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Piell KM, Petri BJ, Xu J, Cai L, Rai SN, Li M, Wilkey DW, Merchant ML, Cave MC, Klinge CM. Chronic Aroclor 1260 exposure alters the mouse liver proteome, selenoproteins, and metals in steatotic liver disease. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2024; 107:104430. [PMID: 38552755 DOI: 10.1016/j.etap.2024.104430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/19/2024] [Accepted: 03/23/2024] [Indexed: 04/09/2024]
Abstract
The prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) continues to increase due in part to the obesity epidemic and to environmental exposures to metabolism disrupting chemicals. A single gavage exposure of male mice to Aroclor 1260 (Ar1260), an environmentally relevant mixture of non-dioxin-like polychlorinated biphenyls (PCBs), resulted in steatohepatitis and altered RNA modifications in selenocysteine tRNA 34 weeks post-exposure. Unbiased approaches identified the liver proteome, selenoproteins, and levels of 25 metals. Ar1260 altered the abundance of 128 proteins. Enrichment analysis of the liver Ar1260 proteome included glutathione metabolism and translation of selenoproteins. Hepatic glutathione peroxidase 4 (GPX4) and Selenoprotein O (SELENOO) were increased and Selenoprotein F (SELENOF), Selenoprotein S (SELENOS), Selenium binding protein 2 (SELENBP2) were decreased with Ar1260 exposure. Increased copper, selenium (Se), and zinc and reduced iron levels were detected. These data demonstrate that Ar1260 exposure alters the (seleno)proteome, Se, and metals in MASLD-associated pathways.
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Affiliation(s)
- Kellianne M Piell
- Department of Biochemistry & Molecular Genetics, University of Louisville School of Medicine, Louisville, KY 40292, USA
| | - Belinda J Petri
- Department of Biochemistry & Molecular Genetics, University of Louisville School of Medicine, Louisville, KY 40292, USA; Kentucky IDeA Networks of Biomedical Research Excellence (KY INBRE) Bioinformatics Core, University of Louisville, Louisville, KY 40202, USA
| | - Jason Xu
- Pediatric Research Institute, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY 40292, USA
| | - Lu Cai
- Pediatric Research Institute, Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY 40292, USA; Departments of Radiation Oncology, Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY 40292, USA; University of Louisville Center for Integrative Environmental Health Sciences (CIEHS), University of Louisville, Louisville, KY 40292, USA
| | - Shesh N Rai
- Division of Biostatistics and Bioinformatics, Department of Environmental and Public Health Sciences, College of Medicine, University of Cincinnati, Cincinnati, OH 45267, USA
| | - Ming Li
- Division of Nephrology & Hypertension, Department of Medicine, University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Daniel W Wilkey
- University of Louisville Hepatobiology and Toxicology Center; University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Michael L Merchant
- University of Louisville Center for Integrative Environmental Health Sciences (CIEHS), University of Louisville, Louisville, KY 40292, USA; Division of Nephrology & Hypertension, Department of Medicine, University of Louisville School of Medicine, Louisville, KY 40202, USA; University of Louisville Hepatobiology and Toxicology Center; University of Louisville School of Medicine, Louisville, KY 40202, USA
| | - Matthew C Cave
- University of Louisville Center for Integrative Environmental Health Sciences (CIEHS), University of Louisville, Louisville, KY 40292, USA; University of Louisville Hepatobiology and Toxicology Center; University of Louisville School of Medicine, Louisville, KY 40202, USA; Division of Gastroenterology, Hepatology & Nutrition, Department of Medicine, University of Louisville School of Medicine, Louisville, KY 40292, USA; The University of Louisville Superfund Research Center, University of Louisville School of Medicine, Louisville, KY 40292, USA
| | - Carolyn M Klinge
- Department of Biochemistry & Molecular Genetics, University of Louisville School of Medicine, Louisville, KY 40292, USA; University of Louisville Center for Integrative Environmental Health Sciences (CIEHS), University of Louisville, Louisville, KY 40292, USA.
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Miao YS, Wang JY, Zhuang RR, Huo XK, Yi ZC, Sun XN, Yu ZL, Tian XG, Ning J, Feng L, Ma XC, Lv X. A high-affinity fluorescent probe for human uridine-disphosphate glucuronosyltransferase 1A9 function monitoring under environmental pollutant exposure. JOURNAL OF HAZARDOUS MATERIALS 2024; 465:133439. [PMID: 38218035 DOI: 10.1016/j.jhazmat.2024.133439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 12/30/2023] [Accepted: 01/02/2024] [Indexed: 01/15/2024]
Abstract
Uridine-disphosphate glucuronosyltransferase 1A9 (UGT1A9), an important detoxification and inactivation enzyme for toxicants, regulates the exposure level of environmental pollutants in the human body and induces various toxicological consequences. However, an effective tool for high-throughput monitoring of UGT1A9 function under exposure to environmental pollutants is still lacking. In this study, 1,3-dichloro-7-hydroxy-9,9-dimethylacridin-2(9H)-one (DDAO) was found to exhibit excellent specificity and high affinity towards human UGT1A9. Remarkable changes in absorption and fluorescence signals after reacting with UGT1A9 were observed, due to the intramolecular charge transfer (ICT) mechanism. Importantly, DDAO was successfully applied to monitor the biological functions of UGT1A9 in response to environmental pollutant exposure not only in microsome samples, but also in living cells by using a high-throughput screening method. Meanwhile, the identified pollutants that disturb UGT1A9 functions were found to significantly influence the exposure level and retention time of bisphenol S/bisphenol A in living cells. Furthermore, the molecular mechanism underlying the inhibition of UGT1A9 by these pollutant-derived disruptors was elucidated by molecular docking and molecular dynamics simulations. Collectively, a fluorescent probe to characterize the responses of UGT1A9 towards environmental pollutants was developed, which was beneficial for elucidating the health hazards of environmental pollutants from a new perspective.
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Affiliation(s)
- Yi-Sheng Miao
- Second Affiliated Hospital, Dalian Medical University, Dalian 116023, China; College of Integrative Medicine, Dalian Medical University, Dalian 116044, China
| | - Jia-Yue Wang
- Second Affiliated Hospital, Dalian Medical University, Dalian 116023, China; College of Integrative Medicine, Dalian Medical University, Dalian 116044, China
| | - Rui-Rui Zhuang
- College of Integrative Medicine, Dalian Medical University, Dalian 116044, China
| | - Xiao-Kui Huo
- Second Affiliated Hospital, Dalian Medical University, Dalian 116023, China
| | - Zi-Chang Yi
- College of Integrative Medicine, Dalian Medical University, Dalian 116044, China
| | - Xiao-Nan Sun
- College of Integrative Medicine, Dalian Medical University, Dalian 116044, China; School of Chemistry and Chemical Engineering, Henan Normal University, Xinxiang 453007, China
| | - Zhen-Long Yu
- College of Integrative Medicine, Dalian Medical University, Dalian 116044, China
| | - Xiang-Ge Tian
- Second Affiliated Hospital, Dalian Medical University, Dalian 116023, China
| | - Jing Ning
- College of Integrative Medicine, Dalian Medical University, Dalian 116044, China
| | - Lei Feng
- Second Affiliated Hospital, Dalian Medical University, Dalian 116023, China; Chengdu University of Traditional Chinese Medicine, Chengdu 611137 China.
| | - Xiao-Chi Ma
- Second Affiliated Hospital, Dalian Medical University, Dalian 116023, China; Heilongjiang University of Chinese Medicine, Harbin 150040, China.
| | - Xia Lv
- Second Affiliated Hospital, Dalian Medical University, Dalian 116023, China; College of Integrative Medicine, Dalian Medical University, Dalian 116044, China.
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Deen L, Clark A, Hougaard KS, Petersen KU, Frederiksen M, Wise LA, Wesselink AK, Meyer HW, Bonde JP, Tøttenborg SS. Exposure to airborne polychlorinated biphenyls and type 2 diabetes in a Danish cohort. ENVIRONMENTAL RESEARCH 2023; 237:117000. [PMID: 37634693 DOI: 10.1016/j.envres.2023.117000] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 04/17/2023] [Accepted: 08/25/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Previous research indicates an association between higher-chlorinated polychlorinated biphenyls (PCBs) and type 2 diabetes (T2D). However, less is known about the extent to which PCB exposure in indoor air, composed primarily of lower-chlorinated PCBs, affects T2D risk. We assessed the association between indoor air exposure to PCBs in residential buildings and T2D incidence. METHODS The register-based 'Health Effects of PCBs in Indoor Air' (HESPAIR) cohort comprises 51,921 Danish residents of two residential areas with apartments built with and without PCB-containing materials (reference apartments). We assessed exposure status by combining register-based information on relocation history with extrapolated values of exposure based on PCB-measurements in indoor air from subsets of the apartments. T2D cases were identified in the Danish registers during 1977-2018. We estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) using Cox regression analyses with time-varying exposure. RESULTS We identified 2737 incident T2D cases during the follow-up. Exposure to ≥3300 ng/m3 PCB × year (3rd tertile of PCByear) was associated with higher risk of T2D (HR 1.15, 95% CI 1.02-1.30) compared with exposure to <300 ng/m3 PCB × year (reference). However, among individuals with lower cumulated PCByear, the risk was similar to residents with exposure <300 ng/m3 PCB × year (300-899 ng/m3 PCB × year: HR 0.98, 95% CI 0.87-1.11; 900-3299 ng/m3 PCB × year: HR 0.96, 95% CI 0.83-1.10). DISCUSSION We observed a marginally higher risk of T2D, but there was no evidence of an exposure-response relationship. The results should be interpreted with caution until confirmed in other independent studies of PCB exposure in indoor air.
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Affiliation(s)
- Laura Deen
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Denmark; Department of Public Health, The Faculty of Health Sciences, University of Copenhagen, Denmark.
| | | | - Karin Sørig Hougaard
- Department of Public Health, The Faculty of Health Sciences, University of Copenhagen, Denmark; National Research Centre for the Working Environment, Denmark
| | - Kajsa Ugelvig Petersen
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Denmark
| | | | - Lauren A Wise
- Department of Epidemiology, School of Public Health, Boston University, United States
| | - Amelia K Wesselink
- Department of Epidemiology, School of Public Health, Boston University, United States
| | - Harald William Meyer
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Denmark
| | - Jens Peter Bonde
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Denmark; Department of Public Health, The Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Sandra Søgaard Tøttenborg
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Denmark; Department of Public Health, The Faculty of Health Sciences, University of Copenhagen, Denmark
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Hegedus C, Andronie L, Uiuiu P, Jurco E, Lazar EA, Popescu S. Pets, Genuine Tools of Environmental Pollutant Detection. Animals (Basel) 2023; 13:2923. [PMID: 37760323 PMCID: PMC10525180 DOI: 10.3390/ani13182923] [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: 06/28/2023] [Revised: 09/10/2023] [Accepted: 09/12/2023] [Indexed: 09/29/2023] Open
Abstract
In a shared environment, our companion animals became unintended sentinels for pollutant exposure consequences, developing even earlier similar conditions to humans. This review focused on the human-pet cohabitation in an environment we all share. Alongside other species, canine and feline companions are veritable models in human medical research. The latency period for showing chronic exposure effects to pollutants is just a few years in them, compared to considerably more, decades in humans. Comparing the serum values of people and their companion animals can, for example, indicate the degree of poisonous lead load we are exposed to and of other substances as well. We can find 2.4 times higher perfluorochemicals from stain- and grease-proof coatings in canine companions, 23 times higher values of flame retardants in cats, and 5 times more mercury compared to the average levels tested in humans. All these represent early warning signals. Taking these into account, together with the animal welfare orientation of today's society, finding non-invasive methods to detect the degree of environmental pollution in our animals becomes paramount, alongside the need to raise awareness of the risks carried by certain chemicals we knowingly use.
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Affiliation(s)
- Cristina Hegedus
- Department of Fundamental Sciences, Faculty of Animal Sciences and Biotechnologies, University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca, 400372 Cluj-Napoca, Romania;
| | - Luisa Andronie
- Department of Biophysics, Meteorology and Climatology, Faculty of Forestry and Cadastre, University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca, 400372 Cluj-Napoca, Romania
| | - Paul Uiuiu
- Department of Fundamental Sciences, Faculty of Animal Sciences and Biotechnologies, University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca, 400372 Cluj-Napoca, Romania;
| | - Eugen Jurco
- Department of Technological Sciences, Faculty of Animal Sciences and Biotechnologies, University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca, 400372 Cluj-Napoca, Romania;
| | - Eva Andrea Lazar
- Association for the Welfare of Horses, 725700 Vatra Dornei, Romania;
| | - Silvana Popescu
- Department of Animal Hygiene and Welfare, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine Cluj-Napoca, 400372 Cluj-Napoca, Romania;
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Head KZ, Bolatimi OE, Gripshover TC, Tan M, Li Y, Audam TN, Jones SP, Klinge CM, Cave MC, Wahlang B. Investigating the effects of long-term Aroclor 1260 exposure on fatty liver disease in a diet-induced obesity mouse model. FRONTIERS IN GASTROENTEROLOGY (LAUSANNE, SWITZERLAND) 2023; 2:1180712. [PMID: 37426695 PMCID: PMC10327714 DOI: 10.3389/fgstr.2023.1180712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Introduction Polychlorinated biphenyls (PCBs) are persistent environmental toxicants that have been implicated in numerous health disorders including liver diseases such as non-alcoholic fatty liver disease (NAFLD). Toxicant-associated NAFLD, also known as toxicant-associated fatty liver disease (TAFLD), consists of a spectrum of disorders ranging from steatosis and steatohepatitis to fibrosis and hepatocellular carcinoma. Previously, our group demonstrated that 12-week exposure to the PCB mixture, Aroclor 1260, exacerbated steatohepatitis in high-fat diet (HFD)-fed mice; however, the longer-term effects of PCBs on TAFLD remain to be elucidated. This study aims to examine the longer-term effects of Aroclor 1260 (>30 weeks) in a diet-induced obesity model to better understand how duration of exposure can impact TAFLD. Methods Male C57BL/6 mice were exposed to Aroclor 1260 (20 mg/kg) or vehicle control by oral gavage at the beginning of the study period and fed either a low-fat diet (LFD) or HFD throughout the study period. Results Aroclor 1260 exposure (>30 weeks) led to steatohepatitis only in LFD-fed mice. Several Aroclor 1260 exposed LFD-fed mice also developed hepatocellular carcinoma (25%), which was absent in HFD-fed mice. The LFD+Aroclor1260 group also exhibited decreased hepatic Cyp7a1 expression and increased pro-fibrotic Acta2 expression. In contrast, longer term Aroclor 1260 exposure in conjunction with HFD did not exacerbate steatosis or inflammatory responses beyond those observed with HFD alone. Further, hepatic xenobiotic receptor activation by Aroclor 1260 was absent at 31 weeks post exposure, suggesting PCB redistribution to the adipose and other extra-hepatic tissues with time. Discussion Overall, the results demonstrated that longer-term PCB exposure worsened TAFLD outcomes independent of HFD feeding and suggests altered energy metabolism as a potential mechanism fueling PCB mediated toxicity without dietary insult. Additional research exploring mechanisms for these longer-term PCB mediated toxicity in TAFLD is warranted.
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Affiliation(s)
- Kimberly Z. Head
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, School of Medicine, University of Louisville, Louisville, KY, United States
- The Hepatobiology and Toxicology Center, University of Louisville, Louisville, KY, United States
| | - Oluwanifemi E. Bolatimi
- Department of Pharmacology and Toxicology, School of Medicine, University of Louisville, Louisville, KY, United States
| | - Tyler C. Gripshover
- Department of Pharmacology and Toxicology, School of Medicine, University of Louisville, Louisville, KY, United States
| | - Min Tan
- Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, United States
| | - Yan Li
- Department of Surgery, School of Medicine, University of Louisville, Louisville, KY, United States
| | - Timothy N. Audam
- Center for Cardiometabolic Science, Department of Medicine, Division of Environmental Medicine, Christina Lee Brown Envirome Institute, University of Louisville, Louisville, KY, United States
| | - Steven P. Jones
- Center for Cardiometabolic Science, Department of Medicine, Division of Environmental Medicine, Christina Lee Brown Envirome Institute, University of Louisville, Louisville, KY, United States
| | - Carolyn M. Klinge
- Department of Biochemistry and Molecular Genetics, School of Medicine, University of Louisville, Louisville, KY, United States
- The Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY, United States
| | - Matthew C. Cave
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, School of Medicine, University of Louisville, Louisville, KY, United States
- The Hepatobiology and Toxicology Center, University of Louisville, Louisville, KY, United States
- Department of Pharmacology and Toxicology, School of Medicine, University of Louisville, Louisville, KY, United States
- Department of Biochemistry and Molecular Genetics, School of Medicine, University of Louisville, Louisville, KY, United States
- The Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY, United States
- University of Louisville (UofL) Superfund Research Center, University of Louisville, Louisville, KY, United States
- Robley Rex Department of Veterans Affairs Medical Center, Louisville, KY, United States
| | - Banrida Wahlang
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, School of Medicine, University of Louisville, Louisville, KY, United States
- The Hepatobiology and Toxicology Center, University of Louisville, Louisville, KY, United States
- The Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY, United States
- University of Louisville (UofL) Superfund Research Center, University of Louisville, Louisville, KY, United States
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Deen L, Clark A, Hougaard KS, Meyer HW, Frederiksen M, Pedersen EB, Petersen KU, Flachs EM, Bonde JPE, Tøttenborg SS. Risk of cardiovascular diseases following residential exposure to airborne polychlorinated biphenyls: A register-based cohort study. ENVIRONMENTAL RESEARCH 2023; 222:115354. [PMID: 36709868 DOI: 10.1016/j.envres.2023.115354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/09/2023] [Accepted: 01/23/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Indoor air in buildings constructed with materials containing polychlorinated biphenyls (PCBs) may be contaminated with especially lower-chlorinated PCBs. So far, the cardiovascular consequences of living with such contamination are unknown. OBJECTIVES To determine the risk of cardiovascular disease (CVD) following residential exposure to predominantly lower-chlorinated PCBs in indoor air. METHODS The Health Effects of PCBs in Indoor Air (HESPAIR) cohort is register-based with 51 921 residents of two residential areas near Copenhagen: Farum Midtpunkt and Brøndby Strand Parkerne. Here, indoor air was contaminated with PCB in one third of the apartments due to construction with materials containing PCB. Individual PCB exposure was estimated based on register-based information on relocation dates and indoor air PCB measurements in subsets of the apartments. Information on CVD was retrieved from the Danish National Patient Register for the follow-up period of 1977-2018. We estimated adjusted hazard ratios using Cox regression with time-varying exposure. RESULTS Cumulative residential exposure to airborne PCB was not associated with a higher overall risk for CVD (HR for highly exposed (≥3300 ng/m3 PCB × year): 1.02, 95% CI 0.94-1.10). This was also the case for most of the specific cardiovascular diseases, apart from acute myocardial infarction where a higher risk was observed for residents exposed to ≥3300 ng/m3 PCB × year compared to the reference group (HR 1.17, 95% CI 1.00-1.35). However, no exposure-response relationship was apparent and additional adjustment for education attenuated the risk estimate. DISCUSSION In this, to our knowledge, first study ever to examine the risk of CVD following residential exposure to PCBs in indoor air, we observed limited support for cardiovascular effects of living in PCB-contaminated indoor air. Considering the prevalence of exposure to airborne PCBs and lack of literature on their potential health effects, these findings need to be corroborated in other studies.
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Affiliation(s)
- Laura Deen
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Denmark; Department of Public Health, The Faculty of Health Sciences, University of Copenhagen, Denmark.
| | - Alice Clark
- Real World Science, Novo Nordisk, Copenhagen, Denmark
| | - Karin Sørig Hougaard
- Department of Public Health, The Faculty of Health Sciences, University of Copenhagen, Denmark; National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Harald William Meyer
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Denmark
| | - Marie Frederiksen
- National Research Centre for the Working Environment, Copenhagen, Denmark
| | - Ellen Bøtker Pedersen
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Denmark
| | - Kajsa Ugelvig Petersen
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Denmark
| | - Esben Meulengracht Flachs
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Denmark
| | - Jens Peter Ellekilde Bonde
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Denmark; Department of Public Health, The Faculty of Health Sciences, University of Copenhagen, Denmark
| | - Sandra Søgaard Tøttenborg
- Department of Occupational and Environmental Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg Hospital, Denmark; Department of Public Health, The Faculty of Health Sciences, University of Copenhagen, Denmark
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