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Wang Y, Zhang X, Xu L, Wang Y, Yan C, Chen H, Chen Y, Wei F, Han W, Wang F, Wang J, Huang X, Mo X. Clinical manifestations, prognostic factors, and outcomes of adenovirus pneumonia after allogeneic hematopoietic stem cell transplantation. Virol J 2024; 21:110. [PMID: 38745209 PMCID: PMC11094961 DOI: 10.1186/s12985-024-02383-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/03/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Severe pneumonia is one of the most important causes of mortality after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Adenovirus (ADV) is a significant cause of severe viral pneumonia after allo-HSCT, and we aimed to identify the clinical manifestations, prognostic factors, and outcomes of ADV pneumonia after allo-HSCT. METHODS Twenty-nine patients who underwent allo-HSCT at the Peking University Institute of Hematology and who experienced ADV pneumonia after allo-HSCT were enrolled in this study. The Kaplan-Meier method was used to estimate the probability of overall survival (OS). Potential prognostic factors for 100-day OS after ADV pneumonia were evaluated through univariate and multivariate Cox regression analyses. RESULTS The incidence rate of ADV pneumonia after allo-HSCT was approximately 0.71%. The median time from allo-HSCT to the occurrence of ADV pneumonia was 99 days (range 17-609 days). The most common clinical manifestations were fever (86.2%), cough (34.5%) and dyspnea (31.0%). The 100-day probabilities of ADV-related mortality and OS were 40.4% (95% CI 21.1%-59.7%) and 40.5% (95% CI 25.2%-64.9%), respectively. Patients with low-level ADV DNAemia had lower ADV-related mortality and better OS than did those with high-level (≥ 106 copies/ml in plasma) ADV DNAemia. According to the multivariate analysis, high-level ADV DNAemia was the only risk factor for intensive care unit admission, invasive mechanical ventilation, ADV-related mortality, and OS after ADV pneumonia. CONCLUSIONS We first reported the prognostic factors and confirmed the poor outcomes of patients with ADV pneumonia after allo-HSCT. Patients with high-level ADV DNAemia should receive immediate and intensive therapy.
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Affiliation(s)
- Yuewen Wang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Xiaohui Zhang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Lanping Xu
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
- Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, Beijing, 2019RU029, China
| | - Yu Wang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Chenhua Yan
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
- Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, Beijing, 2019RU029, China
| | - Huan Chen
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Yuhong Chen
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Fangfang Wei
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Wei Han
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Fengrong Wang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Jingzhi Wang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Xiaojun Huang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
- Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, Beijing, 2019RU029, China
- Peking-Tsinghua Center for Life Sciences, Beijing, 100871, China
| | - Xiaodong Mo
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, No. 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China.
- Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, Beijing, 2019RU029, China.
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Pérez A, Gómez D, Montoro J, Chorão P, Hernani R, Guerreiro M, Villalba M, Albert E, Carbonell-Asins JA, Hernández-Boluda JC, Navarro D, Solano C, Piñana JL. Are any specific respiratory viruses more severe than others in recipients of allogeneic stem cell transplantation? A focus on lower respiratory tract disease. Bone Marrow Transplant 2024:10.1038/s41409-024-02304-4. [PMID: 38730040 DOI: 10.1038/s41409-024-02304-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/23/2024] [Accepted: 04/30/2024] [Indexed: 05/12/2024]
Abstract
In the general population, influenza virus, respiratory syncytial virus, and SARS-CoV-2 are considered the most severe community-acquired respiratory viruses (CARVs). However, allogeneic stem cell transplant (allo-SCT) recipients may also face severe courses from other CARVs. This retrospective study compared outcomes of various CARV lower respiratory tract diseases (LRTD) in 235 adult allo-SCT recipients, excluding co-infection episodes. We included 235 adults allo-SCT recipients experiencing 353 CARV LRTD consecutive episodes (130 rhinovirus, 63 respiratory syncytial virus, 43 influenza, 43 human parainfluenza virus, 23 human metapneumovirus, 19 Omicron SARS-CoV-2, 17 common coronavirus, 10 adenovirus and 5 human bocavirus) between December 2013 and June 2023. Day 100 overall survival ranged from 78% to 90% without significant differences among CARV types. Multivariable analysis of day 100 all-cause mortality identified corticosteroid use of >1 to <30 mg/d [Hazard ratio (HR) 2.45, p = 0.02) and ≥30 mg/d (HR 2.20, p = 0.015) along with absolute lymphocyte count <0.2 × 109/L (HR 5.82, p < 0.001) and number of CARV episodes as a continuous variable per one episode increase (HR 0.48, p = 0.001) as independent risk factors for all-cause mortality. Degree of immunosuppression, rather than intrinsic CARV virulence, has the most significant impact on mortality in allo-SCT recipients with CARV-LRTD.
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Affiliation(s)
- Ariadna Pérez
- Department of Hematology. Hospital Clínico Universitario of Valencia, Spain. INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Dolores Gómez
- Microbiology Service, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Juan Montoro
- Hematology Division, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Pedro Chorão
- Hematology Division, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Rafael Hernani
- Department of Hematology. Hospital Clínico Universitario of Valencia, Spain. INCLIVA Biomedical Research Institute, Valencia, Spain
| | - Manuel Guerreiro
- Hematology Division, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Marta Villalba
- Hematology Division, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Eliseo Albert
- Microbiology Service, Hospital Clínico Universitario, Valencia, Spain
| | | | - Juan Carlos Hernández-Boluda
- Department of Hematology. Hospital Clínico Universitario of Valencia, Spain. INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - David Navarro
- Microbiology Service, Hospital Clínico Universitario, Valencia, Spain
- Department of Microbiology, School of Medicine, University of Valencia, Valencia, Spain
| | - Carlos Solano
- Department of Hematology. Hospital Clínico Universitario of Valencia, Spain. INCLIVA Biomedical Research Institute, Valencia, Spain
- Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
| | - José Luis Piñana
- Department of Hematology. Hospital Clínico Universitario of Valencia, Spain. INCLIVA Biomedical Research Institute, Valencia, Spain.
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Kim SR, Waghmare A, Hijano DR. Approach to hematopoietic cell transplant candidates with respiratory viral detection. Front Pediatr 2024; 11:1339239. [PMID: 38304442 PMCID: PMC10830789 DOI: 10.3389/fped.2023.1339239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 12/19/2023] [Indexed: 02/03/2024] Open
Abstract
The management of respiratory viruses prior to hematopoietic cell transplant (HCT) can be controversial and requires special consideration of host factors, transplant parameters, and the specific respiratory virus (RV). In the setting of adenovirus (ADV), human metapneumovirus (HMPV), influenza, parainfluenza virus (PIV), and respiratory syncytial virus (RSV) detection prior to hematopoietic cell transplant (HCT), clinical practice guidelines recommend transplant delay when possible; however, there is much more ambiguity when other respiratory viruses, such as seasonal coronaviruses (CoVs), human rhinovirus (HRV), and SARS-CoV-2, are detected. Our aims for this review include detailing clinical practical guidelines and reviewing current literature on pre-transplant respiratory viral infections (RVIs), including antiviral therapies and prevention strategies, when available. We will center our discussion on three representative clinical scenarios, with the goal of providing practical guidance to clinicians.
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Affiliation(s)
- Sara R. Kim
- Division of Pediatric Infectious Diseases, Seattle Children’s Hospital, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Alpana Waghmare
- Division of Pediatric Infectious Diseases, Seattle Children’s Hospital, Seattle, WA, United States
- Department of Pediatrics, University of Washington, Seattle, WA, United States
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Diego R. Hijano
- Departments of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, TN, United States
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, TN, United States
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4
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Piñana JL, Pérez A, Chorão P, Guerreiro M, García-Cadenas I, Solano C, Martino R, Navarro D. Respiratory virus infections after allogeneic stem cell transplantation: Current understanding, knowledge gaps, and recent advances. Transpl Infect Dis 2023; 25 Suppl 1:e14117. [PMID: 37585370 DOI: 10.1111/tid.14117] [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: 05/01/2023] [Revised: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 08/18/2023]
Abstract
Before the COVID-19 pandemic, common community-acquired seasonal respiratory viruses (CARVs) were a significant threat to the health and well-being of allogeneic hematopoietic cell transplant (allo-HCT) recipients, often resulting in severe illness and even death. The pandemic has further highlighted the significant risk that immunosuppressed patients, including allo-HCT recipients, face when infected with SARS-CoV-2. As preventive transmission measures are relaxed and CARVs circulate again among the community, including in allo-HSCT recipients, it is crucial to understand the current state of knowledge, gaps, and recent advances regarding CARV infection in allo-HCT recipients. Urgent research is needed to identify seasonal respiratory viruses as potential drivers for future pandemics.
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Affiliation(s)
- Jose L Piñana
- Hematology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Fundación INCLIVA, Instituto de Investigación Sanitaria Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Ariadna Pérez
- Hematology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Fundación INCLIVA, Instituto de Investigación Sanitaria Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Pedro Chorão
- Hematology Division, Hospital universitario y politécnico La Fe, Valencia, Spain
- Instituto de Investigación La Fe, Hospital Universitário y Politécncio La Fe, Valencia, Spain
| | - Manuel Guerreiro
- Hematology Division, Hospital universitario y politécnico La Fe, Valencia, Spain
- Instituto de Investigación La Fe, Hospital Universitário y Politécncio La Fe, Valencia, Spain
| | | | - Carlos Solano
- Hematology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Fundación INCLIVA, Instituto de Investigación Sanitaria Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Rodrigo Martino
- Hematology Division, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - David Navarro
- Microbiology department, Hospital Clinico Universitario de Valencia, Spain
- Department of Medicine, School of Medicine, University of Valencia, Valencia, Spain
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5
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Piñana JL, Heras I, Aiello TF, García-Cadenas I, Vazquez L, Lopez-Jimenez J, Chorão P, Aroca C, García-Vidal C, Arroyo I, Soler-Espejo E, López-Corral L, Avendaño-Pita A, Arrufat A, Garcia-Gutierrez V, Arellano E, Hernández-Medina L, González-Santillana C, Morell J, Hernández-Rivas JÁ, Rodriguez-Galvez P, Mico-Cerdá M, Guerreiro M, Campos D, Navarro D, Cedillo Á, Martino R, Solano C. Remdesivir or Nirmatrelvir/Ritonavir Therapy for Omicron SARS-CoV-2 Infection in Hematological Patients and Cell Therapy Recipients. Viruses 2023; 15:2066. [PMID: 37896843 PMCID: PMC10612015 DOI: 10.3390/v15102066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Scarce data exist that analyze the outcomes of hematological patients with SARS-CoV-2 infection during the Omicron variant period who received treatment with remdesivir or nirmatrelvir/ritonavir. METHODS This study aims to address this issue by using a retrospective observational registry, created by the Spanish Hematopoietic Stem Cell Transplantation and Cell Therapy Group, spanning from 27 December 2021 to 30 April 2023. RESULTS This study included 466 patients, 243 (52%) who were treated with remdesivir and 223 (48%) with nirmatrelvir/ritonavir. Nirmatrelvir/ritonavir was primarily used for mild cases, resulting in a lower COVID-19-related mortality rate (1.3%), while remdesivir was preferred for moderate to severe cases (40%), exhibiting a higher mortality rate (9%). A multivariate analysis in the remdesivir cohort showed that male gender (odds ratio (OR) 0.35, p = 0.042) correlated with a lower mortality risk, while corticosteroid use (OR 9.4, p < 0.001) and co-infection (OR 2.8, p = 0.047) were linked to a higher mortality risk. Prolonged virus shedding was common, with 52% of patients shedding the virus for more than 25 days. In patients treated with remdesivir, factors associated with prolonged shedding included B-cell malignancy as well as underlying disease, severe disease, a later onset of and shorter duration of remdesivir treatment and a higher baseline viral load. Nirmatrelvir/ritonavir demonstrated a comparable safety profile to remdesivir, despite a higher risk of drug interactions. CONCLUSIONS Nirmatrelvir/ritonavir proved to be a safe and effective option for treating mild cases in the outpatient setting, while remdesivir was preferred for severe cases, where corticosteroids and co-infection significantly predicted worse outcomes. Despite antiviral therapy, prolonged shedding remains a matter of concern.
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Affiliation(s)
- José Luis Piñana
- Hematology Department, Hospital Clínico Universitario, 46017 Valencia, Spain; (I.A.); (J.M.); (P.R.-G.); (M.M.-C.); (D.C.); (C.S.)
- INCLIVA, Biomedical Research Institute, 46017 Valencia, Spain
| | - Inmaculada Heras
- Hematology Division, Hospital Morales Meseguer, 30100 Murcia, Spain; (I.H.); (C.A.); (E.S.-E.)
| | | | - Irene García-Cadenas
- Hematology Division, Hospital de la Santa Creu i Sant Pau, 08193 Barcelona, Spain; (I.G.-C.); (A.A.); (R.M.)
| | - Lourdes Vazquez
- Hematology Department, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), 37007 Salamanca, Spain; (L.V.); (L.L.-C.); (A.A.-P.); (L.H.-M.)
| | - Javier Lopez-Jimenez
- Hematology Division, Hospital Ramon y Cajal, 28029 Madrid, Spain; (J.L.-J.); (V.G.-G.)
| | - Pedro Chorão
- Hematology Division, Hospital Universitario y Politécnico La Fe, 46017 Valencia, Spain; (P.C.); (M.G.)
| | - Cristina Aroca
- Hematology Division, Hospital Morales Meseguer, 30100 Murcia, Spain; (I.H.); (C.A.); (E.S.-E.)
| | - Carolina García-Vidal
- Infectious Disease Division, Hospital Clinic, 08193 Barcelona, Spain; (T.F.A.); (C.G.-V.)
| | - Ignacio Arroyo
- Hematology Department, Hospital Clínico Universitario, 46017 Valencia, Spain; (I.A.); (J.M.); (P.R.-G.); (M.M.-C.); (D.C.); (C.S.)
- INCLIVA, Biomedical Research Institute, 46017 Valencia, Spain
| | - Eva Soler-Espejo
- Hematology Division, Hospital Morales Meseguer, 30100 Murcia, Spain; (I.H.); (C.A.); (E.S.-E.)
| | - Lucia López-Corral
- Hematology Department, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), 37007 Salamanca, Spain; (L.V.); (L.L.-C.); (A.A.-P.); (L.H.-M.)
| | - Alejandro Avendaño-Pita
- Hematology Department, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), 37007 Salamanca, Spain; (L.V.); (L.L.-C.); (A.A.-P.); (L.H.-M.)
| | - Anna Arrufat
- Hematology Division, Hospital de la Santa Creu i Sant Pau, 08193 Barcelona, Spain; (I.G.-C.); (A.A.); (R.M.)
| | | | - Elena Arellano
- Hematology Division, Hospital Universitario Virgen Macarena, 41092 Sevilla, Spain;
| | - Lorena Hernández-Medina
- Hematology Department, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), 37007 Salamanca, Spain; (L.V.); (L.L.-C.); (A.A.-P.); (L.H.-M.)
| | | | - Julia Morell
- Hematology Department, Hospital Clínico Universitario, 46017 Valencia, Spain; (I.A.); (J.M.); (P.R.-G.); (M.M.-C.); (D.C.); (C.S.)
- INCLIVA, Biomedical Research Institute, 46017 Valencia, Spain
| | | | - Paula Rodriguez-Galvez
- Hematology Department, Hospital Clínico Universitario, 46017 Valencia, Spain; (I.A.); (J.M.); (P.R.-G.); (M.M.-C.); (D.C.); (C.S.)
- INCLIVA, Biomedical Research Institute, 46017 Valencia, Spain
| | - Mireia Mico-Cerdá
- Hematology Department, Hospital Clínico Universitario, 46017 Valencia, Spain; (I.A.); (J.M.); (P.R.-G.); (M.M.-C.); (D.C.); (C.S.)
- INCLIVA, Biomedical Research Institute, 46017 Valencia, Spain
| | - Manuel Guerreiro
- Hematology Division, Hospital Universitario y Politécnico La Fe, 46017 Valencia, Spain; (P.C.); (M.G.)
| | - Diana Campos
- Hematology Department, Hospital Clínico Universitario, 46017 Valencia, Spain; (I.A.); (J.M.); (P.R.-G.); (M.M.-C.); (D.C.); (C.S.)
- INCLIVA, Biomedical Research Institute, 46017 Valencia, Spain
- Institute of Experimental and Clinical Pharmacology and Toxicology, Center for Brain, Behavior and Metabolism (CBBM), University of Lübeck, 23562 Lübeck, Germany
| | - David Navarro
- Microbiology Service, Hospital Clínico Universitario de Valencia, 46010 Valencia, Spain;
- Department of Medicine, School of Medicine. University of Valencia, 46010 Valencia, Spain
| | - Ángel Cedillo
- Hematopoietic Stem Cell Transplantation and Cell Therapy Group (GETH-TC) Office, 28029 Madrid, Spain;
| | - Rodrigo Martino
- Hematology Division, Hospital de la Santa Creu i Sant Pau, 08193 Barcelona, Spain; (I.G.-C.); (A.A.); (R.M.)
| | - Carlos Solano
- Hematology Department, Hospital Clínico Universitario, 46017 Valencia, Spain; (I.A.); (J.M.); (P.R.-G.); (M.M.-C.); (D.C.); (C.S.)
- INCLIVA, Biomedical Research Institute, 46017 Valencia, Spain
- Department of Medicine, School of Medicine. University of Valencia, 46010 Valencia, Spain
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