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Weitzel J, Welsner M, Taube C, Ballmann M, Sutharsan S. Case Series: Hyperbilirubinemia under elexacaftor/tezacaftor/ivacaftor in the presence of Gilbert's syndrome. BMC Pulm Med 2024; 24:307. [PMID: 38956524 PMCID: PMC11218103 DOI: 10.1186/s12890-024-03114-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 06/19/2024] [Indexed: 07/04/2024] Open
Abstract
Liver-related side effects are a known complication of treatment with elexacaftor/tezacaftor/ivacaftor (ETI) for cystic fibrosis (CF). Gilbert's syndrome is caused by a genetic mutation that reduces activity of the enzyme UDP glucuronosyltransferase 1 polypeptide A1 (UGT1A1), causing elevated levels of unconjugated bilirubin in the blood and duodenal bile. The presence of Gilbert's syndrome and CF might represent additive risk factors for liver-related adverse events during ETI treatment. This case series describes six people with CF (pwCF) in whom previously unknown Gilbert's syndrome was unmasked after initiation of treatment with ETI. Although all patients had some level of hepatic dysfunction and/or elevated levels of bilirubin after initiation of ETI, the clinical course varied. Only one patient had to stop ETI therapy altogether, while the others were able to continue treatment (some at a reduced dosage and others at the full recommended daily dosage). All patients, even those using a lower dosage, experienced clinical benefit during ETI therapy. Gilbert's syndrome is not a contraindication for ETI therapy but may be mistaken for a risk factor for liver-related adverse events in pwCF. This is something that physicians need to be aware of in pwCF who show liver adverse events during ETI therapy.
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Affiliation(s)
- Julia Weitzel
- Department of Pediatrics, Rostock University Medical Centre, Rostock, Germany
| | - Matthias Welsner
- Department of Pulmonary Medicine, Adult Cystic Fibrosis Center, University Hospital Essen - Ruhrlandklinik, Essen, North Rhine-Westphalia, Germany
| | - Christian Taube
- Department of Pulmonary Medicine, Adult Cystic Fibrosis Center, University Hospital Essen - Ruhrlandklinik, Essen, North Rhine-Westphalia, Germany
| | - Manfred Ballmann
- Department of Pediatrics, Rostock University Medical Centre, Rostock, Germany.
| | - Sivagurunathan Sutharsan
- Department of Pulmonary Medicine, Adult Cystic Fibrosis Center, University Hospital Essen - Ruhrlandklinik, Essen, North Rhine-Westphalia, Germany
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Strobl F, Theurich MA. Prolonged Jaundice in a Premature Breastfed Infant With Gilbert's Syndrome. J Hum Lact 2024; 40:270-275. [PMID: 38334089 PMCID: PMC11015704 DOI: 10.1177/08903344241227226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 01/03/2024] [Indexed: 02/10/2024]
Abstract
INTRODUCTION Neonatal jaundice and prematurity pose significant barriers to breastfeeding in the first days of life. There is limited literature exploring the relationship between prolonged jaundice in breastfed infants and Gilbert's (Meulengraght) syndrome. This case study describes the diagnostic and therapeutic challenges associated with Gilbert's syndrome in a late preterm breastfed infant born in Germany. MAIN ISSUE In this case report, an infant born to a primipara woman presented at 3 weeks postpartum to an International Board Certified Lactation Consultant. The initial assessment revealed a late preterm infant with inadequate weight gain and jaundice. The dyad received breastfeeding support and eventually achieved adequate weight gain; however, the infant's jaundice persisted. MANAGEMENT The consulting midwife suggested that the persistent jaundice was "breastmilk jaundice" and recommended temporarily interrupting breastfeeding. Due to a suspected family history of Gilbert's Syndrome, the dyad was referred, instead, to a pediatric gastroenterologist. Pathologic liver disease was excluded, and genetic testing confirmed Gilbert's Syndrome. At 6 months of age, the dyad was successfully breastfeeding and beginning complementary feeding. CONCLUSION Genetic testing for Gilbert's Syndrome should be considered for infants with prolonged jaundice and positive family history. Interruption or cessation of breastfeeding are not evidence-based recommendations, and current guidelines do not support these practices. Lactation professionals play a critical role in the management of breastfeeding for preterm infants with prolonged jaundice and should refer to specialists to rule out pathologic etiologies.
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Affiliation(s)
- Frances Strobl
- School of Life Sciences, Technical University of Munich, Munich, Germany
| | - Melissa Ann Theurich
- Chair of Public Health and Health Services Research, Institute for Medical Information Processing, Biometry and Epidemiology, Pettenkoffer School of Public Health, Faculty of Medicine, Ludwig-Maximilians-Universität München (LMU Munich), Munich, Germany
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R R, Sangameshwar A, Tan YY, Teh Kim Jun K, Tham TY, Cheah Chang Chuen M. Approach to Abnormal Liver Biochemistries in the Primary Care Setting. Cureus 2024; 16:e56541. [PMID: 38646392 PMCID: PMC11026984 DOI: 10.7759/cureus.56541] [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] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
Liver biochemistries are commonly ordered in the primary care setting, and they may return abnormal even in an asymptomatic patient. Primary care physicians need to have a systematic way of interpreting any derangement in these tests so that further investigations, referrals, and management can be arranged appropriately. This review dwells into patterns of liver biochemistry derangement, common aetiologies to consider, history and examinations that are required, initial investigations to order, and when to refer urgently to the emergency department.
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Affiliation(s)
- Rajesh R
- Gastroenterology and Hepatology, Singapore General Hospital, Singapore, SGP
| | | | - Yi Yuan Tan
- Gastroenterology and Hepatology, Singapore General Hospital, Singapore, SGP
| | - Kevin Teh Kim Jun
- Gastroenterology and Hepatology, Singapore General Hospital, Singapore, SGP
| | - Tat Yean Tham
- Family Medicine, Frontier Healthcare, Singapore, SGP
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Zhang L, Liu Z, Xue L. A Rare Case of Primary Sjogren's Syndrome Coexisting With Gilbert Syndrome. Cureus 2023; 15:e45521. [PMID: 37868557 PMCID: PMC10585419 DOI: 10.7759/cureus.45521] [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] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Gilbert syndrome (GS) is an autosomal recessive inherited bilirubin metabolism disorder characterized by chronic unconjugated hyperbilirubinemia in the absence of hemolysis and liver disease. Primary Sjogren's syndrome (pSS), mainly occurring in women, is a common connective tissue disease (CTD) wherein bilirubin levels are generally reduced. We report a rare case of pSS coexisting with GS. A 35-year-old female patient presented to our hospital with pSS and chronic unconjugated hyperbilirubinemia, for which low-dose methylprednisolone was ineffective. The patient's liver function test results were normal, serological tests for hepatitis virus were negative, and abdominal ultrasound did not indicate abnormal liver morphology. Bone mineral density determination showed that the Z scores of the left femoral neck and lumbar spine were -1.9 and -2.6, respectively, with T scores of -2.1 and -2.8, respectively. Full-exon sequencing revealed a homozygous TA insertion in the TATA box (A(TA)7TAA) and a heterozygous base substitution from C to A at nucleotide position 686 in exon 1 (c.686C>A) in the uridine glucuronosyltransferase 1A1 (UGT1A1) gene. Therefore, the patient was diagnosed with pSS, GS, and osteoporosis. The dose of methylprednisolone was then reduced and gradually stopped, and treatment for osteoporosis was strengthened. To our knowledge, this is the first report of pSS with GS. It is important to clarify the cause of hyperbilirubinemia in patients with CTD, including pSS, which affects the formulation of correct treatment plans.
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Affiliation(s)
- Lin Zhang
- Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, CHN
| | - Zhichun Liu
- Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, CHN
| | - Leixi Xue
- Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, CHN
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Adamson C, Jhund PS, McMurray JJV. Reply to 'The 50 shades of bilirubin'. Letter regarding the article 'Liver tests and outcomes in heart failure with reduced ejection fraction: findings from DAPA-HF'. Eur J Heart Fail 2022; 24:2206-2207. [PMID: 36097136 DOI: 10.1002/ejhf.2683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/08/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Carly Adamson
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Monroy-Iglesias MJ, Moss C, Beckmann K, Hammar N, Walldius G, Bosco C, Van Hemelrijck M, Santaolalla A. Serum Total Bilirubin and Risk of Cancer: A Swedish Cohort Study and Meta-Analysis. Cancers (Basel) 2021; 13:cancers13215540. [PMID: 34771701 PMCID: PMC8582941 DOI: 10.3390/cancers13215540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Several studies published to date have shown inconclusive results in the association between serum bilirubin and risk of site-specific cancer types and overall cancer. Therefore, there is a need to further investigate this association. Data from the large Swedish Apolipoprotein Mortality Risk (AMORIS) cohort study was used. We found that overall high levels of bilirubin had no association with overall cancer risk. However, a positive association was found between melanoma and breast cancer risk. On the other hand, an inverse association was found between high levels of bilirubin and risk of gynecological and lung cancers. Further studies are required to establish if bilirubin can be used as a biomarker for risk assessment and/or as a novel therapeutic target. Abstract Bilirubin has strong antioxidant properties that have been hypothesized to be preventive against the development of cancer. Thus, we aimed to investigate the association between serum total bilirubin (STB) and risk of overall and site-specific cancers in the large Swedish Apolipoprotein Mortality Risk (AMORIS) cohort. We also performed a systematic review and meta-analysis for specific cancer types (colorectal, breast and lung). We found no association between high levels of STB and risk of overall cancer. Regarding site-specific cancer, there was an inverse association between increased STB and lung cancer (Hazard Ratio (HR) for the 4th quartile (Q4) vs. Q1: 0.50; 95%CI: 0.44–0.59) and gynecological cancer (HR for Q4 vs. Q1: 0.86; 95%CI: 0.76–0.99). A positive association was found with melanoma (HR for Q4 vs. Q1: 1.25; 95%CI: 1.06–1.47) and breast cancer (HR for Q4 vs. Q1: 1.13; 95%CI: 1.01–1.25) risk. The meta-analysis showed an inverse association between high levels of STB and risk of lung cancer (Relative risk (RR): 0.69; 95%CI: 0.55–0.86). No associations were seen for colorectal and breast cancer risk. Further studies are required to establish if bilirubin can be used as a biomarker for risk assessment and/or as a novel therapeutic target.
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Affiliation(s)
- Maria J. Monroy-Iglesias
- Translational Oncology & Urology Research (TOUR), King’s College London, London SE1 9RT, UK; (M.J.M.-I.); (C.M.); (K.B.); (C.B.); (M.V.H.)
| | - Charlotte Moss
- Translational Oncology & Urology Research (TOUR), King’s College London, London SE1 9RT, UK; (M.J.M.-I.); (C.M.); (K.B.); (C.B.); (M.V.H.)
| | - Kerri Beckmann
- Translational Oncology & Urology Research (TOUR), King’s College London, London SE1 9RT, UK; (M.J.M.-I.); (C.M.); (K.B.); (C.B.); (M.V.H.)
- Cancer Research Institute, University of South Australia, Adelaide, SE 5001, Australia
| | - Niklas Hammar
- Epidemiology Unit, Institute of Environmental Medicine, Karolinska Institute, 171 77 Stockholm, Sweden; (N.H.); (G.W.)
| | - Goran Walldius
- Epidemiology Unit, Institute of Environmental Medicine, Karolinska Institute, 171 77 Stockholm, Sweden; (N.H.); (G.W.)
| | - Cecilia Bosco
- Translational Oncology & Urology Research (TOUR), King’s College London, London SE1 9RT, UK; (M.J.M.-I.); (C.M.); (K.B.); (C.B.); (M.V.H.)
| | - Mieke Van Hemelrijck
- Translational Oncology & Urology Research (TOUR), King’s College London, London SE1 9RT, UK; (M.J.M.-I.); (C.M.); (K.B.); (C.B.); (M.V.H.)
- Epidemiology Unit, Institute of Environmental Medicine, Karolinska Institute, 171 77 Stockholm, Sweden; (N.H.); (G.W.)
| | - Aida Santaolalla
- Translational Oncology & Urology Research (TOUR), King’s College London, London SE1 9RT, UK; (M.J.M.-I.); (C.M.); (K.B.); (C.B.); (M.V.H.)
- Epidemiology Unit, Institute of Environmental Medicine, Karolinska Institute, 171 77 Stockholm, Sweden; (N.H.); (G.W.)
- Correspondence:
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Abstract
Background Gilbert syndrome is a well-recognized condition causing unconjugated hyperbilirubinemia with otherwise normal transaminases and liver function tests. Case A 21 year old male patient presented with recurrent episodes of jaundice over four years. The episodes were preceded by stressful conditions and intercurrent illnesses. All laboratory prameters were normal except an unconjugated hyperbilirubinemia. A diagnosis of Gilbert syndrome was made after careful clinical evaluation. Conclusion Recognizing Gilbert syndrome has important clinical implicaitions by avoiding uncessary and expensive workup of patients with jaundice. Mangement entails avoiding stressful conditions and prolonged fasting.
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Affiliation(s)
- Amir Sultan
- Addis Ababa University, College of Health Sciences, Division of Gastroenterology & Hepatology, Addis Ababa, Ethiopia https://orcid.org/0000-0002-7000-9575
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Minucci A, Onori ME, Urbani A. Commentary: Case Report: Hyperbilirubinemia in Gilbert Syndrome Attenuates Covid-19-Induced Metabolic Disturbances. Front Cardiovasc Med 2021; 8:685835. [PMID: 34368246 PMCID: PMC8339401 DOI: 10.3389/fcvm.2021.685835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/30/2021] [Indexed: 12/12/2022] Open
Affiliation(s)
- Angelo Minucci
- Molecular and Genomic Diagnostics Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Maria Elisabetta Onori
- Molecular and Genomic Diagnostics Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea Urbani
- Molecular and Genomic Diagnostics Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
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Saffari-Chaleshtori J, Shojaeian A, Heidarian E, Shafiee SM. Inhibitory Effects of Bilirubin on Colonization and Migration of A431 and SK-MEL-3 Skin Cancer Cells Compared with Human Dermal Fibroblasts (HDF). Cancer Invest 2021; 39:721-733. [PMID: 34279168 DOI: 10.1080/07357907.2021.1943428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This study evaluated the inhibitory effects of bilirubin on colony formation and cell migration of melanoma and non-melanoma skin cancer cell lines SK-MEL-3 and A431, compared with normal human dermal fibroblasts (HDF). The IC50 obtained from the MTT assay was 125, 100, and 75 μM bilirubin for HDF, A431, and SK-MEL-3 cells, respectively. The colony formation and cell migration of cancer cells, treated with 100 μM bilirubin, were reduced significantly (p < 0.05). Bilirubin decreased cell adhesion and inhibited cell colonization via inducing apoptosis and cell death. Also by interaction with migration main factors, bilirubin caused inhibition the cell migration.
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Affiliation(s)
- Javad Saffari-Chaleshtori
- Department of Biochemistry, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Clinical Biochemistry Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Ali Shojaeian
- Cellular and Molecular Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Esfandiar Heidarian
- Clinical Biochemistry Research Center, Basic Health Sciences Institute, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Sayed Mohammad Shafiee
- Department of Biochemistry, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran.,Autophagy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Picardo E, Tota D, Gemmiti S, Danese S, Benedetto C, Mitidieri M. Acute pancreatitis in pregnancy: Are gallstones and Gilbert's syndrome cofactors? Eur J Obstet Gynecol Reprod Biol 2021; 263:281-282. [PMID: 33994022 DOI: 10.1016/j.ejogrb.2021.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Elisa Picardo
- Azienda Ospedaliero Universitaria Città della Scienza e della Salute di Torino, Ginecologia e Ostetricia SC4, Turin, Italy
| | - Donatella Tota
- Azienda Ospedaliero Universitaria Città della Scienza e della Salute di Torino, Dipartimento di Radiodiagnostica e Radioterapia, Turin, Italy
| | - Silvia Gemmiti
- Università degli Studi di Torino, Dipartimento di Scienze Chirurgiche, Turin, Italy
| | - Saverio Danese
- Azienda Ospedaliero Universitaria Città della Scienza e della Salute di Torino, Ginecologia e Ostetricia SC4, Turin, Italy
| | - Chiara Benedetto
- Università degli Studi di Torino, Dipartimento di Scienze Chirurgiche, Turin, Italy
| | - Marco Mitidieri
- Azienda Ospedaliero Universitaria Città della Scienza e della Salute di Torino, Ginecologia e Ostetricia SC4, Turin, Italy.
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Effect of gilbert's syndrome associated polymorphic alleles (rs8175347 and rs4148323) of UDP-glucuronyl transferase on serum bilirubin level. Meta Gene 2020. [DOI: 10.1016/j.mgene.2020.100788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Negative correlation of high serum bilirubin with cancer development in adults without hepatobiliary disease. Eur J Cancer Prev 2020; 30:69-75. [DOI: 10.1097/cej.0000000000000643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Reisfield GM, Teitelbaum SA, Jones JT. Persistent Urinary Ethyl Sulfate in the Absence of Urinary Ethyl Glucuronide in a Patient with Alcohol Use Disorder Who Claimed Abstinence. J Anal Toxicol 2020; 44:623-626. [PMID: 32091106 DOI: 10.1093/jat/bkaa014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/25/2020] [Indexed: 11/13/2022] Open
Abstract
A 48-year-old nurse with an alcohol use disorder history was being monitored in a professional health program. She consistently produced low-to-moderate urinary ethyl sulfate (EtS) concentrations in the absence of detectable urinary ethyl glucuronide (EtG), blood phosphatidylethanol and breath alcohol. She denied intentional ethanol consumption. After prolonged monitoring in a drug treatment program, including a period in a controlled environment, we concluded that this individual's urinary EtS likely resulted from anatomical and microbial factors related to Roux-en-Y gastric bypass surgery, with possible contributions from hidden dietary sources of ethanol. We have no definitive explanation for the lack of urinary EtG.
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Affiliation(s)
- Gary M Reisfield
- University of Florida College of Medicine, UF Health Springhill, 4037 NW 86th Terrace, Gainesville, FL 32606, USA
| | - Scott A Teitelbaum
- University of Florida College of Medicine, Florida Recovery Center, 4001 SW 13th St., Gainesville, FL 32605, USA
| | - Joseph T Jones
- United States Drug Testing Laboratories, Inc., 1700 S. Mt. Prospect Rd, Des Plaines, IL 60018, USA
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Tolomeo M, Colomba C, Meli M, Cascio A. Hepatotoxicity caused by mebendazole in a patient with Gilbert's syndrome. J Clin Pharm Ther 2019; 44:985-987. [PMID: 31423600 DOI: 10.1111/jcpt.13033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 07/25/2019] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Mebendazole (MBZ) is a broad-spectrum antihelminthic agent of the benzimidazole type. Although MBZ has been reported to cause hepatic injury, case reports of severe hepatic injury are very rare. We report a case of severe hepatitis after administration of MBZ in a patient with Gilbert's syndrome affected by pinworms infestation. CASE SUMMARY Differently from other cases of hepatitis due to MBZ reported in the scientific literature, our patient received standard doses of MBZ for a short period of time. After 18 days from the start of therapy, he developed hepatomegaly, and increases in hepatic enzymes and bilirubin. Hepatic enzymes returned to normal over the following 5 weeks. WHAT IS NEW AND CONCLUSION This is the first case report of important liver injury after administration of MBZ in a patient with Gilbert's syndrome. We suspected that a diminished hepatic glucuronidation of MBZ due to the reduced activity of the glucuronosyltransferase enzyme in our patient could have caused an increase in unconjugated toxic metabolites of MBZ and the consequent liver damage.
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Affiliation(s)
- Manlio Tolomeo
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Claudia Colomba
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Maria Meli
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Antonio Cascio
- Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
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