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Upadhyay C, Rao P, Behzadi MA, Feyznezhad R, Lambert GS, Kumar R, Kumar M, Yang W, Jiang X, Luo CC, Nadas A, Arthos J, Kong XP, Zhang H, Hioe CE, Duty JA. Signal peptide exchange alters HIV-1 envelope antigenicity and immunogenicity. Front Immunol 2024; 15:1476924. [PMID: 39380992 PMCID: PMC11458420 DOI: 10.3389/fimmu.2024.1476924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 09/09/2024] [Indexed: 10/10/2024] Open
Abstract
Introduction HIV-1 envelope (Env) is the key target for antibodies (Abs) against the virus and thus an important HIV-1 vaccine component. Env is synthesized from a gp160 precursor with a signal peptide (SP) at its N-terminus. This study investigated the influence of the SP on Env antigenicity and immunogenicity. Methods Env proteins from two HIV-1 isolates, AA05 and AC02, were analyzed as gp120 and gp160 in their native wild-type (WT) forms and as chimeras with swapped SPs (AA05-02 and AC02-05). The WT and chimeric Env were assessed for antigenicity and glycosylation using monoclonal antibodies (mAbs) and glycan probes. Immunogenicity was tested in mice using three vaccine types: gp120 protein, gp120 DNA+gp120 protein, and gp120 DNA+gp160 DNA. Results The recombinant AC02 gp120 protein was antigenically superior to AA05 as indicated by higher reactivity with most mAbs tested. When SPs were swapped, the antigenicity of the chimeric gp120s (AA05-02 and AC02-05) resembled that of the gp120s from which the SPs were derived; AA05-02 was similar to AC02 and vice versa. Glycan probe reactivity followed a similar pattern: AA05-02 and AC02 showed similar affinity to high-mannose specific mAbs and lectins. Interestingly, the antigenicity of gp160s showed an opposite pattern; membrane-bound gp160 expressed with the AA05 SP (AA05 and AC02-05) showed greater mAb binding than gp160 with the AC02 SP (AC02 and AA05-02). Mice immunized with gp120 protein showed that AA05-02 induced stronger cross-reactive binding Ab responses than AA05 WT, and AC02 elicited stronger responses than AC02-05, indicating AC02 SP enhanced gp120 immunogenicity. However, when DNA vaccines were included (gp120 DNA+gp120 protein and gp120 DNA+gp160 DNA), the use of heterologous SPs diminished the immunogenicity of the WT immunogens. Among the three vaccine regimens tested, only gp120 DNA+gp160 DNA immunization elicited low-level Tier 2 neutralizing Abs, with AA05 WT inducing Abs with greater neutralization capabilities than AA05-02. Conclusion These data demonstrate that the SP can significantly impact the antigenicity and immunogenicity of HIV-1 Env proteins. Hence, while SP swapping is a common practice in constructing Env immunogens, this study highlights the importance of careful consideration of the effects of replacing native SPs on the immunogenicity of Env vaccines.
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Affiliation(s)
- Chitra Upadhyay
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Priyanka Rao
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Mohammad Amin Behzadi
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Roya Feyznezhad
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Gregory S. Lambert
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Rajnish Kumar
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Madhu Kumar
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Weiming Yang
- Department of Pathology, Johns Hopkins University, Baltimore, MD, United States
| | - Xunqing Jiang
- Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, NY, United States
| | - Christina C. Luo
- Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, NY, United States
| | - Arthur Nadas
- Department of Environment Medicine, New York University Grossman School of Medicine, New York, NY, United States
| | - James Arthos
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Xiang-Peng Kong
- Department of Biochemistry and Molecular Pharmacology, New York University Grossman School of Medicine, New York, NY, United States
| | - Hui Zhang
- Department of Pathology, Johns Hopkins University, Baltimore, MD, United States
| | - Catarina E. Hioe
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Research Service, James J. Peters VA Medical Center, Bronx, NY, United States
| | - J. Andrew Duty
- Department of Microbiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Taveira N, Figueiredo I, Calado R, Martin F, Bártolo I, Marcelino JM, Borrego P, Cardoso F, Barroso H. An HIV-1/HIV-2 Chimeric Envelope Glycoprotein Generates Binding and Neutralising Antibodies against HIV-1 and HIV-2 Isolates. Int J Mol Sci 2023; 24:ijms24109077. [PMID: 37240423 DOI: 10.3390/ijms24109077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/15/2023] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
The development of immunogens that elicit broadly reactive neutralising antibodies (bNAbs) is the highest priority for an HIV vaccine. We have shown that a prime-boost vaccination strategy with vaccinia virus expressing the envelope glycoprotein gp120 of HIV-2 and a polypeptide comprising the envelope regions C2, V3 and C3 elicits bNAbs against HIV-2. We hypothesised that a chimeric envelope gp120 containing the C2, V3 and C3 regions of HIV-2 and the remaining parts of HIV-1 would elicit a neutralising response against HIV-1 and HIV-2. This chimeric envelope was synthesised and expressed in vaccinia virus. Balb/c mice primed with the recombinant vaccinia virus and boosted with an HIV-2 C2V3C3 polypeptide or monomeric gp120 from a CRF01_AG HIV-1 isolate produced antibodies that neutralised >60% (serum dilution 1:40) of a primary HIV-2 isolate. Four out of nine mice also produced antibodies that neutralised at least one HIV-1 isolate. Neutralising epitope specificity was assessed using a panel of HIV-1 TRO.11 pseudoviruses with key neutralising epitopes disrupted by alanine substitution (N160A in V2; N278A in the CD4 binding site region; N332A in the high mannose patch). The neutralisation of the mutant pseudoviruses was reduced or abolished in one mouse, suggesting that neutralising antibodies target the three major neutralising epitopes in the HIV-1 envelope gp120. These results provide proof of concept for chimeric HIV-1/HIV-2 envelope glycoproteins as vaccine immunogens that can direct the antibody response against neutralising epitopes in the HIV-1 and HIV-2 surface glycoproteins.
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Affiliation(s)
- Nuno Taveira
- Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz School of Health and Science, 2829-511 Caparica, Portugal
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, University of Lisbon, 1649-003 Lisboa, Portugal
| | - Inês Figueiredo
- Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz School of Health and Science, 2829-511 Caparica, Portugal
| | - Rita Calado
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, University of Lisbon, 1649-003 Lisboa, Portugal
| | - Francisco Martin
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, University of Lisbon, 1649-003 Lisboa, Portugal
| | - Inês Bártolo
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, University of Lisbon, 1649-003 Lisboa, Portugal
| | - José M Marcelino
- Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz School of Health and Science, 2829-511 Caparica, Portugal
- Research Institute for Medicines (iMed.ULisboa), Faculty of Pharmacy, University of Lisbon, 1649-003 Lisboa, Portugal
| | - Pedro Borrego
- Centre for Public Administration and Public Policies, Institute of Social and Political Sciences, Universidade de Lisboa, 1300-663 Lisbon, Portugal
| | - Fernando Cardoso
- Unidade de Microbiologia Médica, Saúde Global e Medicina Tropical, Instituto de Higiene e Medicina Tropical, Universidade NOVA de Lisboa, 1099-085 Lisbon, Portugal
| | - Helena Barroso
- Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz School of Health and Science, 2829-511 Caparica, Portugal
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Martin F, Marcelino JM, Palladino C, Bártolo I, Tracana S, Moranguinho I, Gonçalves P, Mateus R, Calado R, Borrego P, Leitner T, Clemente S, Taveira N. Long-Term and Low-Level Envelope C2V3 Stimulation by Highly Diverse Virus Isolates Leads to Frequent Development of Broad and Elite Antibody Neutralization in HIV-1-Infected Individuals. Microbiol Spectr 2022; 10:e0163422. [PMID: 36445130 PMCID: PMC9769935 DOI: 10.1128/spectrum.01634-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 10/29/2022] [Indexed: 12/03/2022] Open
Abstract
A minority of HIV-1-infected patients produce broadly neutralizing antibodies (bNAbs). Identification of viral and host correlates of bNAb production may help develop vaccines. We aimed to characterize the neutralizing response and viral and host-associated factors in Angola, which has one of the oldest, most dynamic, and most diverse HIV-1 epidemics in the world. Three hundred twenty-two HIV-1-infected adults from Angola were included in this retrospective study. Phylogenetic analysis of C2V3C3 env gene sequences was used for virus subtyping. Env-binding antibody reactivity was tested against polypeptides comprising the C2, V3, and C3 regions. Neutralizing-antibody responses were determined against a reference panel of tier 2 Env pseudoviruses in TZM-bl cells; neutralizing epitope specificities were predicted using ClustVis. All subtypes were found, along with untypeable strains and recombinant forms. Notably, 56% of the patients developed cross neutralizing, broadly neutralizing, or elite neutralizing responses. Broad and elite neutralization was associated with longer infection time, subtype C, lower CD4+ T cell counts, higher age, and higher titer of C2V3C3-specific antibodies relative to failure to develop bNAbs. Neutralizing antibodies targeted the V3-glycan supersite in most patients. V3 and C3 regions were significantly less variable in elite neutralizers than in weak neutralizers and nonneutralizers, suggesting an active role of V3C3-directed bNAbs in controlling HIV-1 replication and diversification. In conclusion, prolonged and low-level envelope V3C3 stimulation by highly diverse and ancestral HIV-1 isolates promotes the frequent elicitation of bNAbs. These results provide important clues for the development of an effective HIV-1 vaccine. IMPORTANCE Studies on neutralization by antibodies and their determinants in HIV-1-infected individuals have mostly been conducted in relatively recent epidemics caused by subtype B and C viruses. Results have suggested that elicitation of broadly neutralizing antibodies (bNAbs) is uncommon. The mechanisms underlying the elicitation of bNAbs are still largely unknown. We performed the first characterization of the plasma neutralizing response in a cohort of HIV-1-infected patients from Angola. Angola is characterized by an old and dynamic epidemic caused by highly diverse HIV-1 variants. Remarkably, more than half of the patients produced bNAbs, mostly targeting the V3-glycan supersite in HIV-1. This was associated with higher age, longer infection time, lower CD4+ T cell counts, subtype C infection, or higher titer of C2V3C3-specific antibodies relative to patients that did not develop bNAbs. These results may help develop the next generation of vaccine candidates for HIV-1.
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Affiliation(s)
- Francisco Martin
- Research Institute for Medicine, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - José Maria Marcelino
- Research Institute for Medicine, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
- Centro de Investigação Interdisciplinar Egas Moniz, Instituto Universitário Egas Moniz, Caparica, Portugal
| | - Claudia Palladino
- Research Institute for Medicine, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Inês Bártolo
- Research Institute for Medicine, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Susana Tracana
- Research Institute for Medicine, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Inês Moranguinho
- Research Institute for Medicine, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Paloma Gonçalves
- Research Institute for Medicine, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Rita Mateus
- Research Institute for Medicine, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Rita Calado
- Research Institute for Medicine, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Pedro Borrego
- Research Institute for Medicine, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
| | - Thomas Leitner
- Theoretical Biology and Biophysics Group, Los Alamos National Laboratory, Los Alamos, New Mexico, USA
| | | | - Nuno Taveira
- Research Institute for Medicine, Faculty of Pharmacy, Universidade de Lisboa, Lisbon, Portugal
- Centro de Investigação Interdisciplinar Egas Moniz, Instituto Universitário Egas Moniz, Caparica, Portugal
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Highly Specific Blood-Brain Barrier Transmigrating Single-Domain Antibodies Selected by an In Vivo Phage Display Screening. Pharmaceutics 2021; 13:pharmaceutics13101598. [PMID: 34683891 PMCID: PMC8540410 DOI: 10.3390/pharmaceutics13101598] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/09/2021] [Accepted: 09/24/2021] [Indexed: 01/27/2023] Open
Abstract
A major bottleneck in the successful development of central nervous system (CNS) drugs is the discovery and design of molecules that can cross the blood-brain barrier (BBB). Nano-delivery strategies are a promising approach that take advantage of natural portals of entry into the brain such as monoclonal antibodies (mAbs) targeting endogenous BBB receptors. However, the main selected mAbs rely on targeting broadly expressed receptors, such as the transferrin and insulin receptors, and in selection processes that do not fully mimic the native receptor conformation, leading to mistargeting and a low fraction of the administered dose effectively reaching the brain. Thus, there is an urgent need to identify new BBB receptors and explore novel antibody selection approaches that can allow a more selective delivery into the brain. Considering that in vitro models fail to completely mimic brain structure complexity, we explored an in vivo cell immunization approach to construct a rabbit derived single-domain antibody (sdAb) library towards BBB endothelial cell receptors. The sdAb antibody library was used in an in vivo phage display screening as a functional selection of novel BBB targeting antibodies. Following three rounds of selections, next generation sequencing analysis, in vitro brain endothelial barrier (BEB) model screenings and in vivo biodistribution studies, five potential sdAbs were identified, three of which reaching >0.6% ID/g in the brain. To validate the brain drug delivery proof-of-concept, the most promising sdAb, namely RG3, was conjugated at the surface of liposomes encapsulated with a model drug, the pan-histone deacetylase inhibitor panobinostat (PAN). The translocation efficiency and activity of the conjugate liposome was determined in a dual functional in vitro BEB-glioblastoma model. The RG3 conjugated PAN liposomes enabled an efficient BEB translocation and presented a potent antitumoral activity against LN229 glioblastoma cells without influencing BEB integrity. In conclusion, our in vivo screening approach allowed the selection of highly specific nano-antibody scaffolds with promising properties for brain targeting and drug delivery.
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Marcelino R, Gramacho F, Martin F, Brogueira P, Janeiro N, Afonso C, Badura R, Valadas E, Mansinho K, Caldeira L, Taveira N, Marcelino JM. Antibody response against selected epitopes in the HIV-1 envelope gp41 ectodomain contributes to reduce viral burden in HIV-1 infected patients. Sci Rep 2021; 11:8993. [PMID: 33903642 PMCID: PMC8076315 DOI: 10.1038/s41598-021-88274-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 04/09/2021] [Indexed: 01/26/2023] Open
Abstract
The ectodomain of gp41 is the target of potent binding and neutralizing antibodies (NAbs) and is being explored in new strategies for antibody-based HIV vaccines. Previous studies have suggested that the W164A-3S (3S) and EC26-2A4 (EC26) peptides located in the gp41 ectodomain may be potential HIV vaccine candidates. We assessed 3S- and EC26-specific binding antibody responses and related neutralizing activity in a large panel of chronic HIV-1-infected Portuguese individuals on ART. A similar proportion of participants had antibodies binding to 3S (9.6%) and EC26 (9.9%) peptides but the level of reactivity against 3S was significantly higher compared to EC26, except in the rare patients with double peptide reactivity. The higher antigenicity of 3S was unrelated with disease stage, as assessed by CD4+ T cell counts, but it was directly related with plasma viral load. Most patients that were tested (89.9%, N = 268) showed tier 1 neutralizing activity, the potency being inversely associated with plasma viral load. In the subset of patients that were tested for neutralization of tier 2 isolates, neutralization breadth was inversely correlated with plasma viral load and directly correlated with CD4+ T cell counts. These results are consistent with a role for neutralizing antibodies in controlling viral replication and preventing the decline of CD4+ T lymphocytes. Importantly, in patients with 3S-specific antibodies, neutralizing titers were inversely correlated with viral RNA levels and proviral DNA levels. Moreover, patients with 3S and/or EC26-specific antibodies showed a 1.9-fold higher tier 2 neutralization score than patients without antibodies suggesting that 3S and/or EC26-specific antibodies contribute to neutralization breadth and potency in HIV-1 infected patients. Overall, these results suggest that antibodies targeting the S3 and EC26 epitopes may contribute to reduce viral burden and provide further support for the inclusion of 3S and EC26 epitopes in HIV-1 vaccine candidates.
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Affiliation(s)
- Rute Marcelino
- Global Health and Tropical Medicine-GHTM, Instituto de Higiene e Medicina Tropical-IHMT, Universidade Nova de Lisboa-UNL, 1349-008, Lisboa, Portugal.,Instituto de Investigação do Medicamento (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Lisboa, 1649-003, Lisboa, Portugal.,Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz, Monte de Caparica, 2829-511, Monte de Caparica, Portugal
| | - Filipa Gramacho
- Hospital de Santa Maria-HSM, Centro Hospitalar Lisboa Norte-CHLN, E.P.E., Lisboa, 1649-028, Lisboa, Portugal
| | - Francisco Martin
- Instituto de Investigação do Medicamento (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Lisboa, 1649-003, Lisboa, Portugal
| | - Pedro Brogueira
- Serviço de Doenças Infeciosas, Hospital Egas Moniz-HEM, Centro Hospitalar Lisboa Ocidental-CHLO, E.P.E., Lisboa, 1349-019, Lisboa, Portugal
| | - Nuno Janeiro
- Hospital de Santa Maria-HSM, Centro Hospitalar Lisboa Norte-CHLN, E.P.E., Lisboa, 1649-028, Lisboa, Portugal.,Clínica Universitária de Doenças Infeciosas, Faculdade de Medicina, Universidade de Lisboa-UL, Lisboa, 1649-028, Lisboa, Portugal
| | - Claudia Afonso
- Hospital de Santa Maria-HSM, Centro Hospitalar Lisboa Norte-CHLN, E.P.E., Lisboa, 1649-028, Lisboa, Portugal.,Clínica Universitária de Doenças Infeciosas, Faculdade de Medicina, Universidade de Lisboa-UL, Lisboa, 1649-028, Lisboa, Portugal
| | - Robert Badura
- Hospital de Santa Maria-HSM, Centro Hospitalar Lisboa Norte-CHLN, E.P.E., Lisboa, 1649-028, Lisboa, Portugal.,Clínica Universitária de Doenças Infeciosas, Faculdade de Medicina, Universidade de Lisboa-UL, Lisboa, 1649-028, Lisboa, Portugal
| | - Emília Valadas
- Hospital de Santa Maria-HSM, Centro Hospitalar Lisboa Norte-CHLN, E.P.E., Lisboa, 1649-028, Lisboa, Portugal.,Clínica Universitária de Doenças Infeciosas, Faculdade de Medicina, Universidade de Lisboa-UL, Lisboa, 1649-028, Lisboa, Portugal
| | - Kamal Mansinho
- Serviço de Doenças Infeciosas, Hospital Egas Moniz-HEM, Centro Hospitalar Lisboa Ocidental-CHLO, E.P.E., Lisboa, 1349-019, Lisboa, Portugal
| | - Luís Caldeira
- Hospital de Santa Maria-HSM, Centro Hospitalar Lisboa Norte-CHLN, E.P.E., Lisboa, 1649-028, Lisboa, Portugal.,Clínica Universitária de Doenças Infeciosas, Faculdade de Medicina, Universidade de Lisboa-UL, Lisboa, 1649-028, Lisboa, Portugal
| | - Nuno Taveira
- Instituto de Investigação do Medicamento (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Lisboa, 1649-003, Lisboa, Portugal.,Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz, Monte de Caparica, 2829-511, Monte de Caparica, Portugal
| | - José M Marcelino
- Global Health and Tropical Medicine-GHTM, Instituto de Higiene e Medicina Tropical-IHMT, Universidade Nova de Lisboa-UNL, 1349-008, Lisboa, Portugal. .,Instituto de Investigação do Medicamento (iMed.ULisboa), Faculdade de Farmácia, Universidade de Lisboa, Lisboa, 1649-003, Lisboa, Portugal. .,Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Universitário Egas Moniz, Monte de Caparica, 2829-511, Monte de Caparica, Portugal.
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Cianci R, Franza L. Genomic Medicine and Advances in Vaccine Technology and Development in the Developing and Developed World. Vaccines (Basel) 2020; 9:vaccines9010009. [PMID: 33374343 PMCID: PMC7823288 DOI: 10.3390/vaccines9010009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/01/2020] [Indexed: 12/20/2022] Open
Affiliation(s)
- Rossella Cianci
- Internal Medicine, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy
- Correspondence: ; Tel.: +39-06-3015-7597; Fax: +39-06-3550-2775
| | - Laura Franza
- Emergency Medicine, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Roma, Italy;
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