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Gupta AK, Shemer A, Economopoulos V, Talukder M. Diabetic Foot and Fungal Infections: Etiology and Management from a Dermatologic Perspective. J Fungi (Basel) 2024; 10:577. [PMID: 39194903 DOI: 10.3390/jof10080577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Revised: 08/07/2024] [Accepted: 08/13/2024] [Indexed: 08/29/2024] Open
Abstract
Diabetes Mellitus (DM) is a significant global concern. Many diabetic patients will experience complications due to angiopathy, neuropathy, and immune dysfunction, namely diabetic foot ulcers (DFU) and diabetic foot infections (DFI), which can result in lower limb amputation and potentially death. The prevalence of common superficial fungal infections, such as tinea pedis and onychomycosis, can directly increase a diabetic patient's risk of developing both DFU and DFI. In this review article, we discuss the etiology of diabetic foot complications as well as considerations for both screening and management. We also discuss the role of the dermatologist within a multidisciplinary care team in prescribing and managing treatments for tinea pedis and onychomycosis infections within this patient population. We believe that reducing the burden of these fungal infections in the context of the diabetic foot will help reduce DFU and DFI complications and their associated morbidity and mortality.
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Affiliation(s)
- Aditya K Gupta
- Division of Dermatology, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 3H2, Canada
- Mediprobe Research Inc., London, ON N5X 2P1, Canada
| | - Avner Shemer
- Department of Dermatology, Sheba Medical Center, Tel-Hashomer, Ramat-Gan 52621, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Vasiliki Economopoulos
- Mediprobe Research Inc., London, ON N5X 2P1, Canada
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Mesbah Talukder
- Mediprobe Research Inc., London, ON N5X 2P1, Canada
- School of Pharmacy, BRAC University, Dhaka 1212, Bangladesh
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Kottferová L, Molnár L, Major P, Sesztáková E, Kuzyšinová K, Vrabec V, Kottferová J. Hedgehog Dermatophytosis: Understanding Trichophyton erinacei Infection in Pet Hedgehogs and Its Implications for Human Health. J Fungi (Basel) 2023; 9:1132. [PMID: 38132733 PMCID: PMC10744110 DOI: 10.3390/jof9121132] [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: 10/30/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Pet hedgehogs, which are increasingly favoured companions, have garnered attention due to their potential as carriers of zoonotic diseases. These small insectivorous mammals, native to Europe, Asia, and Africa, are commonly kept as pets. The encroachment of humans into hedgehog habitats has brought these animals closer to people, raising concerns about disease transmission. This article reviews the current knowledge regarding zoonotic disease associated with pet hedgehogs, with a particular focus on mycotic infections caused by Trichophyton erinacei. Data from various regions and hedgehog species are synthesised to assess the significance of pet hedgehogs as potential reservoirs and transmitters of zoonotic pathogens. Our study highlights the importance of understanding the health risks associated with pet hedgehogs and underscores the need for continued research to mitigate zoonotic disease transmission from these potentially disease-carrying companions.
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Affiliation(s)
- Lucia Kottferová
- Clinic of Birds, Exotic and Free Living Animals, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia; (L.K.); (L.M.); (E.S.); (K.K.); (V.V.)
| | - Ladislav Molnár
- Clinic of Birds, Exotic and Free Living Animals, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia; (L.K.); (L.M.); (E.S.); (K.K.); (V.V.)
| | - Peter Major
- Clinic of Birds, Exotic and Free Living Animals, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia; (L.K.); (L.M.); (E.S.); (K.K.); (V.V.)
| | - Edina Sesztáková
- Clinic of Birds, Exotic and Free Living Animals, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia; (L.K.); (L.M.); (E.S.); (K.K.); (V.V.)
| | - Katarína Kuzyšinová
- Clinic of Birds, Exotic and Free Living Animals, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia; (L.K.); (L.M.); (E.S.); (K.K.); (V.V.)
| | - Vladimír Vrabec
- Clinic of Birds, Exotic and Free Living Animals, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia; (L.K.); (L.M.); (E.S.); (K.K.); (V.V.)
| | - Jana Kottferová
- Department of Public Veterinary Medicine and Animal Welfare, University of Veterinary Medicine and Pharmacy, Komenského 73, 04181 Košice, Slovakia;
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Falotico JM, Lipner SR. Poor Antifungal Coverage for Onychomycosis in a Cross-Sectional Analysis of Medicaid Formularies. J Am Podiatr Med Assoc 2022; 112:21-221. [PMID: 36251605 DOI: 10.7547/21-221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Onychomycosis is the most common nail disease seen in clinical practice. Medication safety, severity of disease, comorbidities, concomitant medications, patient age, and cost are all important considerations when treating onychomycosis. Because cost may affect treatment decisions, we sought to analyze Medicaid formulary coverage of onychomycosis antifungals. METHODS Public state Medicaid formularies were searched for coverage of US Food and Drug Administration-approved onychomycosis medications and off-label oral fluconazole. Total drug cost for a single great toenail was calculated using the National Average Drug Acquisition Cost. Pearson correlation coefficients were calculated to compare coverage and cost, mycologic cure rate, and complete cure rate. RESULTS Oral terbinafine and off-label fluconazole were widely covered for onychomycosis treatment. There was poor coverage of oral itraconazole and topical ciclopirox, and there was no coverage of topical efinaconazole and tavaborole without step-edits or prior authorization. There was a significant negative correlation between medication coverage and cost (r = -0.758; P = .040). There was no correlation between medication coverage and mycologic (r = 0.548; P = .339) and complete (r = 0.768; P = .130) cure rates. CONCLUSIONS There is poor Medicaid coverage of antifungals for the treatment of onychomycosis, with step-edits and prior authorization based on cost rather than treatment safety and efficacy. We recommend involving podiatrists and dermatologists in developing criteria for insurance approval of onychomycosis treatments.
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Affiliation(s)
| | - Shari R Lipner
- †Department of Dermatology, Weill Cornell Medicine, New York, NY
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Garoufalis MG. Total Dystrophic Onychomycosis Successfully Treated with Efinaconazole Topical Solution in Times of Coronavirus Disease of 2019: A Case Study. J Am Podiatr Med Assoc 2022; 112:21-050. [PMID: 34698843 DOI: 10.7547/21-050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Toenail onychomycosis is a common condition that is equally challenging for podiatrists and patients. This case study documents a 26-year-old woman with bilateral total dystrophic onychomycosis of at least 5 years' duration. She had previously failed to respond to treatment with ciclopirox nail lacquer 8% and, despite hiding her condition with nail polish, was suffering from embarrassment, distress, and low self-esteem. At initial consultation, 100% of both great toenails was affected. After discussion of all treatment options, the patient opted for topical efinaconazole 10% solution, once daily for 48 weeks. Significant improvement was noted at the first (4-week) assessment period. This improvement was maintained through each subsequent virtual consultation, and complete cure was seen at a 30-week follow-up visit. To the author's knowledge, this is the first published report on the use of efinaconazole in total dystrophic onychomycosis. It suggests that the product may be effective in patients with even the most severe and treatment-recalcitrant disease, who are unwilling or unable to tolerate systemic antifungal therapy.
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Affiliation(s)
- Matthew G Garoufalis
- *Professional Foot Care Specialists PC, 5241 S Cicero Ave, Chicago, IL 60632. (E-mail:)
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Segal E, Elad D. Human and Zoonotic Dermatophytoses: Epidemiological Aspects. Front Microbiol 2021; 12:713532. [PMID: 34421872 PMCID: PMC8378940 DOI: 10.3389/fmicb.2021.713532] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/09/2021] [Indexed: 12/30/2022] Open
Abstract
Introduction Dermatophytes are a group of molds characterized by the ability to produce keratinases, thereby carving out for themselves specific ecological niches. Their traditional division into three genera, Trichophyton, Microsporum, and Epidermophyton has been expanded to nine and the species in each genus were modified. Dermatophytes are among the most prevalent causes of human and animal mycoses. Their epidemiology is influenced by various factors. These factors may be evolutive such as the predilected environment of the fungus, namely, humans (anthropophilic), animals (zoophilic), or environment (geophilic), is evolutionary and thus may require centuries to develop. Many other factors, however, result from a variety of causes, affecting the epidemiology of dermatophytoses within a shorter time frame. Objective This review aims at summarizing the factors that have modified the epidemiology of dermatophytoses during the last decades. Results Geographic and climatic conditions, demography such as age and gender, migration, socio-economic conditions, lifestyle, and the environment have had an impact on changes in the epidemiology of dermatophytoses, as have changes in the pattern of human interaction with animals, including pets, farm, and wild animals. A typical example of such changes is the increased prevalence of Trichophyton tonsurans, which spread from Latin America to the United States and subsequently becoming a frequent etiological agent of tinea capitis in Africa, Middle East, and other areas. Conclusion The comprehension of the epidemiology of dermatophytoses has a major bearing on their prevention and treatment. Since it is undergoing continuous changes, periodic assessments of the most recent developments of this topic are required. This article aims at providing such an overview.
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Affiliation(s)
- Esther Segal
- Sackler School of Medicine, Department of Clinical Microbiology and Immunology, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Elad
- Department of Clinical Bacteriology and Mycology, Kimron Veterinary Institute, Bet Dagan, Israel
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Bezemer JM, van der Ende J, Limpens J, de Vries HJC, Schallig HDFH. Safety and efficacy of allylamines in the treatment of cutaneous and mucocutaneous leishmaniasis: A systematic review. PLoS One 2021; 16:e0249628. [PMID: 33826660 PMCID: PMC8026199 DOI: 10.1371/journal.pone.0249628] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 03/22/2021] [Indexed: 12/28/2022] Open
Abstract
Cutaneous and mucocutaneous leishmaniasis affect a million people yearly, leading to skin lesions and potentially disfiguring mucosal disease. Current treatments can have severe side effects. Allylamine drugs, like terbinafine, are safe, including during pregnancy. This review assesses efficacy and safety of allylamines for the treatment of cutaneous and mucocutaneous leishmaniasis. It followed the PRISMA statement for reporting and was preregistered in PROSPERO(CRD4201809068). MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Global Health Library, Web of Science, Google Scholar, and clinical trial registers were searched from their creation to May 24th, 2020. All original human, animal, and in vitro studies concerning allylamines and cutaneous or mucocutaneous leishmaniasis were eligible for inclusion. Comparators—if any—included both placebo or alternative cutaneous or mucocutaneous leishmaniasis treatments. Complete cure, growth inhibition, or adverse events served as outcomes. The search identified 312 publications, of which 22 were included in this systematic review. There were one uncontrolled and two randomised controlled trials. The only well-designed randomised controlled trial that compared the treatment efficacy of oral terbinafine versus intramuscular meglumine antimoniate in 80 Leismania tropica infected patients showed a non-significant lower cure rate for terbinafine vs meglumine antimoniate (38% vs 53%). A meta-analysis could not be performed due to the small number of studies, their heterogeneity, and low quality. This systematic review shows that there is no evidence of efficacy of allylamine monotherapy against cutaneous and mucocutaneous leishmaniasis. Further trials of allylamines should be carefully considered as the outcomes of an adequately designed trial were disappointing and in vitro studies indicate minimal effective concentrations that are not achieved in the skin during standard doses. However, the in vitro synergistic effects of allylamines combined with triazole drugs warrant further exploration.
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Affiliation(s)
- Jacob M. Bezemer
- Experimental Parasitology Unit, Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Fundación Misión Cristiana de Salud, Shell, Pastaza, Ecuador
- * E-mail:
| | - Jacob van der Ende
- Fundación Quina Care Ecuador, Puerto el Carmen de Putumayo, Sucumbíos, Ecuador
| | - Jacqueline Limpens
- Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henry J. C. de Vries
- Department of Dermatology, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk D. F. H. Schallig
- Experimental Parasitology Unit, Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Abstract
INTRODUCTION Onychomycosis is the most common nail disease seen in clinical practice. Treatment options include systemic and topical therapies, as well as devices. Following clinical and mycologic diagnosis, treatment must be individualized, accounting for disease severity, infecting organism(s), comorbidities, patient characteristics and drug/device efficacy. Safety is the most important consideration in choosing the most appropriate therapeutic modality. AREAS COVERED This review covers currently available treatments for onychomycosis, with an emphasis on safety and tolerability. Medications and devices were analyzed for side effects, drug-drug interactions, and safety during pregnancy and breastfeeding. EXPERT OPINION Systemic antifungals offer greater efficacy for onychomycosis treatment but are limited by risks of systemic toxicity and drug-drug interactions. The risk of terbinafine-induced hepatotoxicity is negligible in healthy patients. Systemic therapies, especially azole antifungals, are associated with numerous drug-drug interactions, some of which are life-threatening and fatal. Thus, a detailed medication history is critical before prescribing these medications. Topical antifungals are well tolerated and generally safe, with only potential local side effects. Systemic and topical onychomycosis treatments should not be prescribed during pregnancy and breastfeeding. Laser therapy is likely less effective than systemic and topical therapies, but may be safely used during pregnancy and breastfeeding.
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Affiliation(s)
- Jose W Ricardo
- Department of Dermatology, Weill Cornell Medicine , NY, NY, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine , NY, NY, USA
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8
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Fávero MLD, Bonetti AF, Domingos EL, Tonin FS, Pontarolo R. Oral antifungal therapies for toenail onychomycosis: a systematic review with network meta-analysis toenail mycosis: network meta-analysis. J DERMATOL TREAT 2020; 33:121-130. [PMID: 32043906 DOI: 10.1080/09546634.2020.1729336] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Aim: Toenail fungal infections account for half of all nail disease cases, and a highly negative impact on patient quality of life. Our aim was to compare the efficacy and safety of commercially available oral antifungals for onychomycosis.Methods: A systematic review was performed in PubMed and Scopus. Randomized controlled trials evaluating the effect of oral antifungals on mycological cure, discontinuation and adverse events were included. Network meta-analyses were built for each outcome. Results were reported as odds ratios (OR) with 95% credibility intervals (CrI). Ranking probabilities were calculated by surface under the cumulative ranking analysis (SUCRA).Results: We included 40 trials (n = 9568). Albaconazole 400 mg (OR 0.02 [95% CrI 0.01-0.07] versus placebo), followed by posaconazole 200-400 mg and terbinafine 250-350 mg were considered the best therapies (SUCRA probabilities over 75%). For the networks of discontinuation and individual adverse events, few significant differences among treatments were observed, but itraconazole 400 mg was considered the safest drug (SUCRA around 25%). Albaconazole 400 mg, posaconazole 200-400 mg, and terbinafine 250-350 mg were the most effective therapies for onychomycosis, while itraconazole 400 mg was the safest.Conclusion: The profile of albaconazole and posaconazole compared to current first-line therapies should be further investigated in well-designed trials.
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Affiliation(s)
- Maria L D Fávero
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
| | - Aline F Bonetti
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Eric L Domingos
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Fernanda S Tonin
- Pharmaceutical Sciences Postgraduate Program, Federal University of Paraná, Curitiba, Brazil
| | - Roberto Pontarolo
- Department of Pharmacy, Federal University of Paraná, Curitiba, Brazil
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Ravid A, Michael F, Daniel C, Esther S. Dermatomycoses in the Israeli defense forces—Epidemiological and clinical aspects. Mycoses 2019; 63:65-70. [DOI: 10.1111/myc.13015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 09/19/2019] [Accepted: 10/04/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Armon Ravid
- Clinical Microbiology and Immunology Tel Aviv University Tel Aviv Israel
| | - Frenkel Michael
- Clinical Microbiology and Immunology Tel Aviv University Tel Aviv Israel
| | - Cohen Daniel
- Epidemiology and Preventive Medicine Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel
| | - Segal Esther
- Clinical Microbiology and Immunology Tel Aviv University Tel Aviv Israel
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Dars S, Banwell HA, Matricciani L. The use of urea for the treatment of onychomycosis: a systematic review. J Foot Ankle Res 2019; 12:22. [PMID: 31007722 PMCID: PMC6458736 DOI: 10.1186/s13047-019-0332-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 03/28/2019] [Indexed: 12/24/2022] Open
Abstract
Background Onychomycosis, a fungal infection affecting the nail plate, is a common condition often requiring prolonged treatment regimens, with low success rates. Urea is one treatment option, which is thought to improve the efficacy of topical and oral antifungal agents. Despite a theoretical basis for the use of urea for the treatment of onychomycosis, the evidence-base for this treatment has not been systematically reviewed. Aim The purpose of this study was to conduct a systematic literature review to determine the efficacy and safety of urea as a monotherapy and as adjunct therapy, compared to other treatment regimens for onychomycosis. Method A systematic literature search of ten electronic databases was conducted. Only studies that used microscopy and culture or other validated laboratory-based testing method to confirm the presence of a fungal infection before treatment were included. The outcome measures assessed were efficacy (defined in terms of mycological, clinical and complete cure) and safety (defined as self-reported adverse events). Results The systematic search yielded 560 unique studies for review. Of these, only six were eligible for inclusion. All studies were observed to have methodological concerns, most studies consisted of small sample sizes and were difficult to compare given heterogeneity in outcome measures and follow-up time. Despite this, a trend was observed to suggest that urea, when added to topical or oral antifungal treatment regimens, improved efficacy of the treatment. Conclusion This review suggests that topical urea, as an adjunct to topical and oral antifungal treatment regimens, may improve the efficacy of treatment. However, further research is needed. Electronic supplementary material The online version of this article (10.1186/s13047-019-0332-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S Dars
- 1Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, 5001 Australia.,2International Centre for Allied Health Evidence, School of Health Sciences, University of South Australia, City East, Adelaide, SA 5001 Australia
| | - H A Banwell
- 2International Centre for Allied Health Evidence, School of Health Sciences, University of South Australia, City East, Adelaide, SA 5001 Australia
| | - L Matricciani
- 1Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, 5001 Australia
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Alberdi E, Gómez C. Efficiency of methylene blue-mediated photodynamic therapy vs intense pulsed light in the treatment of onychomycosis in the toenails. PHOTODERMATOLOGY PHOTOIMMUNOLOGY & PHOTOMEDICINE 2018; 35:69-77. [DOI: 10.1111/phpp.12420] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 08/03/2018] [Accepted: 08/14/2018] [Indexed: 12/21/2022]
Affiliation(s)
| | - Clara Gómez
- Instituto de Química Física Rocasolano; Consejo Superior de Investigaciones Científicas (CSIC); Madrid Spain
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In Vitro Human Onychopharmacokinetic and Pharmacodynamic Analyses of ME1111, a New Topical Agent for Onychomycosis. Antimicrob Agents Chemother 2017; 62:AAC.00779-17. [PMID: 29084749 DOI: 10.1128/aac.00779-17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 10/22/2017] [Indexed: 11/20/2022] Open
Abstract
ME1111 is a novel antifungal agent currently under clinical development as a topical onychomycosis treatment. A major challenge in the application of topical onychomycotics is penetration and dissemination of antifungal agent into the infected nail plate and bed. In this study, pharmacokinetic/pharmacodynamic parameters of ME1111 that potentially correlate with clinical efficacy were compared with those of marketed topical onychomycosis antifungal agents: efinaconazole, tavaborole, ciclopirox, and amorolfine. An ME1111 solution and other launched topical formulations were applied to an in vitro dose model for 14 days based on their clinical dose and administration. Drug concentrations in the deep layer of the nail and within the cotton pads beneath the nails were measured using liquid chromatography-tandem mass spectrometry. Concentrations of ME1111 in the nail and cotton pads were much higher than those of efinaconazole, ciclopirox, and amorolfine. Free drug concentrations of ME1111 in deep nail layers and cotton pads were orders of magnitude higher than the MIC90 value against Trichophyton rubrum (n = 30). Unlike other drugs, the in vitro antifungal activity of ME1111 was not affected by 5% human keratin and under a mild acidic condition (pH 5.0). The in vitro antidermatophytic efficacy coefficients (ratio of free drug concentration to MIC90s against T. rubrum) of ME1111, as measured in deep nail layers, were significantly higher than those of efinaconazole, tavaborole, ciclopirox, and amorolfine (P < 0.05). This suggests that ME1111 has excellent permeation of human nails and, consequently, the potential to be an effective topical onychomycosis treatment.
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Kreijkamp‐Kaspers S, Hawke K, Guo L, Kerin G, Bell‐Syer SEM, Magin P, Bell‐Syer SV, van Driel ML. Oral antifungal medication for toenail onychomycosis. Cochrane Database Syst Rev 2017; 7:CD010031. [PMID: 28707751 PMCID: PMC6483327 DOI: 10.1002/14651858.cd010031.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fungal infection of the toenails, also called onychomycosis, is a common problem that causes damage to the nail's structure and physical appearance. For those severely affected, it can interfere with normal daily activities. Treatment is taken orally or applied topically; however, traditionally topical treatments have low success rates due to the nail's physical properties. Oral treatments also appear to have shorter treatment times and better cure rates. Our review will assist those needing to make an evidence-based choice for treatment. OBJECTIVES To assess the effects of oral antifungal treatments for toenail onychomycosis. SEARCH METHODS We searched the following databases up to October 2016: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of included and excluded studies for further references to relevant randomised controlled trials (RCTs). We sought to identify unpublished and ongoing trials by correspondence with authors and by contacting relevant pharmaceutical companies. SELECTION CRITERIA RCTs comparing oral antifungal treatment to placebo or another oral antifungal treatment in participants with toenail onychomycosis, confirmed by one or more positive cultures, direct microscopy of fungal elements, or histological examination of the nail. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 48 studies involving 10,200 participants. Half the studies took place in more than one centre and were conducted in outpatient dermatology settings. The participants mainly had subungual fungal infection of the toenails. Study duration ranged from 4 months to 2 years.We assessed one study as being at low risk of bias in all domains and 18 studies as being at high risk of bias in at least one domain. The most common high-risk domain was 'blinding of personnel and participants'.We found high-quality evidence that terbinafine is more effective than placebo for achieving clinical cure (risk ratio (RR) 6.00, 95% confidence interval (CI) 3.96 to 9.08, 8 studies, 1006 participants) and mycological cure (RR 4.53, 95% CI 2.47 to 8.33, 8 studies, 1006 participants). Adverse events amongst terbinafine-treated participants included gastrointestinal symptoms, infections, and headache, but there was probably no significant difference in their risk between the groups (RR 1.13, 95% CI 0.87 to 1.47, 4 studies, 399 participants, moderate-quality evidence).There was high-quality evidence that azoles were more effective than placebo for achieving clinical cure (RR 22.18, 95% CI 12.63 to 38.95, 9 studies, 3440 participants) and mycological cure (RR 5.86, 95% CI 3.23 to 10.62, 9 studies, 3440 participants). There were slightly more adverse events in the azole group (the most common being headache, flu-like symptoms, and nausea), but the difference was probably not significant (RR 1.04, 95% CI 0.97 to 1.12; 9 studies, 3441 participants, moderate-quality evidence).Terbinafine and azoles may lower the recurrence rate when compared, individually, to placebo (RR 0.05, 95% CI 0.01 to 0.38, 1 study, 35 participants; RR 0.55, 95% CI 0.29 to 1.07, 1 study, 26 participants, respectively; both low-quality evidence).There is moderate-quality evidence that terbinafine was probably more effective than azoles for achieving clinical cure (RR 0.82, 95% CI 0.72 to 0.95, 15 studies, 2168 participants) and mycological cure (RR 0.77, 95% CI 0.68 to 0.88, 17 studies, 2544 participants). There was probably no difference in the risk of adverse events (RR 1.00, 95% CI 0.86 to 1.17; 9 studies, 1762 participants, moderate-quality evidence) between the two groups, and there may be no difference in recurrence rate (RR 1.11, 95% CI 0.68 to 1.79, 5 studies, 282 participants, low-quality evidence). Common adverse events in both groups included headache, viral infection, and nausea.Moderate-quality evidence shows that azoles and griseofulvin probably had similar efficacy for achieving clinical cure (RR 0.94, 95% CI 0.45 to 1.96, 5 studies, 222 participants) and mycological cure (RR 0.87, 95% CI 0.50 to 1.51, 5 studies, 222 participants). However, the risk of adverse events was probably higher in the griseofulvin group (RR 2.41, 95% CI 1.56 to 3.73, 2 studies, 143 participants, moderate-quality evidence), with the most common being gastrointestinal disturbance and allergic reaction (in griseofulvin-treated participants) along with nausea and vomiting (in azole-treated participants). Very low-quality evidence means we are uncertain about this comparison's impact on recurrence rate (RR 4.00, 0.26 to 61.76, 1 study, 7 participants).There is low-quality evidence that terbinafine may be more effective than griseofulvin in terms of clinical cure (RR 0.32, 95% CI 0.14 to 0.72, 4 studies, 270 participants) and mycological cure (RR 0.64, 95% CI 0.46 to 0.90, 5 studies, 465 participants), and griseofulvin was associated with a higher risk of adverse events, although this was based on low-quality evidence (RR 2.09, 95% CI 1.15 to 3.82, 2 studies, 100 participants). Common adverse events included headache and stomach problems (in griseofulvin-treated participants) as well as taste loss and nausea (in terbinafine-treated participants). No studies addressed recurrence rate for this comparison.No study addressed quality of life. AUTHORS' CONCLUSIONS We found high-quality evidence that compared to placebo, terbinafine and azoles are effective treatments for the mycological and clinical cure of onychomycosis, with moderate-quality evidence of excess harm. However, terbinafine probably leads to better cure rates than azoles with the same risk of adverse events (moderate-quality evidence).Azole and griseofulvin were shown to probably have a similar effect on cure, but more adverse events appeared to occur with the latter (moderate-quality evidence). Terbinafine may improve cure and be associated with fewer adverse effects when compared to griseofulvin (low-quality evidence).Only four comparisons assessed recurrence rate: low-quality evidence found that terbinafine or azoles may lower the recurrence rate when compared to placebo, but there may be no difference between them.Only a limited number of studies reported adverse events, and the severity of the events was not taken into account.Overall, the quality of the evidence varied widely from high to very low depending on the outcome and comparison. The main reasons to downgrade evidence were limitations in study design, such as unclear allocation concealment and randomisation as well as lack of blinding.
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Affiliation(s)
- Sanne Kreijkamp‐Kaspers
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - Kate Hawke
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - Linda Guo
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - George Kerin
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
| | - Sally EM Bell‐Syer
- CochraneCochrane Editorial UnitSt Albans House57‐59 HaymarketLondonUKSW1Y 4QX
| | - Parker Magin
- The University of NewcastleDiscipline of General Practice, School of Medicine and Public HealthNewbolds Buiding, University of Newcastle,University DriveNewcastleAustralia2308
| | | | - Mieke L van Driel
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineLevel 8, Health Sciences Building 16/910Royal Brisbane & Women's Hospital ComplexBrisbaneHerston, QueenslandAustralia4029
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14
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Shimamura T, Hasegawa N, Kubota N. [Antifungal Activity of Luliconazole Nail Solution on in vitro and in vivo Onychomycosis Model]. Med Mycol J 2016; 57:J13-8. [PMID: 26936347 DOI: 10.3314/mmj.57.j13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We evaluated luliconazole nail solution, originally generated formulation, for the topical treatment of onychomycosis by two infection models. First, a suspension of Trichophyton mentagrophytes was dropped onto the ventral layer of human nail plate and these nails were set in Franz diffusion cells. After 9-day culture, luliconazole nail solutions (1, 3, and 5%) were applied to the dorsal surface of the nails once a day for 7 days. After application, fungal viability was assessed by measuring the ATP contents of the samples. The dose-dependent efficacy was confirmed, with 3% and 5% luliconazole nail solutions producing significantly lower ATP levels at 7-day treatment. When 3% and 5% luliconazole nail solutions were evaluated in a rabbit model of onychomycosis, both concentrations completely inhibited the recovery of fungi on culture after 4-week treatment. We therefore think these results indicate that 5% luliconazole nail solution is sufficiently potent for treatment of onychomycosis.
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15
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Gilaberte Y, Robres MP, Frías MP, García-Doval I, Rezusta A, Aspiroz C. Methyl aminolevulinate photodynamic therapy for onychomycosis: a multicentre, randomized, controlled clinical trial. J Eur Acad Dermatol Venereol 2016; 31:347-354. [PMID: 27515478 DOI: 10.1111/jdv.13842] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/12/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Onychomycosis is a common fungal nail infection that responds poorly to antifungals. OBJECTIVE To investigate the efficacy and safety of methyl aminolevulinate (MAL) photodynamic therapy (PDT) in the treatment of onychomycosis. METHODS A multicentre (3), randomized, placebo-controlled clinical trial compared the effects of three sessions of urea (40%) plus conventional MAL-PDT with urea (40%) plus placebo (red light) photodynamic therapy (pPDT) in onychomycosis patients. Efficacy, both clinical (onychomycosis severity index, OSI) and microbiological, was blindly evaluated after 36 weeks of follow-up. RESULTS Forty patients were analysed in the trial. Twenty-two received MAL-PDT and 18 pPDT. A complete response (OSI = 0) was observed for four patients (18.18%) in the MAL-PDT group and one (5.56%) in the pPDT group (NTT 7.92, 95% CI: 2.98-9.69, P = 0.23). A decrease in OSI score of over 75% (OSI75) was achieved by 40.91% of the patients in the MAL-PDT group and 16.67% in the pPDT group (P = 0.096). Microbiological cure was achieved by seven patients (31.82%) in the MAL-PDT group and two (11.11%) in the pPDT group (P = 0.178). MAL-PDT resulted in better rates of clinical response [OSI >75%: 53.85% vs. 18.75% (P =0.048)] and microbiological cure [41.56% vs. 7.14% (P = 0.037)] in non-dystrophic vs. dystrophic onychomycosis patients. No significant side-effects were reported. The limitations of the study were the reduced sample size and the unexpected efficacy of the control treatment, which was attributed to the 40% urea pre-treatment. CONCLUSION This study did not show significant differences between urea 40% + MAL-PDT and urea 40% + pPDT in the treatment of onychomycosis. However, some results suggest that this treatment may constitute an alternative for dermatophyte and non-dermatophyte mould onychomycosis in patients not eligible for systemic treatment, particularly in the absence of total nail dystrophy.
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Affiliation(s)
- Y Gilaberte
- Department of Dermatology, San Jorge Hospital, Huesca, Spain.,Aragón Institute of Health Science, Zaragoza, Spain
| | - M P Robres
- Department of Microbiology, Royo Villanova Hospital, Zaragoza, Spain
| | - M P Frías
- Department of Dermatology, San Jorge Hospital, Huesca, Spain
| | - I García-Doval
- Research Unit, Spanish Academy of Dermatology and Venereology Foundation, Madrid, Spain
| | - A Rezusta
- Department of Microbiology, Miguel Servet University Hospital, Zaragoza, Spain.,IIS Aragón, Zaragoza, Spain
| | - C Aspiroz
- Aragón Institute of Health Science, Zaragoza, Spain.,Department of Microbiology, Royo Villanova Hospital, Zaragoza, Spain
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16
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Shimamura T, Miyamae A, Imai A, Hirayanagi K, Iwanaga T, Kubota N, Shibuya K. Comparison of Characteristics of Two Topical Therapeutic Agents for Onychomycosis. Med Mycol J 2016; 57:J141-J147. [DOI: 10.3314/mmj.16-00020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
| | | | - Ami Imai
- R&D Laboratories, POLA PHARMA INC
| | | | | | | | - Kazutoshi Shibuya
- Department of Surgical Pathology, Toho University School of Medicine
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17
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Shimamura T, Miyamae A, Arai M, Minemura A, Nozawa A, Kubota N. Distribution of Luliconazole in Nail Plate by In Vitro Permeation and Efficacy by Zone of Inhibition Test after Treatment of Luliconazole Nail Solution. Med Mycol J 2016; 57:J19-25. [DOI: 10.3314/mmj.57.j19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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Gupta AK, Daigle D, Foley KA. Network Meta-Analysis of Onychomycosis Treatments. Skin Appendage Disord 2015; 1:74-81. [PMID: 27170937 DOI: 10.1159/000433473] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 05/19/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Many onychomycosis treatments have not been directly compared in head-to-head clinical trials. OBJECTIVE To determine the relative efficacy of onychomycosis treatments using network meta-analysis (NMA). METHODS We conducted a systematic review and NMA of mycological cure rates. RESULTS Nineteen trials were included in the network. Terbinafine 250 mg was significantly superior to all treatments except itraconazole 400 mg pulse therapy. The itraconazole 400 mg pulse regimen was significantly superior to all topicals except efinaconazole 10% nail solution. Itraconazole 200 mg was significantly superior to all topical treatments, while fluconazole 150-450 mg, efinaconazole 10% nail solution, tavaborole 5% nail solution, ciclopirox nail lacquer 8%, terbinafine nail solution, and amorolfine 5% nail lacquer were significantly superior to placebo. CONCLUSIONS Newly developed topicals have improved the odds ratios (ORs) of mycological cure, yet these ORs were not significantly greater than preexisting topical treatments. Further experience with these agents will reveal their clinical significance, and head-to-head trials are warranted. © 2015 S. Karger AG, Basel.
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Affiliation(s)
- Aditya K Gupta
- Department of Medicine, University of Toronto, Toronto, Ont., Canada; Mediprobe Research Inc., London, Ont., Canada
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19
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Campione E, Paternò EJ, Costanza G, Diluvio L, Carboni I, Marino D, Favalli C, Chimenti S, Bianchi L, Orlandi A. Tazarotene as alternative topical treatment for onychomycosis. DRUG DESIGN DEVELOPMENT AND THERAPY 2015; 9:879-86. [PMID: 25733808 PMCID: PMC4338256 DOI: 10.2147/dddt.s69946] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Distal and lateral onychomycoses are the most frequent forms of onychomycosis, causing subungual hyperkeratosis that usually limits local penetration of antimycotic drugs. Tazarotene exerts anti-inflammatory and immune-modulating activities toward both infective agents and damaged keratinocytes. Given the well-documented efficacy of tazarotene on hyperkeratotic nail psoriasis, we investigated its therapeutic use in onychomycosis. Patients and methods We designed a preliminary open clinical trial in patients affected by distal and lateral subungual onychomycosis of the toenails and verified the fungistatic activity of tazarotene in vitro. Fifteen patients were treated with topical tazarotene 0.1% gel once per day for 12 weeks. Mycological cultures and potassium hydroxide stains of nail samples were performed at the beginning and at the end of the study. Treatment was considered effective when clinical healing and negative mycological culture were obtained. Onycholysis, nail bed discoloration, and subungual hyperkeratosis were measured using standardized methodologies and analyzed by means of Mann–Whitney test and analysis of variance. Fungistatic activity of tazarotene was evaluated by disk diffusion assay. Results Six patients (40%) reached a mycological cure on target nail samples already after 4 weeks of treatment. Complete clinical healing and negative cultures were reached in all patients at week 12, with a significant improvement of all clinical parameters of the infected nails. Disk diffusion assay after 48 hours of incubation with tazarotene solution showed a central area of inhibition in all examined fungal cultures. Conclusion Our results documented a good clinical outcome using topical tazarotene 0.1% gel in distal and lateral subungual onychomycosis and its fungistatic activity of tazarotene in vitro. The majority of patients appeared cured at a 6-month follow-up. The efficacy and safety of tazarotene must be confirmed on a larger number of patients, although already documented in nail psoriasis patients often affected by onychomycosis.
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Affiliation(s)
- Elena Campione
- Department of Dermatology, Policlinic Tor Vergata, Rome, Italy
| | | | - Gaetana Costanza
- Department of Biomedicine and Prevention, Policlinic Tor Vergata, Rome, Italy ; Department of Anatomic Pathology, Policlinic Tor Vergata, Rome, Italy
| | - Laura Diluvio
- Department of Dermatology, Policlinic Tor Vergata, Rome, Italy
| | | | - Daniele Marino
- Department of Microbiology, University of Rome Tor Vergata, Rome, Italy
| | - Cartesio Favalli
- Department of Microbiology, University of Rome Tor Vergata, Rome, Italy
| | - Sergio Chimenti
- Department of Dermatology, Policlinic Tor Vergata, Rome, Italy
| | - Luca Bianchi
- Department of Dermatology, Policlinic Tor Vergata, Rome, Italy
| | - Augusto Orlandi
- Department of Biomedicine and Prevention, Policlinic Tor Vergata, Rome, Italy ; Department of Anatomic Pathology, Policlinic Tor Vergata, Rome, Italy
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20
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Segal R, Shemer A, Hochberg M, Keness Y, Shvarzman R, Mandelblat M, Frenkel M, Segal E. Onychomycosis in Israel: epidemiological aspects. Mycoses 2015; 58:133-9. [DOI: 10.1111/myc.12287] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 11/27/2014] [Accepted: 12/05/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Rina Segal
- Outpatient Dermatology Clinic; Rabin Medical Center; Petah Tikva Israel
| | - Avner Shemer
- Outpatient Dermatology Clinic; Sheba Medical Center; Tel HaShomer Israel
| | - Malca Hochberg
- Outpatient Dermatology Clinic; Hadassa Medical Center; Jerusalem Israel
| | - Yoram Keness
- Clinical Microbiology Laboratory & Outpatient Dermatology Clinic; Emek Medical Center; Afula Israel
| | - Rima Shvarzman
- Central Laboratories Kupat Holim Leumit; Petah Tikva Israel
| | | | - Michael Frenkel
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
| | - Esther Segal
- Sackler School of Medicine; Tel Aviv University; Tel Aviv Israel
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