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Smith DA. Teratogenicity is more likely a function of primary and secondary pharmacology than caused by chemically reactive metabolites: a critical evaluation of 40 years of scientific research. Xenobiotica 2024:1-10. [PMID: 38913781 DOI: 10.1080/00498254.2024.2366302] [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: 05/01/2024] [Accepted: 06/06/2024] [Indexed: 06/26/2024]
Abstract
The number of therapeutic drugs known to be human teratogens is actually relatively small. This may reflect the rigorous animal testing and well defined labelling. Some of these drugs were identified to have reactive metabolites and this has been postulated, historically, to be their teratogenic mechanism. These drugs include thalidomide, various anticonvulsants and retinoic acid derivatives.Many of these experiments were conducted in a period where chemically reactive metabolites were being intensely investigated and associated with all forms of toxicity. The legacy of this is that these examples are routinely cited as well established mechanisms.Examination of mechanism leads to the conclusion that the teratogenicity in humans of these compounds is likely due to the primary and secondary pharmacology of the parent drug and stable circulating metabolites and that association of reactive metabolites to this toxicity is unwarranted.
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Rengel BD, Kowalski TW, Bremm JM, do Amaral Gomes J, Schüler-Faccini L, Vianna FSL, Fraga LR. Genetic evaluation of HAND2 gene and its effects on thalidomide embryopathy. Birth Defects Res 2022; 114:1354-1363. [PMID: 36177858 DOI: 10.1002/bdr2.2092] [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: 04/25/2022] [Revised: 07/28/2022] [Accepted: 09/04/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND HAND2 is a transcription factor important for embryonic development, required for limbs and cardiovascular development. Thalidomide is a drug responsible to a spectrum of congenital anomalies known as Thalidomide Embryopathy (TE), which includes mainly limb and heart defects. It is known that HAND2 interaction with TBX5, an important protein for limbs and heart development, is inhibited by Thalidomide. The aim of this study was to evaluate and characterize HAND2 in the context of TE, and to evaluate its variability in TE individuals. METHODS DNA from 35 TE subjects was extracted from saliva samples and PCR was performed for amplification and Sanger sequencing of HAND2 coding sequence. RESULTS The analysis showed only one variant; a synonymous variant p.P51 (rs59621536) in exon 1 found in three individuals. Further in silico evaluation confirmed highly HAND2 conservation, being the 3'UTR the most polymorphic region of the gene. Additional computational analyses classified the variant as neutral, without alteration in splicing and miRNA sites. In silico predictions pointed to alteration of two CpG islands adjacent to the variant; however, we did not observe any alterations on the methylation pattern of HAND2 gene in our sample. Moreover, alteration of the binding site of MeCP2, a nuclear protein involved in DNA methylation, was predicted along with alteration in HAND2 mRNA structure. CONCLUSIONS Considering HAND2 being a well conserved gene, further studies with a larger sample should be performed to evaluate the role this gene on genetic susceptibility to TE.
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Affiliation(s)
- Bruna Duarte Rengel
- Laboratory of Medical Genetics and Evolution, Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Brazilian Teratogen Information Service (SIAT), Medical Genetics Service of Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Genomic Medicine Laboratory at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Thayne Woycinck Kowalski
- Laboratory of Medical Genetics and Evolution, Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Brazilian Teratogen Information Service (SIAT), Medical Genetics Service of Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Genomic Medicine Laboratory at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,National Institute of Population Medical Genetics (INAGEMP), Porto Alegre, Brazil.,Bioinformatics Core, Hospital de Clínicas de Porto Alegre, HCPA, Porto Alegre, Brazil.,Centro Universitário CESUCA, Cachoeirinha, Brazil
| | - João Matheus Bremm
- Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Julia do Amaral Gomes
- Laboratory of Medical Genetics and Evolution, Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Brazilian Teratogen Information Service (SIAT), Medical Genetics Service of Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Genomic Medicine Laboratory at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,National Institute of Population Medical Genetics (INAGEMP), Porto Alegre, Brazil
| | - Lavínia Schüler-Faccini
- Laboratory of Medical Genetics and Evolution, Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Brazilian Teratogen Information Service (SIAT), Medical Genetics Service of Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,National Institute of Population Medical Genetics (INAGEMP), Porto Alegre, Brazil
| | - Fernanda Sales Luiz Vianna
- Laboratory of Medical Genetics and Evolution, Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Postgraduate Program in Genetics and Molecular Biology, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Brazilian Teratogen Information Service (SIAT), Medical Genetics Service of Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Genomic Medicine Laboratory at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,National Institute of Population Medical Genetics (INAGEMP), Porto Alegre, Brazil.,Postgraduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Lucas Rosa Fraga
- Laboratory of Medical Genetics and Evolution, Department of Genetics, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.,Brazilian Teratogen Information Service (SIAT), Medical Genetics Service of Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.,Genomic Medicine Laboratory at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil.,Postgraduate Program in Medical Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Department of Morphological Sciences, Institute of Health Sciences, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Costa BA, Mouhieddine TH, Richter J. What's Old is New: The Past, Present and Future Role of Thalidomide in the Modern-Day Management of Multiple Myeloma. Target Oncol 2022; 17:383-405. [PMID: 35771402 DOI: 10.1007/s11523-022-00897-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 10/17/2022]
Abstract
Immunomodulatory drugs (IMiDs) have become an integral part of therapy for both newly diagnosed and relapsed/refractory multiple myeloma (RRMM). IMiDs bind to cereblon, leading to the degradation of proteins involved in B-cell survival and proliferation. Thalidomide, a first-generation IMiD, has little to no myelosuppressive potential, negligible renal clearance, and long-proven anti-myeloma activity. However, thalidomide's adverse effects (e.g., somnolence, constipation, and peripheral neuropathy) and the advent of more potent therapeutic options has led to the drug being less frequently used in many countries, including the US and Canada. Newer-generation IMiDs, such as lenalidomide and pomalidomide, are utilized far more frequently. In numerous previous trials, salvage therapy with thalidomide (50-200 mg/day) plus corticosteroids (with or without selected cytotoxic or targeted agents) has been shown to be effective and well-tolerated in the RRMM setting. Hence, thalidomide-based regimens remain important alternatives for heavily pretreated patients, especially for those who have no access to novel therapies and/or are not eligible for their use (due to renal failure, high-grade myelosuppression, or significant comorbidities). Ongoing and future trials may provide further insights into the current role of thalidomide, especially by comparing thalidomide-containing regimens with protocols based on newer-generation IMiDs and by investigating thalidomide's association with novel therapies (e.g., antibody-drug conjugates, bispecific antibodies, and chimeric antigen receptor T cells).
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Affiliation(s)
- Bruno Almeida Costa
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tarek H Mouhieddine
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1185, New York, NY, 10029, USA
| | - Joshua Richter
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1185, New York, NY, 10029, USA.
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Domingo S, Solé C, Moliné T, Ferrer B, Cortés-Hernández J. Thalidomide Exerts Anti-Inflammatory Effects in Cutaneous Lupus by Inhibiting the IRF4/NF-ҡB and AMPK1/mTOR Pathways. Biomedicines 2021; 9:biomedicines9121857. [PMID: 34944673 PMCID: PMC8698478 DOI: 10.3390/biomedicines9121857] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 11/16/2022] Open
Abstract
Thalidomide is effective in patients with refractory cutaneous lupus erythematosus (CLE). However, the mechanism of action is not completely understood, and its use is limited by its potential, severe side-effects. Immune cell subset analysis in thalidomide’s CLE responder patients showed a reduction of circulating and tissue cytotoxic T-cells with an increase of iNKT cells and a shift towards a Th2 response. We conducted an RNA-sequencing study using CLE skin biopsies performing a Therapeutic Performance Mapping System (TMPS) analysis in order to generate a predictive model of its mechanism of action and to identify new potential therapeutic targets. Integrating RNA-seq data, public databases, and literature, TMPS analysis generated mathematical models which predicted that thalidomide acts via two CRBN-CRL4A- (CRL4CRBN) dependent pathways: IRF4/NF-ҡB and AMPK1/mTOR. Skin biopsies showed a significant reduction of IRF4 and mTOR in post-treatment samples by immunofluorescence. In vitro experiments confirmed the effect of thalidomide downregulating IRF4 in PBMCs and mTOR in keratinocytes, which converged in an NF-ҡB reduction that led to a resolution of the inflammatory lesion. These results emphasize the anti-inflammatory role of thalidomide in CLE treatment, providing novel molecular targets for the development of new therapies that could avoid thalidomide’s side effects while maintaining its efficacy.
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Affiliation(s)
- Sandra Domingo
- Lupus Unit, Rheumatology Departament, Hospital Universitari Vall d’Hebron, Institut de Recerca (VHIR), Universitat Autonoma de Barcelona, 08035 Barcelona, Spain; (S.D.); (J.C.-H.)
| | - Cristina Solé
- Lupus Unit, Rheumatology Departament, Hospital Universitari Vall d’Hebron, Institut de Recerca (VHIR), Universitat Autonoma de Barcelona, 08035 Barcelona, Spain; (S.D.); (J.C.-H.)
- Correspondence: ; Tel.: +34-93-489-4045
| | - Teresa Moliné
- Department of Pathology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (T.M.); (B.F.)
| | - Berta Ferrer
- Department of Pathology, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain; (T.M.); (B.F.)
| | - Josefina Cortés-Hernández
- Lupus Unit, Rheumatology Departament, Hospital Universitari Vall d’Hebron, Institut de Recerca (VHIR), Universitat Autonoma de Barcelona, 08035 Barcelona, Spain; (S.D.); (J.C.-H.)
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Melo DG, Sanseverino MTV, Schmalfuss TDO, Larrandaburu M. Why are Birth Defects Surveillance Programs Important? Front Public Health 2021; 9:753342. [PMID: 34796160 PMCID: PMC8592920 DOI: 10.3389/fpubh.2021.753342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 10/08/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Débora Gusmão Melo
- Department of Medicine, Federal University of São Carlos (UFSCar), São Carlos, Brazil
| | - Maria Teresa Vieira Sanseverino
- School of Medicine, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil.,Medical Genetics Service, Clinical Hospital of Porto Alegre, Porto Alegre, Brazil
| | | | - Mariela Larrandaburu
- Disability and Rehabilitation Program, Ministry of Public Health of Uruguay, Montevideo, Uruguay
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Kowalski TW, Caldas-Garcia GB, Gomes JDA, Fraga LR, Schuler-Faccini L, Recamonde-Mendoza M, Paixão-Côrtes VR, Vianna FSL. Comparative Genomics Identifies Putative Interspecies Mechanisms Underlying Crbn-Sall4-Linked Thalidomide Embryopathy. Front Genet 2021; 12:680217. [PMID: 34249098 PMCID: PMC8262662 DOI: 10.3389/fgene.2021.680217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/18/2021] [Indexed: 11/21/2022] Open
Abstract
The identification of thalidomide–Cereblon-induced SALL4 degradation has brought new understanding for thalidomide embryopathy (TE) differences across species. Some questions, however, regarding species variability, still remain. The aim of this study was to detect sequence divergences between species, affected or not by TE, and to evaluate the regulated gene co-expression in a murine model. Here, we performed a comparative analysis of proteins experimentally established as affected by thalidomide exposure, evaluating 14 species. The comparative analysis, regarding synteny, neighborhood, and protein conservation, was performed in 42 selected genes. Differential co-expression analysis was performed, using a publicly available assay, GSE61306, which evaluated mouse embryonic stem cells (mESC) exposed to thalidomide. The comparative analyses evidenced 20 genes in the upstream neighborhood of NOS3, which are different between the species who develop, or not, the classic TE phenotype. Considering protein sequence alignments, RECQL4, SALL4, CDH5, KDR, and NOS2 proteins had the biggest number of variants reported in unaffected species. In co-expression analysis, Crbn was a gene identified as a driver of the co-expression of other genes implicated in genetic, non-teratogenic, limb reduction defects (LRD), such as Tbx5, Esco2, Recql4, and Sall4; Crbn and Sall4 were shown to have a moderate co-expression correlation, which is affected after thalidomide exposure. Hence, even though the classic TE phenotype is not identified in mice, a deregulatory Crbn-induced mechanism is suggested in this animal. Functional studies are necessary, especially evaluating the genes responsible for LRD syndromes and their interaction with thalidomide–Cereblon.
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Affiliation(s)
- Thayne Woycinck Kowalski
- Post-Graduation Program in Genetics and Molecular Biology, PPGBM, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil.,Laboratory of Medical Genetics and Evolution, Genetics Department, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil.,Laboratory of Genomic Medicine, Center of Experimental Research, Hospital de Clínicas de Porto Alegre, HCPA, Porto Alegre, Brazil.,National Institute of Medical Population Genetics, INAGEMP, Porto Alegre, Brazil.,Bioinformatics Core, Hospital de Clínicas de Porto Alegre, HCPA, Porto Alegre, Brazil.,Centro Universitário CESUCA, Cachoeirinha, Brazil
| | - Gabriela Barreto Caldas-Garcia
- Post-Graduation Program in Genetics and Molecular Biology, PPGBM, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil.,Post-Graduation Program in Biodiversity and Evolution, PPGBioEvo Institute of Biology, Universidade Federal da Bahia, UFBA, Salvador, Brazil
| | - Julia do Amaral Gomes
- Post-Graduation Program in Genetics and Molecular Biology, PPGBM, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil.,Laboratory of Medical Genetics and Evolution, Genetics Department, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil.,Laboratory of Genomic Medicine, Center of Experimental Research, Hospital de Clínicas de Porto Alegre, HCPA, Porto Alegre, Brazil.,National Institute of Medical Population Genetics, INAGEMP, Porto Alegre, Brazil
| | - Lucas Rosa Fraga
- Laboratory of Genomic Medicine, Center of Experimental Research, Hospital de Clínicas de Porto Alegre, HCPA, Porto Alegre, Brazil.,National Institute of Medical Population Genetics, INAGEMP, Porto Alegre, Brazil.,Department of Morphological Sciences, Institute of Health Sciences, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Post-Graduation Program in Medical Science, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil.,Teratogen Information System, SIAT, Medical Genetics Service, Hospital de Clínicas de Porto Alegre, HCPA, Porto Alegre, Brazil
| | - Lavínia Schuler-Faccini
- Post-Graduation Program in Genetics and Molecular Biology, PPGBM, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil.,Laboratory of Medical Genetics and Evolution, Genetics Department, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil.,National Institute of Medical Population Genetics, INAGEMP, Porto Alegre, Brazil.,Teratogen Information System, SIAT, Medical Genetics Service, Hospital de Clínicas de Porto Alegre, HCPA, Porto Alegre, Brazil
| | - Mariana Recamonde-Mendoza
- Bioinformatics Core, Hospital de Clínicas de Porto Alegre, HCPA, Porto Alegre, Brazil.,Institute of Informatics, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil
| | - Vanessa Rodrigues Paixão-Côrtes
- Post-Graduation Program in Biodiversity and Evolution, PPGBioEvo Institute of Biology, Universidade Federal da Bahia, UFBA, Salvador, Brazil
| | - Fernanda Sales Luiz Vianna
- Post-Graduation Program in Genetics and Molecular Biology, PPGBM, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil.,Laboratory of Medical Genetics and Evolution, Genetics Department, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil.,Laboratory of Genomic Medicine, Center of Experimental Research, Hospital de Clínicas de Porto Alegre, HCPA, Porto Alegre, Brazil.,National Institute of Medical Population Genetics, INAGEMP, Porto Alegre, Brazil.,Post-Graduation Program in Medical Science, Universidade Federal do Rio Grande do Sul, UFRGS, Porto Alegre, Brazil.,Teratogen Information System, SIAT, Medical Genetics Service, Hospital de Clínicas de Porto Alegre, HCPA, Porto Alegre, Brazil
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7
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Gomes JDA, Olstad EW, Kowalski TW, Gervin K, Vianna FSL, Schüler-Faccini L, Nordeng HME. Genetic Susceptibility to Drug Teratogenicity: A Systematic Literature Review. Front Genet 2021; 12:645555. [PMID: 33981330 PMCID: PMC8107476 DOI: 10.3389/fgene.2021.645555] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/19/2021] [Indexed: 12/19/2022] Open
Abstract
Since the 1960s, drugs have been known to cause teratogenic effects in humans. Such teratogenicity has been postulated to be influenced by genetics. The aim of this review was to provide an overview of the current knowledge on genetic susceptibility to drug teratogenicity in humans and reflect on future directions within the field of genetic teratology. We focused on 12 drugs and drug classes with evidence of teratogenic action, as well as 29 drugs and drug classes with conflicting evidence of fetal safety in humans. An extensive literature search was performed in the PubMed and EMBASE databases using terms related to the drugs of interest, congenital anomalies and fetal development abnormalities, and genetic variation and susceptibility. A total of 29 studies were included in the final data extraction. The eligible studies were published between 1999 and 2020 in 10 different countries, and comprised 28 candidate gene and 1 whole-exome sequencing studies. The sample sizes ranged from 20 to 9,774 individuals. Several drugs were investigated, including antidepressants (nine studies), thalidomide (seven studies), antiepileptic drugs (five studies), glucocorticoids (four studies), acetaminophen (two studies), and sex hormones (estrogens, one study; 17-alpha hydroxyprogesterone caproate, one study). The main neonatal phenotypic outcomes included perinatal complications, cardiovascular congenital anomalies, and neurodevelopmental outcomes. The review demonstrated that studies on genetic teratology are generally small, heterogeneous, and exhibit inconsistent results. The most convincing findings were genetic variants in SLC6A4, MTHFR, and NR3C1, which were associated with drug teratogenicity by antidepressants, antiepileptics, and glucocorticoids, respectively. Notably, this review demonstrated the large knowledge gap regarding genetic susceptibility to drug teratogenicity, emphasizing the need for further efforts in the field. Future studies may be improved by increasing the sample size and applying genome-wide approaches to promote the interpretation of results. Such studies could support the clinical implementation of genetic screening to provide safer drug use in pregnant women in need of drugs.
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Affiliation(s)
- Julia do Amaral Gomes
- Programa de Pós-Graduação em Genética e Biologia Molecular (PPGBM), Departamento de Genética, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Sistema Nacional de Informação sobre Agentes Teratogênicos (SIAT), Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Laboratório de Medicina Genômica, Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Instituto Nacional de Genética Médica Populacional (INAGEMP), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Emilie Willoch Olstad
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Thayne Woycinck Kowalski
- Programa de Pós-Graduação em Genética e Biologia Molecular (PPGBM), Departamento de Genética, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Laboratório de Medicina Genômica, Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Instituto Nacional de Genética Médica Populacional (INAGEMP), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Complexo de Ensino Superior de Cachoeirinha (CESUCA), Cachoeirinha, Brazil
| | - Kristina Gervin
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Division of Clinical Neuroscience, Department of Research and Innovation, Oslo University Hospital, Oslo, Norway
| | - Fernanda Sales Luiz Vianna
- Programa de Pós-Graduação em Genética e Biologia Molecular (PPGBM), Departamento de Genética, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Sistema Nacional de Informação sobre Agentes Teratogênicos (SIAT), Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Laboratório de Medicina Genômica, Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Instituto Nacional de Genética Médica Populacional (INAGEMP), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Lavínia Schüler-Faccini
- Programa de Pós-Graduação em Genética e Biologia Molecular (PPGBM), Departamento de Genética, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Sistema Nacional de Informação sobre Agentes Teratogênicos (SIAT), Serviço de Genética Médica, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Instituto Nacional de Genética Médica Populacional (INAGEMP), Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Hedvig Marie Egeland Nordeng
- Pharmacoepidemiology and Drug Safety Research Group, Department of Pharmacy, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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