1
|
Pike MR, Lipner E, O'Brien KJ, Breen EC, Cohn BA, Cirillo PM, Krigbaum NY, Kring AM, Olino TM, Alloy LB, Ellman LM. Prenatal maternal Inflammation, childhood cognition and adolescent depressive symptoms. Brain Behav Immun 2024; 119:908-918. [PMID: 38761818 DOI: 10.1016/j.bbi.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 04/10/2024] [Accepted: 05/12/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Accumulating evidence indicates that higher prenatal maternal inflammation is associated with increased depression risk in adolescent and adult-aged offspring. Prenatal maternal inflammation (PNMI) may increase the likelihood for offspring to have lower cognitive performance, which, in turn, may heighten risk for depression onset. Therefore, this study explored the potential mediating role of childhood cognitive performance in the relationship between PNMI and adolescent depressive symptoms in offspring. METHODS Participants included 696 mother-offspring dyads from the Child Health and Development Studies (CHDS) cohort. Biomarkers of maternal inflammation [interleukin (IL)-6, IL-8, IL-1 receptor antagonist (IL-1RA) and soluble TNF receptor-II (sTNF-RII)] were assayed from first (T1) and second trimester (T2) sera. Childhood (ages 9-11) cognitive performance was assessed via standardized Peabody Picture Vocabulary Test (PPVT), a measure of receptive vocabulary correlated with general intelligence. Adolescent (ages 15-17) depressive symptoms were assessed via self-report. RESULTS There were no significant associations between T1 biomarkers and childhood PPVT or adolescent depressive symptoms. Higher T2 IL1-RA was directly associated with lower childhood PPVT (b = -0.21, SE = 0.08, t = -2.55, p = 0.01), but not with adolescent depressive symptoms. T2 IL-6 was not directly associated with childhood PPVT, but higher T2 IL-6 was directly associated at borderline significance with greater depressive symptoms in adolescence (b = 0.05, SE = 0.03, t = 1.96, p = 0.05). Lower childhood PPVT predicted significantly higher adolescent depressive symptoms (b = -0.07, SE = 0.02, t = -2.99, p < 0.01). There was a significant indirect effect of T2 IL-1RA on adolescent depressive symptoms via childhood PPVT (b = 0.03, 95 % CI = 0.002-0.03) indicating a partially mediated effect. No significant associations were found with T2 sTNF-RII nor IL-8. CONCLUSIONS Lower childhood cognitive performance, such as that indicated by a lower PPVT score, represents a potential mechanism through which prenatal maternal inflammation contributes to adolescent depression risk in offspring.
Collapse
Affiliation(s)
- Madeline R Pike
- Temple University, Department of Psychology and Neuroscience, 1701 N 13th St, Philadelphia, PA 19122, USA.
| | - Emily Lipner
- Temple University, Department of Psychology and Neuroscience, 1701 N 13th St, Philadelphia, PA 19122, USA
| | - Kathleen J O'Brien
- Temple University, Department of Psychology and Neuroscience, 1701 N 13th St, Philadelphia, PA 19122, USA
| | - Elizabeth C Breen
- Cousins Center for Psychoneuroimmunology, University of California-Los Angeles, 300 Medical Plaza, Suite 3306, Los Angeles, CA 90095-7076, USA
| | - Barbara A Cohn
- Child Health and Development Studies, Public Health Institute, 1683 Shattuck Ave., Suite B, Berkeley, CA 94709, USA
| | - Piera M Cirillo
- Child Health and Development Studies, Public Health Institute, 1683 Shattuck Ave., Suite B, Berkeley, CA 94709, USA
| | - Nickilou Y Krigbaum
- Child Health and Development Studies, Public Health Institute, 1683 Shattuck Ave., Suite B, Berkeley, CA 94709, USA
| | - Ann M Kring
- University of California, Berkeley, Department of Psychology, 2121 Berkeley Way, Berkeley, CA 94720, USA
| | - Thomas M Olino
- Temple University, Department of Psychology and Neuroscience, 1701 N 13th St, Philadelphia, PA 19122, USA
| | - Lauren B Alloy
- Temple University, Department of Psychology and Neuroscience, 1701 N 13th St, Philadelphia, PA 19122, USA
| | - Lauren M Ellman
- Temple University, Department of Psychology and Neuroscience, 1701 N 13th St, Philadelphia, PA 19122, USA
| |
Collapse
|
2
|
Meredith Weiss S, Aydin E, Lloyd-Fox S, Johnson MH. Trajectories of brain and behaviour development in the womb, at birth and through infancy. Nat Hum Behav 2024; 8:1251-1262. [PMID: 38886534 DOI: 10.1038/s41562-024-01896-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 04/04/2024] [Indexed: 06/20/2024]
Abstract
Birth is often seen as the starting point for studying effects of the environment on human development, with much research focused on the capacities of young infants. However, recent imaging advances have revealed that the complex behaviours of the fetus and the uterine environment exert influence. Birth is now viewed as a punctuate event along a developmental pathway of increasing autonomy of the child from their mother. Here we highlight (1) increasing physiological autonomy and perceptual sensitivity in the fetus, (2) physiological and neurochemical processes associated with birth that influence future behaviour, (3) the recalibration of motor and sensory systems in the newborn to adapt to the world outside the womb and (4) the effect of the prenatal environment on later infant behaviours and brain function. Taken together, these lines of evidence move us beyond nature-nurture issues to a developmental human lifespan view beginning within the womb.
Collapse
Affiliation(s)
- Staci Meredith Weiss
- University of Cambridge, Department of Psychology, Cambridge, UK.
- University of Roehampton, School of Psychology, London, UK.
| | - Ezra Aydin
- University of Cambridge, Department of Psychology, Cambridge, UK
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Sarah Lloyd-Fox
- University of Cambridge, Department of Psychology, Cambridge, UK
| | - Mark H Johnson
- University of Cambridge, Department of Psychology, Cambridge, UK
- Centre for Brain and Cognitive Development, Birkbeck, University of London, London, UK
| |
Collapse
|
3
|
Rinne GR, Carroll JE, Guardino CM, Shalowitz MU, Ramey SL, Schetter CD. Parental Preconception Posttraumatic Stress Symptoms and Maternal Prenatal Inflammation Prospectively Predict Shorter Telomere Length in Children. Psychosom Med 2024; 86:410-421. [PMID: 37594236 PMCID: PMC10879462 DOI: 10.1097/psy.0000000000001241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
Abstract
OBJECTIVE Parental trauma exposure and trauma-related distress can increase the risk of adverse health outcomes in offspring, but the pathways implicated in intergenerational transmission are not fully explicated. Accelerated biological aging may be one mechanism underlying less favorable health in trauma-exposed individuals and their offspring. This study examines the associations of preconception maternal and paternal posttraumatic stress disorder (PTSD) symptoms with child telomere length, and maternal prenatal C-reactive protein (CRP) as a biological mechanism. METHODS Mothers ( n = 127) and a subset of the fathers ( n = 84) reported on PTSD symptoms before conception. Mothers provided blood spots in the second and third trimesters that were assayed for CRP. At age 4 years, children provided buccal cells for measurement of telomere length. Models adjusted for parental age, socioeconomic status, maternal prepregnancy body mass index, child biological sex, and child age. RESULTS Mothers' PTSD symptoms were significantly associated with shorter child telomere length ( β = -0.22, SE = 0.10, p = .023). Fathers' PTSD symptoms were also inversely associated with child telomere length ( β = -0.21, SE = 0.11), although nonsignificant ( p = .065). There was no significant indirect effect of mothers' PTSD symptoms on child telomere length through CRP in pregnancy, but higher second-trimester CRP was significantly associated with shorter child telomere length ( β = -0.35, SE = 0.18, p = .048). CONCLUSIONS Maternal symptoms of PTSD before conception and second-trimester inflammation were associated with shorter telomere length in offspring in early childhood, independent of covariates. Findings indicate that intergenerational transmission of parental trauma may occur in part through accelerated biological aging processes and provide further evidence that prenatal proinflammatory processes program child telomere length.Open Science Framework Preregistration:https://osf.io/7c2d5/?view_only=cd0fb81f48db4b8f9c59fc8bb7b0ef97 .
Collapse
Affiliation(s)
| | - Judith E. Carroll
- Cousins Center for Psychoneuroimmunology, University of California, Los Angeles
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
- David Geffen School of Medicine, University of California, Los Angeles
| | | | | | - Sharon Landesman Ramey
- Fralin Biomedical Research Institute. Virginia Polytechnic Institute and State University
| | | |
Collapse
|
4
|
Rinne GR, Mahrer NE, Guardino CM, Shalowitz MU, Ramey SL, Dunkel Schetter C. Childhood family stress modifies the association between perinatal stressful life events and depressive symptoms. JOURNAL OF FAMILY PSYCHOLOGY : JFP : JOURNAL OF THE DIVISION OF FAMILY PSYCHOLOGY OF THE AMERICAN PSYCHOLOGICAL ASSOCIATION (DIVISION 43) 2023; 37:432-442. [PMID: 36996242 PMCID: PMC10238650 DOI: 10.1037/fam0001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The childhood family environment can influence long-term well-being in part by modifying how individuals' respond to and cope with stress across the life span. Theoretical models propose that childhood stress will either exacerbate (stress sensitization) or attenuate (steeling effect) the effects of adult stress on mental health. This study tests whether childhood family stress modifies the association between stressful life events and depressive symptoms in pregnancy and consecutive postpartum periods. A sample of 127 women reported on depressive symptoms after one birth, during a subsequent pregnancy, and postpartum following that birth. Childhood family stress was assessed with the Risky Families Questionnaire. Stressful life events were measured at all three timepoints to capture the number of life events during both pregnancies and between pregnancies. Associations between stressful life events and depressive symptoms varied as a function of childhood family stress. At the between-persons level, more stressful life events were associated with greater depressive symptoms among women who reported infrequent exposure to childhood family stress in this sample, but not among women who reported more frequent exposure to childhood family stress. Results provide novel evidence that moderate exposure to childhood family stress may attenuate the association between stressful life events and depressive symptoms in the perinatal period, consistent with a steeling effect. That is, some degree of childhood family stress may promote resilience to perinatal stress. Findings underscore the utility of examining the interaction of risk factors across the life span in predicting perinatal mental health. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
Collapse
Affiliation(s)
- Gabrielle R. Rinne
- Department of Psychology, University of California, Los Angeles. Los Angeles, CA
| | | | | | | | - Sharon L. Ramey
- Fralin Biomedical Research Institute, Department of Psychology, Department of Psychiatry, Virginia Polytechnic Institute and State University. Blacksburg, VA
| | | |
Collapse
|
5
|
Nigg JT. Considerations toward an epigenetic and common pathways theory of mental disorder. JOURNAL OF PSYCHOPATHOLOGY AND CLINICAL SCIENCE 2023; 132:297-313. [PMID: 37126061 PMCID: PMC10153068 DOI: 10.1037/abn0000748] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Psychopathology emerges from the dynamic interplay of physiological and mental processes and ecological context. It can be seen as a failure of recursive, homeostatic processes to achieve adaptive re-equilibrium. This general statement can be actualized with consideration of polygenic liability, early exposures, and multiunit (multi-"level") analysis of the psychological action and the associated physiological and neural operations, all in the context of the developmental exposome. This article begins by identifying key principles and clarifying key terms necessary to mental disorder theory. It then ventures a sketch of a model that highlights epigenetic dynamics and proposes a common pathways hypothesis toward psychopathology. An epigenetic perspective elevates the importance of developmental context and adaptive systems, particularly in early life, while opening the door to new mechanistic discovery. The key proposal is that a finite number of homeostatic biological and psychological mechanisms are shared across most risky environments (and possibly many genetic liabilities) for psychopathology. Perturbation of these mediating mechanisms leads to development of psychopathology. A focus on dynamic changes in these homeostatic mechanisms across multiple units of analysis and time points can render the problem of explaining psychopathology tractable. Key questions include the mapping of recursive processes over time, at adequate density, as mental disorders unfold across development. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
Collapse
Affiliation(s)
- Joel T Nigg
- Department of Psychiatry, Oregon Health & Science University
| |
Collapse
|
6
|
Méndez Leal AS, Silvers JA, Carroll JE, Cole SW, Ross KM, Ramey SL, Shalowitz MU, Dunkel Schetter C. Maternal early life stress is associated with pro-inflammatory processes during pregnancy. Brain Behav Immun 2023; 109:285-291. [PMID: 36280180 PMCID: PMC10035632 DOI: 10.1016/j.bbi.2022.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 10/12/2022] [Accepted: 10/15/2022] [Indexed: 11/07/2022] Open
Abstract
Early life stress (ELS) is common in the United States and worldwide, and contributes to the development of psychopathology in individuals with these experiences and their offspring. A growing body of research suggests that early life stress may contribute to adverse health partly through modulation of immune (and particularly inflammatory) responses. Therefore, increased maternal prenatal inflammation has been proposed as a mechanistic pathway by which the observed cross-generational effects of parental early life stress on child neuropsychiatric outcomes may be exerted. We examined associations between early life stress and molecular markers of inflammation (specifically pro-inflammatory gene expression and receptor-mediated transcription factor activity) and a commonly studied circulating marker of inflammation (C-Reactive Protein) in a diverse group of women in or near their third trimester of pregnancy, covarying for age, race/ethnicity, BMI, concurrent infection, concurrent perceived stress, and per capita household income. Mothers who experienced higher levels of early life stress had significantly increased pro-inflammatory (NF-κB) and decreased anti-viral (IRF) transcription factor activity. Transcripts that were up or down regulated in mothers with high ELS were preferentially derived from both CD16+ and CD16- monocytes. Early life stress was not associated with elevated CRP. Taken together, these findings provide preliminary evidence for an association between ELS and a pro-inflammatory transcriptional phenotype during pregnancy that may serve as a mechanistic pathway for cross-generational transmission of the effects of early life stress on mental and physical health.
Collapse
Affiliation(s)
| | - Jennifer A Silvers
- Department of Psychology, University of California, Los Angeles, CA, USA
| | - Judith E Carroll
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, CA, USA; Cousins Center for Psychoneuroimmunology, University of California, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Steve W Cole
- Cousins Center for Psychoneuroimmunology, University of California, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Kharah M Ross
- Centre for Social Sciences, Athabasca University, Athabasca, AB, Canada
| | - Sharon L Ramey
- Fralin Biomedical Research Institute, Virginia Tech, Roanoke, VA
| | - Madeleine U Shalowitz
- Department of Pediatrics, NorthShore University HealthSystem Research Institute, Evanston, IL, USA; Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL; Department of Pediatrics, Rush University Medical Center, Chicago, IL
| | | |
Collapse
|
7
|
Orsolini L, Pompili S, Volpe U. C-Reactive Protein (CRP): A Potent Inflammation Biomarker in Psychiatric Disorders. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1411:135-160. [PMID: 36949309 DOI: 10.1007/978-981-19-7376-5_7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
An increasing number of studies have investigated the role of inflammation in psychiatric disorders, by demonstrating how an altered/dysfunctional immunological and inflammatory system may underpin a psychiatric condition. Particularly, several studies specifically investigated the role of a neuroinflammatory biomarker, named C-reactive protein (CRP), in psychiatric disorders. Overall, even though scientific literature so far published still does not appear definitive, CRP is more likely reported to be elevated in several psychiatric disorders, including schizophrenia, mood disorders, anxiety disorders and post-traumatic stress disorder. Moreover, a low-grade inflammation (CRP >3 mg/L) has been more likely observed in a subgroup of patients affected with a more severe psychopathological symptomatology, more treatment resistance and worst clinical mental illness course, strengthening the hypothesis of the need for a different clinical and prognostic characterization based on this concomitant neuroinflammatory predisposition. However, even though further research studies are needed to confirm this preliminary evidence, CRP may represent a potential clinical routine biomarker which could be integrated in the clinical routine practice to better characterize clinical picture and course as well as address clinicians towards a personalized treatment.
Collapse
Affiliation(s)
- Laura Orsolini
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy.
| | - Simone Pompili
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| | - Umberto Volpe
- Unit of Clinical Psychiatry, Department of Clinical Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| |
Collapse
|
8
|
Guardino CM, Rahal D, Rinne GR, Mahrer NE, Davis EP, Adam EK, Shalowitz MU, Ramey SL, Schetter CD. Maternal stress and mental health before pregnancy and offspring diurnal cortisol in early childhood. Dev Psychobiol 2022; 64:e22314. [PMID: 36282760 PMCID: PMC10111814 DOI: 10.1002/dev.22314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/01/2022] [Accepted: 07/08/2022] [Indexed: 01/27/2023]
Abstract
The current study investigates whether prepregnancy maternal posttraumatic stress disorder (PTSD) symptoms, depressive symptoms, and stress predict children's cortisol diurnal slopes and cortisol awakening responses (CARs) adjusting for relevant variables. Mothers were enrolled after delivering a baby and followed through their subsequent pregnancy with 5 years of longitudinal data on their subsequent child. This prospective design allowed assessment of PTSD symptoms, depressive symptoms, and perceived stress prior to pregnancy. Children provided three saliva samples per day on three consecutive days at two timepoints in early childhood (M age = 3.7 years, SD = 0.38; M age = 5.04 years, SD = 0.43). Mothers' PTSD symptoms prior to pregnancy were significantly associated with flatter child diurnal cortisol slopes at 4 and 5 years, but not with child CAR. Findings at the age of 4 years, but not 5 years, remained statistically significant after adjustment for maternal socioeconomic status, race/ethnicity, child age, and other covariates. In contrast, maternal prepregnancy depressive symptoms and perceived stress did not significantly predict cortisol slopes or CAR. Results suggest that maternal prepregnancy PTSD symptoms may contribute to variation in early childhood physiology. This study extends earlier work demonstrating risk of adverse outcomes among children whose mothers experienced trauma but associations cannot be disentangled from effects of prenatal mental health of mothers on children's early childhood.
Collapse
Affiliation(s)
| | - Danny Rahal
- Department of Psychology, University of California, Los Angeles, Los Angeles, California, USA
| | - Gabrielle R Rinne
- Department of Psychology, University of California, Los Angeles, Los Angeles, California, USA
| | - Nicole E Mahrer
- Psychology Department, University of La Verne, La Verne, California, USA
| | - Elysia Poggi Davis
- Department of Psychology, University of Denver, Denver, Colorado, USA
- Department of Pediatrics, University of California, Irvine, Irvine, California, USA
| | - Emma K Adam
- School of Education and Social Policy and Institute for Policy Research, Northwestern University, Evanston, Illinois, USA
| | - Madeleine U Shalowitz
- Department of Pediatrics, NorthShore University HealthSystem Research Institute, Evanston, Illinois, USA
| | - Sharon L Ramey
- Department of Psychology, Virginia Tech, Blacksburg, Virginia, USA
| | | |
Collapse
|
9
|
Salinas-Roca B, Rubió-Piqué L, Montull-López A. Polyphenol Intake in Pregnant Women on Gestational Diabetes Risk and Neurodevelopmental Disorders in Offspring: A Systematic Review. Nutrients 2022; 14:nu14183753. [PMID: 36145129 PMCID: PMC9502213 DOI: 10.3390/nu14183753] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/03/2022] [Accepted: 09/08/2022] [Indexed: 11/18/2022] Open
Abstract
The intake of foods containing polyphenols can have a protective role to avoid comorbidities during pregnancy and, at the same time, promote transgenerational health. This review aims to describe the effect of polyphenol intake through supplements or polyphenol-rich foods during pregnancy on the incidence and evolution of gestational diabetes mellitus (GDM), as well as the link with the neurodevelopment of the fetus. Using PRISMA procedures, a systematic review was conducted by searching in biomedical databases (PubMed, Cinahl and Scopus) from January to June 2022. Full articles were screened (n = 419) and critically appraised. Fourteen studies were selected and were divided into two different thematic blocks considering (i) the effect of polyphenols in GDM and (ii) the effect of GDM to mental disorders in the offspring. A positive relationship was observed between the intake of polyphenols and the prevention and control of cardiometabolic complications during pregnancy, such as GDM, which could be related to thwarted inflammatory and oxidative processes, as well as neuronal factors. GDM is related to a greater risk of suffering from diseases related to neurodevelopment, such as attention deficit hyperactivity disorder, autism spectrum disorder and learning disorder. Further clinical research on the molecule protective mechanism of polyphenols on pregnant women is required to understand the transgenerational impact on fetal neurodevelopment.
Collapse
Affiliation(s)
- Blanca Salinas-Roca
- Global Research on Wellbeing (GRoW) Research Group, Blanquerna School of Health Science, Ramon Llull University, Padilla, 326-332, 08025 Barcelona, Spain
- Department of Nursing and Physiotherapy, University of Lleida, Montserrat Roig 2, 25198 Lleida, Spain
- Correspondence:
| | - Laura Rubió-Piqué
- Antioxidants Research Group, Food Technology Department, AGROTECNIO-CERCA Center, University of Lleida, Av/Alcalde Rovira Roure 191, 25198 Lleida, Spain
| | - Anna Montull-López
- Department of Nursing and Physiotherapy, University of Lleida, Montserrat Roig 2, 25198 Lleida, Spain
| |
Collapse
|