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Monistrol-Mula A, Diaz-Torres S, Felez-Nobrega M, Haro JM, Medland SE, Mitchell BL. Genetic analyses point to alterations in immune-related pathways underpinning the association between psychiatric disorders and COVID-19. Mol Psychiatry 2024:10.1038/s41380-024-02643-0. [PMID: 38956374 DOI: 10.1038/s41380-024-02643-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 07/04/2024]
Abstract
Current literature suggests that people with psychiatric disorders have a higher risk of COVID-19 infection and a worse prognosis of the disease. We aimed to study the genetic contribution to these associations across seven psychiatric disorders as well as a general psychopathology factor (P-factor) and determine whether these are unique or shared across psychiatric disorders using statistical genetic techniques. Using the largest available genome-wide association studies (GWAS), we found a significant genetic overlap between depression, ADHD, PTSD, and the P-factor with both COVID-19 infection and hospitalization, and between anxiety and COVID-19 hospitalization. We used pairwise GWAS to examine this overlap on a fine-grained scale and identified specific regions of the genome shared between several psychiatric disorders, the P-factor, and COVID-19. Gene-based analysis in these genomic regions suggested possible links with immune-related pathways such as thyroid homeostasis, inflammation, and stress response. Finally, we show preliminary evidence for causal associations between depression, ADHD, PTSD, and the P-factor, and higher COVID-19 infection and hospitalization using Mendelian Randomization and Latent Causal Variable methods. Our results support the hypothesis that the relationship between psychiatric disorders and COVID-19 risk is likely due to shared alterations in immune-related pathways and is not a result of environmental factors alone, shedding light on potentially viable therapeutic targets.
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Affiliation(s)
- Anna Monistrol-Mula
- Group of Epidemiology of Psychiatric disorders and Ageing, Sant Joan de Déu Research Institute, Sant Boi de Llobregat, Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.
- Department of Medicine, University of Barcelona, Barcelona, Spain.
- Mental Health and Neuroscience program, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia.
| | - Santiago Diaz-Torres
- Mental Health and Neuroscience program, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Mireia Felez-Nobrega
- Group of Epidemiology of Psychiatric disorders and Ageing, Sant Joan de Déu Research Institute, Sant Boi de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
| | - Josep Maria Haro
- Group of Epidemiology of Psychiatric disorders and Ageing, Sant Joan de Déu Research Institute, Sant Boi de Llobregat, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Sarah E Medland
- Mental Health and Neuroscience program, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- School of Psychology, The University of Queensland, Brisbane, QLD, Australia
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, QLD, Australia
| | - Brittany L Mitchell
- Mental Health and Neuroscience program, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
- School of Biomedical Sciences, University of Queensland, Brisbane, QLD, Australia
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Legnani F, Tassi L, Surace T, Capuzzi E, Caldiroli A, Clerici M, Buoli M. Is Pilates effective in improving depressive disorders? A comprehensive overview. Int Clin Psychopharmacol 2024:00004850-990000000-00122. [PMID: 38277272 DOI: 10.1097/yic.0000000000000541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
Depressive disorders are disabling conditions that account for high social costs. Pilates demonstrated to have several beneficial effects on health. Objective of this manuscript was to systematically review the literature about the effects of Pilates on depressive disorders. A bibliographic search was conducted in the main database sources (Pubmed, Medline, and Scopus). The inclusion criteria consisted of articles written in English language about the effectiveness of Pilates on depressive symptoms. Most of included studies are randomized controlled trials (10 out of 12). The available literature agrees in indicating that Pilates is effective in improving depressive symptoms especially when compared to inactivity and when this practice is administered for a medium-long period (8-16 weeks). In addition, Pilates seems to have at least comparable effectiveness than aerobic exercise. Pilates can be considered a reliable complementary treatment for people with depressive disorders. These findings should be interpreted considering the different types of practice administered as well as the different duration of the programs or rating scales used to assess mood symptoms. Studies with a more homogenous design are needed to confirm and make generalizable the results presented in this review.
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Affiliation(s)
- Francesca Legnani
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan
| | - Lorenzo Tassi
- School of Medicine and Surgery, University of Milano Bicocca
| | - Teresa Surace
- Department of Mental Health, Fondazione IRCCS San Gerardo dei Tintori, Monza (MB)
| | - Enrico Capuzzi
- Department of Mental Health, Fondazione IRCCS San Gerardo dei Tintori, Monza (MB)
| | - Alice Caldiroli
- Department of Mental Health, Fondazione IRCCS San Gerardo dei Tintori, Monza (MB)
| | - Massimo Clerici
- School of Medicine and Surgery, University of Milano Bicocca
- Department of Mental Health, Fondazione IRCCS San Gerardo dei Tintori, Monza (MB)
| | - Massimiliano Buoli
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Budzyńska N, Moryś J. Stress, Burnout, and General Mental Health among Healthcare Workers in Poland during the Long-Lasting COVID-19 Pandemic. Healthcare (Basel) 2023; 11:2617. [PMID: 37830654 PMCID: PMC10572419 DOI: 10.3390/healthcare11192617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/20/2023] [Accepted: 09/21/2023] [Indexed: 10/14/2023] Open
Abstract
Medical professions are characterized by a great responsibility for human health and life; they are also vulnerable to burnout. The outbreak of the COVID-19 pandemic has brought new challenges and threats. This study aimed to assess the mental health of healthcare workers after a year and a half of working in COVID-19 pandemic conditions. The Perceived Stress Scale (PSS-10), the Link Burnout Questionnaire (LBQ), and the General Health Questionnaire (GHQ-28) were utilized in this cross-sectional investigation. A total of 335 healthcare employees from Polish hospitals (median age 44 years) filled out online questionnaires between the 16 August 2021 and the 30 March 2022. Most of the sample was female (86%). In this study, 40.0% of the surveyed healthcare workers reported a high stress intensity. Burnout was reported by 9.6% of the workers, and the most frequently experienced symptom was psychophysical exhaustion. Almost half of the healthcare workers surveyed (49.6%) reported health disorders at both the mental and physiological levels. Interestingly, working in a COVID-19 ward did not significantly differentiate healthcare workers in any of the evaluated variables: PSS-10 (gr. A F = 1.21; gr. B F = 0.71; p > 0.05), LBQ (gr. A F = 1.89, F = 0.94, F = 1.08, F = 2.57; gr. B F = 0.32, F = 1.14, F = 0.77, F = 0.36; p > 0.05), and GHQ-28 (gr. A F = 0.85, F = 0.52, F = 0.57, F = 0.31; gr. B F = 0.31, F = 0.06, F = 0.06, F = 0.54; p > 0.05). Furthermore, there were no statistically significant differences between the compared occupational groups of healthcare workers: PSS-10 (F = 1.08; p > 0.05) and GHQ-28 (F = 1.78; F = 0.85; F = 0.62; F = 0.54; p > 0.05). The mental health of healthcare workers is alarming, and psychophysical conditions can affect the quality of work and relations with patients. Psychological care in workplaces and workshops that build resources for dealing with difficult situations are necessary.
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Affiliation(s)
- Natalia Budzyńska
- Department of Clinical Psychology, Faculty of Health Sciences, Medical University of Gdańsk, 80-210 Gdańsk, Poland
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Fracas E, Costantino A, Vecchi M, Buoli M. Depressive and Anxiety Disorders in Patients with Inflammatory Bowel Diseases: Are There Any Gender Differences? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6255. [PMID: 37444101 PMCID: PMC10340762 DOI: 10.3390/ijerph20136255] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/11/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023]
Abstract
Gender differences were identified in the frequency and clinical presentations of inflammatory bowel disease (IBD) and depressive and anxiety disorders, which are more common in IBD patients than in the general population. The present manuscript provides a critical overview of gender differences in the frequency and clinical course of mood and anxiety disorders in IBD patients, with the aim of helping clinicians provide individualized management for patients. All of the included studies found that IBD patients reported a higher frequency of depressive and anxiety disorders than the general population. These findings should encourage healthcare providers to employ validated tools to monitor the mental health of their IBD patients, such as the Patient Health Questionnaire (PHQ-9). In addition, most studies confirm that women with IBD are more likely than men to develop affective disorders and show that up to 65% of women with IBD have depressive and anxiety disorders. Women with IBD require close mental health monitoring and ultimately a multidisciplinary approach involving mental health professionals. Drug treatment in women should be individualized and medications that may affect mental health (e.g., corticosteroids) should be thoroughly reconsidered. Further data are needed to ensure individualized treatment for IBD patients in a framework of precision medicine.
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Affiliation(s)
- Elia Fracas
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (E.F.); (A.C.); (M.V.)
| | - Andrea Costantino
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (E.F.); (A.C.); (M.V.)
- Division of Gastroenterology and Endoscopy, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Maurizio Vecchi
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (E.F.); (A.C.); (M.V.)
- Division of Gastroenterology and Endoscopy, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Massimiliano Buoli
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy; (E.F.); (A.C.); (M.V.)
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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Li Z, Dang W, Hao T, Zhang H, Yao Z, Zhou W, Deng L, Yu H, Wen Y, Liu L. Shared genetics and causal relationships between major depressive disorder and COVID-19 related traits: a large-scale genome-wide cross-trait meta-analysis. Front Psychiatry 2023; 14:1144697. [PMID: 37426090 PMCID: PMC10328439 DOI: 10.3389/fpsyt.2023.1144697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/31/2023] [Indexed: 07/11/2023] Open
Abstract
Introduction The comorbidity between major depressive disorder (MDD) and coronavirus disease of 2019 (COVID-19) related traits have long been identified in clinical settings, but their shared genetic foundation and causal relationships are unknown. Here, we investigated the genetic mechanisms behind COVID-19 related traits and MDD using the cross-trait meta-analysis, and evaluated the underlying causal relationships between MDD and 3 different COVID-19 outcomes (severe COVID-19, hospitalized COVID-19, and COVID-19 infection). Methods In this study, we conducted a comprehensive analysis using the most up-to-date and publicly available GWAS summary statistics to explore shared genetic etiology and the causality between MDD and COVID-19 outcomes. We first used genome-wide cross-trait meta-analysis to identify the pleiotropic genomic SNPs and the genes shared by MDD and COVID-19 outcomes, and then explore the potential bidirectional causal relationships between MDD and COVID-19 outcomes by implementing a bidirectional MR study design. We further conducted functional annotations analyses to obtain biological insight for shared genes from the results of cross-trait meta-analysis. Results We have identified 71 SNPs located on 25 different genes are shared between MDD and COVID-19 outcomes. We have also found that genetic liability to MDD is a causal factor for COVID-19 outcomes. In particular, we found that MDD has causal effect on severe COVID-19 (OR = 1.832, 95% CI = 1.037-3.236) and hospitalized COVID-19 (OR = 1.412, 95% CI = 1.021-1.953). Functional analysis suggested that the shared genes are enriched in Cushing syndrome, neuroactive ligand-receptor interaction. Discussion Our findings provide convincing evidence on shared genetic etiology and causal relationships between MDD and COVID-19 outcomes, which is crucial to prevention, and therapeutic treatment of MDD and COVID-19.
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Affiliation(s)
- Ziqi Li
- Department of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Weijia Dang
- Department of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Tianqi Hao
- Department of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Hualin Zhang
- Department of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Ziwei Yao
- Department of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Wenchao Zhou
- Department of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Liufei Deng
- Department of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Hongmei Yu
- Department of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yalu Wen
- Department of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
- Department of Statistics, University of Auckland, Auckland, New Zealand
| | - Long Liu
- Department of Health Statistics, School of Public Health, Shanxi Medical University, Taiyuan, Shanxi, China
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Niu YM, Zhang J, Tang H, Cao LH, Jiang TY, Hu YY. Association between DRD2/ANKK1 rs1800497 C > T polymorphism and post-traumatic stress disorder susceptibility: a multivariate meta-analysis. Front Neurosci 2023; 17:1102573. [PMID: 37274216 PMCID: PMC10232825 DOI: 10.3389/fnins.2023.1102573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 03/10/2023] [Indexed: 06/06/2023] Open
Abstract
Background Previous studies have suggested that the DRD2/ANKK1 rs1800497 C > T polymorphism plays a critical role in the risk of post-traumatic stress disorder (PTSD). However, published data are inconsistent or even contradictory. Therefore, we conducted a meta-analysis to explore the underlying correlation between the rs1800497 C > T polymorphism and PTSD risk. Materials and methods A total of five online databases were searched, and all related studies were reviewed up to 1 October 2022. Critical information was extracted, and quality assessment was conducted for all included studies. Multivariate meta-analyses were performed for the genetic model choice, and the odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated to examine the statistical power of the genetic models. In addition, heterogeneity, sensitivity, cumulative analysis, and publication bias were analyzed to guarantee statistical power. Result Overall, 12 observational studies involving 5,515 subjects were included and analyzed in this meta-analysis. Multivariate analysis indicated that a co-dominant genetic model was most likely the best choice. Pooled results revealed an elevated PTSD risk in mutated homozygote TT carriers in the general population (TT vs. CC: OR = 1.73, 95% CI = 1.14-2.62, P = 0.01, I2 = 58.9%) and other specific subgroups. Moreover, similar results were observed in other genetic models using univariate analysis. Conclusion Current evidence suggests that the DRD2/ANKK1 rs1800497 C > T polymorphism may contribute to PTSD susceptibility.
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Affiliation(s)
- Yu-Ming Niu
- Department of Stomatology and Center for Evidence-Based Medicine and Clinical Research, Gongli Hospital of Shanghai Pudong New Area, Shanghai, China
- Department of Psychiatry and Joint Laboratory of Psychiatric Genetic Research, The Third People's Hospital of Zhongshan, Zhongshan, Guangdong Province, China
- Department of Psychiatry, Gannan Medical University, Ganzhou, Jiangxi Province, China
| | - Jie Zhang
- Department of Psychiatry and Joint Laboratory of Psychiatric Genetic Research, The Third People's Hospital of Zhongshan, Zhongshan, Guangdong Province, China
- Department of Psychiatry, Gannan Medical University, Ganzhou, Jiangxi Province, China
| | - Hong Tang
- Department of Psychiatry, Gannan Medical University, Ganzhou, Jiangxi Province, China
| | - Lu-Hua Cao
- Information Department, Gongli Hospital of Shanghai Pudong New Area, Shanghai, China
| | - Ting-Yun Jiang
- Department of Psychiatry and Joint Laboratory of Psychiatric Genetic Research, The Third People's Hospital of Zhongshan, Zhongshan, Guangdong Province, China
| | - Yuan-Yuan Hu
- Department of Stomatology and Center for Evidence-Based Medicine and Clinical Research, Gongli Hospital of Shanghai Pudong New Area, Shanghai, China
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Adorjan K, Stubbe HC. Insight into the long-term psychological impacts of the COVID-19 pandemic. Eur Arch Psychiatry Clin Neurosci 2023; 273:287-288. [PMID: 36971863 PMCID: PMC10040902 DOI: 10.1007/s00406-023-01599-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Affiliation(s)
- Kristina Adorjan
- Department of Psychiatry and Psychotherapy, LMU University Hospital, Nussbaumstr. 7, 80336, Munich, Germany.
| | - Hans Christian Stubbe
- Department of Medicine II, LMU University Hospital, Marchioninistraße 15, 81377, Munich, Germany
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Piccinini A, Bailo P, Barbara G, Miozzo M, Tabano S, Colapietro P, Farè C, Sirchia SM, Battaglioli E, Bertuccio P, Manenti G, Micci L, La Vecchia C, Kustermann A, Gaudi S. Violence against Women and Stress-Related Disorders: Seeking for Associated Epigenetic Signatures, a Pilot Study. Healthcare (Basel) 2023; 11:healthcare11020173. [PMID: 36673541 PMCID: PMC9858929 DOI: 10.3390/healthcare11020173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/22/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Violence against women is a relevant health and social problem with negative consequences on women's health. The interaction between genome and environmental factors, such as violence, represents one of the major challenges in molecular medicine. The Epigenetics for WomEn (EpiWE) project is a multidisciplinary pilot study that intends to investigate the epigenetic signatures associated with intimate partner and sexual violence-induced stress-related disorders. MATERIALS AND METHODS In 2020, 62 women exposed to violence (13 women suffering from sexual violence and 49 from Intimate Partner Violence, IPV) and 50 women with no history of violence were recruited at the Service for Sexual and Domestic Violence. All women aged 18-65 were monitored for their physical and psychological conditions. Blood samples were collected, and DNAs were extracted and underwent the epigenetic analysis of 10 stress-related genes. RESULTS PTSD prevalence in victims was assessed at 8.1%. Quantitative methylation evaluation of the ten selected trauma/stress-related genes revealed the differential iper-methylation of brain-derived neurotrophic factor, dopamine receptor D2 and insulin-like growth factor 2 genes. These genes are among those related to brain plasticity, learning, and memory pathways. CONCLUSIONS The association of early detection of posttraumatic distress and epigenetic marker identification could represent a new avenue for addressing women survivors toward resilience. This innovative approach in gender-based violence studies could identify new molecular pathways associated with the long-term effects of violence and implement innovative protocols of precision medicine.
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Affiliation(s)
- Andrea Piccinini
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20100 Milan, Italy
- Service for Sexual and Domestic Violence( SVSeD), Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20100 Milan, Italy
- Correspondence: ; Tel.: +39-(0)2-5031-5706
| | - Paolo Bailo
- Section of Legal Medicine, School of Law, University of Camerino, 62032 Camerino, Italy
| | - Giussy Barbara
- Service for Sexual and Domestic Violence( SVSeD), Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20100 Milan, Italy
- Gynecology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20100 Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano di Milano, 20100 Milan, Italy
| | - Monica Miozzo
- Medical Genetics, Department of Health Sciences, Università degli Studi di Milano, 20100 Milan, Italy
| | - Silvia Tabano
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20100 Milan, Italy
- Medical Genetics Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20100 Milan, Italy
| | - Patrizia Colapietro
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, 20100 Milan, Italy
| | - Claudia Farè
- Medical Genetics Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20100 Milan, Italy
| | - Silvia Maria Sirchia
- Medical Genetics, Department of Health Sciences, Università degli Studi di Milano, 20100 Milan, Italy
| | - Elena Battaglioli
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, 20100 Milan, Italy
| | - Paola Bertuccio
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
| | - Giulia Manenti
- Department of Biotechnology and Biosciences, University of Milano-Bicocca, 20100 Milan, Italy
| | - Laila Micci
- Service for Sexual and Domestic Violence( SVSeD), Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20100 Milan, Italy
| | - Carlo La Vecchia
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano di Milano, 20100 Milan, Italy
| | - Alessandra Kustermann
- Service for Sexual and Domestic Violence( SVSeD), Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20100 Milan, Italy
| | - Simona Gaudi
- Department of Environment and Health, Italian National Institute of Health, 00161 Rome, Italy
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