1
|
Abdelhak A, Antweiler K, Kowarik MC, Senel M, Havla J, Zettl UK, Kleiter I, Skripuletz T, Haarmann A, Stahmann A, Huss A, Gingele S, Krumbholz M, Benkert P, Kuhle J, Friede T, Ludolph AC, Ziemann U, Kümpfel T, Tumani H. Serum glial fibrillary acidic protein and disability progression in progressive multiple sclerosis. Ann Clin Transl Neurol 2024; 11:477-485. [PMID: 38111972 PMCID: PMC10863922 DOI: 10.1002/acn3.51969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/29/2023] [Accepted: 11/21/2023] [Indexed: 12/20/2023] Open
Abstract
OBJECTIVE Progression prediction is a significant unmet need in people with progressive multiple sclerosis (pwPMS). Studies on glial fibrillary acidic protein (GFAP) have either been limited to single center with relapsing MS or were based solely on Expanded Disability Status Scale (EDSS), which limits its generalizability to state-of-the-art clinical settings and trials applying combined outcome parameters. METHODS Serum GFAP and NfL (neurofilament light chain) were investigated in EmBioProMS participants with primary (PP) or secondary progressive MS. Six months confirmed disability progression (CDP) was defined using combined outcome parameters (EDSS, timed-25-foot walk test (T25FW), and nine-hole-peg-test (9HPT)). RESULTS 243 subjects (135 PPMS, 108 SPMS, age 55.5, IQR [49.7-61.2], 135 female, median follow-up: 29.3 months [17.9-40.9]) were included. NfL (age-) and GFAP (age- and sex-) adjusted Z scores were higher in pwPMS compared to HC (p < 0.001 for both). 111 (32.8%) CDP events were diagnosed in participants with ≥3 visits (n = 169). GFAP Z score >3 was associated with higher risk for CDP in participants with low NfL Z score (i.e., ≤1.0) (HR: 2.38 [1.12-5.08], p = 0.025). In PPMS, GFAP Z score >3 was associated with higher risk for CDP (HR: 2.88 [1.21-6.84], p = 0.016). Risk was further increased in PPMS subjects with high GFAP when NfL is low (HR: 4.31 [1.53-12.13], p = 0.006). INTERPRETATION Blood GFAP may help identify pwPPMS at risk of progression. Combination of high GFAP and low NfL levels could distinguish non-active pwPMS with particularly high progression risk.
Collapse
Affiliation(s)
- Ahmed Abdelhak
- Department of NeurologyUniversity of California San Francisco (UCSF)San FranciscoCaliforniaUSA
- Department of NeurologyUniversity Hospital of UlmUlmGermany
| | - Kai Antweiler
- Department of Medical StatisticsUniversity Medical Centre GöttingenGöttingenGermany
| | - Markus C. Kowarik
- Department of Neurology and StrokeUniversity Hospital of TübingenTübingenGermany
- Hertie Institute for Clinical Brain ResearchUniversity of TübingenTübingenGermany
| | - Makbule Senel
- Department of NeurologyUniversity Hospital of UlmUlmGermany
| | - Joachim Havla
- Institute of Clinical Neuroimmunology, LMU HospitalLudwig‐Maximilians UniversityMunichGermany
| | - Uwe K. Zettl
- Department of Neurology, Neuroimmunological SectionUniversity of RostockRostockGermany
| | - Ingo Kleiter
- Marianne‐Strauß‐KlinikBehandlungszentrum Kempfenhausen für Multiple Sklerose Kranke gGmbHBergGermany
| | | | - Axel Haarmann
- Department of NeurologyUniversity Hospital WürzburgWürzburgGermany
| | - Alexander Stahmann
- Forschungs‐ und Projektentwicklungs‐gGmbHMS‐Registry by the German MS‐SocietyHanoverGermany
| | - Andre Huss
- Department of NeurologyUniversity Hospital of UlmUlmGermany
| | - Stefan Gingele
- Department of NeurologyHannover Medical SchoolHanoverGermany
| | - Markus Krumbholz
- Department of Neurology and StrokeUniversity Hospital of TübingenTübingenGermany
- Hertie Institute for Clinical Brain ResearchUniversity of TübingenTübingenGermany
- Department of Neurology and Pain Treatment, Multiple Sclerosis Center, Center for Translational Medicine, Immanuel Klinik RüdersdorfUniversity Hospital of the Brandenburg Medical School Theodor FontaneRüdersdorf bei BerlinGermany
- Faculty of Health Sciences BrandenburgBrandenburg Medical School Theodor FontaneRüdersdorf bei BerlinGermany
| | - Pascal Benkert
- Multiple Sclerosis Centre and Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Department of BiomedicineUniversity Hospital and University of BaselBaselSwitzerland
- Multiple Sclerosis Centre and Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Department of Clinical ResearchUniversity Hospital and University of BaselBaselSwitzerland
- Department of NeurologyUniversity Hospital and University of BaselBaselSwitzerland
| | - Jens Kuhle
- Multiple Sclerosis Centre and Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Department of BiomedicineUniversity Hospital and University of BaselBaselSwitzerland
- Multiple Sclerosis Centre and Research Center for Clinical Neuroimmunology and Neuroscience (RC2NB), Department of Clinical ResearchUniversity Hospital and University of BaselBaselSwitzerland
- Department of NeurologyUniversity Hospital and University of BaselBaselSwitzerland
| | - Tim Friede
- Department of Medical StatisticsUniversity Medical Centre GöttingenGöttingenGermany
| | - Albert C. Ludolph
- Department of NeurologyUniversity Hospital of UlmUlmGermany
- German Center for Neurodegenerative DiseasesUlmGermany
| | - Ulf Ziemann
- Department of Neurology and StrokeUniversity Hospital of TübingenTübingenGermany
- Hertie Institute for Clinical Brain ResearchUniversity of TübingenTübingenGermany
| | - Tania Kümpfel
- Institute of Clinical Neuroimmunology, LMU HospitalLudwig‐Maximilians UniversityMunichGermany
| | | |
Collapse
|
2
|
Rosenkranz SC, Ploughman M, Hvid LG, Zimmer P, Erickson K, Stellmann JP, Centonze D, Friese MA. The MoxFo initiative-Mechanisms of action: Biomarkers in multiple sclerosis exercise studies. Mult Scler 2023; 29:1569-1577. [PMID: 37880953 PMCID: PMC10637103 DOI: 10.1177/13524585231204453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/25/2023] [Accepted: 02/15/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND As exercise exerts neurobiological and immunomodulatory effects, it might also act as a disease-modifying intervention in MS. However, a clear mechanistic link between exercise and disease-modifying effects in MS has yet to be established. OBJECTIVE Establish recommendations for future mechanistic exercise studies in MS. METHODS In regular meetings, members of the mechanisms of action group within the MoXFo (Moving eXercise research Forward in MS) initiative evaluated gaps of knowledge and discussed unmet needs in mechanistic MS research. RESULTS We concluded that biomarkers assessed in translational studies in humans and animals are essential to decipher the underlying mechanisms of exercise in MS. Consequently, we defined clear definitions of different types of biomarkers examined in MS exercise studies and operationalized their use to align with the research question and optimal testing time points. Furthermore, we provide key considerations to improve the rigor of translational studies and defined minimal reporting criteria for animal studies. CONCLUSION The resulting recommendations are intended to improve the quality of future mechanistic exercise studies in MS and consequently lead to a better understanding of therapeutic approaches.
Collapse
Affiliation(s)
- Sina C Rosenkranz
- Institute of Neuroimmunology and Multiple Sclerosis, Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michelle Ploughman
- Recovery & Performance Laboratory, Faculty of Medicine, Memorial University, St. John’s, NL, Canada
| | - Lars G Hvid
- Exercise Biology, Department of Public Health, Aarhus University, Aarhus, Denmark
- The Danish MS Hospitals in Ry and Haslev, Haslev, Denmark
| | - P. Zimmer
- Division of Performance and Health (Sports Medicine) Institute for Sport and Sport Science TU Dortmund University, Germany
| | - K. Erickson
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
- AdventHealth Research Institute, Neuroscience, Orlando, FL, USA
- PROFITH “PROmoting FITness and Health Through Physical Activity” Research Group, Sport and Health University Research Institute (iMUDS), Department of Physical and Sports Education, Faculty of Sport Sciences, University of Granada, Granada, Spain
| | - Jan-Patrick Stellmann
- Institute of Neuroimmunology and Multiple Sclerosis, Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- APHM, Hopital de la Timone, CEMEREM, Marseille, France
- Aix Marseille University, CNRS, CRMBM, UMR, Marseille, France
| | - Diego Centonze
- Department of Systems Medicine, Tor Vergata University, Rome, Italy
- Unit of Neurology and Neurorehabilitation, IRCCS Neuromed, Pozzilli, Italy
| | - Manuel A Friese
- Institute of Neuroimmunology and Multiple Sclerosis, Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
3
|
Chien C, Seiler M, Eitel F, Schmitz-Hübsch T, Paul F, Ritter K. Prediction of high and low disease activity in early MS patients using multiple kernel learning identifies importance of lateral ventricle intensity. Mult Scler J Exp Transl Clin 2022; 8:20552173221109770. [PMID: 35815061 PMCID: PMC9260586 DOI: 10.1177/20552173221109770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 06/10/2022] [Indexed: 11/15/2022] Open
Abstract
Background Lack of easy-to-interpret disease activity prediction methods in early MS can lead to worse patient prognosis. Objectives Using machine learning (multiple kernel learning – MKL) models, we assessed the prognostic value of various clinical and MRI measures for disease activity. Methods Early MS patients ( n = 148) with at least two associated clinical and MRI visits were investigated. T2-weighted MRIs were cropped to contain mainly the lateral ventricles (LV). High disease activity was defined as surpassing NEDA-3 Criteria more than once per year. Clinical demographic, MRI-extracted image-derived phenotypes (IDP), and MRI data were used as inputs for separate kernels to predict future disease activity with MKL. Model performance was compared using bootstrapped effect size analysis of mean differences. Results A total of 681 visits were included, where 81 (55%) patients had high disease activity in a combined end point measure using all follow-up visits. MKL model discrimination performance was moderate (AUC ≥ 0.62); however, modelling with combined clinical and cropped LV kernels gave the highest prediction performance (AUC = 0.70). Conclusions MRIs contain valuable information on future disease activity, especially in and around the LV. MKL techniques for combining different data types can be used for the prediction of disease activity in a relatively small MS cohort.
Collapse
Affiliation(s)
- Claudia Chien
- Claudia Chien,
Charité-Universitätsmedizin Berlin, NeuroCure Clinical Research Center,
Charitéplatz 1, 10117 Berlin, Germany.
| | | | - Fabian Eitel
- Charité – Universitätsmedizin Berlin, corporate
member of Freie Universität Berlin and Humboldt-Universität zu Berlin,
Department of Psychiatry and Neurosciences, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate
member of Freie Universität Berlin and Humboldt-Universität zu Berlin,
Bernstein Center for Computational Neuroscience, Berlin Center for Advanced
Neuroimaging, Berlin, Germany
| | - Tanja Schmitz-Hübsch
- Charité – Universitätsmedizin Berlin, corporate
member of Freie Universität Berlin and Humboldt-Universität zu Berlin, ECRC
Experimental and Clinical Research Center, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate
member of Freie Universität Berlin and Humboldt-Universität zu Berlin,
NeuroCure Clinical Research Center, Berlin, Germany
| | - Friedemann Paul
- Charité – Universitätsmedizin Berlin, corporate
member of Freie Universität Berlin and Humboldt-Universität zu Berlin, ECRC
Experimental and Clinical Research Center, Berlin, Germany
- Charité – Universitätsmedizin Berlin, corporate
member of Freie Universität Berlin and Humboldt-Universität zu Berlin,
NeuroCure Clinical Research Center, Berlin, Germany
- Charité – Universitätsmedizin Berlin,
corporate member of Freie Universität Berlin and Humboldt-Universität zu
Berlin, Department of Neurology, Berlin, Germany
| | - Kerstin Ritter
- Charité – Universitätsmedizin Berlin,
corporate member of Freie Universität Berlin and Humboldt-Universität zu
Berlin, Department of Psychiatry and Neurosciences, Berlin, Germany
- Charité – Universitätsmedizin Berlin,
corporate member of Freie Universität Berlin and Humboldt-Universität zu
Berlin, Bernstein Center for Computational Neuroscience, Berlin Center for
Advanced Neuroimaging, Berlin, Germany
| |
Collapse
|
4
|
Frahm N, Fneish F, Ellenberger D, Flachenecker P, Paul F, Warnke C, Kleinschnitz C, Parciak T, Krefting D, Hellwig K, Haas J, Rommer PS, Stahmann A, Zettl UK. Therapy Switches in Fingolimod-Treated Patients with Multiple Sclerosis: Long-Term Experience from the German MS Registry. Neurol Ther 2022; 11:319-336. [PMID: 35020157 PMCID: PMC8857375 DOI: 10.1007/s40120-021-00320-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTIONS Therapy switches in patients with multiple sclerosis (MS) receiving treatment with fingolimod occur frequently in clinical practice but are not well represented in real-world data. The aim of this study was to identify and characterize treatment switches and reveal sociodemographic/clinical changes over time in fingolimod-treated people with MS (PwMS). METHODS Data on 2536 fingolimod-treated PwMS extracted from the German MS Registry during different time periods were analyzed (2010-2019). RESULTS Overall, 28.3% of PwMS were treatment-naïve before fingolimod initiation. Interferon beta (30.7%) was the most common pre-fingolimod treatment. Ocrelizumab (19.8%) was the most frequent subsequent treatment in the 944 patients on fingolimod who switched. Between 2010 and 2019, median disease duration at fingolimod initiation decreased from 8.5 to 7.1 years (p < 0.001), and patients taking fingolimod for ≥ 1 year after treatment initiation decreased from 89.6 to 80.5% (p < 0.001). Females (p < 0.001) and young patients (p = 0.003) showed a shorter time on fingolimod. The most frequent reason for switching was disease activity (relapse/MRI) despite treatment. The annualized relapse rate increased from 0.37 in patients on fingolimod to 0.47 after treatment cessation, decreasing to 0.19 after treatment with a subsequent disease-modifying drug (DMD) was initiated. CONCLUSION Treatment switches from fingolimod to subsequent DMDs currently occur after shorter treatment durations than 10 years ago, possibly due to the growing treatment spectrum. Planning adequate washout periods is essential and should be done on an individualized basis.
Collapse
Affiliation(s)
- Niklas Frahm
- MS Forschungs- Und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, 30171 Hannover, Germany
- Neuroimmunological Section, Department of Neurology, University Medical Center of Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany
| | - Firas Fneish
- MS Forschungs- Und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, 30171 Hannover, Germany
| | - David Ellenberger
- MS Forschungs- Und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, 30171 Hannover, Germany
| | - Peter Flachenecker
- Neurological Rehabilitation Center Quellenhof, Kuranlagenallee 2, 75323 Bad Wildbad, Germany
| | - Friedemann Paul
- Experimental and Clinical Research Center, Max Delbrueck Center for Molecular Medicine and Charité–Universitätsmedizin Berlin, Lindenberger Weg 80, 13125 Berlin, Germany
| | - Clemens Warnke
- Department of Neurology, Medical Faculty, University Hospital of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center of Translational and Behavioral Neurosciences (C-TNBS), University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Tina Parciak
- Department of Medical Informatics, University Medical Center Göttingen, Von-Siebold-Str. 3, 37075 Göttingen, Germany
| | - Dagmar Krefting
- Department of Medical Informatics, University Medical Center Göttingen, Von-Siebold-Str. 3, 37075 Göttingen, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Joseph and St. Elisabeth Hospital–Ruhr University, Gudrunstr. 56, 44791 Bochum, Germany
| | - Judith Haas
- Deutsche Multiple Sklerose Gesellschaft, Bundesverband e.V. (German Multiple Sclerosis Society [DMSG], Federal Association), Krausenstr. 50, 30171 Hannover, Germany
| | - Paulus S. Rommer
- Neuroimmunological Section, Department of Neurology, University Medical Center of Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18–20, 1090 Vienna, Austria
| | - Alexander Stahmann
- MS Forschungs- Und Projektentwicklungs-gGmbH (MS Research and Project Development gGmbH [MSFP]), Krausenstr. 50, 30171 Hannover, Germany
| | - Uwe K. Zettl
- Neuroimmunological Section, Department of Neurology, University Medical Center of Rostock, Gehlsheimer Str. 20, 18147 Rostock, Germany
| |
Collapse
|
5
|
Carroccio A, Mansueto P, Soresi M, Fayer F, Di Liberto D, Monguzzi E, Lo Pizzo M, La Blasca F, Geraci G, Pecoraro A, Dieli F, Schuppan D. Wheat Consumption Leads to Immune Activation and Symptom Worsening in Patients with Familial Mediterranean Fever: A Pilot Randomized Trial. Nutrients 2020; 12:E1127. [PMID: 32316660 PMCID: PMC7230718 DOI: 10.3390/nu12041127] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 12/15/2022] Open
Abstract
We have identified a clinical association between self-reported non-celiac wheat sensitivity (NCWS) and Familial Mediterranean Fever (FMF). Objectives: A) To determine whether a 2-week double-blind placebo-controlled (DBPC) cross-over wheat vs. rice challenge exacerbates the clinical manifestations of FMF; B) to evaluate innate immune responses in NCWS/FMF patients challenged with wheat vs. rice. The study was conducted at the Department of Internal Medicine of the University Hospital of Palermo and the Hospital of Sciacca, Italy. Six female volunteers with FMF/NCWS (mean age 36 ± 6 years) were enrolled, 12 age-matched non-FMF, NCWS females, and 8 sex- and age-matched healthy subjects served as controls. We evaluated: 1. clinical symptoms by the FMF-specific AIDAI (Auto-Inflammatory Diseases Activity Index) score; 2. serum soluble CD14 (sCD14), C-reactive protein (CRP), and serum amyloid A (SSA); 3. circulating CD14+ monocytes expressing interleukin (IL)-1β and tumor necrosis factor (TNF)-α. The AIDAI score significantly increased in FMF patients during DBPC with wheat, but not with rice (19 ± 6.3 vs. 7 ± 1.6; p = 0.028). sCD14 values did not differ in FMF patients before and after the challenge, but were higher in FMF patients than in healthy controls (median values 11357 vs. 8710 pg/ml; p = 0.002). The percentage of circulating CD14+/IL-1β+ and of CD14+/TNF-α+ monocytes increased significantly after DBPC with wheat vs. baseline or rice challenge. Self-reported NCWS can hide an FMF diagnosis. Wheat ingestion exacerbated clinical and immunological features of FMF. Future studies performed on consecutive FMF patients recruited in centers for auto-inflammatory diseases will determine the real frequency and relevance of this association.
Collapse
Affiliation(s)
- Antonio Carroccio
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90124 Palermo, Italy; (P.M.); (M.S.); (F.F.); (F.L.B.)
| | - Pasquale Mansueto
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90124 Palermo, Italy; (P.M.); (M.S.); (F.F.); (F.L.B.)
| | - Maurizio Soresi
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90124 Palermo, Italy; (P.M.); (M.S.); (F.F.); (F.L.B.)
| | - Francesca Fayer
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90124 Palermo, Italy; (P.M.); (M.S.); (F.F.); (F.L.B.)
| | - Diana Di Liberto
- Central Laboratory of Advanced Diagnosis and Biomedical Research (CLADIBIOR), University of Palermo, 90129 Palermo, Italy; (D.D.L.); (M.L.P.); (F.D.)
| | - Erika Monguzzi
- Institute of Translational Immunology and Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, 55122 Mainz, Germany;
| | - Marianna Lo Pizzo
- Central Laboratory of Advanced Diagnosis and Biomedical Research (CLADIBIOR), University of Palermo, 90129 Palermo, Italy; (D.D.L.); (M.L.P.); (F.D.)
| | - Francesco La Blasca
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90124 Palermo, Italy; (P.M.); (M.S.); (F.F.); (F.L.B.)
| | - Girolamo Geraci
- Surgery Department, University of Palermo, 90129 Palermo, Italy;
| | - Alice Pecoraro
- Hematology Unit for Rare Diseases, Laboratory of Molecular Genetic, Villa Sofia-Cervello, 90146 Palermo, Italy;
| | - Francesco Dieli
- Central Laboratory of Advanced Diagnosis and Biomedical Research (CLADIBIOR), University of Palermo, 90129 Palermo, Italy; (D.D.L.); (M.L.P.); (F.D.)
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (BIND), University of Palermo, 90129 Palermo, Italy
| | - Detlef Schuppan
- Institute of Translational Immunology and Research Center for Immunotherapy, University Medical Center, Johannes Gutenberg University, 55122 Mainz, Germany;
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| |
Collapse
|