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Shaikh S, Cruz K, Oladipo AF, Figueroa MM. A Scoping Review: Bariatric Providers' Knowledge and Behaviors Related to Contraceptive Counseling. Obes Surg 2024; 34:1358-1365. [PMID: 38376636 DOI: 10.1007/s11695-024-07090-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 02/05/2024] [Accepted: 02/07/2024] [Indexed: 02/21/2024]
Abstract
Bariatric surgery is a common treatment for obesity, and about half of patients undergoing these procedures are patients of reproductive age. Following bariatric procedures, rapid weight loss and an increase in fertility occur. Guidelines recommend pregnancy delay for 12-24 months postoperatively. It is important that patients capable of pregnancy undergoing bariatric procedures receive preoperative contraceptive counseling. Studies surveying bariatric providers demonstrate that most providers understand the importance of delaying pregnancy and contraceptive counseling. However, deficiencies in bariatric provider knowledge, comfort, and practice with contraceptive counseling were identified. These gaps highlight opportunities for improvement in preoperative care to ensure patients are receiving appropriate contraception.
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Affiliation(s)
- Sameeha Shaikh
- Hackensack Meridian School of Medicine, 340 Kingsland St., Nutley, NJ, 07110, USA
| | - Kiana Cruz
- Hackensack Meridian School of Medicine, 340 Kingsland St., Nutley, NJ, 07110, USA
| | - Antonia F Oladipo
- Hackensack Meridian School of Medicine, 340 Kingsland St., Nutley, NJ, 07110, USA
- Department of Obstetrics and Gynecology, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ, 07601, USA
| | - Melissa M Figueroa
- Hackensack Meridian School of Medicine, 340 Kingsland St., Nutley, NJ, 07110, USA.
- Department of Obstetrics and Gynecology, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ, 07601, USA.
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2
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Cook E, Fajardo O, Walden RL, Harvey L. Gynecologic counseling for patients undergoing bariatric surgery: a scoping review. Curr Opin Obstet Gynecol 2023; 35:321-327. [PMID: 37144578 DOI: 10.1097/gco.0000000000000878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
PURPOSE OF REVIEW Obesity is associated with several gynecologic conditions. While bariatric surgery is regarded as the most effective treatment option for obesity, gynecologic counseling for patients planning bariatric surgery is limited and often focused on fertility. The goal of this scoping review is to investigate the current recommendations for gynecologic counseling prior to bariatric surgery. RECENT FINDINGS A comprehensive search was conducted to find peer reviewed studies written in English discussing a gynecologic issue of patients who were planning or previously had bariatric surgery. All the included studies identified a gap in preoperative gynecologic counseling. The majority of the articles made specific recommendations for a multidisciplinary approach to preoperative gynecologic counseling with a call to involve gynecologists or primary care providers. SUMMARY Patients deserve to receive appropriate counseling about how obesity and bariatric surgery impact their overall gynecologic health. We advocate that the scope of gynecologic counseling includes more than pregnancy and contraception counseling. We propose a gynecologic counseling checklist for female patients undergoing bariatric surgery. Offering patients a referral to a gynecologist from the patient's first entry to a bariatric clinic is imperative to facilitate appropriate counseling.
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Affiliation(s)
- Elizabeth Cook
- Minimally Invasive Gynecologic Surgery, Vanderbilt University Medical Center, 1211 Medical Center Drive
| | - Olga Fajardo
- Minimally Invasive Gynecologic Surgery, Vanderbilt University Medical Center
| | - Rachel Lane Walden
- Vanderbilt University Eskind Biomedical Library, Nashville, TN 37232, USA
| | - Lara Harvey
- Minimally Invasive Gynecologic Surgery, Vanderbilt University Medical Center
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3
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Yang JC, Chen G, Du X. Benefits and Risks of Bariatric Surgery on Women's Reproductive Health: a Narrative Review. Obes Surg 2023; 33:1587-1595. [PMID: 36869973 DOI: 10.1007/s11695-023-06513-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/07/2023] [Accepted: 02/15/2023] [Indexed: 03/05/2023]
Abstract
Bariatric surgery (BS) is escalating as the most efficient and endurable therapy for severe obesity. Women's reproductive health is essential to women's quality of life and is receiving increasing attention. However, despite the high prevalence of BS among women, the effect of BS on reproductive health remains underemphasis. The purpose of this narrative review is to provide an overview of BS on women's reproductive health, including their reproductive health before, during, and after pregnancy. Although limited attention has been given, current evidence highlights the substantial implications of bariatric surgery on reproductive health and reminds us of the importance of adopting decision-making conversations about reproductive health before bariatric surgery.
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Affiliation(s)
- Jun-Cheng Yang
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China
| | - Gang Chen
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China.,Department of General Surgery, The Second Clinical Medical College, The Fifth People's Hospital Affiliated to Chengdu University of Traditional Chinese Medicine, Chengdu, 610041, China
| | - Xiao Du
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Chengdu, 610041, China. .,Department of General Surgery, Ya'an People's Hospital, Yaan, 625000, China.
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4
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Yang JC, Chen G, Leng C, Du X. Perception and Practice of Bariatric Surgery and Reproductive Health in Women: a Cross-sectional Study of Chinese Bariatric Surgeons. Obes Surg 2023; 33:1545-1552. [PMID: 36869972 DOI: 10.1007/s11695-023-06514-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/07/2023] [Accepted: 02/15/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND AND PURPOSE Western studies have explored bariatric surgeons concerning their views on bariatric surgery (BS) and reproductive health, but Asian data were lacking. The aim of this study was to explore the perception and practice of bariatric surgeons on the reproductive health of female patients who underwent BS in China to better guide clinical practice and improve clinical outcomes. METHOD An online questionnaire of 31 questions developed by bariatric surgeons was collected by sending to one online communication group (WeChat group) whose members are Chinese bariatric surgeons. RESULT A total of 87 bariatric surgeons from mainland China were surveyed. Almost all (97.7%, 85/87) surgeons considered the reproductive health conversation for women who underwent BS to be important or very important. Only 1/4 of surgeons routinely discuss reproductive health-related issues with patients, and only 56% of doctors always ask patients for postoperative contraception. Less than 20% of bariatric surgeons have full knowledge of postoperative contraception, and nearly 40% of them believe that gynecologists should be responsible for providing contraception. More than 35% of bariatric surgeons have never been involved in the co-management of pregnancy in patients with a history of BS. CONCLUSION Although most bariatric surgeons are aware of the importance of female reproductive health, there is a large gap in the perception and clinical practice of bariatric surgeons in terms of reproductive health. It is necessary to further strengthen the education of bariatric surgeons and enhance multidisciplinary cooperation with gynecology, obstetrics, and other disciplines to bring better clinical outcomes.
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Affiliation(s)
- Jun-Cheng Yang
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Gang Chen
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China.,Department of General Surgery, The Second Clinical Medical College, The Fifth People's Hospital affiliated to Chengdu University of Traditional Chinese Medicine, Chengdu, 610041, China
| | - Cuo Leng
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xiao Du
- Division of Gastrointestinal Surgery, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China. .,Department of General Surgery, Ya'an People's Hospital, Yaan, 625000, China.
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5
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Zawadzka K, Więckowski K, Stefura T, Major P, Szopa M. Current Knowledge and Perceptions of Bariatric Surgery among Diabetologists and Internists in Poland. J Clin Med 2022; 11:jcm11072028. [PMID: 35407634 PMCID: PMC8999568 DOI: 10.3390/jcm11072028] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 03/28/2022] [Accepted: 04/02/2022] [Indexed: 02/04/2023] Open
Abstract
Perioperative care and follow-up after bariatric surgery (BS) engage various medical professionals. It is key for them to be well informed about these procedures. However, knowledge and attitudes may be not satisfactory enough to provide proper care. We aimed to assess knowledge and perceptions of BS among diabetologists and internists. A total of 34 diabetologists and 30 internists completed the electronic questionnaire. There were no differences in self-estimated knowledge between them, except regarding items related to the treatment of diabetes and metabolic control. Several misconceptions were identified in the questions testing the understanding of key issues in BS. Most participants considered BS effective in weight loss and metabolic control. A total of 75% highlighted the lack of appropriate equipment for dealing with morbidly obese patients. Interestingly, in a multivariable linear regression model, self-estimated knowledge was the only variable associated with frequency of referrals to bariatric surgeons. A total of 92% of respondents were interested in broadening their knowledge. Guidelines for long-term follow-up and funding were the most frequently chosen topics to explore. The study showed a positive attitude of diabetologists and internists towards surgical treatment of obesity and identified some significant gaps in knowledge. The results may be helpful in planning trainings to provide the best care for patients suffering from morbid obesity.
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Affiliation(s)
- Karolina Zawadzka
- 2nd Department of General Surgery, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Krakow, Poland; (K.Z.); (K.W.); (T.S.); (P.M.)
| | - Krzysztof Więckowski
- 2nd Department of General Surgery, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Krakow, Poland; (K.Z.); (K.W.); (T.S.); (P.M.)
| | - Tomasz Stefura
- 2nd Department of General Surgery, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Krakow, Poland; (K.Z.); (K.W.); (T.S.); (P.M.)
| | - Piotr Major
- 2nd Department of General Surgery, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Krakow, Poland; (K.Z.); (K.W.); (T.S.); (P.M.)
- Centre for Research, Training and Innovation Jagiellonian (CERTAIN Surgery), 30-688 Krakow, Poland
| | - Magdalena Szopa
- Department of Metabolic Diseases, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Krakow, Poland
- Correspondence:
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Ben-Porat T, Bacon SL. Comment on: Nutrition for Pregnancy after Metabolic and Bariatric Surgery. Surg Obes Relat Dis 2022; 18:830-831. [DOI: 10.1016/j.soard.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/16/2022] [Accepted: 03/18/2022] [Indexed: 11/26/2022]
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Alamri SH, Abdeen GN. Maternal Nutritional Status and Pregnancy Outcomes Post-bariatric Surgery. Obes Surg 2022; 32:1325-1340. [PMID: 35165854 PMCID: PMC8933294 DOI: 10.1007/s11695-021-05822-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 11/30/2022]
Abstract
Obesity in childbearing women leads to pregnancy-related complications such as gestational diabetes mellitus, pregnancy-associated hypertensive disorders, and macrosomia. Weight loss helps reduce these complications. Studies show bariatric surgery reduces obesity-related complications during and after pregnancy. However, bariatric surgery might be associated with adverse outcomes, such as low birth weight and small-for-gestational-age infants. In addition, several studies suggest pregnancy occurring less than a year post-bariatric surgery adversely affects pregnancy outcomes and causes micronutrients deficiency since the dramatic weight loss occurs in the first year. These adverse outcomes may lead to nutritional malabsorption, such as anemia and low vitamin B12 and folic acid levels. The review aims to overview obesity-related complications during pregnancy and the benefits and risks of bariatric surgery on pregnancy outcomes and maternal nutrition status.
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Affiliation(s)
- Sara H Alamri
- Department of Community Health Science, Clinical Nutrition, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia.,Department of Clinical Nutrition Services, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ghalia N Abdeen
- Department of Community Health Science, Clinical Nutrition, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia. .,Strategic Center for Diabetes Research, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Özşahin Z, Aksoy Derya Y. Fertility awareness scale development study in Turkish women. Eur J Integr Med 2022. [DOI: 10.1016/j.eujim.2022.102101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sherf-Dagan S, Sinai T, Goldenshluger A, Globus I, Kessler Y, Schweiger C, Ben-Porat T. Nutritional Assessment and Preparation for Adult Bariatric Surgery Candidates: Clinical Practice. Adv Nutr 2021; 12:1020-1031. [PMID: 33040143 PMCID: PMC8262552 DOI: 10.1093/advances/nmaa121] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/25/2020] [Accepted: 09/03/2020] [Indexed: 12/13/2022] Open
Abstract
Bariatric surgery (BS) has proven to be highly efficacious in the treatment of obesity and its comorbidities. However, careful patient selection is critical for its success. Thus, patients should undergo medical, behavioral, and nutritional assessment by a multidisciplinary team. From the nutritional point of view, BS candidates should undergo nutritional assessment, preparation, and education by a registered dietitian in the preoperative period. Currently, detailed specified and comprehensive information on these topics is lacking. The present narrative review aimed to summarize the available literature concerning both the preoperative nutritional assessment components and the preoperative nutritional preparation and education components of patients planning to undergo BS. Current literature indicates that proper management before BS should include a comprehensive nutritional assessment, in which it is advisable to perform a clinical interview to assess patients' medical background, weight management history, eating patterns and pathologies, oral health, physical activity habits, nutritional status, supplementation usage, BS knowledge, surgery expectations and anthropometric measurements. Nutritional preparation and educational strategies should include an individualized preoperative weight-loss nutrition program, improvement of glycemic control, micronutrients deficiencies correction, eating and lifestyle habits adaptation, physical activity initiation, and strengthening knowledge on obesity and BS. At this stage, more well-designed intervention and long-term cohort studies are needed in order to formulate uniform evidence-based nutritional guidelines for patients who plan to undergo BS, including populations at higher nutritional risk. Moreover, postoperative outcomes of presurgical nutritional intervention programs should be studied.
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Affiliation(s)
- Shiri Sherf-Dagan
- Department of Nutritional Sciences, School of Health Sciences, Ariel University, Ariel, Israel
- Department of Nutrition, Assuta Medical Center, Tel Aviv, Israel
| | - Tali Sinai
- Israel Center for Disease Control, Ministry of Health, Ramat Gan, Israel
- School of Nutritional Sciences, The Hebrew University of Jerusalem, Rehovot, Israel
| | - Ariela Goldenshluger
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, and Sylvan Adams Sports Institute, Tel-Aviv University, Tel Aviv, Israel
| | | | - Yafit Kessler
- Department of Nutritional Sciences, School of Health Sciences, Ariel University, Ariel, Israel
- Assia Medical Group, Assuta Medical Center, Tel Aviv, Israel
| | - Chaya Schweiger
- Nutrition Service, Rabin Medical Center, Campus Beilinson, Petach Tiqva, Israel
| | - Tair Ben-Porat
- Department of Nutrition, Hadassah-Hebrew University Medical Center, Ein-Kerem Campus, Jerusalem, Israel
- Department of Human Metabolism and Nutrition, Braun School of Public Health, Hebrew University, Jerusalem, Israel
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Extremely early pregnancy (<6 mo) after sleeve gastrectomy: maternal and perinatal outcomes. Surg Obes Relat Dis 2020; 17:356-362. [PMID: 33268326 DOI: 10.1016/j.soard.2020.09.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 08/24/2020] [Accepted: 09/09/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Data are scarce regarding outcomes of pregnancies occurring very early after bariatric surgery. OBJECTIVES We compared outcomes of pregnancies occurring extremely early (surgery-to-conception interval <6 mos) after laparoscopic sleeve gastrectomy (LSG) with those occurring later (≥6 mos postsurgery). SETTING A university hospital. METHODS We reviewed the records of all women who underwent LSG and delivered during 2006-2019. RESULTS Of 196 women, 23 (11.7%) became pregnant within 6 months of surgery. For these women, the median surgery-to-conception interval was 116 [interquartile range 76-161] days, compared with 903 [465-1377] days for the remaining cohort. Three (13.0%) women turned out postoperatively to be pregnant at the time of LSG. Compared with women who conceived later, the extremely early pregnancy group had lower gestational weight gain (median 4 versus 10 kg, P < .001), including negative gestational weight gain in 9 (39.1%) women. The proportion of small for gestational age (SGA) infants was higher among women who conceived within 6 months after surgery rather than later (26.1% versus 10.4%, P = .04). Other maternal and perinatal outcomes were similar between the groups. In multivariate analysis, conceiving within 6 months after LSG was the only independent factor associated with delivering a SGA infant (odds ratio [95% confidence interval]: 3.35 (1.12, 10.01), P = .03). CONCLUSIONS Pregnancy occurring in the first 6 months after LSG was independently associated with a higher rate of SGA infants. Delaying conception during the very early postoperative period is recommended. Providing adequate contraception and excluding the presence of early pregnancy at the time of surgery are of utmost importance.
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Goldenshluger A, Elazary R, Ben Porat T, Farhat HG, Levin G, Rottenstreich A. Knowledge, attitudes, and behaviors of women during pregnancy after bariatric surgery. Surg Obes Relat Dis 2020; 16:925-930. [PMID: 32317215 DOI: 10.1016/j.soard.2020.02.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/13/2020] [Accepted: 02/28/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Women of childbearing age constitute a substantial proportion of the patients who undergo weight loss procedures. However, little is known regarding attitudes and behaviors of women during pregnancy after bariatric surgery (BS). OBJECTIVES We explored women's experience and behavior during pregnancy after BS. SETTING University hospital. METHODS A cross-sectional survey study was performed among women who underwent sleeve gastrectomy and delivered at our center. RESULTS Overall, 111 women completed the questionnaire (response rate 88.1%). The median surgery-to-conception interval was 34 (25-50) months. For 28 (25.2%) women, future pregnancy was a motivation for undergoing the weight loss procedure. Only 10 (9.0%) received contraceptive advice perioperatively. Oral contraception was the most commonly used method after surgery (n = 47, 42.3%). Pregnancy was reported as unintended by 37 (33.3%) women. Only 14 (12.6%) women stated receiving an explanation regarding the implications of BS on pregnancy outcomes. Rates of follow-up with maternal-fetal medicine specialists, bariatric surgeons, and dieticians during pregnancy were 36.0%, 9.0%, and 23.4%, respectively. Forty-four women (39.6%) felt follow-up throughout gestation was inadequate. Satisfaction from BS improved after pregnancy in 23 (20.7%) women, and 75 (67.6%) stated that they would recommend BS to a friend with obesity who plans to conceive in the future. CONCLUSIONS Women reported insufficient knowledge regarding the expected outcomes of pregnancy after surgery, with low rates of medical and nutritional follow-up. Only a minority of respondents received contraceptive advice after surgery, and unintended pregnancies were common. These observations represent areas of improvement for following women of childbearing age who undergo weight loss procedures.
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Affiliation(s)
- Ariela Goldenshluger
- Department of Nutrition, Hadassah-Hebrew University Medical Center, Ein-Kerem Campus, Jerusalem, Israel
| | - Ram Elazary
- Department of Surgery, Hadassah-Hebrew University Medical Center, Ein-Kerem Campus, Jerusalem, Israel
| | - Tair Ben Porat
- Department of Nutrition, Hadassah-Hebrew University Medical Center, Ein-Kerem Campus, Jerusalem, Israel
| | - Heba Geraisi Farhat
- Department of Surgery, Hadassah-Hebrew University Medical Center, Ein-Kerem Campus, Jerusalem, Israel
| | - Gabriel Levin
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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Vale-Fernandes E, Monteiro MP. Comment on: Reproductive health counseling, attitudes, and practices: a cross-sectional survey among bariatric surgeons. Surg Obes Relat Dis 2019; 15:2107-2108. [PMID: 31711950 DOI: 10.1016/j.soard.2019.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/05/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Emídio Vale-Fernandes
- Clinical and Experimental Endocrinology, Unit for Multidisciplinary Research in Biomedicine, Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal; Centre for Medically Assisted Procreation, Gynaecology Department, Centro Materno Infantil do Norte Dr. Albino Aroso, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Mariana P Monteiro
- Clinical and Experimental Endocrinology, Unit for Multidisciplinary Research in Biomedicine, Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
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