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Zhao WJ, Deng JH, Li CF. Lipid profiles in patients with juvenile idiopathic arthritis: a systematic literature review and meta-analysis. Lipids Health Dis 2023; 22:136. [PMID: 37626321 PMCID: PMC10464163 DOI: 10.1186/s12944-023-01885-1] [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: 06/08/2023] [Accepted: 07/27/2023] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVE The purpose of this study was to comprehensively evaluate the lipid profiles in patients with juvenile idiopathic arthritis (JIA). METHODS The literature and relevant reviews were searched for published clinical studies on the relationship between JIA and blood lipid levels. The Newcastle-Ottawa scale (NOS) was applied to evaluate the risk and methodological value of the included case‒control and cohort studies. Standardized mean differences (SMDs) and 95% confidence intervals were derived for all variables with adequate unprocessed data. This meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. RESULTS In total, 16 studies were incorporated through screening. The analysis findings revealed that the levels of very low-density lipoprotein cholesterol [SMD=-0.411, 95% CI (-0.774~-0.048), P = 0.026], high-density lipoprotein cholesterol [SMD=-0.528, 95% CI (-0.976~-0.079), P = 0.021], and apolipoprotein A1 [SMD=-1.050, 95% CI (-1.452~-0.647), P = 0.000] in JIA patients were statistically lower than those observed in healthy controls. The level of low-density lipoprotein cholesterol [SMD = 0.202, 95% CI (0.003 ~ 0.400), P = 0.046] was significantly higher in JIA patients than in healthy controls. In JIA patients, body mass index [SMD=-0.189, 95% CI (-0.690 ~ 0.311), P = 0.459], high-density lipoprotein [SMD =-1.235, 95% CI (-2.845 ~ 0.374), P = 0.133), low-density lipoprotein [SMD = 0.616, 95% CI (-0.813 ~ 2.046), P = 0.398), triglycerides (SMD = 0.278, 95% CI (-0.182 ~ 0.738), P = 0.236], total cholesterol [SMD=-0.073, 95% CI (-0.438 ~ 0.293), P = 0.696] and apolipoprotein B levels [SMD = 0.226, 95% CI (-0.133 ~ 0.585), P = 0.217] were not significantly different from those in healthy controls. CONCLUSIONS The outcomes of this meta-analysis suggest that dyslipidemia is common in JIA patients compared to healthy controls. Patients with JIA have a significantly increased risk of atherosclerosis and cardiovascular disease later in life.
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Affiliation(s)
- Wen-Jia Zhao
- Department of Rheumatology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Nan Li Shi Road No. 56, Beijing, 100045, China
| | - Jiang-Hong Deng
- Department of Rheumatology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Nan Li Shi Road No. 56, Beijing, 100045, China
| | - Cai-Feng Li
- Department of Rheumatology, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Nan Li Shi Road No. 56, Beijing, 100045, China.
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Patra PK, Banday AZ, Asghar A, Nisar R, Das RR, Reddy P, Bhattarai D. Vascular dysfunction in juvenile idiopathic arthritis: a systematic review and meta-analysis. Rheumatol Int 2023; 43:33-45. [PMID: 36469106 DOI: 10.1007/s00296-022-05255-5] [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: 08/13/2022] [Accepted: 11/27/2022] [Indexed: 12/12/2022]
Abstract
We performed a systematic review and meta-analysis of studies evaluating vascular function in patients with JIA. Relevant literature published from 1st January 1965 to 1st March 2022 was searched systematically utilizing PubMed, Web of Science, and Embase databases. Observational studies were included-patients with JIA (classified according to the International League of Associations for Rheumatology criteria) were included as cases (study population) and age/sex-matched healthy participants as controls (comparator group). Outcome measures were differences in non-invasive parameters of vascular function. Online Population, Intervention, Comparison, Outcomes Portal was used for deduplication of studies and data extraction. Review Manager, Comprehensive Meta-analysis, and Meta-Essential softwares were used for data synthesis/analysis (encompassing data pooling and evaluation of heterogeneity and publication bias). Newcastle-Ottawa Scale and GRADEpro GDT software were utilized to assess study quality and certainty of evidence, respectively. Of 338 citations, 17 observational studies with 1423 participants (cases = 757, controls = 666) were included. Carotid intima-media thickness (CIMT) was higher [mean difference (MD) 0.02 mm {95% confidence interval (CI) 0.01-0.04}, p = 0.0006, I2 = 69%] in patients with JIA. Besides, decreased flow-mediated dilatation (FMD) [MD - 2.18% {95%CI - 3.69- - 0.68}, p = 0.004, I2 = 73%] was also observed. Results of studies assessing pulse wave velocity or arterial stiffness could not be pooled due to significant methodological variations. A 'very low' certainty of evidence suggests the presence of vascular dysfunction in JIA. Future longitudinal studies are required to determine whether altered CIMT and FMD in patients with JIA translate to an enhanced risk of (adverse) clinical cardiovascular events. PROSPERO (CRD42022323752).
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Affiliation(s)
- Pratap Kumar Patra
- Department of Pediatrics, Allergy Immunology Unit, All India Institute of Medical Sciences (AIIMS), Patna, 801105, India.
| | - Aaqib Zaffar Banday
- Rheumatology Division, Kashmir Clinics Group, Balgarden, Srinagar, India
- Clinical Immunology and Rheumatology Division, Department of Pediatrics, Khyber Medical Institute, Nowpora, Srinagar, India
| | | | - Rahila Nisar
- Department of Microbiology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, India
| | | | - Pakkiresh Reddy
- Department of Pediatrics, Allergy Immunology Unit, All India Institute of Medical Sciences (AIIMS), Patna, 801105, India
| | - Dharmagat Bhattarai
- Advanced Center for Immunology and Rheumatology, Om Hospital and Research Center, Katmandu, Nepal
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Rodrigues WDR, Sarni ROS, Fonseca FLA, Araújo A, Len CA, Terreri MT. Biomarkers of lipid metabolism in patients with juvenile idiopathic arthritis: relationship with disease subtype and inflammatory activity. Pediatr Rheumatol Online J 2021; 19:66. [PMID: 33941215 PMCID: PMC8091710 DOI: 10.1186/s12969-021-00538-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To describe the biomarkers of lipid metabolism in children and adolescents with polyarticular and systemic JIA and to relate them to diseases subtypes, diseases activity markers, and nutritional status. METHODS A cross-sectional study including 62 JIA patients was performed. The following variables were evaluated: disease activity and medications used, body mass index, height for age (z-score), skin folds (bicipital, tricipital, subscapular and suprailiac), food intake based on three 24-h food recalls, lipid profile (total cholesterol (CT), low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides (TG) and non-HDL (N-HDLc), glycemia and insulin, erythrocyte sedimentation rate (ESR), ultrasensitive C-reactive protein (us-CRP) and apolipoproteins A-I and B (Apo A-I and Apo B). RESULTS Dyslipidemia was observed in 83.3% of the patients. Based on classical lipid profile, low HDL-c levels was the most frequently alteration observed. Inadequate levels of LDL-c, Apo B and NHDL-c were significantly more frequent in the systemic JIA subtype when compared to the polyarticular subtype (p = 0.017, 0.001 and 0.042 respectively). Patients on biological therapy had a better adequacy of Apo A-I concentrations. The ESR showed a negative correlation with Apo A-I level (r = - 0.25, p = 0.047). CONCLUSION We concluded that dyslipidemia is common in patients with JIA, especially in systemic subtype. The systemic subtype and an elevated ESR were associated with lower concentrations of Apo A-I, suggesting the participation of the inflammatory process.
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Affiliation(s)
- Wellington Douglas Rocha Rodrigues
- Department of Pediatrics, Universidade Federal de São Paulo, Rua Borges Lagoa, 802 - Vila Clementino, São Paulo, SP, CEP: 04038-001, Brazil
| | - Roseli Oselka Saccardo Sarni
- Department of Pediatrics, Universidade Federal de São Paulo, Rua Borges Lagoa, 802 - Vila Clementino, São Paulo, SP, CEP: 04038-001, Brazil
| | - Fernando Luiz Affonso Fonseca
- Department of Pediatrics, Universidade Federal de São Paulo, Rua Borges Lagoa, 802 - Vila Clementino, São Paulo, SP, CEP: 04038-001, Brazil
| | - Annelyse Araújo
- Department of Pediatrics, Universidade Federal de São Paulo, Rua Borges Lagoa, 802 - Vila Clementino, São Paulo, SP, CEP: 04038-001, Brazil
| | - Claudio Arnaldo Len
- Department of Pediatrics, Universidade Federal de São Paulo, Rua Borges Lagoa, 802 - Vila Clementino, São Paulo, SP, CEP: 04038-001, Brazil
| | - Maria Teresa Terreri
- Department of Pediatrics, Universidade Federal de São Paulo, Rua Borges Lagoa, 802 - Vila Clementino, São Paulo, SP, CEP: 04038-001, Brazil.
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Adorni MP, Ronda N, Bernini F, Zimetti F. High Density Lipoprotein Cholesterol Efflux Capacity and Atherosclerosis in Cardiovascular Disease: Pathophysiological Aspects and Pharmacological Perspectives. Cells 2021; 10:cells10030574. [PMID: 33807918 PMCID: PMC8002038 DOI: 10.3390/cells10030574] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 02/06/2023] Open
Abstract
Over the years, the relationship between high-density lipoprotein (HDL) and atherosclerosis, initially highlighted by the Framingham study, has been revealed to be extremely complex, due to the multiple HDL functions involved in atheroprotection. Among them, HDL cholesterol efflux capacity (CEC), the ability of HDL to promote cell cholesterol efflux from cells, has emerged as a better predictor of cardiovascular (CV) risk compared to merely plasma HDL-cholesterol (HDL-C) levels. HDL CEC is impaired in many genetic and pathological conditions associated to high CV risk such as dyslipidemia, chronic kidney disease, diabetes, inflammatory and autoimmune diseases, endocrine disorders, etc. The present review describes the current knowledge on HDL CEC modifications in these conditions, focusing on the most recent human studies and on genetic and pathophysiologic aspects. In addition, the most relevant strategies possibly modulating HDL CEC, including lifestyle modifications, as well as nutraceutical and pharmacological interventions, will be discussed. The objective of this review is to help understanding whether, from the current evidence, HDL CEC may be considered as a valid biomarker of CV risk and a potential pharmacological target for novel therapeutic approaches.
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Affiliation(s)
- Maria Pia Adorni
- Unit of Neurosciences, Department of Medicine and Surgery, University of Parma, 43125 Parma, Italy;
| | - Nicoletta Ronda
- Department of Food and Drug, University of Parma, 43124 Parma, Italy; (N.R.); (F.Z.)
| | - Franco Bernini
- Department of Food and Drug, University of Parma, 43124 Parma, Italy; (N.R.); (F.Z.)
- Correspondence:
| | - Francesca Zimetti
- Department of Food and Drug, University of Parma, 43124 Parma, Italy; (N.R.); (F.Z.)
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Aranda-Valera IC, Arias de la Rosa I, Roldán-Molina R, Ábalos-Aguilera MDC, Torres-Granados C, Patiño-Trives A, Luque-Tevar M, Ibáñez-Costa A, Guzmán-Ruiz R, Malagón MDM, Escudero-Contreras A, López-Pedrera C, Collantes-Estévez E, Barbarroja N. Subclinical cardiovascular risk signs in adults with juvenile idiopathic arthritis in sustained remission. Pediatr Rheumatol Online J 2020; 18:59. [PMID: 32665015 PMCID: PMC7362625 DOI: 10.1186/s12969-020-00448-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 07/03/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Juvenile Idiopathic Arthritis (JIA) is one of the most common chronic diseases of childhood that often persists into adulthood and can result in significant long-term morbidity. As a long lasting chronic inflammatory disease, concern has been raised regarding the risk of premature development of cardiovascular disease (CVD) in JIA. This study aims to determine whether adults with JIA in clinical remission display clinical and subclinical signs of CVD risk: inflammatory mediators, adipokines, endothelial dysfunction and oxidative stress markers. METHODS This is a cross-sectional study including 25 patients diagnosed with JIA according to the International League of Associations for Rheumatology criteria (ILAR 2001) and 25 age- and sex-matched controls. Remission was determined by JADAS10 < 1 and according to Wallace criteria. The presence of traditional CVD risk factors was analyzed. An extensive clinical analysis including body mass index (BMI), lipid profile, homeostatic model assessment - insulin resistance (HOMA-IR) and arterial blood pressure was performed. Intima media thickness of the common carotid artery (CIMT) was measured as a marker of subclinical atherosclerosis. Several proinflammatory cytokines, molecules involved in the endothelial dysfunction, oxidative stress and adipokines were quantified on serum by ELISA and on peripheral blood mononuclear cells (PBMCs) by RT-PCR. In vitro studies were carried out in healthy PBMCs, adipocytes and endothelial cells which were treated with serum from JIA patients under sustained remission. RESULTS Mean duration of the disease was 13.47 ± 5.47 years. Mean age was 25.11 ± 7.21. Time in remission was 3.52 ± 3.33 years. Patients were in remission with no treatment (40%) and with treatments (60%). CVD risk factors and CIMT were similar in JIA patients and controls. However, cholesterol levels were significantly elevated in JIA patients. Levels of adipocytokines, oxidative stress and endothelial activation markers were elevated in serum and PBMCs from JIA patients. Serum of those JIA patients induced the activation of adipocytes, endothelial cells and healthy PBMCs. CONCLUSIONS JIA adult patients in remission have subclinical signs of inflammation and CVD risk, showed by an increase in the levels of inflammatory cytokines, endothelial activation and oxidative stress markers and adipokines, molecules closely involved in the alteration of the vascular system.
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Affiliation(s)
| | - Iván Arias de la Rosa
- grid.428865.50000 0004 0445 6160Rheumatology Department, IMIBIC/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain ,grid.428865.50000 0004 0445 6160Medicine Department, University of Cordoba/IMIBIC/Reina Sofía University Hospital, Cordoba, Spain
| | - Rosa Roldán-Molina
- grid.428865.50000 0004 0445 6160Rheumatology Department, IMIBIC/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
| | - María del Carmen Ábalos-Aguilera
- grid.428865.50000 0004 0445 6160Rheumatology Department, IMIBIC/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
| | - Carmen Torres-Granados
- grid.428865.50000 0004 0445 6160Rheumatology Department, IMIBIC/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
| | - Alejandra Patiño-Trives
- grid.428865.50000 0004 0445 6160Rheumatology Department, IMIBIC/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
| | - María Luque-Tevar
- grid.428865.50000 0004 0445 6160Rheumatology Department, IMIBIC/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
| | - Alejandro Ibáñez-Costa
- grid.428865.50000 0004 0445 6160Rheumatology Department, IMIBIC/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
| | - Rocío Guzmán-Ruiz
- grid.411901.c0000 0001 2183 9102Department of Cell Biology, Physiology and Immunology, IMIBIC, Reina Sofía University Hospital, University of Córdoba, Cordoba, Spain
| | - María del Mar Malagón
- grid.411901.c0000 0001 2183 9102Department of Cell Biology, Physiology and Immunology, IMIBIC, Reina Sofía University Hospital, University of Córdoba, Cordoba, Spain ,grid.413448.e0000 0000 9314 1427CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Alejandro Escudero-Contreras
- grid.428865.50000 0004 0445 6160Rheumatology Department, IMIBIC/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
| | - Chary López-Pedrera
- grid.428865.50000 0004 0445 6160Rheumatology Department, IMIBIC/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain
| | - Eduardo Collantes-Estévez
- grid.428865.50000 0004 0445 6160Rheumatology Department, IMIBIC/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain ,grid.428865.50000 0004 0445 6160Medicine Department, University of Cordoba/IMIBIC/Reina Sofía University Hospital, Cordoba, Spain
| | - Nuria Barbarroja
- Rheumatology Department, IMIBIC/Reina Sofía University Hospital/University of Cordoba, Cordoba, Spain. .,Medicine Department, University of Cordoba/IMIBIC/Reina Sofía University Hospital, Cordoba, Spain. .,CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain.
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Duong M, Uno K, Nankivell V, Bursill C, Nicholls SJ. Induction of obesity impairs reverse cholesterol transport in ob/ob mice. PLoS One 2018; 13:e0202102. [PMID: 30216355 PMCID: PMC6138368 DOI: 10.1371/journal.pone.0202102] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 07/27/2018] [Indexed: 11/25/2022] Open
Abstract
Objectives Obesity is an independent risk factor for cardiovascular disease. Reverse cholesterol transport (RCT) is an important cardioprotective mechanism. This study aimed to investigate RCT changes in a murine model of obesity. Methods Ob/ob and control mice were injected with [3H]-cholesterol-labelled macrophages and cholesterol accumulation quantified after 48 h. Ex vivo, cholesterol efflux and uptake were determined in hepatic and adipose tissues. Results Ob/ob mice had more labelled cholesterol in their plasma (86%, p<0.001), suggesting impaired RCT. SR-BI-mediated cholesterol efflux was elevated from ob/ob mice (serum, 33%; apoB-depleted plasma, 14%, p<0.01) and HDL-c were also higher (60%, p<0.01). Ex vivo it was found that cholesterol uptake was significantly lower into the livers and adipose tissue of ob/ob mice, compared to non-obese wildtype controls. Furthermore, ex vivo cholesterol efflux was reduced in ob/ob liver and adipose tissue towards apoA-I and HDL. Consistent with this, protein levels of SR-BI and ABCG1 were significantly lower in ob/ob hepatic and adipose tissue than in wildtype mice. Finally, labelled cholesterol concentrations were lower in ob/ob bile (67%, p<0.01) and faeces (76%, p<0.0001). Conclusion Obesity causes impairment in RCT due to reduced plasma cholesterol uptake and efflux by hepatocytes and adipocytes. A reduction in the capacity for plasma cholesterol clearance may partly account for increased CVD risk with obesity.
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Affiliation(s)
- MyNgan Duong
- Heart Health, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Department of Cell Biology and Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, United States of America
- * E-mail:
| | - Kiyoko Uno
- Department of Cell Biology and Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, United States of America
| | - Victoria Nankivell
- Heart Health, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Christina Bursill
- Heart Health, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Stephen J. Nicholls
- Heart Health, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- Department of Cell Biology and Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, United States of America
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Zimetti F, De Vuono S, Gomaraschi M, Adorni MP, Favari E, Ronda N, Ricci MA, Veglia F, Calabresi L, Lupattelli G. Plasma cholesterol homeostasis, HDL remodeling and function during the acute phase reaction. J Lipid Res 2017; 58:2051-2060. [PMID: 28830907 DOI: 10.1194/jlr.p076463] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 08/19/2017] [Indexed: 12/18/2022] Open
Abstract
Acute phase reaction (APR) is a systemic inflammation triggered by several conditions associated with lipid profile alterations. We evaluated whether APR also associates with changes in cholesterol synthesis and absorption, HDL structure, composition, and cholesterol efflux capacity (CEC). We analyzed 59 subjects with APR related to infections, oncologic causes, or autoimmune diseases and 39 controls. We detected no difference in markers of cholesterol synthesis and absorption. Conversely, a significant reduction of LpA-I- and LpAI:AII-containing HDL (-28% and -44.8%, respectively) and of medium-sized HDL (-10.5%) occurred in APR. Total HDL CEC was impaired in APR subjects (-18%). Evaluating specific CEC pathways, we found significant reductions in CEC by aqueous diffusion and by the transporters scavenger receptor B-I and ABCG1 (-25.5, -41.1 and -30.4%, respectively). ABCA1-mediated CEC was not affected. Analyses adjusted for age and gender provided similar results. In addition, correcting for HDL-cholesterol (HDL-C) levels, the differences in aqueous diffusion total and ABCG1-CEC remained significant. APR subjects displayed higher levels of HDL serum amyloid A (+20-folds; P = 0.003). In conclusion, APR does not associate with cholesterol synthesis and absorption changes but with alterations of HDL composition and a marked impairment of HDL CEC, partly independent of HDL-C serum level reduction.
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Affiliation(s)
| | - Stefano De Vuono
- Department of Medicine, Internal Medicine, "Santa Maria della Misericordia" Hospital, University of Perugia, Perugia, Italy
| | - Monica Gomaraschi
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Centro E. Grossi Paoletti, Università degli Studi di Milano, Milano, Italy
| | | | - Elda Favari
- Department of Food and Drug, University of Parma, Parma, Italy
| | - Nicoletta Ronda
- Department of Food and Drug, University of Parma, Parma, Italy
| | - Maria Anastasia Ricci
- Department of Medicine, Internal Medicine, "Santa Maria della Misericordia" Hospital, University of Perugia, Perugia, Italy
| | | | - Laura Calabresi
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Centro E. Grossi Paoletti, Università degli Studi di Milano, Milano, Italy
| | - Graziana Lupattelli
- Department of Medicine, Internal Medicine, "Santa Maria della Misericordia" Hospital, University of Perugia, Perugia, Italy
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