Pisa Syndrome Secondary to Drugs: A Scope Review
Abstract
:1. Introduction
2. Methodology
2.1. Search Strategy
2.2. Inclusion and Exclusion Criteria
2.3. Data Extraction
2.4. Statistical Analysis
2.5. Definitions
3. Prevalence and Risk Factors Associated with Pisa Syndrome
Risk Factors
4. Drugs Associated with Pisa Syndrome
5. Physical Examination and Diagnostic Criteria
6. Pathophysiology
7. Clinical Manifestations
8. Differential Diagnosis
9. Management
9.1. Conservative Management
9.2. Specialized Peripheral Denervation
9.3. Deep Brain Stimulation
10. New Perspectives and Future Studies
11. Limitations
12. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Query | Search Terms | Results |
---|---|---|
Pisa syndrome | “Pisa” [All Fields] AND (“syndrom” [All Fields] OR “syndromal” [All Fields] OR “syndromally” [All Fields] OR “syndrome” [MeSH Terms] OR “syndrome” [All Fields] OR “syndromes” [All Fields] OR “syndromes” [All Fields] OR “syndromic” [All Fields] OR “syndroms” [All Fields]) | 3506 |
Pleurothotonus | “Pleurothotonus” [All Fields] | 31 |
Reference | Prevalence | Note |
---|---|---|
Yassa et al. (1991) [12] | 9.3% of females and 6.4% of males, and the mean was 8.3% | Antipsychotic treatment between 1984 and 1989 at a Canadian center |
Stübner et al. (2000) [13] | 0.037% | Large population with psychiatric disorders |
Tinazzi et al. (2015) [14] | 15% | Patients with PD who developed dopaminergic drug-induced Pisa syndrome |
Lee et al. (2018) [15] | 0.45% of males and 0.37% of females | Neuroleptic treatment. Also, there is a higher frequency of occurrence in males than in females unlike previous studies |
Naguy et al. (2022) [16] | 0.04% | Patients with Alzheimer’s disease taking acetylcholinesterase inhibitors |
Wyant et al. (2023) [17] | 0.09% to 1.7% | Antipsychotic treatment |
Reference | Age/Sex | Cause of Pisa Syndrome | Movement Disorder Onset | Management | Movement Disorder Recovery | Note |
---|---|---|---|---|---|---|
Ekbom et al. (1972) [3] | 59/F | Methylperone | Days | Methylperone was discontinued. | 2 months. Partial recovery | |
63/F | Methylperone | 7 days | Methylperone was discontinued. | 2 days. CR. | ||
69/F | Methylperone | 2 days | Methylperone was discontinued. | 2 weeks | ||
Yassa et al. (1985) [35] | 57/M | Chlorpromazine | 8 years | Chlorpromazine was discontinued. Benztropine trial was unsuccessful. | 16 h. CR. | |
32/M | Chlorpromazine | 1 week | Benztropine trial was unsuccessful. | No recovery. | ||
Guy et al. (1986) [36] | 44/F | Antipsychotic | NA | Antipsychotic was discontinued. | Undetermined time. Partial recovery. | |
Saxena et al. (1986) [37] | 37/M | Fluphenazine | 3 years | Fluphenazine was discontinued. | 6 months. CR. | |
Amore et al. (1988) [38] | 25/M | Haloperidol and chlorpromazine | NA | Haloperidol and chlorpromazine were discontinued. | Undetermined time. CR. | |
Davidson et al. (1988) [39] | 66/M | Haloperidol | 1 week | Haloperidol dose was maintained. Amantadine was prescribed. | Undetermined time. Partial recovery. | |
Remington et al. (1988) [40] | 46/M | Amitriptyline and thioridazine. | 4 days | Amitriptyline and thioridazine were discontinued. | 2 days. | Benztropine was administered, but no effect was observed. |
Chiu et al. (1989) [41] | 38/F | Several antipsychotics | Variable times | Several antipsychotics. | Variable times. Partial recovery. | Patient had partial improvement even though structural changes were observed. |
Turk et al. (1991) [42] | 15/F | Trifluoperazine | 4 days | Trifluoperazine was discontinued. | 1 week. CR. | |
Fichtner et al. (1992) [43] | 15/F | Droperidol, prochlorperazine | 2 days | Droperidol and prochlorperazine were discontinued. | 1 day. CR. | Misdiagnosed as a functional disorder. |
Suzuki et al. (1992) [44] | 22/M | Haloperidol | NA | Haloperidol was switched to pimozide. | Undetermined time. CR. | |
Suzuki et al. (1997) [33] | 58/M | Nortriptyline | 9 days | Nortriptyline dose was maintained. Biperiden was started. | 4 days. CR. | |
Bruneau et al. (1998) [45] | 45/F | Clozapine | 6 weeks | Clozapine dose was maintained. Procyclidine was started. | Undetermined time. CR. | |
Padberg et al. (1998) [46] | 85/F | Sertindole | 10 weeks | Sertindole dose was reduced. | 4 days. CR. | |
Kwak et al. (2000) [47] | 53/F | Donepezil | 4 weeks | Donepezil was discontinued. | 7 days | |
73/F | Rivastigmine | 10 days | Rivastigmine was discontinued. | 3 weeks | ||
Kropp et al. (2001) [48] | 62/F | Metoclopramide | 2 days | Metoclopramide was discontinued. | 8 days. CR. | |
Miyaoka et al. (2001) [49] | 57/M | Donepezil | 4 weeks | Donepezil was discontinued. | 7 days | |
Wölfl et al. (2001) [50] | 33/M | Intoxication with tramadol, alprazolam, diazepam, bromazepam, alcohol and dothiepin | 3 days | Intoxication episode. | 3 days. CR. | |
Jagadheesan et al. (2002) [51] | 24/F | Risperidone | 2 weeks | Risperidone was discontinued. Trihexyphenidyl was started. | Undetermined time. Partial recovery. | |
Harada et al. (2002) [52] | 25/M | Risperidone | 15 months | Risperidone was discontinued. Biperiden dose was decreased. | 3 weeks. Partial recovery. | |
Azcano et al. (2003) [53] | 19/M | Paliperidone | 1 year | Paliperidone was discontinued. | Undetermined time. CR. | |
Villarejo et al. (2003) [54] | 77/F | Donepezil | 4 weeks | Donepezil was discontinued. Biperiden was prescribed. | NA | |
72/F | Donepezil | 2 months | Donepezil was discontinued. | 10 days | ||
Ziegenbein et al. (2003) [55] | 38/F | Ziprasidone | 18 days | Ziprasidone was discontinued. | 14 days. CR. | |
Cossu et al. (2004) [34] | 72/F | Galantamine | 4 weeks | Galantamine was discontinued. Responsive to botulinum toxin. | Partial recovery. | |
Duggal et al. (2004) [56] | 82/F | Clozapine | 11 days | Clozapine was discontinued. | 2 days. CR. | |
Cannas et al. (2005) [57] | 56/M | Pergolide | 4 months | Pergolide was discontinued. | 3 months. CR. | |
Vanacore et al. (2005) [58] | 83/F | Donepezil | 1 month | Donepezil was discontinued. | 16 days | |
84/F | Donepezil | 4 months | Donepezil was discontinued. | 7 days | ||
75/F | Donepezil | 2.5 years | Donepezil was discontinued. | 14 days | ||
Arora et al. (2006) [59] | 22/M | Olanzapine | 9 months | Olanzapine was switched to clozapine. | 6 weeks. CR. | |
González Pablos et al. (2006) [60] | 60/F | Risperidone | 1 year | Risperidone was discontinued. | NA. | |
Yohanan et al. (2006) [61] | 65/M | Valproate | Months | Valproate was discontinued. | Undetermined time. CR. | |
Huvent-Grelle et al. (2007) [62] | 78/F | Galantamine | 11 months | Galantamine was discontinued. | 15 days | |
75/F | Donepezil | 4 years | Donepezil was discontinued. | 15 days | ||
72/F | Galantamine | 6 months | Galantamine was discontinued. | NA | Switching to rivastigmine. | |
76/F | Donepezil | 12 months | Donepezil was discontinued. | Partial recovery. | ||
79/M | Rivastigmine | 24 months | Rivastigmine was discontinued. | NA | ||
Hung et al. (2007) [63] | 39/F | Clozapine | 5 months | Clozapine dose was reduced. | 4 weeks. CR. | |
Nishimura et al. (2007) [64] | 29/M | Risperidone | 4 months | Risperidone was discontinued. Trihexyphenidyl was started. | 2 months. Partial recovery. | |
Rota et al. (2007) [65] | 77/F | Aripiprazole | 6 days | Aripiprazole was discontinued. | 3 days | |
Strauss et al. (2007) [66] | 50/F | Risperidone | NA | Risperidone was discontinued. | Undetermined time. CR. | |
Chen et al. (2008) [67] | 65/F | Galantamine | 6 months | Galantamine was discontinued. | Partial recovery. | |
Cordeiro et al. (2008) [68] | 18/M | Risperidone | 8 weeks | Risperidone was discontinued. Biperiden was started. | 3 days. CR. | |
Ogihara et al. (2008) [69] | 70/F | Donepezil | NA | Donepezil was discontinued. | 4 weeks. | Pisa syndrome only appeared after the introduction in a long-term donepezil therapy. |
67/F | Donepezil | 16 months | Donepezil was discontinued. | 3 weeks | Previous episodes of Pisa syndrome with quetiapine and trazodone. | |
Solla et al. (2008) [70] | 62/M | Levodopa/carbidopa/entacapone | 2 weeks | Levodopa/carbidopa/entacapone was discontinued. | Days. CR. | |
Uemura et al. (2008) [71] | 56/F | Clomipramine | 2 months | Clomipramine dose was reduced. | 1 month. CR. | |
Wang et al. (2008) [72] | 77/M | Rivastigmine | 2 weeks | Rivastigmine dose was reduced. | 3 days. CR. | Rivastigmine was correlated with a dose-dependent effect. |
Huvent-Grelle et al. (2009) [73] | 98/M | Donepezil | 3 months | Donepezil was discontinued. | 7 days. CR. | |
80/M | Donepezil | 18 months | Donepezil was discontinued. | Partial recovery | ||
Huang et al. (2009) [74] | 46/F | Aripiprazole | 3 days | Aripiprazole was discontinued. | 3 days | |
Kuo et al. (2009) [75] | 57/M | Amilsupride | 10 days | Amilsupride was discontinued. | 2 days | |
Silić et al. (2009) [76] | NA/M | Ziprasidone | 6 days | Ziprasidone was discontinued. Biperiden was started. | 1 day | |
Yeh et al. (2009) [77] | 38/M | Ziprasidone | 1 month | Ziprasidone was discontinued. Amilsupride was started without motor symptoms. | 1 week | |
Walder et al. (2009) [27] | 69/F | Quetiapine | 5 days | Quetiapine was discontinued. | 3 days | |
Albuquerque et al. (2010) [78] | 33/F | Haloperidol | 13 year | Haloperidol was discontinued. Trihexyphenidyl was started. | 3 months. Partial recovery. | New worsening with risperidone. |
Chen et al. (2010) [79] | 44/F | Aripiprazole | 2 months | Aripiprazole was discontinued. | 4 days | |
Li et al. (2010) [80] | 26/M | Amilsupride | 2 weeks | Amilsupride was discontinued. | 12 days. Partial recovery. | |
Ulhaq et al. (2010) [81] | 31/M | Risperidone | NA | Risperidone was discontinued. | Undetermined time. CR. | Reports of patients with intellectual disability. |
46/F | Risperidone | NA | Risperidone was discontinued. | Undetermined time. CR. | ||
Wu et al. (2010) [82] | 29/M | Amisulpride | 3 days | Amilsupride was discontinued. Trihexyphenidyl was started. | 1 day. CR. | |
Fasano et al. (2011) [5] | 64/M | Rasagiline | 3 weeks | Rasagiline was discontinued. | 4 weeks | |
73/M | Rasagiline | 4 weeks | Rasagiline was discontinued. | 4 weeks | ||
72/M | Rasagiline | 3 weeks | Rasagiline was discontinued. | 2 weeks | ||
67/F | Rasagiline | 4 weeks | Rasagiline was discontinued. | 3 weeks | ||
Miodownik et al. (2011)—Case 1 and Case 2 [83] | 58/M | Sertindole | 6 weeks | Sertindole was discontinued. | 2 weeks. Partial recovery. | |
38/M | Ziprasidone | 3 months | Ziprasidone was discontinued. | 2 weeks. Partial recovery. | ||
Shinfuku et al. (2011) [84] | 71/F | Donepezil | 12 months | Donepezil was discontinued. | Partial recovery. | |
Ducasse et al. (2012) [85] | 72/F | Risperidone | 1 weeks | Risperidone was discontinued. | Undetermined time. Partial recovery. | |
Ioannidis et al. (2012) [86] | 74/F | Donepezil | 1 day | Donepezil was discontinued. | 8 days | |
Kaufmann et al. (2012) [87] | 23/F | Risperidone | 1 year | Risperidone was discontinued. Biperiden was discontinued. Baclofen was started. | 1 week. Partial recovery. | |
Leelavathi et al. (2012) [88] | 80/M | Rivastigmine | 18 months | Rivastigmine was discontinued. | Partial recovery. | Switching to donepezil. |
Liuu et al. (2012) [89] | 73/M | Valproate | NA | NA | NA | |
Perrone et al. (2012) [90] | 47/F | Sertraline | 1 month | Sertraline was discontinued. | 3 weeks. Partial recovery. | |
Iuppa et al. (2013) [91] | 31/M | Risperidone | 11 years | Risperidone was discontinued. | 1 week | |
Méndez Guerrero et al. (2013) [92] | 61/F | Mirtazapine | Single dose | Mirtazapine was discontinued. | Three days. CR. | |
Teng et al. (2013) [93] | 42/M | Paliperidone | 2 months | Paliperidone was discontinued. | 2 weeks. CR. | |
Galati et al. (2014) [94] | 68/F | Ropinirole | NA | Ropinirole was discontinued. | Undetermined time. CR. | |
Olsson et al. (2014) Case 2 [95] | 38/M | Olanzapine | days | Olanzapine dose was reduced. | Undetermined time. CR. | |
Pan et al. (2014) [96] | 18/M | Paliperidone | 12 months | Paliperidone was discontinued. | 1 week. CR. | |
Wang et al. (2014) [97] | 60/F | Clotiapine withdrawal | 3 days | Baclofen and biperiden were started. | Partial recovery. | |
Zannas et al. (2014) [98] | 74.7 (mean)/17F+ 4M | Donepezil | NA | NA | NA | Food and Drug Administration Adverse Event Reporting System database |
73.9 (mean)/13F + 4M | Galantamine | NA | NA | NA | ||
75.1 (mean)/5F + 9M | Rivastigmine | NA | NA | NA | ||
Arjunan et al. (2015) [99] | 83/M | Risperidone | 2 days | Risperidone was discontinued. | Undetermined time. CR. | |
Faridhosseini et al. (2015) [2] | 33/F | Clozapine | 2 years | Clozapine dose was reduced. Biperiden was started. | 1 month. CR. | |
Miletić et al. (2015) [100] | 67/F | Risperidone | 3 days | Risperidone was discontinued. | 2 weeks. Partial recovery. | |
Pellene et al. (2015) [20] | 71/M | Pramipexole | 4 years | Pramipexole was discontinued. | 20 days. CR. | |
Botturi et al. (2016) [101] | 59/M | Valproate | 3 months | Valproate was discontinued. | Weeks. Partial recovery. | |
De Risio et al. (2016) [102] | 25/F | Aripiprazole | 28 months | Aripiprazole was discontinued. | 4 weeks | |
Güneş et al. (2016) [28] | 15/M | Risperidone | 4 years | Risperidone dose was reduced. | 2 weeks | |
Tsou et al. (2016) [103] | 37/M | Paliperidone | 3 months | Paliperidone was discontinued. Anticholinergic drugs were prescribed, but no improvement was observed. | 1 month | |
Hsu et al. (2017) [104] | 57/F | Rivastigmine | 19 months | Rivastigmine was discontinued. | 1 month | |
Kumar et al. (2017) [105] | 49/M | Lithium | 2 years | Lithium was discontinued. | 3 months | |
Mahmoud et al. (2017) [106] | 14/NA | Valproate | 5 years | Valproate was discontinued. | NA | |
Pollock et al. (2017) [107] | 87/M | Donepezil | 2 years | Donepezil was discontinued. | 3 months | |
Suresh Kumar et al. (2017) [108] | 52/F | Clozapine | 2 years | NA | NA | |
Sutter et al. (2017) [109] | 56/F | Risperidone | 4 years | Risperidone was discontinued. | 6 months | |
Chao et al. (2018) [110] | 67/F | Rivastigmine | 5 days | Rivastigmine was discontinued. | 7 days | |
Filipe et al. (2018) [111] | 56/F | Clozapine and mirabegron | 5 days | Clozapine and mirabegron | 30 days. CR. | |
Huang et al. (2018) [112] | 31/F | Clotiapine | 2 weeks | Clotiapine was discontinued. | 10 days | |
Lee et al. (2018) [15] | 47 (mean)/9M, 4F | Antipsychotics | NA | NA | NA | 13 individuals |
López-Blanco et al. (2018) [113] | 76/F | Betahistine | Single dose | Betahistine was discontinued. | 1 day | |
Mukku et al. (2018) [114] | 60/M | Donepezil | 3 months | Donepezil was discontinued. Promethazine was prescribed with partial response. Clonazepam was infective. | 3 days | |
Sosa et al. (2018) [115] | 77/F | Codeine | 1 day | Codeine was discontinued. | 3 days | |
Yamada et al. (2018) [116] | 79/F | Mirtazapine | 12 days | Mirtazapine was discontinued. | 3 days | |
Yasuda et al. (2018) [117] | 68/M | Istradefylline | 4 months | Istradefylline was discontinued. | 4 months | Patient already had a previous trunk deviation due to lumbar spondylosis. The istradefylline increased the angle. |
Ciner et al. (2019) [118] | 45/M | Paliperidone | 2 years | Paliperidone was discontinued. | NA | |
Guler et al. (2020) [119] | 12/F | Olanzapine | 3 months | Olanzapine was discontinued. Biperiden was prescribed. | 15 days | |
Hsieh et al. (2020) [120] | 62/M | Lithium | 1 week | Lithium was discontinued. | 1 day | There was worsening of the angle with lithium therapy. Dose-dependent effect. |
Mimura et al. (2020) [1] | 60/F | Galantamine | 2 weeks | Galantamine was discontinued. | 2 weeks | |
Atmaca et al. (2021) [121] | 81/F | Piribedil | 1 month | Piribedil was discontinued. | 1 month | |
Bicho et al. (2021) [122] | 48/F | Antipsychotic | NA | Antipsychotic discontinuation. Anticholinergic prescribed. | NA | |
Bruggeman et al. (2021) [123] | 68/F | Donepezil | 5 years | Donepezil discontinuation. | 6 months. CR. | Video. |
Erdem et al. (2021) [124] | 47/M | Amilsupride | 10 years | Amilsupride discontinued. Biperiden and baclofen were started. | Partial recovery | Attempt of botulinum toxin injection without improvement. |
Mascia et al. (2021) [31] | 46/M | Cocaine, sniffed | 1 h | Biperiden prescription. | 2 h | Cocaine rechallenged revealed reappearance of the symptoms. |
Santos et al. (2021) [125] | 73/F | Clozapine | NA | NA | NA | |
Simões et al. (2021) [126] | 72/F | Donepezil | 5 months | Donepezil discontinuation. | 7 days. CR. | Rivastigmine was attempted, but she had similar symptoms of donepezil use. |
Nagai et al. (2022) [127] | 71/F | Brexpiprazole | 2 months | Brexpiprazole was switched to quetiapine. | NA. Partial recovery. | |
Naguy et al. (2022) [16] | 13/M | Lithium | 4 weeks | Lithium discontinuation. | 2 weeks. CR. | |
Shen et al. (2022) [128] | 62/M | Clozapine | 3 years | Clozapine dose was reduced. | 3 days. Partial recovery. | Pisa syndrome with oral-buccal-lingual dyskinesia. |
Weise et al. (2022) [129] | 41/F | Clozapine and cariprazine | 4 weeks | Discontinuation of cariprazine. Lorazepam and biperiden were prescribed. | 3 days. CR. | Add-on cariprazine in resistant schizophrenia. |
63/M | Clozapine and cariprazine | 2 weeks | Discontinuation of cariprazine. Prescription of biperiden. | 3 weeks. CR. | Add-on cariprazine in resistant schizophrenia. | |
Muller et al. (2023) [130] | NA | Clozapine | NA | NA | NA | |
Waykar et al. (2023) [131] | 75/F | Donepezil | 6 months | Discontinuation of donepezil. Mematine prescription. | 1 month. CR. |
Drug Class | Number of Reports | Medications |
---|---|---|
Acetylcholinesterase inhibitors | 87 | Donepezil [126], galantamine [1], rasagiline [4], rivastigmine [47]. |
Atypical antipsychotics | 50 | Amilsupride [124], aripiprazole [102], brexpiprazole [127], clotiapine [112], clozapine [129], olanzapine [119], paliperidone [118], risperidone [109], ziprasidone [83]. |
Typical antipsychotics | 30 | Chlorpromazine [35], droperidol [43], fluphenazine [37], haloperidol [78], methylperone [3], sertindole [46], trifluoperazine [42]. |
Antiparkisonian medications | 6 | Istradefylline [117], levodopa/carbidopa/entacapone [70], pergolide [57], piribedil [121], pramipexole [20], ropinirole [94]. |
Anti-seizure medications | 4 | Valproate [106]. |
Antidepressants | 3 | Mirtazapine [116], sertraline [90]. |
Mood stabilizers | 3 | Lithium [16]. |
Tricyclic antidepressants | 3 | Amitriptyline [40], clomipramine [71], nortriptyline [33]. |
Opioid | 1 | Codeine [115]. |
Antiemetics | 1 | Metoclopramide [48]. |
Addictive stimulant drug | 1 | Cocaine [31]. |
Anti-vertigo medication | 1 | Betahistine [113]. |
Intoxication | 1 | Intoxication with a mixture of tramadol, alprazolam, diazepam, bromazepam, alcohol, and dothiepin [50]. |
Criteria | Reference |
---|---|
(A) More than 10 degrees of lateral trunk flexion. Bonanni et al. recommended more than 15 degrees. Tinazzi et al. classified mild (<20°) or severe (>20°) according to the angle. | Doherty et al. (2011) [136] Bonanni et al. (2007) [135] Tinazzi et al. (2015) [14] |
(B) Lateral trunk flexion is relieved by passive mobilization or supine posture. | Doherty et al. (2011) [136] |
(C) Lateral trunk flexion worsens during walking and in the absence of any mechanical restriction of the trunk. | Bonanni et al. (2007) [131] Ekbom et al. (1972) [3] |
(D) Electromyography pattern of activation of paraspinal muscles and non-paraspinal muscles. | Tassorelli et al. (2012) [133] |
(E) Supplementary imaging of neurospine for evaluation of degenerative process and musculoskeletal abnormalities. |
Medication | Movement Disorder Onset | Movement Disorder Recovery | Reference |
---|---|---|---|
Levodopa/Benserazide | 15 days | 20 days | Cannas et al. (2009) [165] |
Carbidopa/Levodopa/Entacapone | 2 weeks to 1 month | Few days to 10 days | Solla et al. (2008) [70] Cannas et al. (2009) [165] |
Rasagiline | 3–4 weeks | 2–4 weeks | Fasano et al. (2011) [4] |
Pramipexole | 2 months | 40 days | Cannas et al. (2009) [165] |
Levodopa/Carbidopa | 2 months | 2 months | Cannas et al. (2009) [165] |
Pergolide | 2–3 months | 3 months | Cannas et al. (2005) [57] Cannas et al. (2009) [165] |
Istradefylline | 4 months | 4 months | Yasuda et al. (2018) [117] |
Ropinirole | 1 year | 3 months | Galati et al. (2014) [94] |
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Pitton Rissardo, J.; Murtaza Vora, N.; Danaf, N.; Ramesh, S.; Shariff, S.; Fornari Caprara, A.L. Pisa Syndrome Secondary to Drugs: A Scope Review. Geriatrics 2024, 9, 100. https://doi.org/10.3390/geriatrics9040100
Pitton Rissardo J, Murtaza Vora N, Danaf N, Ramesh S, Shariff S, Fornari Caprara AL. Pisa Syndrome Secondary to Drugs: A Scope Review. Geriatrics. 2024; 9(4):100. https://doi.org/10.3390/geriatrics9040100
Chicago/Turabian StylePitton Rissardo, Jamir, Nilofar Murtaza Vora, Naseeb Danaf, Saivignesh Ramesh, Sanobar Shariff, and Ana Letícia Fornari Caprara. 2024. "Pisa Syndrome Secondary to Drugs: A Scope Review" Geriatrics 9, no. 4: 100. https://doi.org/10.3390/geriatrics9040100