Research Report
Physical Activity Scale for the Elderly (PASE)
Score Is Related to Sarcopenia
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in Noninstitutionalized Older Adults
Francesco Curcio, MD1; Ilaria Liguori, MD1; Michele Cellulare, MD1;
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Giuseppe Sasso, MD1; David Della-Morte, MD, PhD2,3; Gaetano Gargiulo, MD4;
Gianluca Testa, MD, PhD1,5; Francesco Cacciatore, MD, PhD1,6;
Domenico Bonaduce, MD1; Pasquale Abete, MD, PhD1
ABSTRACT
Background and Purpose: Sarcopenia, a loss of muscle mass
and strength accompanying aging, is common in older adults
who are not physically active. Nevertheless, the association
between physical activity and sarcopenia has not been exten-
sively studied. Therefore, we examined the relationship of both
muscle mass and muscle strength with physical activity as
quantified using the Physical Activity Scale for Elderly (PASE).
Methods: PASE score, muscle mass by bioimpendiometry, and
muscle strength by handgrip were evaluated in a cohort study
of 420 older adult participants (mean age 82.4 [5.9] years),
admitted to the Comprehensive Geriatric Assessment Cen-
ter. Sarcopenia was assessed as indicated in the European
Working Group on Sarcopenia in Older People (EWGSOP)
consensus.
1Department
of Translational Medical Sciences, University
of Naples “Federico II,” Naples, Italy.
2Department of Systems Medicine, University of Rome Tor
Vergata, Rome, Italy.
3San Raffaele Roma Open University, Rome, Italy.
4Division of Internal Medicine, AOU San Giovanni di
Dio e Ruggi di Aragona, Salerno, Italy.
5Department of Medicine and Health Sciences, University of
Molise, Campobasso, Italy.
6Azienda Ospedaliera dei Colli, Monaldi Hospital, Heart
Transplantation Unit, Naples, Italy.
Supported by Progetto AIFA COD, FARM7K7XZB and
Fondazione Roma NCDS-2013-00000331—Sarcopenia
and Insulin Resistance in the Elderly; Age-Associated
Inflammation as a Shared Pathogenic Mechanism and
Potential Therapeutical Target (They contributed to the
purchase of materials utilized in the study.)
The authors declare no conflicts of interest.
Address Correspondence to: Pasquale Abete, MD, PhD,
Dipartimento di Scienze Mediche Traslazionali, Università
di Napoli Federico II, Via S. Pansini, 80131 Naples, Italy
(p.abete@unina.it).
Richard Bohannon was the Decision Editor.
Copyright © 2017 Academy of Geriatric Physical Therapy,
APTA.
DOI: 10.1519/JPT.0000000000000139
130
Copyright © 2017 The Academy of Geriatric Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
Results: PASE score was lower in sarcopenic (40.2 [89.0])
than in non-sarcopenic (92.0 [52.4]) older adults (P < .001).
Curvilinear regression analysis demonstrated that PASE score
is related with muscle mass (R2 = 0.63; P < .001) and
strength (R2 = 0.51; P < .001).
Conclusions: The present study indicates that PASE score is
curvilinearly related to muscle mass and strength and that low
PASE score identifies sarcopenic noninstitutionalized older
adults. This evidence suggests that PASE score evaluated
together with muscle mass and strength may identify older
adults at high risk of sarcopenia.
Key Words: older adults, physical activity, sarcopenia
(J Geriatr Phys Ther 2019;42(3):130-135.)
INTRODUCTION
Sarcopenia, previously defined as an age-related loss of
muscle mass, is now considered as a geriatric syndrome
characterized by progressive and generalized loss of skel-
etal muscle mass and strength.1,2 After the age of 50 years,
muscle mass tends to be reduced at a rate of 1% to 2% per
year, and this decline is mainly due to the progressive atro-
phy and loss of type II muscle fibers and motor neurons.3
This phenomenon is particularly prevalent in individuals
older than 80 years and increases the risk of morbidity and
mortality4,5 in older adults, especially in older individuals
residing in nursing homes.6
The pathogenesis of sarcopenia is complex and several
factors are involved. Indeed, hormonal, metabolic, nutri-
tional, and inflammatory factors and, very importantly,
physical inactivity are implicated.3
A sedentary lifestyle determines a greater and more
rapid loss of muscle than an active one.7 Strong evidences
suggest that disuse may be responsible for muscle atrophy
and weakness more than aging.8 In addition, either acute
conditions, such as hospitalization, or chronic conditions
characterized by physical inactivity, such as cancer, diabetes
and peripheral artery disease, seem to accelerate the pro-
gression of muscle atrophy.9
Nevertheless, the relationship between muscle mass and
strength and physical activity levels is poorly investigated.
Volume 42 • Number 3 • July-September 2019

One possible explanation for this phenomenon might be
underutilization of valid measurement tools to quantify
physical activity in older adults. In this regard, the Physical
Activity Scale for the Elderly (PASE) is a reliable and valid
self-reported questionnaire for older people, specifically
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conceived to assess the amount of occupational, house-
hold, and leisure physical activity carried out over the
last week.10 The test can be easily administered and it is
frequently incorporated into a comprehensive geriatric
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assessment.
Thus, in the present study we aimed to investigate the
relationship between muscle mass and strength and physi-
cal activity, as assessed by PASE, in older adults who under-
went comprehensive geriatric assessment.
METHODS
Study Population
This cohort study enrolled 420 older adults (≥65 years)
consecutively admitted to the “Comprehensive Geriatric
Assessment Center” of the Azienda Ospedaliera
Universitaria Federico II (Naples, Italy) from January
2015 to December 2016. The study received full ethi-
cal approval from the “Research Ethics Committee”
in accordance with the ethical standards laid down in
the 1964 Declaration of Helsinki and its later amend-
ments. All participants signed an informed consent form,
and the institutional review board approved the study.
Anthropometric measurements including age, sex, body
mass index (BMI), and waist circumference were col-
lected.11
Comprehensive Geriatric Assessment
Participants underwent a comprehensive geriatric multidi-
mensional evaluation. Cognitive function and depression
were assessed through the Mini-Mental State Examination
(MMSE)12 and Geriatric Depression Scale (GDS), respec-
tively.13 Comorbidity presence and severity were evalu-
ated by means of the Cumulative Illness Rating Scale
(CIRS-comorbidity and CIRS-severity)14 and drugs num-
ber count.15 The presence and degree of disability were
examined via the number of lost basic (BADL)16 and
instrumental activities of daily living (IADL).17 Nutritional
assessment was performed using the Mini-Nutritional
Assessment (MNA).18 The assessment of physical per-
formance was carried out using 4-m gait speed (m/s)
evaluation.19 Social support analysis was performed using
the Social Support Assessment, scoring from 17 (par-
ticipants with the lowest support) to 0 (participants with
the highest support).20 Risk of falling was evaluated by
Tinetti Mobility Test or Performance-Oriented Mobility
Assessment.21 Frailty was assessed by Fried’s method
(≥3 of the following criteria were present: unintentional
10-lb loss in past year, self-reported exhaustion, weakness,
slow walking speed, and low physical activity)22 and by
Rockwood’s methods (40 deficits including signs and/or
symptoms routinely assessed in older adults).23
Journal of GERIATRIC Physical Therapy
Copyright © 2017 The Academy of Geriatric Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
Research Report
Assessment of Physical Activity
The PASE was used to assess participants’ usual physical activ-
ity.10 The PASE scale is a brief and easily scored survey spe-
cifically designed to assess physical activity in epidemiologic
studies involving persons 65 years and older. The PASE evalu-
ates physical activity performed over a 1-week time frame.
Participation in leisure activities, including walking outside
the home, light, moderate, and strenuous sport and recreation,
and muscle strengthening were recorded as never, seldom
(1-2 days/week), sometimes (3-4 days/week), and often
(5-7 days/week) performed. Duration was categorized as
“less than 1 hour,” “between 1 and 2 hours,” “2 to
4 hours,” or “more than 4 hours.” Paid or unpaid work, other
than work that involves mostly sitting activity, was recorded
in total hours per week. Housework (light and heavy), lawn
work/yard care, home repair, outdoor gardening, and caring
for other people were recorded as “yes” or “no.” Frequency
and duration of household activities were not requested. The
total PASE score was computed by multiplying the amount of
time spent in each activity (hours/week) or participation (yes/
no) in an activity by the empirically derived item weights and
summing over all activities. The PASE score was stratified in
tertiles: 0 to 40 (sedentary), 41 to 90 (light physical activity)
and more than 90 (moderate to intense activity).
Assessment of Muscle Mass and Strength
Muscle mass was measured by bioelectrical impedance
analysis (BIA) using a Quantum/S Bioelectrical Body
Composition Analyzer (Akern Srl, Florence, Italy). Whole-
body BIA measurements were taken between the right wrist
and ankle, with the participant in a supine position. Muscle
mass was calculated using the BIA equation of Janssen and
colleagues.24
Muscle strength was assessed by a handheld dynamom-
eter held by a tester and applied to a participant (Mecmesin
Advanced Force Gauge 500N, GDM, Italy).
Applying the algorithm of the European Working Group
on Sarcopenia in Older People (EWGSOP) consensus, par-
ticipants first performed a gait speed test. If they presented a
slow gait speed (≤0.8 m/s), they underwent a grip strength
measurement. Values of muscle strength (kg) for each range
of BMI values were used as a cutoff point to classify “low
muscle strength” (BMI ≤24 = ≤29 kg, BMI 24.1 to 28
= ≤30 kg, and BMI >28 = ≤32 kg for men, respectively;
BMI ≤23 = ≤17 kg, BMI 23.1 to 26 = ≤17.3 kg, BMI
26.1 to 29 = ≤18 kg, and BMI >29 = ≤21 kg for women,
respectively). Participants with low grip strength presenting
low muscle mass (skeletal muscle index less than 8.87 and
6.42 kg/m2 in men and women, respectively) were classified
as “sarcopenic.”25
Statistical Analysis
A sample size of a minimum 312 patients was calculated by
considering a type I error rate of 0.05 and a type II error rate
of 0.90, and by assuming a proportion of participants in the
“sarcopenia-yes” group (exposed) of 15% (n = 47) and
a proportion of participants in the “sarcopenia-no” group
131
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(unexposed) of 85% (n = 265) with an effect size of RESULTS

0.5 and a standard deviation of the outcome in the The sample consisted of 420 older adult participants,
population = 10. We enrolled 420 participants, and there- with a mean age of 82.4 ± 5.9 years; 241 (57.4%)
fore exceeded the number of patients required to reach a were female and 179 (42.6%) were male. Table 1 shows
sufficient sample size. anthropometric measurements and comprehensive geriatric
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Baseline characteristics of the sample are expressed as
mean (standard deviation). Participants were stratified by
the presence or absence of sarcopenia and by tertiles of
PASE (0-40, 41-90, and >90 points). Data on the presence
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assessment stratified for the presence and absence of sar-
copenia, according to EWGSOP definition and diagnostic
algorithm.26 Sarcopenic older adults had higher comorbid-
ity, as showed by higher CIRS-comorbidity and severity

or absence of sarcopenia were analyzed with “2-indepen-
dent sample T tests.” When participants were stratified in
tertiles of PASE, analysis of variance and Bonferroni’s post
hoc test was applied. Categorical variables were analyzed
using χ2 testing, and continuous variables using a 1-way
analysis of variance. A curvilinear relationship between
PASE and muscle mass and strength was performed by
applying the “1-phase association” model (y =y0 +
(plateau − y0) × (1 − exp[−K × x]).
All statistical analyses were performed with SPSS soft-
ware (version 15.0, SPSS Inc, Chicago, Illinois). A P value
less than .05 was considered statistically significant.
score and drug number. Also, 4-m walking speed, MNA
and Tinetti score and, more interestingly, PASE score along
with muscle mass and grip strength significantly differed
between nonsarcopenic and sarcopenic older adults, sug-
gesting the presence of functional impairment in the latter
(Table 1). As expected, both frailty by Fried’s and frailty
by Rockwood’s were more prevalent in sarcopenic older
adults (Table 1).
In our sample, mean age and the proportion of female
individuals progressively decreased as PASE score increased
as well as MMSE score increased whereas depressive symp-
toms (GDS) decreased. Moreover, with increasing PASE

Table 1. Baseline Characteristics of the 420 Patients Enrolled in the Study Stratified for the Presence and Absence of Sarcopenia
Sarcopenia
Characteristics No (n = 365, 87%) Yes (n = 55, 13%) P Value
Anthropometric data
Age, mean (SD), y 74.7 (8.2) 80.2 (7.3) .112
Female sex, n (%) 286 (68) 134 (32) .054
Body mass index, mean (SD), kg/m2 27.5 (3.2) 24.8 (4.7) .082
Waist circumference, mean (SD), cm 99.1 (11.8) 99.2 (12.6) .124
Geriatric evaluation
Mini-Mental State Examination, score, mean (SD) 23.3 (6.9) 21.8 (4.6) .064
Geriatric Depression Scale, score, mean (SD) 6.9 (4.2) 8.2 (5.5) .110
CIRS-comorbidity, score, mean (SD) 3.21 (1.69) 5.01 (2.06) .032
CIRS-severity, score, mean (SD) 1.65 (0.25) 2.28 (0.45) .042
Drug number, n., mean (SD) 2.0 (1.0) 4.0 (1.0) .020
BADL lost, n., mean (SD) 1.3 (1.8) 2.4 (1.8) .412
IADL lost, n., mean (SD) 3.0 (1.6) 4.4 (3.4) .621
Tinetti, score, mean (SD) 22.8 (4.6) 20.1 (2.6) .042
Mini-Nutritional Assessment, score, mean (SD) 15.0 (4.8) 22.6 (4.2) .024
4-m walking speed, mean (SD), m/s 0.90 (0.19) 0.64 (0.40) .05
PASE, score, mean (SD) 92.0 (52.4) 40.2 (89.1) .001
Social support, score, mean (SD) 7.3 (2.7) 9.2 (1.8) .05
Frailty by Fried, score, mean (SD) 2.6 (1.4) 4.0 (1.5) .05
Frailty by Rockwood, score, mean (SD) 16.5 (9.4) 25.2 (7.1) .05
Muscle measurements
Muscle strength, mean (SD), kg 32.7 (7.4) 23.6 (9.5) .05
Muscle mass, mean (SD), kg/m2 9.2 (1.7) 6.89 (1.4) .01
Abbreviations: BADL, basic activity of daily living; CIRS, Cumulative Illness Rating Scale; IADL, instrumental activity of daily living; PASE, Physical Activity Scale for the Elderly; SD, standard deviation.

132 Volume 42 • Number 3 • July-September 2019

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 Research Report

Table 2. Baseline Characteristics of the 420 Older Adult Participants Enrolled in the Study
PASE Score
0-40 (n = 135, 41-90 (n = 156, >90 (n = 129,
Characteristics All (n = 420) 32.1%) 37.2%) 30.7%) P for Trend
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Anthropometric data
Age, mean (SD), y 82.4 (5.9) 82.9 (5.8) 81.9 (5.6) 80.3 (7.5)a .001
Female sex, n (%) 179 (42.6) 88 (65.5) 35 (22.4) 16 (12.1)a .001
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Body mass index, mean (SD), kg/m2 27.5 (4.7) 27.7 (4.9) 27.3 (4.5) 26.8 (4.1) .249
Waist circumference, mean (SD), cm 99.7 (13.5) 100.1 (9.3) 98.7 (11.4) 98.3 (11.2) .456
Geriatric evaluation
Mini-Mental State Examination, score, mean (SD) 22.0 (6.5) 20.0 (6.8) 25.8 (3.5)a 26.5 (2.0)a .001
Geriatric Depression Scale, score, mean (SD) 6.1 (4.9) 7.4 (5.1) 4.0 (3.9)a 2.7 (2.0)a .001
CIRS-comorbidity, score, mean (SD) 3.4 (1.6) 3.5 (1.6) 3.2 (1.3) 3.1 (2.1) .629
CIRS-severity, score, mean (SD) 1.8 (0.3) 1.8 (0.3) 1.8 (0.5) 1.7 (0.4) .451
Drug number, n, mean (SD) 5.3 (3.2) 6.0 (3.4) 4.0 (2.0) 3.0 (1.4)a .175
BADL lost, n, mean (SD) 1.8 (1.8) 2.4 (1.8) 0.7 (0.9)a 0.0 (00) .001
IADL lost, n, mean (SD) 3.6 (2.9) 5.0 (2.4) 0.9 (1.0)a 0.7 (1.8)a .001
Tinetti, score, mean (SD) 18.0 (7.7) 15.1 (7.0) 22.9 (5.8) 25.3 (4.5) .001
Mini-Nutritional Assessment, score, mean (SD) 20.9 (4.1) 20.0 (4.0) 22.6 (3.8) 23.0 (4.0)a .001
4-m walking speed, mean (SD), m/s 0.33 (0.4) 0.62 (0.42)a 0.18 (0.4)a 0.04 (0.1) .001
PASE, score, mean (SD) 31.4 (42.1) 6.4 (10.9) 62.6 (13.9)a 124.6 (33.6)a .001
Social support, score, mean (SD) 7.1 (5.7) 7.9 (5.8) 6.2 (5.6) 3.5 (2.8)a .015
Frailty by Fried, score, mean (SD) 3.6 (1.5) 4.0 (1.5) 2.8 (1.2) 2.7 (1.0) .001
Frailty by Rockwood, score, mean (SD) 19.58 (9.49) 22.2 (9.1) 15.2 (8.2)a 12.0 (6.7)a .001
Abbreviations: BADL, basic activity of daily living; CIRS, Cumulative Illness Rating Scale; IADL, instrumental activity of daily living; PASE, Physical Activity Scale for the Elderly; SD, standard deviation.
aP < .01 versus PASE score = 0 to 40 at Bonferroni post hoc test; female sex was analyzed with χ2 test.

score, we observed a reduction of the comorbidity severity identifies older adults at high risk of loss of muscle mass
score, lost BADL, MNA score, 4-m walking speed, and and strength, which are well-known specific markers of
low social support. Interestingly, frailty scores decreased as sarcopenia.
PASE score increased, especially when frailty was assessed
by means of the Rockwood index (Table 2).
The relationship among muscle mass and strength
and PASE score in noninstitutionalized older adults is
shown in Figure 1. In our sample, both muscle mass
(8.2 [1.0] to 15.5 [2.8] kg/m2) and muscle strength (22.1
[6.8] to 43.9 [8.5] kg) significantly increased as PASE
score increased.
Finally, Figures 2A and 2B show the curvilinear relation-
ships between skeletal muscle mass (A) and strength (B)
and PASE that were found in our sample of noninstitution-
alized older adults.

DISCUSSION
The present study indicates that PASE score, one of the
most appropriate tools for the assessment of physical
activity in the older adults, is lower in sarcopenic than in
nonsarcopenic, noninstitutionalized older adults. In these Figure 1. Muscle mass and strength stratified by Physical
participants, moreover, there is a curvilinear relationship Activity Scale for the Elderly 0 to 40, 41 to 90, and more
between PASE score and both muscle mass and strength. than 90 in noninstitutionalized elderly people; P for trend
This evidence suggests that a reduction in physical activity .001 for both muscle mass and strength.

Journal of GERIATRIC Physical Therapy 133

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 Research Report
A more rapid loss of muscle mass and strength, indicating
y=4.68+(22.04-4.68)*(1-exp(-0.008x))
R2=0.63
25
Muscle Mass, kg/m 2
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20
15
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10
5 In contrast, exercise training has frequently been shown
0 viduals, which is also associated with functional improve-
0 50 100
PASE
B
y=13.16+(75.62-13.16)*(1-exp(-0.005x))
R2=0.51
80
Muscle Strength, kg
60
40
20
0
0 50 100
PASE
Figure 2. Regression linear relationship among muscle
mass (A) and muscle strength (B) and Physical Activity
Scale for the Elderly in noninstitutionalized elderly people.
Sarcopenia and Physical Activity
Our conclusions seem consistent with previous observa-
tions using self-report and objective measures of physical
activity.26,27 In community-dwelling Japanese individuals
aged 65 to 84 years, participants with higher usual physi-
cal activity levels had higher lean mass over the 5 years of
observation. In particular, a multivariate-adjusted propor-
tional hazards model predicted that, over the next 5 years,
men and women in the 2 lowest activity quartiles (<6700
and <6800 steps per day) were 2.3 and 3.0 times as likely
to be sarcopenic compared with those in the highest activity
quartile (>9000 and >8400 steps per day), respectively.26
It has been demonstrated that, in 2264 Korean community-
dwelling older adults aged 65 years and older, moderate
and high levels of physical activity were associated with a
lower risk of sarcopenia.27 Accordingly, it is widely known
that disuse and a sedentary lifestyle lead to greater and
134
Copyright © 2017 The Academy of Geriatric Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
that disuse may be more responsible for muscle atrophy
and weakness than aging alone.8 Another classical example
of disuse-induced sarcopenia is hospitalization: in this
context the rate of sarcopenic muscle loss is exaggerated.27
Accordingly, physical inactivity may negatively influence
muscle anabolism and catabolism and determine oxidative
stress, muscle inflammation, muscle denervation, and exci-
tation-contraction coupling alterations leading to a progres-
sive fiber loss and fiber atrophy.28 Interestingly, recently it
has been suggested that the surviving fibers are still prone to
plasticity in response to functional demand such as exercise,
in order to maintain optimal force-generating capacity.29
to preserve or improve muscle mass in healthy older indi-
150 200 ments in muscle strength. In fact, quadriceps muscle volume
was higher in parallel with increased fiber cross-sectional
area in adults older than 75 years performing 12 weeks of
aerobic exercise.30
Sarcopenia and PASE Score
To the best of our knowledge, this is the first report on the
relationship between sarcopenia and PASE score. In our
sample of noninstitutionalized older adults, the PASE score
was lower in sarcopenic than in nonsarcopenic participants.
The PASE score was also correlated with muscle strength
and mass indices through a curvilinear relationship (R2 =
0.63 and R2 = 0.51, respectively), indicating that low PASE
scores are strictly related to low muscle mass and strength.
Interestingly, when stratified in tertiles, participants in the
lowest tertile (0-40 PASE score) had several characteristics
of frail older adults (ie, low MMSE score, high GDS score,
150 200 and BADL and IADL lost), whereas in the highest tertile (ie,
>90), these characteristics were absent. Accordingly, the
frailty scores identified by Fried’s and Rockwood’s methods
were 2.7 (1.0) and 12.0 (6.7) at the highest PASE tertile
whereas were 4.0 (1.5) and 22.2 (9.1) at the lowest PASE
tertile, respectively.
CONCLUSIONS
Scores from the PASE, one of the most appropriate tools
for the assessment of physical activity in older adults, are
lower in sarcopenic noninstitutionalized older adults, and are
curvilinearly related to muscle mass and strength. Detection
of sarcopenia with BIA methods and not with dual-energy
x-ray absorptiometry (preferred tool for the diagnosis of sar-
copenia) may represent a limitation of the study. However,
the BIA method allows the identification of older adults at
high risk of sarcopenia in the presence of a low PASE score.
ACKNOWLEDGMENT
PA is the initiator of the study and responsible for the con-
cept and design, data acquisition, analysis, interpretation,
and preparation of the article. DB and FC contributed to
the concept and design, analysis, and interpretation, and
Volume 42 • Number 3 • July-September 2019

preparation of the article. All authors contributed to the
acquisition of the data, study concept and design and criti-
cal review of the article. All authors read and approved the
final article and agree to be accountable for all aspects of
the work.
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The study was performed according to the Declaration
of Helsinki, and was approved by the Committee for
Medical and Health Research Ethics of University of
Naples Federico II, Italy (n.17/2014). Informed consent
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/29/2023
was signed by the patients before entering the study. No
experimental interventions were performed.
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