prevention Institute, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Viktor von Wyl
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
- Institute for Implementation Science in Health Care, University of Zurich, Zurich, Switzerland
| | - Patrick E. Beeler
- Division of Occupational and Environmental Medicine, Epidemiology, Biostatistics and Prevention Institute, University of Zurich and University Hospital Zurich, Zurich, Switzerland
- Center for Primary and Community Care, University of Lucerne, Lucerne, Switzerland
| | - Holger Dressel
- Division of Occupational and Environmental Medicine, Epidemiology, Biostatistics and Prevention Institute, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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Souza R, Mouches P, Wilms M, Tuladhar A, Langner S, Forkert ND. An analysis of the effects of limited training data in distributed learning scenarios for brain age prediction. J Am Med Inform Assoc 2022; 30:112-119. [PMID: 36287916 PMCID: PMC9748540 DOI: 10.1093/jamia/ocac204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 10/08/2022] [Accepted: 10/12/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Distributed learning avoids problems associated with central data collection by training models locally at each site. This can be achieved by federated learning (FL) aggregating multiple models that were trained in parallel or training a single model visiting sites sequentially, the traveling model (TM). While both approaches have been applied to medical imaging tasks, their performance in limited local data scenarios remains unknown. In this study, we specifically analyze FL and TM performances when very small sample sizes are available per site. MATERIALS AND METHODS 2025 T1-weighted magnetic resonance imaging scans were used to investigate the effect of sample sizes on FL and TM for brain age prediction. We evaluated models across 18 scenarios varying the number of samples per site (1, 2, 5, 10, and 20) and the number of training rounds (20, 40, and 200). RESULTS Our results demonstrate that the TM outperforms FL, for every sample size examined. In the extreme case when each site provided only one sample, FL achieved a mean absolute error (MAE) of 18.9 ± 0.13 years, while the TM achieved a MAE of 6.21 ± 0.50 years, comparable to central learning (MAE = 5.99 years). DISCUSSION Although FL is more commonly used, our study demonstrates that TM is the best implementation for small sample sizes. CONCLUSION The TM offers new opportunities to apply machine learning models in rare diseases and pediatric research but also allows even small hospitals to contribute small datasets.
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Affiliation(s)
- Raissa Souza
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, Alberta, Canada
| | - Pauline Mouches
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, Alberta, Canada
| | - Matthias Wilms
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Anup Tuladhar
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Biomedical Engineering Graduate Program, University of Calgary, Calgary, Alberta, Canada
| | - Sönke Langner
- Institute for Diagnostic Radiology and Neuroradiology, Rostock University Medical Center, Rostock, Germany
| | - Nils D Forkert
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Messiaen C, Racine C, Khatim A, Soussand L, Odent S, Lacombe D, Manouvrier S, Edery P, Sigaudy S, Geneviève D, Thauvin-Robinet C, Pasquier L, Petit F, Rossi M, Willems M, Attié-Bitach T, Roux-Levy PH, Demougeot L, Slama LB, Landais P, Jannot AS, Binquet C, Sandrin A, Verloes A, Faivre L. 10 years of CEMARA database in the AnDDI-Rares network: a unique resource facilitating research and epidemiology in developmental disorders in France. Orphanet J Rare Dis 2021; 16:345. [PMID: 34348744 PMCID: PMC8335940 DOI: 10.1186/s13023-021-01957-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 07/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In France, the Ministry of Health has implemented a comprehensive program for rare diseases (RD) that includes an epidemiological program as well as the establishment of expert centers for the clinical care of patients with RD. Since 2007, most of these centers have entered the data for patients with developmental disorders into the CEMARA population-based registry, a national online data repository for all rare diseases. Through the CEMARA web portal, descriptive demographic data, clinical data, and the chronology of medical follow-up can be obtained for each center. We address the interest and ongoing challenges of this national data collection system 10 years after its implementation. METHODS Since 2007, clinicians and researchers have reported the "minimum dataset (MDS)" for each patient presenting to their expert center. We retrospectively analyzed administrative data, demographic data, care organization and diagnoses. RESULTS Over 10 years, 228,243 RD patients (including healthy carriers and family members for whom experts denied any suspicion of RD) have visited an expert center. Among them, 167,361 were patients affected by a RD (median age 11 years, 54% children, 46% adults, with a balanced sex ratio), and 60,882 were unaffected relatives (median age 37 years). The majority of patients (87%) were seen no more than once a year, and 52% of visits were for a diagnostic procedure. Among the 2,869 recorded rare disorders, 1,907 (66.5%) were recorded in less than 10 patients, 802 (28%) in 10 to 100 patients, 149 (5.2%) in 100 to 1,000 patients, and 11 (0.4%) in > 1,000 patients. Overall, 45.6% of individuals had no diagnosis and 6.7% had an uncertain diagnosis. Children were mainly referred by their pediatrician (46%; n = 55,755 among the 121,136 total children referrals) and adults by a medical specialist (34%; n = 14,053 among the 41,564 total adult referrals). Given the geographical coverage of the centers, the median distance from the patient's home was 25.1 km (IQR = 6.3 km-64.2 km). CONCLUSIONS CEMARA provides unprecedented support for epidemiological, clinical and therapeutic studies in the field of RD. Researchers can benefit from the national scope of CEMARA data, but also focus on specific diseases or patient subgroups. While this endeavor has been a major collective effort among French RD experts to gather large-scale data into a single database, it provides tremendous potential to improve patient care.
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Affiliation(s)
- Claude Messiaen
- Banque Nationale de Données Maladies Rares, DSI-WIND, APHP, Paris, France.
| | - Caroline Racine
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU de Dijon, Dijon, France
| | - Ahlem Khatim
- Banque Nationale de Données Maladies Rares, DSI-WIND, APHP, Paris, France
| | - Louis Soussand
- Banque Nationale de Données Maladies Rares, DSI-WIND, APHP, Paris, France
| | - Sylvie Odent
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, Hôpital Sud, CHU de Rennes, Rennes, France
| | - Didier Lacombe
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU Bordeaux, et INSERM U1211, Bordeaux, France
| | - Sylvie Manouvrier
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU de Lille, EA 7364 RADEME Maladies Rares du Développement et du Métabolisme, Université Lille, Lille, France
| | - Patrick Edery
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, Hôpital Femme-Mère-Enfant Hospices Civils de Lyon, Bron, France
| | - Sabine Sigaudy
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, Département de Génétique Médicale, CHU de Marseille - Hôpital de La Timone, Marseille, France
| | - David Geneviève
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU Montpellier, Montpellier, France
| | - Christel Thauvin-Robinet
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU de Dijon, Dijon, France.,Filière AnDDI-Rares, CHU Dijon, Dijon, France.,INSERM UMR1231 et FHU TRANSLAD, Université de Bourgogne, Dijon, France
| | - Laurent Pasquier
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, Hôpital Sud, CHU de Rennes, Rennes, France
| | - Florence Petit
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU de Lille, EA 7364 RADEME Maladies Rares du Développement et du Métabolisme, Université Lille, Lille, France
| | - Massimiliano Rossi
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, Hôpital Femme-Mère-Enfant Hospices Civils de Lyon, Bron, France
| | - Marjolaine Willems
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU Montpellier, Montpellier, France
| | | | | | | | - Lilia Ben Slama
- Filière AnDDI-Rares, CHU Dijon, Dijon, France.,Hôpital Necker-Enfants Malades, Paris, France
| | - Paul Landais
- Service de Biostatistique, Epidémiologie, Santé Publique et d'Information Médicale, CHU de Nîmes, Faculté de Médecine Montpellier Nîmes, Nîmes, France
| | | | - Anne-Sophie Jannot
- Banque Nationale de Données Maladies Rares, DSI-WIND, APHP, Paris, France.,AP-HP. Centre - Université de Paris, Paris, France
| | - Christine Binquet
- Inserm, CIC1432, module épidémiologie clinique, Dijon, France.,CHU Dijon-Bourgogne, Centre d'Investigation Clinique, Epidémiologie Clinique/Essais Cliniques, Dijon, France
| | - Arnaud Sandrin
- Banque Nationale de Données Maladies Rares, DSI-WIND, APHP, Paris, France
| | - Alain Verloes
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, AP-HP-Nord-Université de Paris, Hôpital Robert Debré, Department of Medical Genetics and INSERM UMR 1141, Paris, France
| | - Laurence Faivre
- Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU de Dijon, Dijon, France. .,Filière AnDDI-Rares, CHU Dijon, Dijon, France. .,INSERM UMR1231 et FHU TRANSLAD, Université de Bourgogne, Dijon, France. .,Centre de Génétique et Centre de Référence Anomalies du Développement et Syndromes Malformatifs, Filière AnDDI-Rares, Hôpital D'Enfants, CHU Dijon, 14 rue Gaffarel, Dijon, France.
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Zerka F, Urovi V, Bottari F, Leijenaar RTH, Walsh S, Gabrani-Juma H, Gueuning M, Vaidyanathan A, Vos W, Occhipinti M, Woodruff HC, Dumontier M, Lambin P. Privacy preserving distributed learning classifiers - Sequential learning with small sets of data. Comput Biol Med 2021; 136:104716. [PMID: 34364262 DOI: 10.1016/j.compbiomed.2021.104716] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/16/2021] [Accepted: 07/28/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Artificial intelligence (AI) typically requires a significant amount of high-quality data to build reliable models, where gathering enough data within a single institution can be particularly challenging. In this study we investigated the impact of using sequential learning to exploit very small, siloed sets of clinical and imaging data to train AI models. Furthermore, we evaluated the capacity of such models to achieve equivalent performance when compared to models trained with the same data over a single centralized database. METHODS We propose a privacy preserving distributed learning framework, learning sequentially from each dataset. The framework is applied to three machine learning algorithms: Logistic Regression, Support Vector Machines (SVM), and Perceptron. The models were evaluated using four open-source datasets (Breast cancer, Indian liver, NSCLC-Radiomics dataset, and Stage III NSCLC). FINDINGS The proposed framework ensured a comparable predictive performance against a centralized learning approach. Pairwise DeLong tests showed no significant difference between the compared pairs for each dataset. INTERPRETATION Distributed learning contributes to preserve medical data privacy. We foresee this technology will increase the number of collaborative opportunities to develop robust AI, becoming the default solution in scenarios where collecting enough data from a single reliable source is logistically impossible. Distributed sequential learning provides privacy persevering means for institutions with small but clinically valuable datasets to collaboratively train predictive AI while preserving the privacy of their patients. Such models perform similarly to models that are built on a larger central dataset.
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Affiliation(s)
- Fadila Zerka
- The D-Lab, Department of Precision Medicine, GROW - School for Oncology, Maastricht University, Maastricht, the Netherlands; Radiomics (Oncoradiomics SA), Liège, Belgium.
| | - Visara Urovi
- Institute of Data Science (IDS), Maastricht University, the Netherlands
| | | | | | - Sean Walsh
- Radiomics (Oncoradiomics SA), Liège, Belgium
| | | | | | - Akshayaa Vaidyanathan
- The D-Lab, Department of Precision Medicine, GROW - School for Oncology, Maastricht University, Maastricht, the Netherlands; Radiomics (Oncoradiomics SA), Liège, Belgium
| | - Wim Vos
- Radiomics (Oncoradiomics SA), Liège, Belgium
| | | | - Henry C Woodruff
- The D-Lab, Department of Precision Medicine, GROW - School for Oncology, Maastricht University, Maastricht, the Netherlands; Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Michel Dumontier
- Institute of Data Science (IDS), Maastricht University, the Netherlands
| | - Philippe Lambin
- The D-Lab, Department of Precision Medicine, GROW - School for Oncology, Maastricht University, Maastricht, the Netherlands; Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
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8
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Taruscio D, Mantovani A. Multifactorial Rare Diseases: Can Uncertainty Analysis Bring Added Value to the Search for Risk Factors and Etiopathogenesis? ACTA ACUST UNITED AC 2021; 57:medicina57020119. [PMID: 33525390 PMCID: PMC7911455 DOI: 10.3390/medicina57020119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/23/2021] [Accepted: 01/24/2021] [Indexed: 11/16/2022]
Abstract
Uncertainty analysis is the process of identifying limitations in knowledge and evaluating their implications for scientific conclusions. Uncertainty analysis is a stable component of risk assessment and is increasingly used in decision making on complex health issues. Uncertainties should be identified in a structured way and prioritized according to their likely impact on the outcome of scientific conclusions. Uncertainty is inherent to the rare diseases (RD) area, where research and healthcare have to cope with knowledge gaps due to the rarity of the conditions; yet a systematic approach toward uncertainties is not usually undertaken. The uncertainty issue is particularly relevant to multifactorial RD, whose etiopathogenesis involves environmental factors and genetic predisposition. Three case studies are presented: the newly recognized acute multisystem inflammatory syndrome in children and adolescents associated with SARS-CoV-2 infection; the assessment of risk factors for neural tube defects; and the genotype-phenotype correlation in familial Mediterranean fever. Each case study proposes the initial identification of the main epistemic and sampling uncertainties and their impacts. Uncertainty analysis in RD may present aspects similar to those encountered when conducting risk assessment in data-poor scenarios; therefore, approaches such as expert knowledge elicitation may be considered. The RD community has a main strength in managing uncertainty, as it proactively develops stakeholder involvement, data sharing and open science. The open science approaches can be profitably integrated by structured uncertainty analysis, especially when dealing with multifactorial RD involving environmental and genetic risk factors.
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Affiliation(s)
- Domenica Taruscio
- National Center for Rare Diseases, Italian National Institute of Health (ISS), 00161 Roma, Italy
- Correspondence:
| | - Alberto Mantovani
- Department on Food Safety, Nutrition and Veterinary Public Health, Italian National Institute of Health (ISS), 00161 Roma, Italy;
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Mancuso M, Filosto M, Lamperti C, Musumeci O, Santorelli FM, Servidei S, Valente EM, Zeviani M, Mancardi G, Tedeschi G, Federico A. Awareness of rare and genetic neurological diseases among italian neurologist. A national survey. Neurol Sci 2020; 41:1567-1570. [PMID: 31989346 DOI: 10.1007/s10072-020-04271-2] [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: 12/17/2019] [Accepted: 01/20/2020] [Indexed: 10/25/2022]
Abstract
Rare neurological diseases (RNDs) are a heterogeneous group of disorders mainly affecting the central and peripheral nervous systems, representing almost 50% of all rare diseases; this explains why neurologists are very often involved in their diagnosis, treatment and research. The purpose of this study was to quantitatively describe the awareness of RNDs among the neurological community of the Italian Society of Neurology (SIN). A survey of the Italian Neurogenetics and Rare diseases group of the SIN, similar to what was submitted to the members of the EAN Task Force on Rare Neurologic Diseases and to EAN Panels Scientific Committee Management Groups, was launched in January 2019 in order to verify the specific Italian situations and possibly the regional differences. Answers were collected online. We observed that Italian Members of the SIN Neurogenetics and Rare Neurologic Diseases Scientific Group are well aware of the burden posed by RNDs but at the national and regional level, the relative awareness is sketchy and disparate. Although many national initiatives have been undertaken to facilitate the diagnosis and management in Italy, our survey reveals that much works has to be done in supporting RNDs patients, including a deeper collaboration between politics, universities and all stakeholders in the field.
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Affiliation(s)
- Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.
| | - Massimiliano Filosto
- Unit of Neurology, ASST "Spedali Civili" and University of Brescia, Brescia, Italy
| | - Costanza Lamperti
- UO Medical Genetics and Neurogentics, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Olimpia Musumeci
- Department of Clinical and Experimental Medicine Unit of Neurological and Neuromuscular Disorders, University of Messina, Messina, Italy
| | - Filippo M Santorelli
- Molecular Medicine for Neurodegenerative and Neuromuscular Diseases Unit, IRCCS Stella Maris Foundation, 56128, Pisa, Italy
| | - Serenella Servidei
- UOC Neurofisiopatologia Fondazione Policlinico Universitario, A. Gemelli IRCCS, Istituto di Neurologia Università Cattolica del Sacro Cuore, Roma, Italy
| | - Enza M Valente
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- IRCCS Mondino Foundation, Pavia, Italy
| | - Massimo Zeviani
- Department of Neuroscience, University of Padua, Padua, Italy
| | - Gianluigi Mancardi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health and Neuromotor Department, University of Genova and IRCCS ICS Maugeri, Genoa and Pavia, Italy
| | - Gioacchino Tedeschi
- Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonio Federico
- Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
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Primary Sclerosing Cholangitis: Burden of Disease and Mortality Using Data from the National Rare Diseases Registry in Italy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17093095. [PMID: 32365682 PMCID: PMC7246900 DOI: 10.3390/ijerph17093095] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/20/2020] [Accepted: 04/26/2020] [Indexed: 12/12/2022]
Abstract
Introduction: Studies on the epidemiology of primary sclerosing cholangitis (PSC) are mainly based on tertiary referral centers; and are retrospective case series susceptible to selection bias. The aim of this study was to estimate incidence; survival and cause of mortality of PSC in Italy; using population-based data. Methods: Data collected from the National Rare Diseases Registry (RNMR) and the National Mortality Database (NMD) were integrated and analyzed. Results: We identified 502 PSC incident cases. The crude incidence rate between 2012 and 2014 was 0.10 per 100,000 individuals. Sixty percent were male; mean age at disease onset and at diagnosis were 33 and 37 years; respectively; highlighting a mean diagnostic delay of 4 years. The rate of interregional mobility was 12%. Ten-year survival was 92%. In 32% of cases the cause of death was biliary-related; 12% died of biliary or gallbladder cancer. Conclusions: For rare diseases such as PSC; population-based cohort’s studies are of paramount importance. Incidence rates of PSC in Italy are markedly lower and survival much longer than the ones reported from tertiary; single-centre series. Moreover; the diagnostic delay and the patient interregional mobility highlights the need for increasing awareness on the disease and for resource reallocation among Italian regions within the National Health Service
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Riccò M, Vezzosi L, Balzarini F, Gualerzi G, Ranzieri S. Prevalence of Huntington Disease in Italy: a systematic review and meta-analysis. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:119-127. [PMID: 32275276 PMCID: PMC7975892 DOI: 10.23750/abm.v91i3-s.9441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 01/24/2023]
Abstract
Worldwide prevalence of Huntington’s disease (HD) is quite heterogenous. As Italy is characterized by significant genetic heterogeneity, with presumptive differences between Italian regions, this review was undertaken to define available data of HD prevalence in Italy, to assess geographic heterogeneity, and reconcile possible variation in HD prevalence rates with the availability of genetic testing.
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Affiliation(s)
- Matteo Riccò
- Azienda USL di Reggio EmiliaV.le Amendola n.2 - 42122 REServizio di Prevenzione e Sicurezza negli Ambienti di Lavoro (SPSAL)Dip. di Prevenzione.
| | - Luigi Vezzosi
- Agenzia di Tutela della Salute (ATS) della Val Padana; Via Toscani n.1; Mantova (MN), Italy.
| | - Federica Balzarini
- University "Vita e Salute", San Raffaele Hospital; Via Olgettina n. 58, 20132; Milan (MI), Italy.
| | - Giovanni Gualerzi
- University of Parma, Department of Medicine and Surgery, School of Medicine; Via Gramsci n.14, 43123; Parma (PR), Italy.
| | - Silvia Ranzieri
- University of Parma, Department of Medicine and Surgery, School of Occupational Medicine; Via Gramsci n.14, 43123; Parma (PR), Italy.
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Valent F, Deroma L, Moro A, Ciana G, Martina P, De Martin F, Michelesio E, Da Riol MR, Macor D, Bembi B. Value of the Rare Disease Registry of the Italian Region Friuli Venezia Giulia. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1003-1011. [PMID: 31511176 DOI: 10.1016/j.jval.2019.04.1917] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/27/2019] [Accepted: 04/04/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND The lack of epidemiological and clinical data is a major obstacle in health service planning for rare diseases. Patient registries are examples of real-world data that may fill the information gap. OBJECTIVE We describe the Rare Disease Registry of the Friuli Venezia Giulia region of Italy and its potential for research and health planning. METHODS The Rare Disease Registry data were linked with information on mortality, hospital discharges, ambulatory care, and drug prescriptions contained in administrative databases. All information is anonymous, and data linkage was based on a stochastic key univocal for each patient. Average annual costs owing to hospitalizations, outpatient care, and medications were estimated. RESULTS Implementation of the Registry started in 2010, and 4250 participants were registered up to 2017. A total of 2696 patients were living in the region as of January 1, 2017. The overall raw prevalence of rare diseases was 22 per 10,000 inhabitants, with higher prevalence in the pediatric population. The most common disease groups were congenital malformations, chromosomal and genetic syndromes, and circulatory and nervous diseases. In 2017, 30 patients died, 648 were hospitalized, and 2355 received some type of ambulatory care. The total annual estimated cost was approximately €6.5 million, with great variability in the average patient cost across diseases. CONCLUSIONS The possibility of following the detailed real-world care experience of patients with each specific rare disease and assessing the costs related to each step in their care path represents a unique opportunity to identify inefficiencies, optimize care, and reduce waste of resources.
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Affiliation(s)
- Francesca Valent
- Institute of Hygiene and Clinical Epidemiology, University Hospital of Udine, Udine, Italy.
| | - Laura Deroma
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
| | - Alessandro Moro
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
| | - Giovanni Ciana
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
| | | | | | | | - Maria Rosalia Da Riol
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
| | - Daniela Macor
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
| | - Bruno Bembi
- Regional Coordinating Center for Rare Diseases, University Hospital of Udine, Udine, Italy
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Crisafulli S, Sultana J, Ingrasciotta Y, Addis A, Cananzi P, Cavagna L, Conter V, D’Angelo G, Ferrajolo C, Mantovani L, Pastorello M, Scondotto S, Trifirò G. Role of healthcare databases and registries for surveillance of orphan drugs in the real-world setting: the Italian case study. Expert Opin Drug Saf 2019; 18:497-509. [DOI: 10.1080/14740338.2019.1614165] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
| | - Janet Sultana
- Department of Biomedical and Dental Sciences and Morpho-functional Imaging, University of Messina, Messina, Italy
| | - Ylenia Ingrasciotta
- Unit of Clinical Pharmacology, A.O.U. Policlinico “G. Martino”, Messina, Italy
| | - Antonio Addis
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | - Pasquale Cananzi
- Health Department of Sicily, Sicilian Regional Centre of Pharmacovigilance, Palermo, Italy
| | - Lorenzo Cavagna
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo Foundation, Pavia, Italy
| | - Valentino Conter
- Department of Pediatrics, University of Milano-Bicocca, Ospedale S Gerardo, Monza, Italy
| | - Gabriella D’Angelo
- Department of Clinical and Experimental Medicine, A.O.U. Policlinico “G. Martino”, Messina, Italy
- Neonatal and Pediatric Intensive Care Unit, Department of Human Pathology in Adult and Developmental Age “Gaetano Barresi”, University of Messina, Messina, Italy
| | - Carmen Ferrajolo
- Department of Experimental Medicine, University of Campania “Vanvitelli”, and Campania Regional Center of Pharmacovigilance and Pharmacoepidemiology, Naples, Italy
| | - Lorenzo Mantovani
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | | | - Salvatore Scondotto
- Epidemiologic Observatory of the Sicily Regional Health Service, Palermo, Italy
| | - Gianluca Trifirò
- Unit of Clinical Pharmacology, A.O.U. Policlinico “G. Martino”, Messina, Italy
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Vignatelli L, Antelmi E, Ceretelli I, Bellini M, Carta C, Cortelli P, Ferini-Strambi L, Ferri R, Guerrini R, Ingravallo F, Marchiani V, Mari F, Pieroni G, Pizza F, Verga MC, Verrillo E, Taruscio D, Plazzi G. Red Flags for early referral of people with symptoms suggestive of narcolepsy: a report from a national multidisciplinary panel. Neurol Sci 2018; 40:447-456. [PMID: 30539345 PMCID: PMC6433801 DOI: 10.1007/s10072-018-3666-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 11/28/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Narcolepsy is a lifelong disease, manifesting with excessive daytime sleepiness and cataplexy, arising between childhood and young adulthood. The diagnosis is typically made after a long delay that burdens the disease severity. The aim of the project, promoted by the "Associazione Italiana Narcolettici e Ipersonni" is to develop Red Flags to detect symptoms for early referral, targeting non-sleep medicine specialists, general practitioners, and pediatricians. MATERIALS AND METHODS A multidisciplinary panel, including patients, public institutions, and representatives of national scientific societies of specialties possibly involved in the diagnostic process of suspected narcolepsy, was convened. The project was accomplished in three phases. Phase 1: Sleep experts shaped clinical pictures of narcolepsy in pediatric and adult patients. On the basis of these pictures, Red Flags were drafted. Phase 2: Representatives of the scientific societies and patients filled in a form to identify barriers to the diagnosis of narcolepsy. Phase 3: The panel produced suggestions for the implementation of Red Flags. RESULTS Red Flags were produced representing three clinical pictures of narcolepsy in pediatric patients ((1) usual sleep symptoms, (2) unusual sleep symptoms, (3) endocrinological signs) and two in adult patients ((1) usual sleep symptoms, (2) unusual sleep symptoms). Inadequate knowledge of symptoms at onset by medical doctors turned out to be the main reported barrier to diagnosis. CONCLUSIONS This report will hopefully enhance knowledge and awareness of narcolepsy among non-specialists in sleep medicine in order to reduce the diagnostic delay that burdens patients in Italy. Similar initiatives could be promoted across Europe.
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Affiliation(s)
- L Vignatelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - E Antelmi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy
| | - I Ceretelli
- Associazione Italiana Narcolettici e Ipersonni (AIN), Florence, Italy
| | - M Bellini
- Azienda USL Toscana centro Sedi di Prato, Prato, Italy
| | - C Carta
- National Centre for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - P Cortelli
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy
| | - L Ferini-Strambi
- Department of Clinical Neurosciences, Neurology - Sleep Disorders Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - R Ferri
- Sleep Research Centre, Department of Neurology I.C., Oasi Research Institute - IRCCS, Troina, Italy
| | - R Guerrini
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Children's Hospital A. Meyer-University of Florence, Florence, Italy
| | - F Ingravallo
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - V Marchiani
- Child Neuropsychiatric Unit, Polyclinic S. Orsola-Malpighi, University of Bologna, Bologna, Italy
| | - F Mari
- Pediatric Neurology, Neurogenetics and Neurobiology Unit and Laboratories, Children's Hospital A. Meyer-University of Florence, Florence, Italy
| | - G Pieroni
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - F Pizza
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy
| | - M C Verga
- Primary Care Pediatrics, ASL Salerno, Vietri sul Mare, SA, Italy
| | - E Verrillo
- Sleep and Long Term Ventilation Unit, Pediatric Pulmonology & Respiratory Intermediate Care Unit, Academic Department of Pediatrics (DPUO) Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - D Taruscio
- National Centre for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Giuseppe Plazzi
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.
- Department of Biomedical and Neuromotor Sciences, University of Bologna, via Ugo Foscolo n 7, 40123, Bologna, Italy.
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