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Arnaud C, Billoir E, de Melo Junior AF, Pereira SA, O'Halloran KD, Monteiro EC. Chronic intermittent hypoxia-induced cardiovascular and renal dysfunction: from adaptation to maladaptation. J Physiol 2023; 601:5553-5577. [PMID: 37882783 DOI: 10.1113/jp284166] [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: 07/07/2023] [Accepted: 10/12/2023] [Indexed: 10/27/2023] Open
Abstract
Chronic intermittent hypoxia (CIH) is the dominant pathological feature of human obstructive sleep apnoea (OSA), which is highly prevalent and associated with cardiovascular and renal diseases. CIH causes hypertension, centred on sympathetic nervous overactivity, which persists following removal of the CIH stimulus. Molecular mechanisms contributing to CIH-induced hypertension have been carefully delineated. However, there is a dearth of knowledge on the efficacy of interventions to ameliorate high blood pressure in established disease. CIH causes endothelial dysfunction, aberrant structural remodelling of vessels and accelerates atherosclerotic processes. Pro-inflammatory and pro-oxidant pathways converge on disrupted nitric oxide signalling driving vascular dysfunction. In addition, CIH has adverse effects on the myocardium, manifesting atrial fibrillation, and cardiac remodelling progressing to contractile dysfunction. Sympatho-vagal imbalance, oxidative stress, inflammation, dysregulated HIF-1α transcriptional responses and resultant pro-apoptotic ER stress, calcium dysregulation, and mitochondrial dysfunction conspire to drive myocardial injury and failure. CIH elaborates direct and indirect effects in the kidney that initially contribute to the development of hypertension and later to chronic kidney disease. CIH-induced morphological damage of the kidney is dependent on TLR4/NF-κB/NLRP3/caspase-1 inflammasome activation and associated pyroptosis. Emerging potential therapies related to the gut-kidney axis and blockade of aryl hydrocarbon receptors (AhR) are promising. Cardiorenal outcomes in response to intermittent hypoxia present along a continuum from adaptation to maladaptation and are dependent on the intensity and duration of exposure to intermittent hypoxia. This heterogeneity of OSA is relevant to therapeutic treatment options and we argue the need for better stratification of OSA phenotypes.
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Affiliation(s)
- Claire Arnaud
- Université Grenoble-Alpes INSERM U1300, Laboratoire HP2, Grenoble, France
| | - Emma Billoir
- Université Grenoble-Alpes INSERM U1300, Laboratoire HP2, Grenoble, France
| | | | - Sofia A Pereira
- iNOVA4Health, NOVA Medical School, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Ken D O'Halloran
- Department of Physiology, School of Medicine, College of Medicine & Health, University College Cork, Cork, Ireland
| | - Emilia C Monteiro
- iNOVA4Health, NOVA Medical School, Universidade NOVA de Lisboa, Lisboa, Portugal
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2
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Fernandes JL, Martins FO, Olea E, Prieto-Lloret J, Braga PC, Sacramento JF, Sequeira CO, Negrinho AP, Pereira SA, Alves MG, Rocher A, Conde SV. Chronic Intermittent Hypoxia-Induced Dysmetabolism Is Associated with Hepatic Oxidative Stress, Mitochondrial Dysfunction and Inflammation. Antioxidants (Basel) 2023; 12:1910. [PMID: 38001763 PMCID: PMC10669005 DOI: 10.3390/antiox12111910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/13/2023] [Accepted: 10/23/2023] [Indexed: 11/26/2023] Open
Abstract
The association between obstructive sleep apnea (OSA) and metabolic disorders is well-established; however, the underlying mechanisms that elucidate this relationship remain incompletely understood. Since the liver is a major organ in the maintenance of metabolic homeostasis, we hypothesize that liver dysfunction plays a crucial role in the pathogenesis of metabolic dysfunction associated with obstructive sleep apnea (OSA). Herein, we explored the underlying mechanisms of this association within the liver. Experiments were performed in male Wistar rats fed with a control or high fat (HF) diet (60% lipid-rich) for 12 weeks. Half of the groups were exposed to chronic intermittent hypoxia (CIH) (30 hypoxic (5% O2) cycles, 8 h/day) that mimics OSA, in the last 15 days. Insulin sensitivity and glucose tolerance were assessed. Liver samples were collected for evaluation of lipid deposition, insulin signaling, glucose homeostasis, hypoxia, oxidative stress, antioxidant defenses, mitochondrial biogenesis and inflammation. Both the CIH and HF diet induced dysmetabolism, a state not aggravated in animals submitted to HF plus CIH. CIH aggravates hepatic lipid deposition in obese animals. Hypoxia-inducible factors levels were altered by these stimuli. CIH decreased the levels of oxidative phosphorylation complexes in both groups and the levels of SOD-1. The HF diet reduced mitochondrial density and hepatic antioxidant capacity. The CIH and HF diet produced alterations in cysteine-related thiols and pro-inflammatory markers. The results obtained suggest that hepatic mitochondrial dysfunction and oxidative stress, leading to inflammation, may be significant factors contributing to the development of dysmetabolism associated with OSA.
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Affiliation(s)
- Joana L. Fernandes
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1150-069 Lisboa, Portugal; (J.L.F.); (F.O.M.); (J.F.S.); (C.O.S.); (A.P.N.); (S.A.P.)
| | - Fátima O. Martins
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1150-069 Lisboa, Portugal; (J.L.F.); (F.O.M.); (J.F.S.); (C.O.S.); (A.P.N.); (S.A.P.)
| | - Elena Olea
- Departamento de Enfermeria, Universidad de Valladolid, 47005 Valladolid, Spain;
- Unidad de Excelencia Instituto de Biomedicina y Genética Molecular (IBGM), Consejo Superior de Investigaciones Científicas, Universidad de Valladolid, 47005 Valladolid, Spain; (J.P.-L.); (A.R.)
| | - Jesus Prieto-Lloret
- Unidad de Excelencia Instituto de Biomedicina y Genética Molecular (IBGM), Consejo Superior de Investigaciones Científicas, Universidad de Valladolid, 47005 Valladolid, Spain; (J.P.-L.); (A.R.)
- Departamento de Bioquímica, Biologia Molecular y Fisiologia, Universidad de Valladolid, 47005 Valladolid, Spain
| | - Patrícia C. Braga
- Unit for Multidisciplinary Research in Biomedicine (UMIB), Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, 4050-313 Porto, Portugal; (P.C.B.); (M.G.A.)
- ITR-Laboratory for Integrative and Translational Research in Population Health, 4050-313 Porto, Portugal
- Institute of Biomedicine—iBiMED and Department of Medical Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
| | - Joana F. Sacramento
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1150-069 Lisboa, Portugal; (J.L.F.); (F.O.M.); (J.F.S.); (C.O.S.); (A.P.N.); (S.A.P.)
| | - Catarina O. Sequeira
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1150-069 Lisboa, Portugal; (J.L.F.); (F.O.M.); (J.F.S.); (C.O.S.); (A.P.N.); (S.A.P.)
| | - Ana P. Negrinho
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1150-069 Lisboa, Portugal; (J.L.F.); (F.O.M.); (J.F.S.); (C.O.S.); (A.P.N.); (S.A.P.)
| | - Sofia A. Pereira
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1150-069 Lisboa, Portugal; (J.L.F.); (F.O.M.); (J.F.S.); (C.O.S.); (A.P.N.); (S.A.P.)
| | - Marco G. Alves
- Unit for Multidisciplinary Research in Biomedicine (UMIB), Institute of Biomedical Sciences Abel Salazar (ICBAS), University of Porto, 4050-313 Porto, Portugal; (P.C.B.); (M.G.A.)
- ITR-Laboratory for Integrative and Translational Research in Population Health, 4050-313 Porto, Portugal
- Institute of Biomedicine—iBiMED and Department of Medical Sciences, University of Aveiro, 3810-193 Aveiro, Portugal
| | - Asunción Rocher
- Unidad de Excelencia Instituto de Biomedicina y Genética Molecular (IBGM), Consejo Superior de Investigaciones Científicas, Universidad de Valladolid, 47005 Valladolid, Spain; (J.P.-L.); (A.R.)
- Departamento de Bioquímica, Biologia Molecular y Fisiologia, Universidad de Valladolid, 47005 Valladolid, Spain
| | - Silvia V. Conde
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, 1150-069 Lisboa, Portugal; (J.L.F.); (F.O.M.); (J.F.S.); (C.O.S.); (A.P.N.); (S.A.P.)
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Pimpão AB, Sousa C, Correia MJ, Coelho NR, Monteiro EC, Melo Junior AF, Pereira SA. Control of Arterial Hypertension by the AhR Blocker CH-223191: A Chronopharmacological Study in Chronic Intermittent Hypoxia Conditions. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1427:35-42. [PMID: 37322333 DOI: 10.1007/978-3-031-32371-3_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Chronic intermittent hypoxia (CIH) is a major contributor to the development of hypertension (HTN) in obstructive sleep apnea (OSA). OSA subjects frequently display a non-dipping pattern of blood pressure (BP) and resistant HTN. After discovering that AHR-CYP1A1 axis is a druggable target in CIH-HTN, we hypothesized that CH-223191 could control BP in both active and inactive periods of the animals, recovering the BP dipping profile in CIH conditions.We evaluated the chronopharmacology of the antihypertensive efficacy of the AhR blocker CH-223191 in CIH conditions (21% to 5% of O2, 5.6 cycles/h, 10.5 h/day, in inactive period of Wistar rats). BP was measured by radiotelemetry, at 8 am (active phase) and at 6 pm (inactive phase) of the animals. The circadian variation of AhR activation in the kidney in normoxia was also assessed, measuring the CYP1A1 (hallmark of AhR activation) protein levels.Despite drug administration before starting the inactive period of the animals, CH-223191 was not able to decrease BP during the inactive phase, in CIH conditions, therefore not reverting the non-dipping profile. These results suggest that a higher dose or different time of administration of CH-223191 might be needed for an antihypertensive effect throughout the 24-h cycle.
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Affiliation(s)
- António B Pimpão
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Cátia Sousa
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Maria J Correia
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Nuno R Coelho
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade Nova de Lisboa, Lisboa, Portugal
- Egas Moniz Center for Interdisciplinary Research, Egas Moniz School of Health and Science, Caparica, Portugal
| | - Emília C Monteiro
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Antonio F Melo Junior
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Sofia A Pereira
- iNOVA4Health, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM, Universidade Nova de Lisboa, Lisboa, Portugal.
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Aaronson PI, Rocher A. Oxygen Sensing: Physiology and Pathophysiology. Antioxidants (Basel) 2022; 11:1018. [PMID: 35624881 PMCID: PMC9138106 DOI: 10.3390/antiox11051018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 02/01/2023] Open
Abstract
Oxygen is such an essential element for life that multiple mechanisms have evolved to maintain oxygen homeostasis, including those which detect decreases in arterial O2 and generate adaptive responses to hypoxia [...].
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Affiliation(s)
- Philip I. Aaronson
- Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King’s College London, London SE1 1UL, UK
| | - Asuncion Rocher
- Departamento de Bioquímica, Biología Molecular y Fisiología, Facultad de Medicina, University of Valladolid, 47005 Valladolid, Spain
- Unidad de Excelencia Instituto de Biología y Genética Molecular (IBGM), University of Valladolid-CSIC, 47005 Valladolid, Spain
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Correia MJ, Pimpão AB, Fernandes DGF, Morello J, Sequeira CO, Calado J, Antunes AMM, Almeida MS, Branco P, Monteiro EC, Vicente JB, Serpa J, Pereira SA. Cysteine as a Multifaceted Player in Kidney, the Cysteine-Related Thiolome and Its Implications for Precision Medicine. Molecules 2022; 27:1416. [PMID: 35209204 PMCID: PMC8874463 DOI: 10.3390/molecules27041416] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/15/2022] [Accepted: 02/17/2022] [Indexed: 11/16/2022] Open
Abstract
In this review encouraged by original data, we first provided in vivo evidence that the kidney, comparative to the liver or brain, is an organ particularly rich in cysteine. In the kidney, the total availability of cysteine was higher in cortex tissue than in the medulla and distributed in free reduced, free oxidized and protein-bound fractions (in descending order). Next, we provided a comprehensive integrated review on the evidence that supports the reliance on cysteine of the kidney beyond cysteine antioxidant properties, highlighting the relevance of cysteine and its renal metabolism in the control of cysteine excess in the body as a pivotal source of metabolites to kidney biomass and bioenergetics and a promoter of adaptive responses to stressors. This view might translate into novel perspectives on the mechanisms of kidney function and blood pressure regulation and on clinical implications of the cysteine-related thiolome as a tool in precision medicine.
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Affiliation(s)
- Maria João Correia
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal; (M.J.C.); (A.B.P.); (J.M.); (C.O.S.); (M.S.A.); (P.B.); (E.C.M.); (J.S.)
| | - António B. Pimpão
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal; (M.J.C.); (A.B.P.); (J.M.); (C.O.S.); (M.S.A.); (P.B.); (E.C.M.); (J.S.)
| | - Dalila G. F. Fernandes
- Instituto de Tecnologia Química e Biológica António Xavier (ITQB NOVA), 2780-157 Oeiras, Portugal; (D.G.F.F.); (J.B.V.)
| | - Judit Morello
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal; (M.J.C.); (A.B.P.); (J.M.); (C.O.S.); (M.S.A.); (P.B.); (E.C.M.); (J.S.)
| | - Catarina O. Sequeira
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal; (M.J.C.); (A.B.P.); (J.M.); (C.O.S.); (M.S.A.); (P.B.); (E.C.M.); (J.S.)
| | - Joaquim Calado
- Centre for Toxicogenomics and Human Health (ToxOmics), Genetics, Oncology and Human Toxicology, Nova Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal;
- Nephrology Department, Centro Hospitalar Universitário de Lisboa Central, 1069-166 Lisboa, Portugal
| | - Alexandra M. M. Antunes
- Centro de Química Estrutural, Institute of Molecular Sciences, Instituto Superior Técnico, 1049-001 Lisboa, Portugal;
| | - Manuel S. Almeida
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal; (M.J.C.); (A.B.P.); (J.M.); (C.O.S.); (M.S.A.); (P.B.); (E.C.M.); (J.S.)
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, 2790-134 Carnaxide, Portugal
| | - Patrícia Branco
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal; (M.J.C.); (A.B.P.); (J.M.); (C.O.S.); (M.S.A.); (P.B.); (E.C.M.); (J.S.)
- Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, 2790-134 Carnaxide, Portugal
| | - Emília C. Monteiro
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal; (M.J.C.); (A.B.P.); (J.M.); (C.O.S.); (M.S.A.); (P.B.); (E.C.M.); (J.S.)
| | - João B. Vicente
- Instituto de Tecnologia Química e Biológica António Xavier (ITQB NOVA), 2780-157 Oeiras, Portugal; (D.G.F.F.); (J.B.V.)
| | - Jacinta Serpa
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal; (M.J.C.); (A.B.P.); (J.M.); (C.O.S.); (M.S.A.); (P.B.); (E.C.M.); (J.S.)
- Instituto Português de Oncologia de Lisboa Francisco Gentil (IPOLFG), 1099-023 Lisboa, Portugal
| | - Sofia A. Pereira
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056 Lisboa, Portugal; (M.J.C.); (A.B.P.); (J.M.); (C.O.S.); (M.S.A.); (P.B.); (E.C.M.); (J.S.)
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Martins FO, Conde SV. Gender Differences in the Context of Obstructive Sleep Apnea and Metabolic Diseases. Front Physiol 2022; 12:792633. [PMID: 34970158 PMCID: PMC8712658 DOI: 10.3389/fphys.2021.792633] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 11/17/2021] [Indexed: 11/13/2022] Open
Abstract
The relationship between obstructive sleep apnea (OSA) and endocrine and metabolic disease is unequivocal. OSA, which is characterized by intermittent hypoxia and sleep fragmentation, leads to and exacerbates obesity, metabolic syndrome, and type 2 diabetes (T2D) as well as endocrine disturbances, such as hypothyroidism and Cushing syndrome, among others. However, this relationship is bidirectional with endocrine and metabolic diseases being considered major risk factors for the development of OSA. For example, polycystic ovary syndrome (PCOS), one of the most common endocrine disorders in women of reproductive age, is significantly associated with OSA in adult patients. Several factors have been postulated to contribute to or be critical in the genesis of dysmetabolic states in OSA including the increase in sympathetic activation, the deregulation of the hypothalamus-pituitary axis, the generation of reactive oxygen species (ROS), insulin resistance, alteration in adipokines levels, and inflammation of the adipose tissue. However, probably the alterations in the hypothalamus-pituitary axis and the altered secretion of hormones from the peripheral endocrine glands could play a major role in the gender differences in the link between OSA-dysmetabolism. In fact, normal sleep is also different between men and women due to the physiologic differences between genders, with sex hormones such as progesterone, androgens, and estrogens, being also connected with breathing pathologies. Moreover, it is very well known that OSA is more prevalent among men than women, however the prevalence in women increases after menopause. At the same time, the step-rise in obesity and its comorbidities goes along with mounting evidence of clinically important sex and gender differences. Metabolic and cardiovascular diseases, seen as a men's illness for decades, presently are more common in women than in men and obesity has a higher association with insulin-resistance-related risk factors in women than in men. In this way, in the present manuscript, we will review the major findings on the overall mechanisms that connect OSA and dysmetabolism giving special attention to the specific regulation of this relationship in each gender. We will also detail the gender-specific effects of hormone replacement therapies on metabolic control and sleep apnea.
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Affiliation(s)
- Fátima O Martins
- Chronic Diseases Research Center (CEDOC), NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Sílvia V Conde
- Chronic Diseases Research Center (CEDOC), NOVA Medical School, Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisboa, Portugal
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Coelho NR, Pimpão AB, Correia MJ, Rodrigues TC, Monteiro EC, Morello J, Pereira SA. Pharmacological blockage of the AHR-CYP1A1 axis: a call for in vivo evidence. J Mol Med (Berl) 2021; 100:215-243. [PMID: 34800164 PMCID: PMC8605459 DOI: 10.1007/s00109-021-02163-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/27/2021] [Accepted: 11/03/2021] [Indexed: 01/21/2023]
Abstract
The aryl hydrocarbon receptor (AHR) is a ligand-activated transcription factor that can be activated by structurally diverse compounds arising from the environment and the microbiota and host metabolism. Expanding evidence has been shown that the modulation of the canonical pathway of AHR occurs during several chronic diseases and that its abrogation might be of clinical interest for metabolic and inflammatory pathological processes. However, most of the evidence on the pharmacological abrogation of the AHR-CYP1A1 axis has been reported in vitro, and therefore, guidance for in vivo studies is needed. In this review, we cover the state-of-the-art of the pharmacodynamic and pharmacokinetic properties of AHR antagonists and CYP1A1 inhibitors in different in vivo rodent (mouse or rat) models of disease. This review will serve as a road map for those researchers embracing this emerging therapeutic area targeting the AHR. Moreover, it is a timely opportunity as the first AHR antagonists have recently entered the clinical stage of drug development.
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Affiliation(s)
- N R Coelho
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056, Lisboa, Portugal
| | - A B Pimpão
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056, Lisboa, Portugal
| | - M J Correia
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056, Lisboa, Portugal
| | - T C Rodrigues
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056, Lisboa, Portugal
| | - E C Monteiro
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056, Lisboa, Portugal
| | - J Morello
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056, Lisboa, Portugal
| | - S A Pereira
- CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056, Lisboa, Portugal.
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