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Babiloni C, Gentilini Cacciola E, Tucci F, Vassalini P, Chilovi A, Jakhar D, Musat AM, Salvatore M, Soricelli A, Stocchi F, Vacca L, Ferri R, Catania V, Mastroianni C, D'Ettorre G, Noce G. Resting-state EEG rhythms are abnormal in post COVID-19 patients with brain fog without cognitive and affective disorders. Clin Neurophysiol 2024; 161:159-172. [PMID: 38492271 DOI: 10.1016/j.clinph.2024.02.034] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 02/13/2024] [Accepted: 02/29/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVES Several persons experiencing post-covid-19 (post-COVID) with "brain fog" (e.g., fatigue, cognitive and psychiatric disorders, etc.) show abnormal resting-state electroencephalographic (rsEEG) rhythms reflecting a vigilance dysfunction. Here, we tested the hypothesis that in those post-COVID persons, abnormal rsEEG rhythms may occur even when cognitive and psychiatric disorders are absent. METHODS The experiments were performed on post-COVID participants about one year after hospitalization for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Inclusion criteria included a "brain fog" claim, no pre-infection, and actual organic chronic disease. Matched controls (no COVID) were also enrolled. All participants underwent clinical/neuropsychological assessment (including fatigue assessment) and rsEEG recordings. The eLORETA freeware estimated regional rsEEG cortical sources at individual delta (<4 Hz), theta (4-7 Hz), and alpha (8-13 Hz) bands. Beta (14-30 Hz) and gamma (30-40 Hz) bands were pre-fixed. RESULTS More than 90% of all post-COVID participants showed no cognitive or psychiatric disorders, and 75% showed ≥ 2 fatigue symptoms. The post-COVID group globally presented lower posterior rsEEG alpha source activities than the Control group. This effect was more significant in the long COVID-19 patients with ≥ 2 fatigue symptoms. CONCLUSIONS In post-COVID patients with no chronic diseases and cognitive/psychiatric disorders, "brain fog" can be associated with abnormal posterior rsEEG alpha rhythms and subjective fatigue. SIGNIFICANCE These abnormalities may be related to vigilance and allostatic dysfunctions.
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Affiliation(s)
- Claudio Babiloni
- Department of Physiology and Pharmacology "Erspamer," Sapienza University of Rome, Rome, Italy; Hospital San Raffaele Cassino, Cassino, FR, Italy.
| | - Elio Gentilini Cacciola
- Department of Public Health and Infectious Diseases, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Federico Tucci
- Department of Physiology and Pharmacology "Erspamer," Sapienza University of Rome, Rome, Italy
| | - Paolo Vassalini
- Department of Public Health and Infectious Diseases, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Agnese Chilovi
- Department of Public Health and Infectious Diseases, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Dharmendra Jakhar
- Department of Physiology and Pharmacology "Erspamer," Sapienza University of Rome, Rome, Italy
| | - Andreea Maria Musat
- Department of Physiology and Pharmacology "Erspamer," Sapienza University of Rome, Rome, Italy
| | | | - Andrea Soricelli
- IRCCS Synlab SDN, Naples, Italy; Department of Medical, Movement and Wellbeing Sciences, University of Naples Parthenope, Naples, Italy
| | - Fabrizio Stocchi
- IRCCS San Raffaele Rome, Rome, Italy; Telematic University San Raffaele, Rome, Italy
| | | | | | | | - Claudio Mastroianni
- Department of Public Health and Infectious Diseases, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Gabriella D'Ettorre
- Department of Public Health and Infectious Diseases, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
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Babiloni C, Del Percio C, Piervincenzi C, Carducci F, Ferri R, Onorati P, Toma G, Ferracuti S, Roma P, Correr V, Di Campli F, Aceti A, Salvatore M, Soricelli A, Teti E, Pennica A, Sarmati L, Vullo V, D'Ettorre G, Mastroianni C, Petsas N, Pantano P, Floris R, Stocchi F, Andreoni M, Di Perri G, Calcagno A, Noce G. Parietal resting-state EEG alpha source connectivity is associated with subcortical white matter lesions in HIV-positive people. Clin Neurophysiol 2023; 156:19-27. [PMID: 37844524 DOI: 10.1016/j.clinph.2023.09.006] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 08/07/2023] [Accepted: 09/21/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVE Parietal resting-state electroencephalographic (rsEEG) alpha (8-10 Hz) source connectivity is abnormal in HIV-positive persons. Here we tested whether this abnormality may be associated with subcortical white matter vascular lesions in the cerebral hemispheres. METHODS Clinical, rsEEG, and magnetic resonance imaging (MRI) datasets in 38 HIV-positive persons and clinical and rsEEG datasets in 13 healthy controls were analyzed. Radiologists visually evaluated the subcortical white matter hyperintensities from T2-weighted FLAIR MRIs (i.e., Fazekas scale). In parallel, neurophysiologists estimated the eLORETA rsEEG source lagged linear connectivity from parietal cortical regions of interest. RESULTS Compared to the HIV participants with no/negligible subcortical white matter hyperintensities, the HIV participants with mild/moderate subcortical white matter hyperintensities showed lower parietal interhemispheric rsEEG alpha lagged linear connectivity. This effect was also observed in HIV-positive persons with unimpaired cognition. This rsEEG marker allowed good discrimination (area under the receiver operating characteristic curve > 0.80) between the HIV-positive individuals with different amounts of subcortical white matter hyperintensities. CONCLUSIONS The parietal rsEEG alpha source connectivity is associated with subcortical white matter vascular lesions in HIV-positive persons, even without neurocognitive disorders. SIGNIFICANCE Those MRI-rsEEG markers may be used to screen HIV-positive persons at risk of neurocognitive disorders.
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Affiliation(s)
- Claudio Babiloni
- Department of Physiology and Pharmacology "Erspamer", Sapienza University of Rome, Rome, Italy; Hospital San Raffaele Cassino, Cassino, (FR), Italy.
| | - Claudio Del Percio
- Department of Physiology and Pharmacology "Erspamer", Sapienza University of Rome, Rome, Italy
| | | | - Filippo Carducci
- Department of Physiology and Pharmacology "Erspamer", Sapienza University of Rome, Rome, Italy
| | | | - Paolo Onorati
- Department of Physiology and Pharmacology "Erspamer", Sapienza University of Rome, Rome, Italy
| | - Ginevra Toma
- Department of Physiology and Pharmacology "Erspamer", Sapienza University of Rome, Rome, Italy
| | - Stefano Ferracuti
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Paolo Roma
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Valentina Correr
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Francesco Di Campli
- Infectious Diseases, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Antonio Aceti
- Infectious Diseases, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | | | - Andrea Soricelli
- IRCCS Synlab SDN, Naples, Italy; Department of Motor Sciences and Healthiness, University of Naples Parthenope, Naples, Italy
| | - Elisabetta Teti
- Clinical Infectious Diseases, University of Rome "Tor Vergata", Rome, Italy
| | - Alfredo Pennica
- Infectious Diseases, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Loredana Sarmati
- Clinical Infectious Diseases, University of Rome "Tor Vergata", Rome, Italy
| | - Vincenzo Vullo
- Department of Public Health and Infectious Diseases, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Gabriella D'Ettorre
- Department of Public Health and Infectious Diseases, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Claudio Mastroianni
- Department of Public Health and Infectious Diseases, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | | | - Patrizia Pantano
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy; IRCCS NEUROMED, Pozzilli, IS, Italy
| | - Roberto Floris
- Diagnostic and Interventional Radiology, University of Rome "Tor Vergata", Rome, Italy
| | - Fabrizio Stocchi
- IRCCS San Raffaele, Rome, Italy; Telematic University San Raffaele, Rome, Italy
| | - Massimo Andreoni
- Clinical Infectious Diseases, University of Rome "Tor Vergata", Rome, Italy
| | - Giovanni Di Perri
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Turin, Turin, Italy
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Babiloni C, Noce G, Pennica A, Onorati P, Capotosto P, Del Percio C, Roma P, Correr V, Piccinni E, Toma G, Soricelli A, Di Campli F, Gianserra L, Ciullini L, Aceti A, Teti E, Sarmati L, Crocetti G, Ferri R, Catania V, Pascarelli MT, Andreoni M, Ferracuti S. Cortical sources of resting state electroencephalographic rhythms probe brain function in naïve HIV individuals. Clin Neurophysiol 2017; 129:431-441. [PMID: 29304418 DOI: 10.1016/j.clinph.2017.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 10/31/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Here we evaluated the hypothesis that resting state electroencephalographic (EEG) cortical sources correlated with cognitive functions and discriminated asymptomatic treatment-naïve HIV subjects (no AIDS). METHODS EEG, clinical, and neuropsychological data were collected in 103 treatment-naïve HIV subjects (88 males; mean age 39.8 years ± 1.1 standard error of the mean, SE). An age-matched group of 70 cognitively normal and HIV-negative (Healthy; 56 males; 39.0 years ± 2.0 SE) subjects, selected from a local university archive, was used for control purposes. LORETA freeware was used for EEG source estimation in fronto-central, temporal, and parieto-occipital regions of interest. RESULTS Widespread sources of delta (<4 Hz) and alpha (8-12 Hz) rhythms were abnormal in the treatment-naïve HIV group. Fronto-central delta source activity showed a slight but significant (p < 0.05, corrected) negative correlation with verbal and semantic test scores. So did parieto-occipital delta/alpha source ratio with memory and composite cognitive scores. These sources allowed a moderate classification accuracy between HIV and control individuals (area under the ROC curves of 70-75%). CONCLUSIONS Regional EEG abnormalities in quiet wakefulness characterized treatment-naïve HIV subjects at the individual level. SIGNIFICANCE This EEG approach may contribute to the management of treatment-naïve HIV subjects at risk of cognitive deficits.
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Affiliation(s)
- Claudio Babiloni
- Department of Physiology and Pharmacology, University of Rome "La Sapienza", Rome, Italy; Institute for Research and Medical Care, IRCCS San Raffaele Pisana, Rome, Italy.
| | - Giuseppe Noce
- Department of Integrated Imaging, IRCCS SDN, Naples, Italy
| | - Alfredo Pennica
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | - Paolo Onorati
- Department of Physiology and Pharmacology, University of Rome "La Sapienza", Rome, Italy; Institute for Research and Medical Care, IRCCS San Raffaele Pisana, Rome, Italy
| | - Paolo Capotosto
- Department of Neuroscience, Imaging and Clinical Sciences, and ITAB-Institute of Advanced Biomedical Technologies "G. d'Annunzio" University of Chieti and Pescara, Chieti, Italy
| | | | - Paolo Roma
- Department of Neurology and Psychiatry, University of Rome "La Sapienza", Rome, Italy
| | - Valentina Correr
- Department of Neurology and Psychiatry, University of Rome "La Sapienza", Rome, Italy
| | - Elisa Piccinni
- Department of Neurology and Psychiatry, University of Rome "La Sapienza", Rome, Italy
| | - Ginevra Toma
- Department of Physiology and Pharmacology, University of Rome "La Sapienza", Rome, Italy
| | - Andrea Soricelli
- Department of Integrated Imaging, IRCCS SDN, Naples, Italy; Department of Motor Sciences and Healthiness, University of Naples Parthenope, Naples, Italy
| | - Francesco Di Campli
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | - Laura Gianserra
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | - Lorenzo Ciullini
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | - Antonio Aceti
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | - Elisabetta Teti
- Clinical Infectious Diseases, University of Rome "Tor Vergata", Rome, Italy
| | - Loredana Sarmati
- Clinical Infectious Diseases, University of Rome "Tor Vergata", Rome, Italy
| | - Gloria Crocetti
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | - Raffaele Ferri
- Department of Neurology, IRCCS Oasi Institute for Research on Mental Retardation and Brain Aging, Troina, Enna, Italy
| | - Valentina Catania
- Department of Neurology, IRCCS Oasi Institute for Research on Mental Retardation and Brain Aging, Troina, Enna, Italy
| | - Maria Teresa Pascarelli
- Department of Neurology, IRCCS Oasi Institute for Research on Mental Retardation and Brain Aging, Troina, Enna, Italy
| | - Massimo Andreoni
- Clinical Infectious Diseases, University of Rome "Tor Vergata", Rome, Italy
| | - Stefano Ferracuti
- Department of Neurology and Psychiatry, University of Rome "La Sapienza", Rome, Italy
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Babiloni C, Pennica A, Del Percio C, Noce G, Cordone S, Lopez S, Berry K, Muratori C, Ferracuti S, Roma P, Correr V, Di Campli F, Gianserra L, Ciullini L, Aceti A, Soricelli A, Teti E, Viscione M, Limatola C, Onorati P, Capotosto P, Andreoni M. Antiretroviral therapy affects the z-score index of deviant cortical EEG rhythms in naïve HIV individuals. Neuroimage Clin 2016; 12:144-56. [PMID: 27408799 PMCID: PMC4933036 DOI: 10.1016/j.nicl.2016.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 05/12/2016] [Accepted: 06/06/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Here we tested the effect of combined antiretroviral therapy (cART) on deviant electroencephalographic (EEG) source activity in treatment-naïve HIV individuals. METHODS Resting state eyes-closed EEG data were recorded before and after 5 months of cART in 48 male HIV subjects, who were naïve at the study start. The EEG data were also recorded in 59 age- and sex-matched healthy subjects as a control group. Frequency bands of interest included delta, theta, alpha1, alpha2 and alpha3, based on alpha frequency peak specific to each individual. They also included beta1 (13-20 Hz) and beta2 (20-30 Hz). Low-resolution brain electromagnetic tomography (LORETA) estimated EEG cortical source activity in frontal, central, temporal, parietal, and occipital regions. RESULTS Before the therapy, the HIV group showed greater parietal delta source activity and lower spatially diffuse alpha source activity compared to the control group. Thus, the ratio of parietal delta and alpha3 source activity served as an EEG marker. The z-score showed a statistically deviant EEG marker (EEG +) in 50% of the HIV individuals before therapy (p < 0.05). After 5 months of cART, delta source activity decreased, and alpha3 source activity increased in the HIV subjects with EEG + (about 50% of them showed a normalized EEG marker). CONCLUSIONS This procedure detected a deviant EEG marker before therapy and its post-therapy normalization in naïve HIV single individuals. SIGNIFICANCE The parietal delta/alpha3 EEG marker may be used to monitor cART effects on brain function in such individuals.
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Affiliation(s)
- Claudio Babiloni
- Department of Physiology and Pharmacology, University of Rome “La Sapienza”, Rome, Italy
- IRCCS S. Raffaele Pisana, Rome, Italy
| | - Alfredo Pennica
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Rome, Italy
| | | | | | - Susanna Cordone
- Department of Physiology and Pharmacology, University of Rome “La Sapienza”, Rome, Italy
| | - Susanna Lopez
- Department of Physiology and Pharmacology, University of Rome “La Sapienza”, Rome, Italy
| | - Ketura Berry
- Department of Physiology and Pharmacology, University of Rome “La Sapienza”, Rome, Italy
| | | | - Stefano Ferracuti
- Psychiatry, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Rome, Italy
| | - Paolo Roma
- Psychiatry, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Rome, Italy
| | - Valentina Correr
- Psychiatry, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Rome, Italy
| | - Francesco Di Campli
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Rome, Italy
| | - Laura Gianserra
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Rome, Italy
| | - Lorenzo Ciullini
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Rome, Italy
| | - Antonio Aceti
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Rome, Italy
| | - Andrea Soricelli
- IRCCS SDN, Naples, Italy
- Department of Motor Sciences and Healthiness, University of Naples Parthenope, Naples, Italy
| | - Elisabetta Teti
- Clinical Infectious Diseases, University of Rome “Tor Vergata”, Rome, Italy
| | - Magdalena Viscione
- Clinical Infectious Diseases, University of Rome “Tor Vergata”, Rome, Italy
| | - Cristina Limatola
- Department of Physiology and Pharmacology, University of Rome “La Sapienza”, Rome, Italy
| | - Paolo Onorati
- Department of Physiology and Pharmacology, University of Rome “La Sapienza”, Rome, Italy
- IRCCS S. Raffaele Pisana, Rome, Italy
| | | | - Massimo Andreoni
- Clinical Infectious Diseases, University of Rome “Tor Vergata”, Rome, Italy
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Babiloni C, Pennica A, Del Percio C, Noce G, Cordone S, Muratori C, Ferracuti S, Donato N, Di Campli F, Gianserra L, Teti E, Aceti A, Soricelli A, Viscione M, Limatola C, Andreoni M, Onorati P. Abnormal cortical sources of resting state electroencephalographic rhythms in single treatment-naïve HIV individuals: A statistical z-score index. Clin Neurophysiol 2015; 127:1803-12. [PMID: 26762948 DOI: 10.1016/j.clinph.2015.12.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/26/2015] [Accepted: 12/05/2015] [Indexed: 01/06/2023]
Abstract
OBJECTIVE This study tested a simple statistical procedure to recognize single treatment-naïve HIV individuals having abnormal cortical sources of resting state delta (<4 Hz) and alpha (8-13 Hz) electroencephalographic (EEG) rhythms with reference to a control group of sex-, age-, and education-matched healthy individuals. Compared to the HIV individuals with a statistically normal EEG marker, those with abnormal values were expected to show worse cognitive status. METHODS Resting state eyes-closed EEG data were recorded in 82 treatment-naïve HIV (39.8 ys.±1.2 standard error mean, SE) and 59 age-matched cognitively healthy subjects (39 ys.±2.2 SE). Low-resolution brain electromagnetic tomography (LORETA) estimated delta and alpha sources in frontal, central, temporal, parietal, and occipital cortical regions. RESULTS Ratio of the activity of parietal delta and high-frequency alpha sources (EEG marker) showed the maximum difference between the healthy and the treatment-naïve HIV group. Z-score of the EEG marker was statistically abnormal in 47.6% of treatment-naïve HIV individuals with reference to the healthy group (p<0.05). Compared to the HIV individuals with a statistically normal EEG marker, those with abnormal values exhibited lower mini mental state evaluation (MMSE) score, higher CD4 count, and lower viral load (p<0.05). CONCLUSIONS This statistical procedure permitted for the first time to identify single treatment-naïve HIV individuals having abnormal EEG activity. SIGNIFICANCE This procedure might enrich the detection and monitoring of effects of HIV on brain function in single treatment-naïve HIV individuals.
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Affiliation(s)
- Claudio Babiloni
- Department of Physiology and Pharmacology, University of Rome "La Sapienza", Rome, Italy; IRCCS S. Raffaele Pisana, Rome, Italy.
| | - Alfredo Pennica
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | | | | | - Susanna Cordone
- Department of Physiology and Pharmacology, University of Rome "La Sapienza", Rome, Italy
| | | | - Stefano Ferracuti
- Psychiatry, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | - Nicole Donato
- Psychiatry, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | - Francesco Di Campli
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | - Laura Gianserra
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | - Elisabetta Teti
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | - Antonio Aceti
- Infectious Diseases, Faculty of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
| | - Andrea Soricelli
- IRCCS SDN, Naples, Italy; Department of Motor Sciences and Healthiness, University of Naples Parthenope, Naples, Italy
| | - Magdalena Viscione
- Clinical Infectious Diseases, University of Rome "Tor Vergata", Rome, Italy
| | - Cristina Limatola
- Department of Physiology and Pharmacology, University of Rome "La Sapienza", Rome, Italy
| | - Massimo Andreoni
- Clinical Infectious Diseases, University of Rome "Tor Vergata", Rome, Italy
| | - Paolo Onorati
- Department of Physiology and Pharmacology, University of Rome "La Sapienza", Rome, Italy; IRCCS S. Raffaele Pisana, Rome, Italy
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