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Mathias SD, Burke L, Colwell HH, Mensing G, Savage W, Naik H. Development and Content Validation of Novel Patient-Reported Outcome Measures to Assess Disease Severity and Change in Patients with Erythropoietic Protoporphyria: The EPP Impact Questionnaire (EPIQ). Patient Relat Outcome Meas 2024; 15:17-30. [PMID: 38375415 PMCID: PMC10875163 DOI: 10.2147/prom.s438892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024] Open
Abstract
Purpose Erythropoietic protoporphyria (EPP), a rare inherited disorder, presents in early childhood with severe, painful phototoxicity, with significant impacts on health-related quality of life (HRQoL). Previous studies have not captured all concepts important to patients. Therefore, this study sought to develop a novel, comprehensive, and content valid patient-reported outcome (PRO) measure to assess the efficacy of new therapies. Patients and Methods Qualitative interviews were conducted with EPP participants and clinical experts to obtain views on concepts relevant to patients. Results informed the development of novel PROs, which were debriefed during subsequent combined concept elicitation and cognitive debriefing interviews. Results Twenty-three interviews were conducted with 17 adults and 6 adolescents with EPP. Concept elicitation revealed that participants experienced many symptoms with significant variability. The most common were burning, pain, swelling, and tingling. Tingling was the most common prodromal symptom, while burning was the most bothersome, and pain was the worst full reaction symptom. Participants reported being negatively impacted in their ability to do daily activities, and social and emotional functioning. Many reported impacted ability to work and be productive at their job. Participants reviewed and completed the newly developed PRO measures assessing full reactions and ability to do activities, as well as items to assess severity and change in severity of prodromal symptoms, full reactions, and EPP overall. All measures were found to be comprehensive, clear, and relevant. Conclusion PRO measures are needed to assess important aspects of HRQoL and evaluate therapeutic response. These PRO measures are unique in assessing overall severity and change in EPP.
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Affiliation(s)
| | | | | | | | | | - Hetanshi Naik
- Department of Genetics, Stanford University School of Medicine, Palo Alto, CA, USA
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Heerfordt IM, Philipsen PA, Lerche CM, Wulf HC. Phototesting in erythropoietic protoporphyria trials: A systematic review. Exp Dermatol 2023. [PMID: 37052136 DOI: 10.1111/exd.14809] [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: 01/15/2023] [Revised: 03/29/2023] [Accepted: 04/02/2023] [Indexed: 04/14/2023]
Abstract
Severe skin pain when exposed to long wave ultraviolet radiation or visible light is the main symptom of erythropoietic protoporphyria (EPP). Treatment options for EPP are inadequate and new treatments are needed but hampered by the lack of valid efficacy outcomes. Phototesting with well-defined illumination of the skin can be performed reliably. We aimed to provide an overview of phototest procedures used to evaluate EPP treatments. Systematic searches of Embase, MEDLINE and the Cochrane Library were performed. Searches identified 11 studies using photosensitivity as efficacy outcome. The studies used eight different phototest protocols. Illuminations were performed with a filtered high-pressure mercury arc, or a xenon arc lamp equipped with monochromator or filters. Some used broadband, others narrowband illumination. In all protocols phototests were performed on the hands or the back. Endpoints were minimal dose required to induce either first symptom of discomfort, erythema, urticaria or intolerable pain. Other endpoints were change in erythema intensity or diameter of any type of flare after exposure compared to before. In conclusion, protocols displayed extensive variability in illumination set-up and evaluation of phototest reactions. Implementation of a standardized phototest method will allow more consistent and reliable outcome evaluation in future therapeutic research of protoporphyric photosensitivity.
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Affiliation(s)
- Ida M Heerfordt
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Peter A Philipsen
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Catharina M Lerche
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Pharmacy, University of Copenhagen, Copenhagen, Denmark
| | - Hans Christian Wulf
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
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5
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Balwani M, Bonkovsky HL, Levy C, Anderson KE, Bissell DM, Parker C, Takahashi F, Desnick RJ, Belongie K. Dersimelagon in Erythropoietic Protoporphyrias. N Engl J Med 2023; 388:1376-1385. [PMID: 37043653 DOI: 10.1056/nejmoa2208754] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
BACKGROUND Erythropoietic protoporphyria and X-linked protoporphyria are inborn errors of heme biosynthesis that cause elevated circulating levels of metal-free protoporphyrin and phototoxicity. Both disorders are characterized by excruciating phototoxic attacks after exposure to visible light. Dersimelagon is a new, orally administered, selective melanocortin 1 receptor agonist that increases levels of skin eumelanin. METHODS We conducted a randomized, placebo-controlled, phase 2 trial to investigate the efficacy and safety of dersimelagon with respect to the time to onset and the severity of symptoms associated with sunlight exposure in patients with erythropoietic protoporphyria or X-linked protoporphyria. Patients 18 to 75 years of age were randomly assigned in a 1:1:1 ratio to receive placebo or dersimelagon at a dose of 100 or 300 mg once daily for 16 weeks. The primary end point was the change from baseline to week 16 in the time to the first prodromal symptom associated with sunlight exposure. Patients recorded daily sunlight exposure and symptom data in an electronic diary. Quality of life and safety were also assessed. RESULTS Of the 102 patients (93 with erythropoietic protoporphyria and 9 with X-linked protoporphyria) who underwent randomization, 90% completed the treatment period. The mean daily time to the first prodromal symptom associated with sunlight exposure increased significantly with dersimelagon: the least-squares mean difference from placebo in the change from baseline to week 16 was 53.8 minutes in the 100-mg dersimelagon group (P = 0.008) and 62.5 minutes in the 300-mg dersimelagon group (P = 0.003). The results also suggest that quality of life improved in patients receiving dersimelagon as compared with placebo. The most common adverse events that occurred or worsened during treatment were nausea, freckles, headache, and skin hyperpigmentation. CONCLUSIONS At both doses evaluated, dersimelagon significantly increased the duration of symptom-free sunlight exposure in patients with erythropoietic protoporphyria or X-linked protoporphyria. (Funded by Mitsubishi Tanabe Pharma; Endeavor ClinicalTrials.gov number, NCT03520036.).
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Affiliation(s)
- Manisha Balwani
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Herbert L Bonkovsky
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Cynthia Levy
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Karl E Anderson
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - D Montgomery Bissell
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Charles Parker
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Fumihiro Takahashi
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Robert J Desnick
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
| | - Kirstine Belongie
- From the Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York (M.B., R.J.D.); the Section on Gastroenterology and Hepatology, Wake Forest University-North Carolina Baptist Medical Center, Winston-Salem (H.L.B.); Schiff Center for Liver Diseases, University of Miami Miller School of Medicine, Miami (C.L.); the Division of Gastroenterology and Hepatology and the Porphyria Center, University of Texas Medical Branch, Galveston (K.E.A.); Liver Center and Porphyria Center, University of California, San Francisco, San Francisco (D.M.B.); the Division of Hematology and Hematologic Malignancies, University of Utah, Salt Lake City (C.P.); Mitsubishi Tanabe Pharma Corporation, Tokyo (F.T.); and Mitsubishi Tanabe Pharma Development America, Jersey City, NJ (K.B.)
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Experimental and approved treatments for skin photosensitivity in individuals with erythropoietic protoporphyria or X-linked protoporphyria: A systematic review. Biomed Pharmacother 2023; 158:114132. [PMID: 36525819 DOI: 10.1016/j.biopha.2022.114132] [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: 10/13/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/15/2022] Open
Abstract
Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are characterized by skin photosensitivity caused by accumulation of protoporphyrin IX. We aimed to review the clinical evidence of efficacy and safety of skin photosensitivity treatments in individuals with EPP or XLP. We systematically searched MEDLINE, Embase, the Cochrane Library, and ClinicalTrials.gov. A total of 40 studies with data on 18 treatment modalities were included. Comprehensive treatment safety data were obtained from the European Medicines Agency and the United States Food and Drug Administration. The studies used different outcome measures to evaluate the sensitivity without a generally accepted method to assess treatment effect on skin photosensitivity. Of the included studies, 13 were controlled trials. Gathered, the trials showed moderate positive effect of inorganic sunscreen application and subcutaneous implant of afamelanotide and no effect of organic sunscreen application, or oral treatment with beta-carotene, cysteine, N-acetylcysteine, vitamin C, or warfarin. Studies without control groups suggested treatment effect of foundation cream, dihydroxyacetone/lawsone cream, narrow-band ultraviolet B phototherapy, erythrocyte transfusion, extracorporeal erythrocyte photodynamic therapy, or oral treatment with zinc sulphate, terfenadine, cimetidine, or canthaxanthin, but the real effect is uncertain. Assessment of treatment effect on photosensitivity in patients with EPP or XLP carries a high risk of bias since experienced photosensitivity varies with both weather conditions, exposure pattern, and pigmentation. Controlled trials of promising treatment options are important although challenging in this small patient population.
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7
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Heerfordt IM, Philipsen PA, Lerche CM, Wulf HC. Protection against visible light by dihydroxyacetone in erythropoietic protoporphyria. Photodiagnosis Photodyn Ther 2023; 41:103302. [PMID: 36690194 DOI: 10.1016/j.pdpdt.2023.103302] [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: 12/22/2022] [Revised: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients with erythropoietic protoporphyria (EPP) are hypersensitive to long wave ultraviolet (UVA) radiation and visible light and they experience severe skin pain by light exposure. The patients have very limited treatment options. Sunless skin tanning with dihydroxyacetone (DHA) is now being investigated as a possible treatment modality of skin photosensitivity in EPP. METHODS We simulated the theoretical light protection factor provided by DHA application. In addition, we present 19 cases with EPP who were treated at our department with DHA weekly during spring and summer from 2018 to 2021 inclusive. RESULTS The protection factor against UVA and visible light was estimated to approximately two. Out of the 19 patients with EPP who were treated with DHA in 2018, 11 patients experienced a sustained good effect and continued to use the treatment on a weekly basis in the spring and summer of 2019, 2020, and 2021. CONCLUSION AND PERSPECTIVES Both the theoretical estimates and the uncontrolled study suggest that sunless tanning with DHA reduces photosensitivity in patients with EPP. Our hypothesis is that skin treated with DHA can tolerate twice the daylight dose compared to untreated skin before onset of skin symptoms. To validate this conclusion, we plan a randomized clinical trial to determine the effect of DHA application to reduce photosensitivity in patients with EPP under controlled clinical conditions. The study protocol for this trial is presented in the paper.
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Affiliation(s)
- Ida M Heerfordt
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark.
| | - Peter A Philipsen
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark
| | - Catharina M Lerche
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark; Department of Pharmacy, University of Copenhagen, Denmark
| | - Hans Christian Wulf
- Department of Dermatology, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Denmark
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Di Pierro E, Granata F, De Canio M, Rossi M, Ricci A, Marcacci M, De Luca G, Sarno L, Barbieri L, Ventura P, Graziadei G. Recognized and Emerging Features of Erythropoietic and X-Linked Protoporphyria. Diagnostics (Basel) 2022; 12:diagnostics12010151. [PMID: 35054318 PMCID: PMC8775248 DOI: 10.3390/diagnostics12010151] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/31/2021] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
Abstract
Erythropoietic protoporphyria (EPP) and X-linked protoporphyria (XLP) are inherited disorders resulting from defects in two different enzymes of the heme biosynthetic pathway, i.e., ferrochelatase (FECH) and delta-aminolevulinic acid synthase-2 (ALAS2), respectively. The ubiquitous FECH catalyzes the insertion of iron into the protoporphyrin ring to generate the final product, heme. After hemoglobinization, FECH can utilize other metals like zinc to bind the remainder of the protoporphyrin molecules, leading to the formation of zinc protoporphyrin. Therefore, FECH deficiency in EPP limits the formation of both heme and zinc protoporphyrin molecules. The erythroid-specific ALAS2 catalyses the synthesis of delta-aminolevulinic acid (ALA), from the union of glycine and succinyl-coenzyme A, in the first step of the pathway in the erythron. In XLP, ALAS2 activity increases, resulting in the amplified formation of ALA, and iron becomes the rate-limiting factor for heme synthesis in the erythroid tissue. Both EPP and XLP lead to the systemic accumulation of protoporphyrin IX (PPIX) in blood, erythrocytes, and tissues causing the major symptom of cutaneous photosensitivity and several other less recognized signs that need to be considered. Although significant advances have been made in our understanding of EPP and XLP in recent years, a complete understanding of the factors governing the variability in clinical expression and the severity (progression) of the disease remains elusive. The present review provides an overview of both well-established facts and the latest findings regarding these rare diseases.
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Affiliation(s)
- Elena Di Pierro
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
- Correspondence: or ; Tel.: +39-0255036155
| | - Francesca Granata
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
| | - Michele De Canio
- Porphyria and Rare Diseases Centre, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (M.D.C.); (L.B.)
| | - Mariateresa Rossi
- Department of Dermatology, ASST Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy; (M.R.); (L.S.)
| | - Andrea Ricci
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.); (P.V.)
| | - Matteo Marcacci
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.); (P.V.)
| | - Giacomo De Luca
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
| | - Luisa Sarno
- Department of Dermatology, ASST Spedali Civili di Brescia, University of Brescia, 25123 Brescia, Italy; (M.R.); (L.S.)
| | - Luca Barbieri
- Porphyria and Rare Diseases Centre, San Gallicano Dermatological Institute IRCCS, 00144 Rome, Italy; (M.D.C.); (L.B.)
| | - Paolo Ventura
- Internal Medicine Unit, Department of Medical and Surgical Science for Children and Adults, University of Modena e Reggio Emilia, 41124 Modena, Italy; (A.R.); (M.M.); (P.V.)
| | - Giovanna Graziadei
- Dipartimento di Medicina Interna, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy; (F.G.); (G.D.L.); (G.G.)
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