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Sahota JS, Sharma B, Guleria K, Sambyal V. Candidate genes for infertility: an in-silico study based on cytogenetic analysis. BMC Med Genomics 2022; 15:170. [PMID: 35918717 PMCID: PMC9347124 DOI: 10.1186/s12920-022-01320-x] [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: 05/11/2022] [Accepted: 07/22/2022] [Indexed: 11/26/2022] Open
Abstract
Background The cause of infertility remains unclear in a significant proportion of reproductive-age couples who fail to conceive naturally. Chromosomal aberrations have been identified as one of the main genetic causes of male and female infertility. Structural chromosomal aberrations may disrupt the functioning of various genes, some of which may be important for fertility. The present study aims to identify candidate genes and putative functional interaction networks involved in male and female infertility using cytogenetic data from cultured peripheral blood lymphocytes of infertile patients. Methods Karyotypic analyses was done in 201 infertile patients (100 males and 101 females) and 201 age and gender matched healthy controls (100 males and 101 females) after 72 h peripheral lymphocyte culturing and GTG banding, followed by bioinformatic analysis using Cytoscape v3.8.2 and Metascape. Results Several chromosomal regions with a significantly higher frequency of structural aberrations were identified in the infertile males (5q2, 10q2, and 17q2) and females (6q2, 16q2, and Xq2). Segregation of the patients based on type of infertility (primary v/s secondary infertility) led to the identification of chromosomal regions with a significantly higher frequency of structural aberrations exclusively within the infertile males (5q2, 17q2) and females (16q2) with primary infertility. Cytoscape identified two networks specific to these regions: a male specific network with 99 genes and a female specific network with 109 genes. The top enriched GO terms within the male and female infertility networks were “skeletal system morphogenesis” and “mRNA transport” respectively. PSME3, PSMD3, and CDC27 were the top 3 hub genes identified within the male infertility network. Similarly, UPF3B, IRF8, and PSMB1 were the top 3 hub genes identified with the female infertility network. Among the hub genes identified in the male- and female-specific networks, PSMB1, PSMD3, and PSME3 are functional components of the proteasome complex. These hub genes have a limited number of reports related to their respective roles in maintenance of fertility in mice model and humans and require validation in further studies. Conclusion The candidate genes predicted in the present study can serve as targets for future research on infertility. Supplementary Information The online version contains supplementary material available at 10.1186/s12920-022-01320-x.
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Affiliation(s)
- Jatinder Singh Sahota
- Department of Human Genetics, Cytogenetics Laboratory, Guru Nanak Dev University (GNDU), Amritsar, Punjab, 143005, India
| | - Bhavna Sharma
- Department of Human Genetics, Cytogenetics Laboratory, Guru Nanak Dev University (GNDU), Amritsar, Punjab, 143005, India
| | - Kamlesh Guleria
- Department of Human Genetics, Cytogenetics Laboratory, Guru Nanak Dev University (GNDU), Amritsar, Punjab, 143005, India
| | - Vasudha Sambyal
- Department of Human Genetics, Cytogenetics Laboratory, Guru Nanak Dev University (GNDU), Amritsar, Punjab, 143005, India.
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2
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Assidi M. Infertility in Men: Advances towards a Comprehensive and Integrative Strategy for Precision Theranostics. Cells 2022; 11:cells11101711. [PMID: 35626747 PMCID: PMC9139678 DOI: 10.3390/cells11101711] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 02/05/2023] Open
Abstract
Male infertility is an increasing and serious medical concern, though the mechanism remains poorly understood. Impaired male reproductive function affects approximately half of infertile couples worldwide. Multiple factors related to the environment, genetics, age, and comorbidities have been associated with impaired sperm function. Present-day clinicians rely primarily on standard semen analysis to diagnose male reproductive potential and develop treatment strategies. To address sperm quality assessment bias and enhance analysis accuracy, the World Health Organization (WHO) has recommended standardized sperm testing; however, conventional diagnostic and therapeutic options for male infertility, including physical examination and semen standard analysis, remain ineffective in relieving the associated social burden. Instead, assisted reproductive techniques are becoming the primary therapeutic approach. In the post-genomic era, multiomics technologies that deeply interrogate the genome, transcriptome, proteome, and/or the epigenome, even at single-cell level, besides the breakthroughs in robotic surgery, stem cell therapy, and big data, offer promises towards solving semen quality deterioration and male factor infertility. This review highlights the complex etiology of male infertility, especially the roles of lifestyle and environmental factors, and discusses advanced technologies/methodologies used in characterizing its pathophysiology. A comprehensive combination of these innovative approaches in a global and multi-centric setting and fulfilling the suitable ethical consent could ensure optimal reproductive and developmental outcomes. These combinatorial approaches should allow for the development of diagnostic markers, molecular stratification classes, and personalized treatment strategies. Since lifestyle choices and environmental factors influence male fertility, their integration in any comprehensive approach is required for safe, proactive, cost-effective, and noninvasive precision male infertility theranostics that are affordable, accessible, and facilitate couples realizing their procreation dream.
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Affiliation(s)
- Mourad Assidi
- Center of Excellence in Genomic Medicine Research, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia; ; Tel.: +966-(012)-6402000 (ext. 69267)
- Medical Laboratory Department, Faculty of Applied Medical Sciences, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia
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3
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Botezatu A, Vladoiu S, Fudulu A, Albulescu A, Plesa A, Muresan A, Stancu C, Iancu IV, Diaconu CC, Velicu A, Popa OM, Badiu C, Dinu-Draganescu D. Advanced molecular approaches in male infertility diagnosis. Biol Reprod 2022; 107:684-704. [PMID: 35594455 DOI: 10.1093/biolre/ioac105] [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: 12/30/2021] [Revised: 04/29/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
In the recent years a special attention has been given to a major health concern namely to male infertility, defined as the inability to conceive after 12 months of regular unprotected sexual intercourse, taken into account the statistics that highlight that sperm counts have dropped by 50-60% in recent decades. According to the WHO, infertility affects approximately 9% of couples globally, and the male factor is believed to be present in roughly 50% of cases, with exclusive responsibility in 30%. The aim of this manuscript is to present an evidence-based approach for diagnosing male infertility that includes finding new solutions for diagnosis and critical outcomes, retrieving up-to-date studies and existing guidelines. The diverse factors that induce male infertility generated in a vast amount of data that needed to be analysed by a clinician before a decision could be made for each individual. Modern medicine faces numerous obstacles as a result of the massive amount of data generated by the molecular biology discipline. To address complex clinical problems, vast data must be collected, analysed, and used, which can be very challenging. The use of artificial intelligence (AI) methods to create a decision support system can help predict the diagnosis and guide treatment for infertile men, based on analysis of different data as environmental and lifestyle, clinical (sperm count, morphology, hormone testing, karyotype, etc.) and "omics" bigdata. Ultimately, the development of AI algorithms will assist clinicians in formulating diagnosis, making treatment decisions, and predicting outcomes for assisted reproduction techniques.
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Affiliation(s)
- A Botezatu
- "Stefan S. Nicolau" Institute of Virology, Bucharest, Romania
| | - S Vladoiu
- "CI Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - A Fudulu
- "Stefan S. Nicolau" Institute of Virology, Bucharest, Romania
| | - A Albulescu
- "Stefan S. Nicolau" Institute of Virology, Bucharest, Romania.,National Institute for Chemical pharmaceutical Research & Development
| | - A Plesa
- "Stefan S. Nicolau" Institute of Virology, Bucharest, Romania
| | - A Muresan
- "CI Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - C Stancu
- "CI Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - I V Iancu
- "Stefan S. Nicolau" Institute of Virology, Bucharest, Romania
| | - C C Diaconu
- "Stefan S. Nicolau" Institute of Virology, Bucharest, Romania
| | - A Velicu
- "CI Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - O M Popa
- "CI Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - C Badiu
- "CI Parhon" National Institute of Endocrinology, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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4
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Rotondo JC, Lanzillotti C, Mazziotta C, Tognon M, Martini F. Epigenetics of Male Infertility: The Role of DNA Methylation. Front Cell Dev Biol 2021; 9:689624. [PMID: 34368137 PMCID: PMC8339558 DOI: 10.3389/fcell.2021.689624] [Citation(s) in RCA: 78] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 06/17/2021] [Indexed: 12/18/2022] Open
Abstract
In recent years, a number of studies focused on the role of epigenetics, including DNA methylation, in spermatogenesis and male infertility. We aimed to provide an overview of the knowledge concerning the gene and genome methylation and its regulation during spermatogenesis, specifically in the context of male infertility etiopathogenesis. Overall, the findings support the hypothesis that sperm DNA methylation is associated with sperm alterations and infertility. Several genes have been found to be differentially methylated in relation to impaired spermatogenesis and/or reproductive dysfunction. Particularly, DNA methylation defects of MEST and H19 within imprinted genes and MTHFR within non-imprinted genes have been repeatedly linked with male infertility. A deep knowledge of sperm DNA methylation status in association with reduced reproductive potential could improve the development of novel diagnostic tools for this disease. Further studies are needed to better elucidate the mechanisms affecting methylation in sperm and their impact on male infertility.
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Affiliation(s)
- John Charles Rotondo
- Laboratories of Cell Biology and Molecular Genetics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Carmen Lanzillotti
- Laboratories of Cell Biology and Molecular Genetics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Chiara Mazziotta
- Laboratories of Cell Biology and Molecular Genetics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Mauro Tognon
- Laboratories of Cell Biology and Molecular Genetics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Fernanda Martini
- Laboratories of Cell Biology and Molecular Genetics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
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Holcomb RJ, Oura S, Nozawa K, Kent K, Yu Z, Robertson MJ, Coarfa C, Matzuk MM, Ikawa M, Garcia TX. The testis-specific serine proteases PRSS44, PRSS46, and PRSS54 are dispensable for male mouse fertility†. Biol Reprod 2021; 102:84-91. [PMID: 31403672 PMCID: PMC7013879 DOI: 10.1093/biolre/ioz158] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 07/06/2019] [Accepted: 07/28/2019] [Indexed: 12/19/2022] Open
Abstract
High-throughput transcriptomics and proteomics approaches have recently identified a large number of germ cell-specific genes with many that remain to be studied through functional genetics approaches. Serine proteases (PRSS) constitute nearly one-third of all proteases, and, in our bioinformatics screens, we identified many that are testis specific. In this study, we chose to focus on Prss44, Prss46, and Prss54, which we confirmed as testis specific in mouse and human. Based on the analysis of developmental expression in the mouse, expression of all four genes is restricted to the late stage of spermatogenesis concomitant with a potential functional role in spermiogenesis, spermiation, or sperm function. To best understand the male reproductive requirement and functional roles of these serine proteases, each gene was individually ablated by CRISPR/Cas9-mediated ES cell or zygote approach. Homozygous deletion mutants for each gene were obtained and analyzed for phenotypic changes. Analyses of testis weights, testis and epididymis histology, sperm morphology, and fertility revealed no significant differences in Prss44, Prss46, and Prss54 knockout mice in comparison to controls. Our results thereby demonstrate that these genes are not required for normal fertility in mice, although do not preclude the possibility that these genes may function in a redundant manner. Elucidating the individual functional requirement or lack thereof of these novel genes is necessary to build a better understanding of the factors underlying spermatogenesis and sperm maturation, which has implications in understanding the etiology of male infertility and the development of male contraceptives.
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Affiliation(s)
- Richard J Holcomb
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.,Department of Biology and Biotechnology, University of Houston-Clear Lake, Houston, TX, USA.,Center for Drug Discovery, Baylor College of Medicine, Houston, TX, USA
| | - Seiya Oura
- Department of Experimental Genome Research, Research Institute for Microbial Diseases, Osaka University, Suita, Osaka, Japan
| | - Kaori Nozawa
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.,Center for Drug Discovery, Baylor College of Medicine, Houston, TX, USA
| | - Katarzyna Kent
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.,Department of Biology and Biotechnology, University of Houston-Clear Lake, Houston, TX, USA.,Center for Drug Discovery, Baylor College of Medicine, Houston, TX, USA
| | - Zhifeng Yu
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.,Center for Drug Discovery, Baylor College of Medicine, Houston, TX, USA
| | - Matthew J Robertson
- Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA.,Advanced Technology Cores, Baylor College of Medicine, Houston, TX, USA
| | - Cristian Coarfa
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX, USA
| | - Martin M Matzuk
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.,Center for Drug Discovery, Baylor College of Medicine, Houston, TX, USA.,Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA.,Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX, USA.,Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.,Department of Pharmacology and Chemical Biology, Baylor College of Medicine, Houston, TX, USA
| | - Masahito Ikawa
- Department of Experimental Genome Research, Research Institute for Microbial Diseases, Osaka University, Suita, Osaka, Japan.,Graduate School of Pharmaceutical Sciences, Osaka University, Suita, Osaka, Japan.,The Institute of Medical Science, The University of Tokyo, Minato-ku, Tokyo, Japan
| | - Thomas X Garcia
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA.,Department of Biology and Biotechnology, University of Houston-Clear Lake, Houston, TX, USA.,Center for Drug Discovery, Baylor College of Medicine, Houston, TX, USA
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6
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Narud B, Khezri A, Zeremichael TT, Stenseth EB, Heringstad B, Johannisson A, Morrell JM, Collas P, Myromslien FD, Kommisrud E. Sperm chromatin integrity and DNA methylation in Norwegian Red bulls of contrasting fertility. Mol Reprod Dev 2021; 88:187-200. [PMID: 33634579 DOI: 10.1002/mrd.23461] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/18/2021] [Accepted: 02/10/2021] [Indexed: 12/28/2022]
Abstract
In this study, the complexity of chromatin integrity was investigated in frozen-thawed semen samples from 37 sires with contrasting fertility, expressed as 56-day non-return rates (NR56). Protamine deficiency, thiols, and disulfide bonds were assessed and compared with previously published data for DNA fragmentation index (DFI) and high DNA stainability (HDS). In addition, in vitro embryo development and sperm DNA methylation were assessed using semen samples from 16 of these bulls. The percentages of DFI and HDS were negatively associated with NR56 and cleavage rate and positively associated with sperm protamine deficiency (p < 0.05). Significant differences in cleavage and blastocyst rates were observed between bulls of high and low NR56. However, once fertilization occurred, further development into blastocysts was not associated with NR56. The differential methylation analysis showed that spermatozoa from bulls of low NR56 were hypermethylated compared to bulls of high NR56. Pathway analysis showed that genes annotated to differentially methylated cytosines could participate in different biological pathways and have important biological roles related to bull fertility. In conclusion, sperm cells from Norwegian Red bulls of inferior fertility have less compact chromatin structure, higher levels of DNA damage, and are hypermethylated compared with bulls of superior fertility.
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Affiliation(s)
- Birgitte Narud
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of Biotechnology, Inland Norway University of Applied Sciences, Hamar, Norway
| | - Abdolrahman Khezri
- Department of Biotechnology, Inland Norway University of Applied Sciences, Hamar, Norway
| | | | - Else-Berit Stenseth
- Department of Biotechnology, Inland Norway University of Applied Sciences, Hamar, Norway
| | - Bjørg Heringstad
- Department of Animal and Aquacultural Sciences, Faculty of Biosciences, Norwegian University of Life Sciences, Ås, Norway
| | - Anders Johannisson
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Jane M Morrell
- Department of Clinical Sciences, Swedish University of Agricultural Sciences, Uppsala, Sweden
| | - Philippe Collas
- Department of Molecular Medicine, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway.,Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Elisabeth Kommisrud
- Department of Biotechnology, Inland Norway University of Applied Sciences, Hamar, Norway
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7
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Garrido N, Cruz F, Egea RR, Simon C, Sadler-Riggleman I, Beck D, Nilsson E, Ben Maamar M, Skinner MK. Sperm DNA methylation epimutation biomarker for paternal offspring autism susceptibility. Clin Epigenetics 2021; 13:6. [PMID: 33413568 PMCID: PMC7789568 DOI: 10.1186/s13148-020-00995-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 12/17/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Autism spectrum disorder (ASD) has increased over tenfold over the past several decades and appears predominantly associated with paternal transmission. Although genetics is anticipated to be a component of ASD etiology, environmental epigenetics is now also thought to be an important factor. Epigenetic alterations, such as DNA methylation, have been correlated with ASD. The current study was designed to identify a DNA methylation signature in sperm as a potential biomarker to identify paternal offspring autism susceptibility. METHODS AND RESULTS Sperm samples were obtained from fathers that have children with or without autism, and the sperm then assessed for alterations in DNA methylation. A genome-wide analysis (> 90%) for differential DNA methylation regions (DMRs) was used to identify DMRs in the sperm of fathers (n = 13) with autistic children in comparison with those (n = 13) without ASD children. The 805 DMR genomic features such as chromosomal location, CpG density and length of the DMRs were characterized. Genes associated with the DMRs were identified and found to be linked to previously known ASD genes, as well as other neurobiology-related genes. The potential sperm DMR biomarkers/diagnostic was validated with blinded test sets (n = 8-10) of individuals with an approximately 90% accuracy. CONCLUSIONS Observations demonstrate a highly significant set of 805 DMRs in sperm that can potentially act as a biomarker for paternal offspring autism susceptibility. Ancestral or early-life paternal exposures that alter germline epigenetics are anticipated to be a molecular component of ASD etiology.
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Affiliation(s)
- Nicolás Garrido
- IVI-RMA València, and IVI Foundation, Health Research Institute La Fe, València, Spain
| | - Fabio Cruz
- IVI-RMA València, and IVI Foundation, Health Research Institute La Fe, València, Spain
| | - Rocio Rivera Egea
- IVI-RMA València, and IVI Foundation, Health Research Institute La Fe, València, Spain
| | - Carlos Simon
- Dept Ob/Gyn, València University/Instituto de Investigacion Clinica, Hospital Clinico de Valencia (INCLIVA), and Igenomix Foundation, València, Spain
- Beth Israel Deaconess Medical Center, Harvard University, Boston, USA
| | - Ingrid Sadler-Riggleman
- Center for Reproductive Biology, School of Biological Sciences, Washington State University, Pullman, WA, 99164-4236, USA
| | - Daniel Beck
- Center for Reproductive Biology, School of Biological Sciences, Washington State University, Pullman, WA, 99164-4236, USA
| | - Eric Nilsson
- Center for Reproductive Biology, School of Biological Sciences, Washington State University, Pullman, WA, 99164-4236, USA
| | - Millissia Ben Maamar
- Center for Reproductive Biology, School of Biological Sciences, Washington State University, Pullman, WA, 99164-4236, USA
| | - Michael K Skinner
- Center for Reproductive Biology, School of Biological Sciences, Washington State University, Pullman, WA, 99164-4236, USA.
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8
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Franzago M, La Rovere M, Guanciali Franchi P, Vitacolonna E, Stuppia L. Epigenetics and human reproduction: the primary prevention of the noncommunicable diseases. Epigenomics 2019; 11:1441-1460. [PMID: 31596147 DOI: 10.2217/epi-2019-0163] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Epigenetic regulation of gene expression plays a key role in affecting human health and diseases with particular regard to human reproduction. The major concern in this field is represented by the epigenetic modifications in the embryo and the increased risk of long-life disorders induced by the use of assisted reproduction techniques, able to affect the epigenetic assessment in the first steps of embryo development. In this review, we analyze the correlation between epigenetic modifications and human reproduction, suggesting that the reversibility of the epigenetic processes could represent a novel resource for the treatment of the couple's infertility and that parental lifestyle in periconceptional period could be considered as an important issue of primary prevention.
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Affiliation(s)
- Marica Franzago
- Department of Medicine & Aging, School of Medicine & Health Sciences, 'G. d'Annunzio' University, Chieti-Pescara, Chieti, Italy.,Center for Aging Studies & Translational Medicine (CESI-MET), 'G. d'Annunzio' University of Chieti-Pescara, Chieti, Italy
| | - Marina La Rovere
- Department of Psychological, Health & Territorial Sciences, School of Medicine & Health Sciences, 'G. d'Annunzio' University of Chieti-Pescara, Chieti, Italy
| | - Paolo Guanciali Franchi
- Department of Medical, Oral & Biotechnological Sciences, School of Medicine & Health Sciences, 'G. d'Annunzio' University of Chieti-Pescara, Chieti, Italy
| | - Ester Vitacolonna
- Department of Medicine & Aging, School of Medicine & Health Sciences, 'G. d'Annunzio' University, Chieti-Pescara, Chieti, Italy
| | - Liborio Stuppia
- Center for Aging Studies & Translational Medicine (CESI-MET), 'G. d'Annunzio' University of Chieti-Pescara, Chieti, Italy.,Department of Psychological, Health & Territorial Sciences, School of Medicine & Health Sciences, 'G. d'Annunzio' University of Chieti-Pescara, Chieti, Italy
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