1
|
van den Heuvel LL, Smit AM, Stalder T, Kirschbaum C, Seedat S, Emsley R. Hair cortisol levels in schizophrenia and metabolic syndrome. Early Interv Psychiatry 2022; 16:902-911. [PMID: 34978366 DOI: 10.1111/eip.13238] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 08/16/2021] [Accepted: 10/19/2021] [Indexed: 11/28/2022]
Abstract
AIM Individuals with schizophrenia demonstrate higher rates of metabolic syndrome (MetS) than the general population. Hair cortisol concentrations (HCC) reflect longer-term cortisol secretion and can provide additional insights into the role of the hypothalamic pituitary adrenal (HPA) axis in schizophrenia and co-occurring MetS. METHODS In a case-control study of 16 patients with schizophrenia (11 first episode psychosis [FEP] and 5 chronic) and 21 controls hair samples, representing a 3-month retrospective window of cortisol, were collected and analysed utilizing liquid chromatography tandem mass spectrometry. We investigated whether schizophrenia and MetS co-occurrence were associated with HCC utilizing multivariate regression models. We also explored the longitudinal trajectory of HCC in FEP patients by conducting a mixed models analysis. RESULTS At baseline HCC were significantly lower (Cohen's d = 0.88) in patients with schizophrenia than in controls (p = .014). HCC increased from baseline to month-12 in FEP patients compared to controls, demonstrating a trend towards significance (p = .097). MetS was not associated with HCC at baseline, but HCC increased significantly from baseline to month-12 in relation to MetS (p = .037). CONCLUSIONS In a subgroup of schizophrenia patients, psychosis may be associated with a blunted HPA axis with lower long-term cortisol output. MetS was associated with an increase in HCC and elevated cortisol levels observed in schizophrenia may be related to increased rates of MetS in schizophrenia patients.
Collapse
Affiliation(s)
- Leigh Luella van den Heuvel
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.,South African Medical Research Council, Stellenbosch University Genomics of Brain Disorders Research Unit, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anna Margaretha Smit
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Tobias Stalder
- Clinical Psychology, University of Siegen, Siegen, Germany
| | - Clemens Kirschbaum
- Biological Psychology, Dresden University of Technology, Dresden, Germany
| | - Soraya Seedat
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.,South African Medical Research Council, Stellenbosch University Genomics of Brain Disorders Research Unit, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Robin Emsley
- Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa.,South African Medical Research Council, Stellenbosch University Genomics of Brain Disorders Research Unit, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
2
|
Godoy Izquierdo D, Vázquez Pérez ML, Lara Moreno R, Godoy García JF. Training coping skills and coping with stress self-efficacy for successful daily functioning and improved clinical status in patients with psychosis: A randomized controlled pilot study. Sci Prog 2021; 104:368504211056818. [PMID: 34939872 PMCID: PMC10450595 DOI: 10.1177/00368504211056818] [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] [Indexed: 11/17/2022]
Abstract
Due to the symptom diversity and pervasive function impairments (e.g. in perception, cognition, language, affect, behavior, daily and social functioning and sense of self), recurrent relapses, elevated disability, high rates of (co)morbidity, heightened premature mortality and high burden of care of psychotic disorders, psychosocial interventions are part of patients' standard care. There is growing evidence on the relevance of self-efficacy for well-being and functioning among these patients, but specific coping with stress self-efficacy has rarely been investigated. This study explored the outcomes of an intervention for the improvement of coping resources based on training in coping skills and coping with stress self-efficacy. Fourteen adult volunteers with schizophrenia (n = 12) or schizoaffective disorder (n = 2) were matched in clinical and sociodemographic characteristics and randomly assigned to the study groups. The intervention group received the training-with 15 twice per week sessions (8 weeks)-along with their pharmacological therapy; the control group received their prescribed drug therapy. Participants completed self-reports on coping with stress self-efficacy, perceived successful daily functioning based on coping skills and clinical status (Expanded Brief Psychiatric Rating Scale). Trained patients showed a significant increase in coping with stress self-efficacy and reported greater successful functioning status, and significant improvements in their clinical status were also observed. All these enhancements remained at 3-month and 6-month follow-ups. The intervention condition interacted with coping with stress self-efficacy and perceived coping functioning in explaining improvements in clinical status: in the treatment group, greater coping with stress self-efficacy translated into enhanced daily functioning, and this improvement predicted better clinical status. These findings stress the relevance of promoting coping resources in psychotic disorders and provide preliminary evidence for the potential benefits of coping with stress self-efficacy.
Collapse
Affiliation(s)
- Débora Godoy Izquierdo
- Grupo de Investigación Psicología de la Salud y Medicina Conductual (Health Psychology & Behavioral Medicine Research Group), (CTS-267), Departamento de Personalidad, Evaluación y Tratamiento Psicológico, Facultad de Psicología Research Center “Mind, Brain and Behavior” CIMCYC, Universidad de Granada, Campus Universitario de Cartuja, Spain
| | - María Luisa Vázquez Pérez
- Grupo de Investigación Psicología de la Salud y Medicina Conductual (Health Psychology & Behavioral Medicine Research Group), (CTS-267), Departamento de Personalidad, Evaluación y Tratamiento Psicológico, Facultad de Psicología Research Center “Mind, Brain and Behavior” CIMCYC, Universidad de Granada, Campus Universitario de Cartuja, Spain
| | - Raquel Lara Moreno
- Grupo de Investigación Psicología de la Salud y Medicina Conductual (Health Psychology & Behavioral Medicine Research Group), (CTS-267), Departamento de Personalidad, Evaluación y Tratamiento Psicológico, Facultad de Psicología Research Center “Mind, Brain and Behavior” CIMCYC, Universidad de Granada, Campus Universitario de Cartuja, Spain
| | - Juan F Godoy García
- Grupo de Investigación Psicología de la Salud y Medicina Conductual (Health Psychology & Behavioral Medicine Research Group), (CTS-267), Departamento de Personalidad, Evaluación y Tratamiento Psicológico, Facultad de Psicología Research Center “Mind, Brain and Behavior” CIMCYC, Universidad de Granada, Campus Universitario de Cartuja, Spain
| |
Collapse
|
3
|
Zhu Y, Ji H, Tao L, Cai Q, Wang F, Ji W, Li G, Fang Y. Functional Status of Hypothalamic-Pituitary-Thyroid and Hypothalamic-Pituitary-Adrenal Axes in Hospitalized Schizophrenics in Shanghai. Front Psychiatry 2020; 11:65. [PMID: 32174848 PMCID: PMC7056840 DOI: 10.3389/fpsyt.2020.00065] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/24/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Neuroendocrine dysfunction is related to the pathogenesis of mental disorders, but conclusions from clinical research lack consistency. We aimed to investigate the neuroendocrinal pathophysiology and its correlation with clinical symptoms in patients with schizophrenia. METHODS The present cross-sectional study included 486 inpatients with schizophrenia admitted at a psychiatric hospital in Shanghai within one year, and 154 healthy controls (HC) matched on age and gender. The serum hemoconcentrations of thyroid-stimulating hormone (TSH), total triiodothyronine (TT3), total thyroxine (TT4), free triiodothyronine (FT3), free thyroxine (FT4), adrenocorticotrophic hormone (ACTH), and cortisol (COR) were measured via electrochemical luminescence immunoassay. Pathophysiological conversions of neuroendocrine were then associated with gender, age, age at onset, antipsychotic treatment using hierarchical multiple linear regression. RESULTS When compared to HC, the schizophrenia group showed elevated ACTH and COR levels and decreased TT3 and TT4 levels (p's < 0.05). First-episode patients showed lower TSH and higher FT3 and FT4 (p's < 0.05) compared to recurrent patients. Female patients showed higher TSH and lower TT3, FT3, and ACTH levels (p's < 0.05) compared to males. We observed the area under the curve (AUC) of the predictive model to distinguish between schizophrenia and HC to be 0.737 among total samples and between first-episode and recurrent schizophrenia to be 0.890 among subgroups. CONCLUSIONS Decreased TT3 and TT4 and elevated ACTH and COR levels appear to be associated with schizophrenia symptoms. The chronic recurrent trait of schizophrenia may cause long-term effects on FT3 and FT4 while changes in thyroid, and adrenal function as a result of mental disorder varied with gender. The pathophysiological parameters provide fair to good accuracy of these models.
Collapse
Affiliation(s)
- Yuncheng Zhu
- Clinical Research Center & Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Division of Psychiatry, Shanghai Changning Mental Health Center, Affiliated Greenland Hospital of Bio-X Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Haifeng Ji
- Division of Psychiatry, Shanghai Changning Mental Health Center, Affiliated Greenland Hospital of Bio-X Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Lily Tao
- Key Laboratory of Brain Functional Genomics (MOE & STCSM), Shanghai Changning-ECNU Mental Health Center, Institute of Cognitive Neuroscience, School of Psychology and Cognitive Science, East China Normal University, Shanghai, China
| | - Qing Cai
- Key Laboratory of Brain Functional Genomics (MOE & STCSM), Shanghai Changning-ECNU Mental Health Center, Institute of Cognitive Neuroscience, School of Psychology and Cognitive Science, East China Normal University, Shanghai, China
| | - Fang Wang
- Division of Psychiatry, Shanghai Yangpu Mental Health Center, Shanghai, China
| | - Weidong Ji
- Division of Psychiatry, Shanghai Changning Mental Health Center, Affiliated Greenland Hospital of Bio-X Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Guohai Li
- Zhenjiang Mental Health Center, Zhenjiang, China
| | - Yiru Fang
- Clinical Research Center & Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,CAS Center for Excellence in Brain Science and Intelligence Technology, Shanghai, China.,Shanghai Key Laboratory of Psychotic Disorders, Shanghai, China
| |
Collapse
|
4
|
Cullen AE, Rai S, Vaghani MS, Mondelli V, McGuire P. Cortisol Responses to Naturally Occurring Psychosocial Stressors Across the Psychosis Spectrum: A Systematic Review and Meta-Analysis. Front Psychiatry 2020; 11:513. [PMID: 32595532 PMCID: PMC7300294 DOI: 10.3389/fpsyt.2020.00513] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/19/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Individuals with established psychosis and those at high-risk for the disorder have been found to show abnormalities within the hypothalamic-pituitary-adrenal (HPA) axis, including elevations in basal and diurnal cortisol, but a blunted cortisol awakening response. However, the extent to which these features are associated with psychosocial stressors encountered in the natural environment (which are known to be more commonly experienced by these groups, and more distressing) is currently unclear. We therefore conducted a systematic review and meta-analysis to investigate the concordance between naturally-occurring psychosocial stressors and cortisol levels in these populations. METHODS PubMed, PsycINFO, and EMBASE were searched up to November 2019 to identify studies examining the concordance between psychosocial stressors and cortisol in healthy controls and individuals on the psychosis spectrum (patients with established psychosis and/or high-risk individuals). An overall meta-analysis (including data for all stressor-cortisol pairings) was performed to determine the degree of concordance irrespective of group status, with meta-regression employed to test whether the degree of concordance differed in established psychosis and high-risk groups compared to controls. Planned stratified analyses were then performed to examine group differences (where established psychosis and high-risk groups were combined) within individual stressor-cortisol pairings. RESULTS Eighteen studies (16 datasets) were eligible for inclusion. The overall model, comprising 134 effect sizes, showed that stressors and cortisol measures were only weakly correlated [r=0.05 (95% CI: -0.00 to 0.10), p=0.059] and that neither established psychosis status (r=0.01, p=0.838) nor high-risk status (r=0.02, p=0.477) had a significant effect of the strength of correlation. In stratified analyses, significant differences between healthy controls and psychosis spectrum groups were observed for only one of the six stressor-cortisol pairings examined, where life event exposure and diurnal cortisol were positively correlated in controls [r=0.25 (95% CI: 0.01 to 0.46)], but negatively correlated in the psychosis spectrum group [r=-0.28 (95% CI: -0.49 to -0.04)]. CONCLUSIONS Overall, we observed poor concordance between naturally-occurring psychosocial stressors and cortisol irrespective of stressor type, cortisol measure, or group status. We consider a range of methodological factors that may have obscured the ability to detect "true" associations and provide recommendations for future studies in this field.
Collapse
Affiliation(s)
- Alexis E Cullen
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Sushma Rai
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Meghna S Vaghani
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom
| | - Valeria Mondelli
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.,NIHR Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, United Kingdom.,NIHR Biomedical Research Centre, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
5
|
Hook V, Kind T, Podvin S, Palazoglu M, Tran C, Toneff T, Samra S, Lietz C, Fiehn O. Metabolomics Analyses of 14 Classical Neurotransmitters by GC-TOF with LC-MS Illustrates Secretion of 9 Cell-Cell Signaling Molecules from Sympathoadrenal Chromaffin Cells in the Presence of Lithium. ACS Chem Neurosci 2019; 10:1369-1379. [PMID: 30698015 DOI: 10.1021/acschemneuro.8b00432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The classical small molecule neurotransmitters are essential for cell-cell signaling in the nervous system for regulation of behaviors and physiological functions. Metabolomics approaches are ideal for quantitative analyses of neurotransmitter profiles but have not yet been achieved for the repertoire of 14 classical neurotransmitters. Therefore, this study developed targeted metabolomics analyses by full scan gas chromatography/time-of-flight mass spectrometry (GC-TOF) and hydrophilic interaction chromatography-QTRAP mass spectrometry (HILIC-MS/MS) operated in positive ionization mode for identification and quantitation of 14 neurotransmitters consisting of acetylcholine, adenosine, anandamide, aspartate, dopamine, epinephrine, GABA, glutamate, glycine, histamine, melatonin, norepinephrine, serine, and serotonin. GC-TOF represents a new metabolomics method for neurotransmitter analyses. Sensitive measurements of 11 neurotransmitters were achieved by GC-TOF, and three neurotransmitters were analyzed by LC-MS/MS (acetylcholine, anandamide, and melatonin). The limits of detection (LOD) and limits of quantitation (LOQ) were assessed for linearity for GC-TOF and LC-MS/MS protocols. In neurotransmitter-containing dense core secretory vesicles of adrenal medulla, known as chromaffin granules (CG), metabolomics measured the concentrations of 9 neurotransmitters consisting of the catecholamines dopamine, norepinephrine, and epinephrine, combined with glutamate, serotonin, adenosine, aspartate, glycine, and serine. The CG neurotransmitters were constitutively secreted from sympathoadrenal chromaffin cells in culture. Nicotine- and KCl-stimulated release of the catecholamines and adenosine. Lithium, a drug used for the treatment of bipolar disorder, decreased the constitutive secretion of dopamine and norepinephrine and decreased nicotine-stimulated secretion of epinephrine. Lithium had no effect on other secreted neurotransmitters. Overall, the newly developed GC-TOF with LC-MS/MS metabolomics methods for analyses of 14 neurotransmitters will benefit investigations of neurotransmitter regulation in biological systems and in human disease conditions related to drug treatments.
Collapse
Affiliation(s)
- Vivian Hook
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California 92093, United States
- Department of Neurosciences and Department of Pharmacology, School of Medicine, University of California, San Diego, La Jolla, California 92093, United States
| | - Tobias Kind
- West Coast Metabolomics Center, UC Davis Genome Center, University of California, Davis, Davis, California 95616, United States
| | - Sonia Podvin
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California 92093, United States
| | - Mine Palazoglu
- West Coast Metabolomics Center, UC Davis Genome Center, University of California, Davis, Davis, California 95616, United States
| | - Carol Tran
- West Coast Metabolomics Center, UC Davis Genome Center, University of California, Davis, Davis, California 95616, United States
| | - Thomas Toneff
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California 92093, United States
| | - Stephanie Samra
- West Coast Metabolomics Center, UC Davis Genome Center, University of California, Davis, Davis, California 95616, United States
| | - Christopher Lietz
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California 92093, United States
| | - Oliver Fiehn
- West Coast Metabolomics Center, UC Davis Genome Center, University of California, Davis, Davis, California 95616, United States
| |
Collapse
|
6
|
Elevated allostatic load early in the course of schizophrenia. Transl Psychiatry 2018; 8:246. [PMID: 30420620 PMCID: PMC6232085 DOI: 10.1038/s41398-018-0299-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/17/2018] [Accepted: 07/14/2018] [Indexed: 12/19/2022] Open
Abstract
Stress plays a significant role in schizophrenia from disease onset to exacerbation of psychotic symptoms. Allostatic load (AL) is a measure of cumulative stress to the organism. This study is an extension of our previous work on AL and its relationship to brain structures. Here, we further determined whether elevated AL is a function of illness chronicity, or if it is already present early in the course of schizophrenia. AL was compared in schizophrenia patients early in the illness (within 5 years of disease onset), patients with chronic schizophrenia (more than 5 years of illness), and two groups of healthy controls that were age-and sex-matched to the two patient groups. This work is presented with an expanded sample and includes about two-thirds of the participants who were previously reported. We found that patients with early psychosis had significantly elevated AL score compared with their age-matched controls (p = 0.005). Chronic course patients also had elevated AL compared with age-matched controls (p = 0.003). Immune and stress hormone AL subcomponents were nominally higher in early-stage patients compared with controls (p = 0.005 and 0.04, respectively). Greater AL was also associated with more severe positive psychotic symptoms in early-stage patients (r = 0.54, p = 0.01). Elevated levels of allostatic load are already present in the early years of the schizophrenia illness, particularly in patients with more severe psychotic symptoms. AL may be a useful evaluation for the need of early intervention on psychosomatic comorbidity.
Collapse
|
7
|
Puljak L. If there is only one author or only one database was searched, a study should not be called a systematic review. J Clin Epidemiol 2017; 91:4-5. [PMID: 28823649 DOI: 10.1016/j.jclinepi.2017.08.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 08/09/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Livia Puljak
- Cochrane Croatia, University of Split School of Medicine, Soltanska 2, 21000 Split, Croatia; Department for Development, Research and Health Technology Assessment, Agency for Quality and Accreditation in Health Care and Social Welfare, Planinska 13, Zagreb 10000, Croatia.
| |
Collapse
|
8
|
Bougioukas KI, Liakos A, Tsapas A, Ntzani E, Haidich AB. Preferred reporting items for overviews of systematic reviews including harms checklist: a pilot tool to be used for balanced reporting of benefits and harms. J Clin Epidemiol 2017; 93:9-24. [PMID: 29037888 DOI: 10.1016/j.jclinepi.2017.10.002] [Citation(s) in RCA: 148] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/18/2017] [Accepted: 10/06/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVES An overview of systematic reviews (OoSRs) is a study designed to synthesize multiple evidence from existing systematic reviews on a specific domain. The aim of this paper was to offer a pilot version checklist with Preferred Reporting Items for OoSRs (PRIO-harms) to promote a more balanced reporting of benefits and harms in OoSRs of health care interventions. STUDY DESIGN AND SETTING The included items were developed by combining key features from health care OoSRs designs with recommendations from statements of other relevant checklists and pertinent methodological review articles. Two raters independently used the PRIO-harms checklist to assess a sample of 20 OoSRs. RESULTS The PRIO-harms tool consists of a 27-item (56 (sub-)items in total) checklist and is accompanied by a five-stage process flow diagram (identification, screening, eligibility, inclusion, and separation of relevant studies). The mean interrater reliability (Gwet's AC1 statistic) between reviewers was 0.90 (95% confidence interval: 0.88, 0.92) indicating a very good agreement. CONCLUSION The PRIO-harms tool can be used in every OoSRs that addresses health care interventions. This instrument will assist overview authors to improve completeness and transparency of research reporting with emphasis on harms. However, it might benefit from critical review and further validation from experts and research teams that produce OoSRs.
Collapse
Affiliation(s)
- Konstantinos I Bougioukas
- Department of Hygiene and Epidemiology, Medical School, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | - Aris Liakos
- Second Medical Department, Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Konstantinoupoleos 49, 54642 Thessaloniki, Greece
| | - Apostolos Tsapas
- Second Medical Department, Clinical Research and Evidence-Based Medicine Unit, Aristotle University of Thessaloniki, Konstantinoupoleos 49, 54642 Thessaloniki, Greece; Harris Manchester College, University of Oxford, Mansfield Rd, Oxford, OX1 3TD, UK
| | - Evangelia Ntzani
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, University Campus, Stavros Niarchos Av., Ioannina, Greece; Center for Evidence Synthesis in Health, Department of Health Services, Policy and Practice, School of Public Health, Brown University, 121 South Main Street, Providence, RI 02903, USA
| | - Anna-Bettina Haidich
- Department of Hygiene and Epidemiology, Medical School, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece.
| |
Collapse
|