Emilio Filippucci

Università Politecnica delle Marche, Ancona, The Marches, Italy

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Publications (187)579.95 Total impact

  • Emilio Filippucci, Luca Di Geso, Walter Grassi
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    ABSTRACT: For decades, diagnostic imaging in rheumatology has used conventional radiography. Over the past 10 years, MRI and ultrasonography have clearly shown their potential in diagnostic imaging in rheumatology and their use is revolutionizing the management of chronic arthritis, revealing subclinical inflammation and predicting progression of joint damage. Although validation processes for these imaging modalities are still ongoing, several investigations have now established the positive correlation between subclinical synovitis and radiographic progression of joint damage. Despite the available evidence and the diagnostic potential, there remains a substantial proportion of rheumatologists for whom MRI and ultrasonography findings do not influence their clinical decision-making. This Perspectives will discuss the key issues related to diagnostic imaging in patients with chronic arthritis, outlining how new imaging techniques have evolved over the past two decades and presenting the most attractive technological advances in this field.
    Nature Reviews Rheumatology 09/2014; · 9.75 Impact Factor
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    ABSTRACT: Objective To standardize ultrasound (US) in enthesitis.Methods An initial Delphi exercise was undertaken to define US-detected enthesitis and its core components. These definitions were subsequently tested on static images taken from spondyloarthritis patients in order to evaluate their reliability.ResultsExcellent agreement (>80%) was obtained for including hypoechogenicity, increased thickness of the tendon insertion, calcifications, enthesophytes, erosions, and Doppler activity as core elementary lesions of US-detected enthesitis. US definitions were subsequently obtained for each elementary component. On static images, the intraobserver reliability showed a high degree of variability for the detection of elementary lesions, with kappa coefficients ranging from 0.13–1. The interobserver kappa values were variable, with the lowest kappa coefficient for enthesophytes (0.24) and the highest coefficient for Doppler activity at the enthesis (0.63).Conclusion This is the first consensus-based US definition of enthesitis and its elementary components and the first step performed to ensure a higher degree of homogeneity and comparability of results between studies and in daily clinical work.
    Arthritis Care & Research. 05/2014; 66(5).
  • Walter Grassi, Emilio Filippucci
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    ABSTRACT: Ultrasonography in the '70s was a well-known and widely used method within several medical specialties but not in rheumatology. Initial development of the field was led by radiologists who mainly investigated the potential of ultrasound in the assessment of large joints. In the late '80s, the first studies supporting the role of ultrasound in the detection of soft tissue changes and bone erosions in the hands of patients with rheumatoid arthritis were published. In the '90s, the dramatic improvement of spatial resolution due to the new generation high frequency probes opened up new avenues for the exploration of otherwise undetectable anatomical details. Ultrasound research during this period was enhanced by the growing use of colour Doppler and power Doppler and by the first prototypes of three dimensional ultrasound. Over the last 10 years, the buzz words in ultrasound research in rheumatology have been standardisation, early diagnosis and therapy monitoring.
    Clinical and experimental rheumatology 02/2014; · 2.66 Impact Factor
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    ABSTRACT: In the last decade, an increasing number of rheumatologists have been using ultrasound (US) for assessing patients with gout and calcium pyrophosphate deposition (CPPD) disease. The high reflectivity of the crystalline aggregates and the ability of US to detect even minimal crystal deposits explain the high sensitivity of this imaging technique. Furthermore, the peculiar distribution within the target tissues results in the generation of typical US patterns and explains the excellent specificity of some US findings. The large spectrum of US findings and their wide combination generate different scenarios in different patients and also in the same subject. Such a high variety impaired the standardisation of the definitions of each US finding. This review presents the main US findings indicative of crystal deposits, discusses the available evidence supporting the use of US in patients with gout and CPPD disease, and provides a research agenda to guide further investigations. The combined US examination of the target tissues and the clinically involved sites represents the key issue to obtain the best compromise between accuracy and feasibility, in the daily US assessment of patients with crystal-related arthropathies. Moreover, the US guided aspiration of synovial fluid may enhance the possibility to reach a crystal-proven diagnosis, making US a complementary tool, not in contrast, with microscopy, which rests the current gold standard. Finally, even if at moment other US findings are not included among the typical ones for crystal-related arthropathies, it is possible that in the future, thanks to continuous technological advances, we will be able to identify other specific patterns of pathology.
    Clinical and experimental rheumatology 02/2014; · 2.66 Impact Factor
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    ABSTRACT: Objective. The objective of this study was to determine the prevalence and distribution of bone erosions detectable by US in patients with early RA (ERA) in comparison with long-standing RA (LSRA), other erosive diseases and healthy controls.Methods. Thirty patients with ERA and 80 patients with LSRA were consecutively recruited. Thirty patients with PsA, 15 with primary OA, 10 with gout and 20 healthy subjects were included as controls. Bone erosions were investigated at the following anatomical sites: the second and fifth metacarpal heads, the ulnar head and the first and fifth metatarsal heads, bilaterally. Dorsal, volar and lateral aspects were explored on longitudinal and transverse views.Results. At least one US bone erosion was found in 20 (66.7%) of 30 patients with ERA and in 10 (33%) of them it was found on the fifth metatarsal head. Bone erosions were most frequently found on the lateral quadrants of all scanned anatomical sites. If the second and fifth metacarpal heads and the fifth metatarsal head were scanned, an erosive disease could be found in 60% of ERA patients. The first metatarsal head was most frequently involved in the disease control group.Conclusion. This study found a high percentage of ERA patients with US bone erosions, with the fifth metatarsal head and the lateral aspects the most frequently involved site and quadrants. US scanning for bone erosions on a few target joints was found feasible and provided information not obtainable with clinical examination.
    Rheumatology (Oxford, England) 02/2014; · 4.24 Impact Factor
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    ABSTRACT: Shoulder pain is a common condition in the rheumatologist's practice, yet there are no guidelines on how to report shoulder ultrasound (US) examinations. The aim of this study was to compare scanning and reporting techniques performed by radiologists and rheumatologists and identify any discrepancies between the two. The participants in this study were five rheumatologists and two radiologists specialized in musculoskeletal US. The study was divided in 2 phases. In the first phase, each participant performed an US of 3 patients and reported the findings without knowing the patient diagnosis and the findings reported by the other operators. Other three investigators reported the US technique of each operator. Reports and images were subsequently compared to identify any discrepancies and reach consensus on a common approach. In the second phase, a US scan was performed on a fourth patient in a plenary session to assess feasibility and efficacy of the common approach The US scanning technique was similar for all operators. The differences in reporting emerged in the description of the rotator cuff disease. Radiologists provided a detailed description of lesions (measurements along 2 axis and scoring of lesions), whereas rheumatologists described carefully the inflammatory changes. The experts concluded that lesions should be measured along 2 axes and the grade of degeneration and the age of the lesion should be reported. Another difference emerged in the description of the irregularities of the bone surface. The experts concluded that the term erosion should be used only when an inflammatory joint disease is suspected. This study led to the clarification of some inconsistencies in US reporting, and represented an interesting collaborative experience between radiologists and rheumatologists.
    Reumatismo. 01/2014; 66(3):233-9.
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    ABSTRACT: To summarize the work performed by the Outcome Measures in Rheumatology (OMERACT) Ultrasound (US) Task Force on the validity of different US measures in rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA) presented during the OMERACT 11 Workshop. The Task Force is an international group aiming to iteratively improve the role of US in arthritis clinical trials. Recently a major focus of the group has been the assessment of responsiveness of a person-level US synovitis score in RA: the US Global Synovitis Score (US-GLOSS) combines synovial hypertrophy and power Doppler signal in a composite score detected at joint level. Work has also commenced examining assessment of tenosynovitis in RA and the role of US in JIA. The US-GLOSS was tested in a large RA cohort treated with biologic therapy. It showed early signs of improvement in synovitis starting at Day 7 and increasing to Month 6, and demonstrated sensitivity to change of the proposed grading. Subsequent voting questions concerning the application of the US-GLOSS were endorsed by > 80% of OMERACT delegates. A standardized US scoring system for detecting and grading severity of RA tenosynovitis and tendon damage has been developed, and acceptable reliability data were presented from a series of exercises. A preliminary consensus definition of US synovitis in pediatric arthritis has been developed and requires further testing. At OMERACT 11, consensus was achieved on the application of the US-GLOSS for evaluating synovitis in RA; and work continues on development of RA tenosynovitis scales as well as in JIA synovitis.
    The Journal of Rheumatology 11/2013; · 3.26 Impact Factor
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    ABSTRACT: Objective. The objective of this study was to draw up a set of recommendations for the format and content of the musculoskeletal ultrasonography (MSUS) report in rheumatology.Methods. A panel of rheumatologists, members of the MSUS Study Group of the Italian Society of Rheumatology, met in order to identify the main discrepancies in the MSUS report. A set of 15 recommendations was then defined, aimed at resolving the main discrepancies. They consisted of information about the motivations for the MSUS examination, the equipment, the US modalities and scanning technique, a list of the examined structures and findings, the scoring/grading systems, the number of images and main findings to include and conclusions. Subsequently a Delphi-based procedure was started in order to obtain agreement on a core set of recommendations. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%.Results. Three complete rounds were performed. The response rate was 85.2% for the first round, 78.3% for the second and 88.9% for the third. Finally, consensus was obtained for 14 of 15 statements. These 14 statements represent the recommendations of the group for the format and content of the report and documentation in MSUS in rheumatology.Conclusion. To the best of our knowledge, our group has produced the first recommendations for the format and content of the report and documentation in MSUS in rheumatology. The report is an integral part of the MSUS examination and its use in a homogeneous form can help in the correct interpretation of the findings.
    Rheumatology (Oxford, England) 11/2013; · 4.24 Impact Factor
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    ABSTRACT: Objective. To determine the sensitivity, specificity and accuracy of ultrasound (US) in the detection of cartilage calcification at knee level in patients with calcium pyrophosphate deposition (CPPD) and to assess the inter-observer reliability. Methods. Seventy-four CPPD disease patients and 83 controls with other chronic arthritis were included. All patients underwent a clinical examination, synovial fluid analysis and X-ray assessment of the knee. US examinations were performed aimed to detect hyperechoic spots within the hyaline cartilage layer and hyperechoic areas within the meniscal fibrocartilage. Twenty patients were assessed by two operators in order to calculate the inter-observer reliability. Results. A total of 314 knees in 157 patients (74 with CPPD disease, 19 with RA, 17 with SpA, 32 with OA and 15 with gout) were assessed. In patients with CPPD disease, hyaline cartilage spots were detected by US in at least one knee of 44 out of 74 (59.5%) whereas 34 out of 74 (45.9%) were detected by X-ray (p < 0.001). Meniscal fibrocartilage calcifications were detected by US in at least one knee of 67 out of 74 (90.5%) whereas 62 out of 74 (83.7%) were detected by conventional radiography (p = 0.011). The criterion validity expressed as percentage of sensitivity, specificity and accuracy of US in the detection of articular cartilage calcification was high. Both κ values and overall agreement percentages showed moderate to excellent agreement.
    Arthritis care & research. 10/2013;
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    ABSTRACT: To develop the first ultrasound scoring system of tendon damage in rheumatoid arthritis (RA) and assess its intraobserver and interobserver reliability. We conducted a Delphi study on ultrasound-defined tendon damage and ultrasound scoring system of tendon damage in RA among 35 international rheumatologists with experience in musculoskeletal ultrasound. Twelve patients with RA were included and assessed twice by 12 rheumatologists-sonographers. Ultrasound examination for tendon damage in B mode of five wrist extensor compartments (extensor carpi radialis brevis and longus; extensor pollicis longus; extensor digitorum communis; extensor digiti minimi; extensor carpi ulnaris) and one ankle tendon (tibialis posterior) was performed blindly, independently and bilaterally in each patient. Intraobserver and interobserver reliability were calculated by κ coefficients. A three-grade semiquantitative scoring system was agreed for scoring tendon damage in B mode. The mean intraobserver reliability for tendon damage scoring was excellent (κ value 0.91). The mean interobserver reliability assessment showed good κ values (κ value 0.75). The most reliable were the extensor digiti minimi, the extensor carpi ulnaris, and the tibialis posterior tendons. Ultrasound is a reproducible tool for evaluating tendon damage in RA. This study strongly supports a new reliable ultrasound scoring system for tendon damage.
    Annals of the rheumatic diseases 08/2013; · 8.11 Impact Factor
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    ABSTRACT: In order to optimize and standardize musculoskeletal ultrasonography education for rheumatologists, there is a need for competency assessments addressing the required training and practical and theoretical skills. This paper describes how these competency assessments for rheumatologists were developed and what they contain.
    Ultraschall in der Medizin 05/2013; · 4.12 Impact Factor
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    ABSTRACT: The Musculoskeletal Ultrasound Study Group of the Italian Society of Rheumatology (SIR) was founded during the 68th SIR Congress, on November 2011. The request of activation of this group was based on the increasing interest and the widespread diffusion of ultrasound in the scientific rheumatology community and on the solid experience of some Italian rheumatologists in the field. The aims of the Study Group are to stimulate the applications and use of ultrasound in the clinical practice at the level of the Italian rheumatology units and, in addition, to develop research projects at a national level...
    Reumatismo 03/2013; 65(1):46-7.
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    ABSTRACT: OBJECTIVE: To assess the extent of calcium pyrophosphate dihydrate (CPP) crystal deposition and the distribution of affected sites, using ultrasonography (US), in patients affected by CPP deposition disease (CPPD). PATIENTS AND METHODS: 42 consecutive patients affected by definite CPPD according to the McCarty criteria were enrolled in the study. All patients underwent an US examination of metacarpophalangeal joints of II, III, IV and V fingers of both hands, wrists and knees, Achilles' tendons and plantar fascia looking for CPP deposits. A dichotomous score for presence/absence of CPP and a semiquantitative score for extent of deposits (0-3: 0, absent; 1, 1-2 spots; 2, more than two spots covering <50% of the structure; 3, deposits covering >50% of the structure) were assigned to each site examined. A site distribution score (total number of affected sites) was then calculated as well as an extent score equal to the sum of the extent scores of all sites. RESULTS: The mean involvement in our patients was 4.7 sites (SD±1.7, range 2-8 sites). The knee was the most affected, site (41 of 42) followed by the wrist (at least one in 37 patients) the Achilles' tendons (23 patients), plantar fascia (11 patients) and metacarpophalangeal joints (four patients). The highest mean values of the extent score were in the menisci, followed by the hyaline cartilage of the femoral condyles and the entheses. CONCLUSIONS: The deposition of CPP crystals involves at least two sites with a mean of four sites involved in most patients affected by CPPD and is therefore an oligoarticular or polyarticular disease.
    Annals of the rheumatic diseases 03/2013; · 8.11 Impact Factor
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    ABSTRACT: Objective.To describe the learning curve of Rheumatologists with limited experience in Ultrasound (US) attending an intensive disease-oriented training programme focusing on the skills required to obtain and interpret US signs of Monosodium urate (MSU) crystal deposits at joint and periarticular tissues. Methods. Three investigators participated in a seven-days training programme, carried out on 12 male patients with gout. The agreement between the expert and the beginners was calculated in 4 sessions on eight patients with gout The US assessment was performed at the following anatomic sites: second and third metacarpophalangeal (MCP) joints; knee, tibiotalar and first metatarsophalangeal (MTP) joints; second and third finger flexors; quadriceps and patellar posterior tibialis; peroneus longus and brevis, and Achilles tendons. The presence or absence of synovial fluid/synovial hypertrophy, double contour sign, intra- or periarticular and intratendinous tophi, bursitis, bone erosions, and tendon tears was recorded. Results. A total of 416 anatomical sites were studied. Both κ values and overall agreement percentages of qualitative assessments of US gout findings showed, at the end of exercise, moderate to excellent agreement, while in the first session a poor/fair agreement was obtained. At the end of the training session, sensitivity, specificity, and feasibility of the beginners were also improved. Conclusions. After 1 week of the disease-oriented training programme, Rheumatologists with limited experience in US were satisfactorily able to detect and interpret the main US signs indicative of MSU crystal deposits at different tissues in patients with gout. © 2013 by the American College of Rheumatology.
    Arthritis care & research. 03/2013;
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    ABSTRACT: OBJECTIVES: To investigate the prevalence of shoulder ultrasound (US) detectable abnormalities in asymptomatic individuals of various ages and to correlate the US findings with clinical data. METHODS: 97 healthy subjects were enrolled in the present study. They were subgrouped according to their age, as follows: group I (20-29 years); group II (30-39 years); group III (40-49 years); group IV (50-59 years); group V (>60 years). A physical examination of both shoulders, based on a series of provocative maneuvers, was carried out. The US assessment was performed by using a Logiq9 machine equipped with a multi-frequency linear probe working at 12MHz and included the study of a number of structures for the evaluation of local abnormalities, as follows: the long head of biceps tendon (synovial effusion (SE), synovial hypertrophy (SH), power Doppler (PD) signal); the subacromion-subdeltoid and sub-scapularis bursae (SE, SH, PD signal); the rotator cuff tendons (tendinosis, calcifications, tears, impingement); the acromionclavicular (ACJ) and gleno-humeral joints (SE, SH, PD signal, osteophytes, erosions, fibrocartilage calcifications, cartilage abnormalities, tophaceous deposits). In addition, deltoid, throchite and throchine enthesopathy were searched for. RESULTS: 194 shoulders were studied in total. A low but variable percentage of joints of healthy individuals (3.1-13.4%) showed positive provocative maneuvers. 138 shoulders (71.1%) did not show any US abnormalities. The most frequent changes were SE of ACJ (25.5%), osteophytes of ACJ (23.3%), and supraspinatus tendinosis (20.6%). The prevalence of abnormalities progressively increased with age. Sub-clinical involvement was present in most cases, being provocative maneuvers positive only in a low percentage of joints. CONCLUSIONS: The present study demonstrated the presence of a wide set of US-detectable changes in healthy subjects, that were more frequently present in elderly individuals. The absence of any clinical sign of local pathology cannot exclude the presence of local abnormalities.
    Clinical and experimental rheumatology 03/2013; · 2.66 Impact Factor
  • Walter Grassi, Emilio Filippucci
    Nature Reviews Rheumatology 03/2013; · 9.75 Impact Factor
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    ABSTRACT: This case series evaluates the clinical and ultrasound response to tocilizumab treatment in patients with rheumatoid arthritis (RA). Six patients with active RA (DAS28 ≥ 3.2) for ≥6 months, refractory to conventional DMARDs or anti-TNF agents, received tocilizumab 8 mg/kg every 4 weeks, as monotherapy or in combination with DMARDs, for 6 months. The following clinical parameters were assessed monthly: number of tender joints (28 and 44 joints), number of swollen joints (28 and 44 joints), DAS28-ESR, DAS28-CRP, VAS score, global health status, health assessment questionnaire, patient global assessment of disease activity, physician global assessment of disease activity, functional assessment of chronic illness therapy (FACIT), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). All patients also underwent a gray-scale ultrasonography (US) assessment with power Doppler evaluation at each visit. All clinical parameters improved during the study, versus baseline. This improvement was statistically significant for most parameters 2 months following tocilizumab initiation and was sustained to the end of the observation period. The number of tender joints (44-joint evaluation), the FACIT score, and ESR and CRP concentrations were significantly improved versus baseline values after the first month of tocilizumab treatment. The course of US evaluations mirrored that of clinical parameters; a faster and more evident response was observed for foot joints, with respect to hand joints. This case series suggested the rapid clinical benefit of tocilizumab. Ultrasound assessment showed that the onset of this effect was faster in the foot joints than in the hand joints.
    Rheumatology International 01/2013; · 2.21 Impact Factor
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    ABSTRACT: Ultrasound (US) may be used to diagnose chronic worsened gout. US confirmed the clinical evidence of tophaceous deposits in the left elbow of a 75-year-old man; it also identified crystalline materials on the cartilage surface of the second metacarpophalangeal joint of the left hand. US may be helpful to detect signs of deposition of monosodium urate crystals in periarticular and intra-articular joints of patients with clinically suspected chronic worsened gout.
    Journal of Medical Ultrasonics 01/2013; 40(4). · 0.64 Impact Factor
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    ABSTRACT: OBJECTIVES: Musculoskeletal ultrasonography (US) has lately been applied to patients with polymyalgia rheumatica for the examination of shoulders and hip, and included in the 2012 PMR classification criteria. We aimed to perform a comprehensive overview of the literature on this topic with a systematic review. METHODS: We searched PubMed, Embase, the Cochrane library and the proceedings from EULAR and ACR congresses (2011-2012). We included studies evaluating patients with confirmed or suspected PMR, undergoing US of shoulders and/or hips. The diagnosis of PMR could be based on expert opinion or diagnostic criteria. Cohort, case-control, diagnostic accuracy studies and case-series were eligible for inclusion. The features of the included studies were presented. When available, sensitivities and specificities were calculated for primary studies. RESULTS: Out of 1736 papers identified by our search, 13 articles and 1 abstract were finally included in the review. Eight studies focused on shoulder US, 1 on hip US, 4 on both. Studies were extremely variable in terms of population, US examination, reference standard and control population. In general, at the shoulder, pathological bilateral US findings in most studies were more prevalent in patients with PMR compared to controls. When sensitivity and specificity could be calculated, bilateral findings were more sensitive. Notably, less information was available on hip US. CONCLUSIONS: US (especially in shoulder examination) is confirmed to be a potentially useful instrument to integrate clinical information in the management of patients with PMR. Its additional value in conjunction with the new classification criteria should be further tested.
    Clinical and experimental rheumatology 01/2013; 31(1):1-7. · 2.66 Impact Factor
  • Walter Grassi, Ian Gaywood, Ira Pande, Emilio Filippucci
    Clinical and experimental rheumatology 09/2012; 30(5):649-651. · 2.66 Impact Factor

Publication Stats

2k Citations
579.95 Total Impact Points


  • 2003–2014
    • Università Politecnica delle Marche
      • • Chair of Rheumatology
      • • Department of Molecular Pathology and Innovative Therapies
      Ancona, The Marches, Italy
  • 2011–2013
    • Glostrup Hospital
      • Department of Rheumatology
      København, Capital Region, Denmark
  • 2008–2013
    • Policlinico San Matteo Pavia Fondazione IRCCS
      Ticinum, Lombardy, Italy
    • Instituto Nacional de Rehabilitación
      Ciudad de México, The Federal District, Mexico
  • 2006–2013
    • Sapienza University of Rome
      • Department of Medicine
      Roma, Latium, Italy
  • 2008–2011
    • Hospital Universitario Severo Ochoa
      Madrid, Madrid, Spain
  • 2007–2011
    • Università di Pisa
      Pisa, Tuscany, Italy
    • St George Hospital
      Sydney, New South Wales, Australia
  • 2008–2010
    • Medisch Centrum Leeuwarden
      Leewarden, Friesland, Netherlands
  • 2009
    • Ankara Numune Training and Research Hospital
      Engüri, Ankara, Turkey
    • University of Pavia
      Ticinum, Lombardy, Italy
  • 2008–2009
    • Antrim Area Hospital
      Aontroim, N Ireland, United Kingdom
  • 2001
    • Università degli Studi di Siena
      Siena, Tuscany, Italy