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Elkin ER, Su AL, Kilburn BA, Bakulski KM, Armant DR, Loch-Caruso R. Toxicity assessments of selected trichloroethylene and perchloroethylene metabolites in three in vitro human placental models. Reprod Toxicol 2022; 109:109-120. [PMID: 35304307 PMCID: PMC9107309 DOI: 10.1016/j.reprotox.2022.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 03/07/2022] [Accepted: 03/10/2022] [Indexed: 01/25/2023]
Abstract
Residential and occupational exposures to the industrial solvents perchloroethylene (PERC) and trichloroethylene (TCE) present public health concerns. In humans, maternal PERC and TCE exposures can be associated with adverse birth outcomes. Because PERC and TCE are biotransformed to toxic metabolites and placental dysfunction can contribute to adverse birth outcomes, the present study compared the toxicity of key PERC and TCE metabolites in three in vitro human placenta models. We measured cell viability and caspase 3 + 7 activity in the HTR-8/SVneo and BeWo cell lines, and caspase 3 + 7 activity in first trimester villous explant cultures. Cultures were exposed for 24 h to 5-100 µM S-(1,2-dichlorovinyl)-L-cysteine (DCVC) and S-(1,2,2-trichlorovinyl)-L-cysteine (TCVC), or 5-200 µM trichloroacetate (TCA) and dichloroacetate (DCA). DCVC significantly reduced cell viability and increased caspase 3 + 7 activity in HTR-8/SVneo cells at a lower concentration (20 µM) compared with concentrations toxic to BeWo cells and villous explants. Similarly, TCVC reduced cell viability and increased caspase 3 + 7 activity in HTR-8/SVneo cells but not in BeWo cells. TCA and DCA had only negligible effects on HTR-8/SVneo or BeWo cells. This study advances understanding of potential risks of PERC and TCE exposure during pregnancy by identifying metabolites toxic in placental cells and tissues.
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Affiliation(s)
- Elana R Elkin
- Department of Environmental Health Sciences, University of Michigan, Ann Arbor, Michigan, USA; Department of Nutritional Sciences, University of Michigan, Ann Arbor, Michigan, USA.
| | - Anthony L Su
- Department of Environmental Health Sciences, University of Michigan, Ann Arbor, Michigan, USA; Department of Nutritional Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - Brian A Kilburn
- Department of Nutritional Sciences, University of Michigan, Ann Arbor, Michigan, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Kelly M Bakulski
- Department of Epidemiology, University of Michigan, Ann Arbor, Michigan, USA; Department of Nutritional Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - D Randall Armant
- Department of Nutritional Sciences, University of Michigan, Ann Arbor, Michigan, USA; Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA; Department of Anatomy and Cell Biology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Rita Loch-Caruso
- Department of Environmental Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
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Liu C, Messerlian C, Chen YJ, Mustieles V, Huang LL, Sun Y, Deng YL, Cheng YH, Liu J, Liu AM, Lu WQ, Wang YX. Trimester-specific associations of maternal exposure to disinfection by-products, oxidative stress, and neonatal neurobehavioral development. ENVIRONMENT INTERNATIONAL 2021; 157:106838. [PMID: 34450548 DOI: 10.1016/j.envint.2021.106838] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 08/13/2021] [Accepted: 08/15/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Toxicological studies suggest that maternal exposure to disinfection by-products (DBPs) can impair fetal neurodevelopment. However, evidence from epidemiological studies is scarce and the underlying mechanisms remain unclear. OBJECTIVE To explore the trimester-specific associations between maternal blood trihalomethane (THM) and urinary haloacetic acid (HAA) concentrations and neonatal neurobehavioral development, and the potential mediating role of oxidative stress (OS). METHODS We included 438 pregnant Chinese women from the Xiaogan Disinfection By-Products (XGDBP) birth cohort. Biospecimens were repeatedly collected across trimesters and measured for blood THMs, urinary HAAs, and urinary OS biomarker concentrations. On the third day after birth, the Neonatal Behavioral Neurological Assessment (NBNA) test was administered to newborns. Associations of trimester-specific DBP measurements and OS biomarkers with neonatal NBNA scores were assessed using linear regression models with generalized estimating equations. The potential mediating role of maternal OS biomarkers was also investigated using mediation analyses. RESULTS After adjusting for potential confounders, blood bromodichloromethane (BDCM) concentrations in the first trimester were inversely associated with NBNA scores [percent change comparing the extreme BDCM tertiles = -28.1% (95% CI: -55.2%, -0.88%); p for trend = 0.043]. Besides, third-trimester urinary trichloroacetic acid (TCAA) concentrations were inversely associated with NBNA scores [percent change comparing the extreme TCAA tertiles = -32.9% (95% CI: -64.7%, -1.0%); p for trend = 0.046]. These inverse associations differed across pregnancy trimesters (Type 3p-value = 0.066 and 0.053, respectively) and were stronger in male infants and mothers aged ≥25 years. There was no evidence of mediating effect by 8-hydroxy-2-deoxyguanosine (8-OHdG), 4-hydroxy-2-nonenal-mercapturic acid (HNE-MA), or 8-iso-prostaglandin F2α (8-isoPGF2α). CONCLUSIONS Higher prenatal BDCM and TCAA concentrations during specific pregnancy trimesters were associated with lower NBNA scores. However, additional research is required to investigate underlying mechanisms.
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Affiliation(s)
- Chong Liu
- Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Carmen Messerlian
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ying-Jun Chen
- Department of Epidemiology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, PR China
| | - Vicente Mustieles
- University of Granada, Center for Biomedical Research (CIBM), Spain; Consortium for Biomedical Research in Epidemiology & Public Health (CIBERESP), Madrid, Spain
| | - Li-Li Huang
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Yang Sun
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Yan-Ling Deng
- Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Ying-Hui Cheng
- The Maternal and Child Health Care Service Centre of Xiaonan District, Xiaogan City, Hubei, PR China
| | - Jing Liu
- The Maternal and Child Health Care Service Centre of Xiaonan District, Xiaogan City, Hubei, PR China
| | - A-Mei Liu
- The Maternal and Child Health Care Service Centre of Xiaonan District, Xiaogan City, Hubei, PR China
| | - Wen-Qing Lu
- Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.
| | - Yi-Xin Wang
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
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Deng YL, Yang P, Cao WC, Wang YX, Liu C, Chen YJ, Huang LL, Lu WQ, Wang LQ, Zeng Q. Urinary biomarker of late pregnancy exposure to drinking water disinfection by-products and ultrasound measures of fetal growth in Wuhan, China. ENVIRONMENTAL RESEARCH 2019; 170:128-133. [PMID: 30579986 DOI: 10.1016/j.envres.2018.12.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 11/24/2018] [Accepted: 12/10/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Disinfection by-products (DBPs) have been shown to be reproductive and developmental toxicity. However, few studies examine the effect of prenatal exposure to DBPs on fetal growth via ultrasound measures. OBJECTIVE To investigate the associations between maternal exposure to DBPs during late pregnancy and ultrasound measures of fetal growth. METHODS We included 332 pregnant women who presented to a hospital to wait for delivery in Wuhan, China. Ultrasound parameters of fetal growth including femur length (FL), head circumference (HC), abdominal circumference (AC) and biparietal diameter (BPD) were assessed. We measured maternal TCAA concentrations in first morning urine collected from late pregnancy as a biomarker of in utero DBP exposure levels. Multivariable linear regression models were used to examine the associations between maternal urinary TCAA concentrations during late pregnancy and ultrasound parameters of fetal growth. RESULTS We found that elevated maternal creatinine (Cr)-adjusted urinary TCAA levels had negative associations with BPD, HC and FL in boys but not in girls (P interaction = 0.04, 0.05 and 0.08, respectively). Male fetal BPD, HC and FL had decreases of 0.21 cm (95% CI: -0.35, -0.07; P for trend = 0.003), 0.46 cm (95% CI: -0.81, -0.10; P for trend = 0.01) and 0.17 cm (95% CI: -0.30, -0.04; P for trend = 0.01) for the highest vs. lowest tertile of Cr-adjusted urinary TCAA, respectively. These negative associations persisted for maternal Cr-adjusted urinary TCAA concentrations modeled as continuous variables. CONCLUSION The results from our study suggest that maternal exposure to TCAA during late pregnancy may have adverse effects on male fetal growth.
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Affiliation(s)
- Yan-Ling Deng
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Pan Yang
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Wen-Cheng Cao
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Yi-Xin Wang
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Chong Liu
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Ying-Jun Chen
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Li-Li Huang
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Wen-Qing Lu
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Long-Qiang Wang
- Department of Thyroid and Breast Surgery, the Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China
| | - Qiang Zeng
- Department of Occupational and Environmental Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China; Key Laboratory of Environment and Health, Ministry of Education & Ministry of Environmental Protection, and State Key Laboratory of Environmental Health (incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, PR China.
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Rivera-Núñez Z, Wright JM, Meyer A. Exposure to disinfectant by-products and the risk of stillbirth in Massachusetts. Occup Environ Med 2018; 75:742-751. [PMID: 30061312 DOI: 10.1136/oemed-2017-104861] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 05/17/2018] [Accepted: 06/03/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVES We examined stillbirths in relation to disinfection by-product (DBP) exposures including chloroform, bromodichloromethane (BDCM), dibromochloromethane, bromoform, trichloroacetic acid, dichloroacetic acid (DCAA), monobromoacetic acid and summary DBP measures (trihalomethanes (THM4), haloacetic acids (HAA5), THMBr (brominated trihalomethanes) and DBP9 (sum of THM4 and HAA5)). METHODS We randomly selected 10 controls for each of the 2460 stillbirth cases with complete quarterly 1997-2004 THM4 and HAA5 town-level drinking water data. Adjusted (aORs) were calculated based on weight-averaged second-trimester DBP exposures. RESULTS We detected statistically significant associations for stillbirths and the upper DCAA quartiles (aOR range: 1.50-1.71). We also found positive associations for the upper four HAA5 quintiles and different stillbirth cause of death categories that were examined including unexplained stillbirth (aOR range: 1.24-1.72), compression of umbilical cord (aOR range: 1.08-1.94), prematurity (aOR range: 1.37-2.88), placental separation and haemorrhage (aOR range: 1.44-2.01) and asphyxia/hypoxia (aOR range: 1.52-1.97). Additionally, we found positive associations between stillbirths and chloroform exposure (aOR range: 1.29 - 1.36) and unexplained stillbirths and BDCM exposure (aOR range: 1.51 - 1.78). We saw no evidence of exposure-response relationships for any categorical DBP metrics. CONCLUSIONS Consistent with some previous studies, we found associations between stillbirths and chloroform and unexplained stillbirth and BDCM exposures. These findings strengthen existing evidence of prenatal THM exposures increasing the risk of stillbirth. Additionally, we saw statistically significant associations between DCAA and stillbirth. Future research should examine cause-specific stillbirths in relation to narrower critical windows and additional DBP exposure metrics beyond trihalomethanes and haloacetic acids.
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Affiliation(s)
| | - J Michael Wright
- U.S. Environmental Protection Agency, National Center for Environmental Assessment, Cincinnati, Ohio, USA
| | - Amy Meyer
- Oak Ridge Institute of Science and Education Research, Oak Ridge, Tennessee, USA
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Villanueva CM, Gracia-Lavedan E, Julvez J, Santa-Marina L, Lertxundi N, Ibarluzea J, Llop S, Ballester F, Fernández-Somoano A, Tardón A, Vrijheid M, Guxens M, Sunyer J. Drinking water disinfection by-products during pregnancy and child neuropsychological development in the INMA Spanish cohort study. ENVIRONMENT INTERNATIONAL 2018; 110:113-122. [PMID: 29107351 DOI: 10.1016/j.envint.2017.10.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 10/09/2017] [Accepted: 10/22/2017] [Indexed: 05/19/2023]
Abstract
BACKGROUND Disinfection by-products (DBPs) constitute a complex mixture of prevalent chemicals in drinking water and there is evidence of neurotoxicity for some of them. OBJECTIVES We evaluated the association between estimates of DBP exposure during pregnancy and child neuropsychological outcomes at 1 and 4-5years of age. METHODS We conducted a population-based mother-child cohort study in Spain with recruitment at first trimester of gestation (INMA Project, 2003-2008). Neuropsychological development was measured at 1year of age using the Bayley Scales of Infant Development and at 4-5years with the McCarthy Scales of Children's Abilities. Modeled tap water concentrations of trihalomethanes (THM) were combined with personal ingestion, showering and bathing habits to estimate exposure as ingestion uptake, all route (showering, bathing, ingestion) uptake (μg/day) and crude levels (μg/l) in the residence. Chloroform, brominated THMs (bromodichloromethane, dibromochloromethane, bromoform) and total THMs (chloroform and brominated THMs) were analysed separately. Nine haloacetic acids levels were available in one of the areas. Linear regression was used to estimate associations in 1855 subjects adjusting for covariables. RESULTS The median concentration of total THMs, chloroform, brominated THMs, total haloacetic acids, dichloroacetic acid, and trichloroacetic acid were, respectively 30.3μg/L, 9.4μg/L, 11.6μg/L, 10.5μg/L, 2.7μg/L, and 3.1μg/L. The associations between THM exposure and neuropsychological outcomes were null, except for total and brominated THM uptake though all routes and the general cognitive score at 4-5years, with a decrease in -0.54 points (95%CI -1.03, -0.05) and -0.64 (95%CI -1.16, -0.12), respectively, for doubling total and brominated THM uptake. A positive association found between dichloroacetic acid and the mental score at 1year did not persist at 4-5years. CONCLUSIONS Minor associations observed between DBP exposure during gestation and child neuropsychological development at 1year disappeared at 4-5years. Although a suggestive association is identified for exposure to brominated THMs and the cognitive score at 4-5years, chance cannot be ruled out.
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Affiliation(s)
- Cristina M Villanueva
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.
| | - Esther Gracia-Lavedan
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Jordi Julvez
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
| | - Loreto Santa-Marina
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; BIODONOSTIA Health Research Institute, San Sebastian, Basque Country, Spain; Sub-Directorate for Public Health of Guipúzcoa, Department of Health, Government of the Basque Country, San Sebastian, Spain
| | - Nerea Lertxundi
- Faculty of Psychology, University of the Basque Country UPV/EHU, San Sebastian, Basque Country, Spain; Sub-Directorate for Public Health of Guipúzcoa, Department of Health, Government of the Basque Country, San Sebastian, Spain
| | - Jesús Ibarluzea
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; BIODONOSTIA Health Research Institute, San Sebastian, Basque Country, Spain; Faculty of Psychology, University of the Basque Country UPV/EHU, San Sebastian, Basque Country, Spain; Sub-Directorate for Public Health of Guipúzcoa, Department of Health, Government of the Basque Country, San Sebastian, Spain
| | - Sabrina Llop
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Epidemiology and Environmental Health Joint Research Unit, FISABIO-Universitat Jaume I-Universitat de València, Valencia,Spain
| | - Ferran Ballester
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Epidemiology and Environmental Health Joint Research Unit, FISABIO-Universitat Jaume I-Universitat de València, Valencia,Spain
| | - Ana Fernández-Somoano
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Preventive Medicine and Public Health Area, Department of Medicine, University of Oviedo, Asturias, Spain
| | - Adonina Tardón
- CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Preventive Medicine and Public Health Area, Department of Medicine, University of Oviedo, Asturias, Spain
| | - Martine Vrijheid
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Mònica Guxens
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Department of Child and Adolescent Psychiatry/Psychology, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jordi Sunyer
- ISGlobal, Centre for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain
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