Chronic pelvic pain:mastcells,
medical and psychological comorbiditycomorbidity
Alessandra Graziottin MDCenter of Gynecology and Medical Sexology H. San Raffaele Resnati, Milan, Italy
www.alessandragraziottin.itwww.alessandragraziottin.it
DISCLOSURE• Speakers ’ bureau:
Bayer, Biotest, Epitech, Janssen-Cilag, Pantarhei, Sanofi, Valeas
• Advisory Boards :• Advisory Boards :Bayer, Janssen -Cilag , Novonordisk , Theramex , Valeas
• Consultant :Bayer , Epitech , Theramex
Question 1.
Chronic Pelvic Pain
What is the new evidence What is the new evidence on the common
biological correlates of chronic pelvic pain
and inflammation?
NEUROGENIC (“ NOCICEPTIVE”)
NEUROGENIC (“ NOCICEPTIVE”)
SOMATIC
VISCERAL
SUPERFICIAL
DEEP
Classification of Pain
NEUROPATHICNEUROPATHIC
PAINVISCERAL
PERIPHERAL
CENTRALBonica, 1993; Melzack & Wall, 2000;
Turk et Al, 2001; Behrman et Al, 2006; Bernardes et al, 2007 A.Graziottin, 2011
Pain perception in womencontributing factors
Biological factorsPAIN: severity of tissue damageneurological, mucocutaneous, vascularmuscular, endocrineimmunitaryimmunitary
Contextual factors•quality of family support•socioeconomic level•working conditions•social acceptance or not
•meaning of pain
Psychologicalfactors•fear of pain and its meaning•coping strategies•psychosexual history•body image
A.Graziottin, 2010
Bonica, 1993; Melzack & Wall, 2000; Turk et Al, 2001; Behrman et Al, 2006; Graziottin, 2000, 2006; Latthe et al, 2006, Graziottin, 2010
NonNon--cyclical chronic pelvic pain: risk factorscyclical chronic pelvic pain: risk factors-- a meta analysis a meta analysis --
PallaviPallavi LattheLatthe etet Al, Al, FactorsFactors predisposingpredisposing women women toto chronicchronic pelvicpelvic painpain: : systematicsystematic reviewreviewBMJ 332; 74BMJ 332; 74--755, 2006755, 2006
NonNon--cyclical chronic pelvic pain: risk factorscyclical chronic pelvic pain: risk factors-- a meta analysis a meta analysis --
Pallavi Latthe et Al, Factors predisposing women to chronic pelvic pain: systematic review Pallavi Latthe et Al, Factors predisposing women to chronic pelvic pain: systematic review BMJ 332; 74BMJ 332; 74--755, 2006755, 2006
Anxiety and depression
Type of pain Anxiety Depression
Dysmenorrhea OR=2.77 OR=2.59Non Non sensuality:OR=8.12
Dyspareunia OR=3.23 OR=7.77
CPP OR=2.28 OR=2.69PTSD=OR 5.47
Psychosomatic=8.01Pallavi Latthe et Al, Factors predisposing women to chronic pelvic pain: Pallavi Latthe et Al, Factors predisposing women to chronic pelvic pain: systematic review BMJ 332; 74systematic review BMJ 332; 74--755, 2006755, 2006
A.Graziottin, 2006
The protagonists of the Chronic Pelvic Pain
scenarioChronicChronic
inflammationinflammation
PeripheralPeripheral NervousNervousSystem System PAINPAIN
CentralCentral NervousNervousSystemSystem
EndometriosisEndometriosis
WhoWho isis the the directordirectorofof the the painpain orchestra ?orchestra ?
The The mastmast--cellcellisis the the powerfulpowerful protagonistprotagonistbehindbehind the the clinicalclinical scenarioscenarioofof inflammationinflammation and and painpain
Picture: Picture: CourtesyCourtesy ofof R. Della ValleR. Della Valle
More More thanthan 45.000 45.000 paperspapers (!) (!) creditcreditthe the mastcellmastcell toto bebe the the directordirector
ofof the the chronicchronic inflammationinflammation orchestraorchestra
THE UPTHE UP--REGULATED MASTCELLREGULATED MASTCELLMenstrualMenstrual bloodblood
in the in the tissuetissue
NeurogenicNeurogenic stimulusstimulus& & neurotrophicneurotrophic changeschanges
x 52x 52--58% 58% enlargementenlargementofof peripheralperipheral neuronsneurons
x 10 x 10 ProliferationProliferation ofof painpain fibersfibersBornsteinBornstein, 2001, 2004, 2008; , 2001, 2004, 2008; BohmeBohme--starkestarke, 1998, 2001 , 1998, 2001
Mechanical traumaMechanical traumaIntercourseIntercourse!!!!!!
Chemical &Chemical &physical noxaephysical noxae
EstrogensEstrogens AgonistAgonist
A.GraziottinA.Graziottin, 2005, 2005
VasoactiveVasoactivefactorsfactors
HystamineHystamine
BradychinineBradychinine
SerotonineSerotonine
NERVE GROWTH NERVE GROWTH FACTOR (x 50!)FACTOR (x 50!)
Dupont et Al, 2001Dupont et Al, 2001
InfectionsInfections
AgonistAgoniststimulistimuli
FromFrom inflammationinflammation toto chronicchronic painpain
Acute Acute inflammationinflammation healinghealing RestitutioRestitutio ad ad
integrumintegrum
PersistencePersistence or or recurrencerecurrence ofoffactorsfactors causingcausing tissuetissue damagedamage
and and inflammationinflammation
NociceptiveNociceptivepainpain
RegulatedRegulatedMastcellMastcell
UpUp--regulatedregulatedMastcellMastcell ModulationModulationand and inflammationinflammation
ChronicChronic tissuetissue inflammationinflammationUpUp--regulatedregulated mastcellsmastcells
ChronicChronicpainpain
NeuropathicNeuropathicpainpain
A.GraziottinA.Graziottin, 2010, 2010DepressionDepression
MastcellMastcell ModulationModulationofof
mastcellsmastcellsisis keykey
The The interactioninteractionbetweenbetween mastcellsmastcellsand and nervenerve fibersfibersisis the the biologicalbiological
prerequisiteprerequisite ofof the the
CortesyCortesy ofof di di R.dellaR.della Valle, 2007Valle, 2007
prerequisiteprerequisite ofof the the shiftshift fromfrom acute acute toto
chronicchronicneuropathicneuropathic painpain
NAKANISHI and FURUNO. NAKANISHI and FURUNO. Cellular & Molecular Immunology Cellular & Molecular Immunology 20082008
TimeTime--coursescourses ofof FluoFluo--33 fluorescencefluorescence
intensityintensity changeschanges inin RBLsRBLs andand inin SCGSCG
neuritesneurites.. AnAn arrowarrow indicatesindicates thethe timetime
pointpoint ofof bradykininbradykinin additionaddition..
NerveNerve--inducedinduced mastmast cellcell activationactivation..
DifferentialDifferential interferenceinterference contrastcontrast imageimage andand
sequentialsequential CaCa22++ imagesimages afterafter thethe additionaddition ofof
bradykininbradykinin (time(time == 00)) inin thethe SCGSCG--RBLRBL coco--
cultureculture..
NAKANISHI and FURUNO. NAKANISHI and FURUNO. Cellular & Molecular Immunology Cellular & Molecular Immunology 20082008
TimeTime--coursescourses ofof FluoFluo--33 fluorescencefluorescence intensityintensity
changeschanges inin RBLsRBLs andand inin SCGSCG neuritesneurites.. AnAn arrowarrow
indicatesindicates thethe timetime pointpoint ofof antigenantigen additionaddition..
MastMast cellcell--inducedinduced neuriteneurite activationactivation.. RepresentativeRepresentative DICDIC imageimage
andand sequentialsequential CaCa22++ imagesimages afterafter thethe additionaddition ofof antigenantigen (time(time ==
00)) inin thethe SCGSCG--RBLRBL coculturecoculture.. ArrowheadsArrowheads indicateindicate thethe neuriteneurite
whichwhich isis stronglystrongly activatedactivated..
CROSSCROSS--TALKTALK
CENTRAL CENTRAL SENSITIZATIONSENSITIZATION CHRONIC MASTCHRONIC MAST--CELL CELL
UPUP--REGULATIONREGULATION
ACTIVATEDMICROGLIA
FIRST NEURON
SECONDNEURON
ChronicChronic NeuropathicNeuropathicPelvicPelvic PainPain -- CPPCPP
NERVE LESIONNERVE LESION
Milligan ED & Watkins LR_2009 Nature Rev Neurosci.10(1):23-36
A.Graziottin, 2011
DepressionDepression
NEUROPLASTICITYNEUROPLASTICITY NEUROTOXICITYNEUROTOXICITY
PathwayPathway fromfrom InflammationInflammation totoDepressionDepression
DepressionDepression
PSYCHOGENIC STIMULIPSYCHOGENIC STIMULISPINALSPINAL--CORD CORD NEUROINFLAMMATIONNEUROINFLAMMATION
Blood-brain barrier
Neuroprotectivemicroglia
Activatedmicroglia
McNally L et al Review Article_2008 CNS Spectr.13(6):501-510
Conclusion 1
•The mast-cell is the director of the inflammatory process
•There is a close dialogue between mastcells and pain fibers
•They are intimately connected and use a common language: neurotransmitters and cytochines in the tissue and in the spinal cord/brain
Question 2.
Chronic Pelvic Pain
and mastcellsand mastcellsWhat is the evidence
on the key role of Mastcells in
chronic pelvic pain syndromes?
Chronic Pelvic Pain: Medical & sexual comorbidities
deep dyspareunia Endometriosis dysmenorrhea
infertility
Pelvic inflammatory disease infertilitydeep dyspareuniadeep dyspareunia
Vulvar vestibulitis introital dyspareunia
vulvodynia post-coital cystitis
Interstitial cystitis bladder pain, dysuria introital dyspareunia
Irritable bowel syndrome abdominal pain dyspareunia
www.fondazionegraziottin.orgwww.fondazionegraziottin.org
Heterogeneity of CPP.
Predictors of CPP include different factors:• Biological: endometriosis, PID, CS, pelvic adhesions • Affective: anxiety, depression, PTSD, Psychosomatic• Context dependent: sexual and emotional abuse
Comorbidity is frequent and underdiagnosed
A.GraziottinA.Graziottin, 2011, 2011
What is the common denominatorof chronic pelvic pain?
CHRONIC INFLAMMATIONCHRONIC INFLAMMATIONMediatedMediated byby the MASTthe MAST--CELLSCELLS
and and hyperactivationhyperactivation ofof painpain fibersfibers
AnafAnaf etet al; al; FertilFertil SterilSteril 20062006
ObjectiveObjective: : To detect and quantify mast cells in peritoneal, ovarian, and deep infiltrating To detect and quantify mast cells in peritoneal, ovarian, and deep infiltrating
endometriosis and to study the relationship between mast cells and nerves in endometriosis and to study the relationship between mast cells and nerves in
endometriosis.endometriosis.
TryptaseTryptase--Positive Mast Cells CountPositive Mast Cells Count
Anaf et al; Fertil Steril 2006Anaf et al; Fertil Steril 2006
Number of Number of degranulatingdegranulating Mast Cells/mmMast Cells/mm22
AnafAnaf etet al; al; FertilFertil SterilSteril 20062006
AnafAnaf etet al; al; FertilFertil SterilSteril 20062006
Mast Cells Located < 25 µm from Nerve StructuresMast Cells Located < 25 µm from Nerve Structures
WangWang,, HumanHuman Reproduction,Reproduction, 20092009
ThereThere werewere significantlysignificantly moremore nervenerve fibresfibres inin
DIEDIE ((6767..66++6565..11/mm/mm22)) thanthan inin peritonealperitoneal
endometrioticendometriotic lesionslesions ((1616..33++1010..00/mm/mm22)) (P(P ,,
00..0101))..
DIEDIE waswas innervatedinnervated abundantlyabundantly byby sensorysensory
AAγγ,, sensorysensory C,C, cholinergiccholinergic andand adrenergicadrenergic
nervenerve fibresfibres;; NGF,NGF, TrkTrk--AA andand pp7575
werewere stronglystrongly expressedexpressed inin endometrioticendometriotic
glandsglands andand stromastroma ofof DIEDIE..
MastcellsMastcells in in endometriosisendometriosisConclusionsConclusions
The presence of increased activated The presence of increased activated and and degranulatingdegranulating mast cells mast cells
in deeply infiltrating endometriosis in deeply infiltrating endometriosis and the close histological relationship and the close histological relationship
between mast cells and nerves between mast cells and nerves between mast cells and nerves between mast cells and nerves strongly suggest that mast cells strongly suggest that mast cells
could contribute to the development of pain could contribute to the development of pain and and hyperalgesiahyperalgesiain endometriosis, in endometriosis,
possibly by a direct effect on nerve structures. possibly by a direct effect on nerve structures.
Mastcellsand Vulvar Vestibulitis
The chronically damaged introital tissueactivates the up -regulation of the :• mastcells, with increased production of pain factors and • mastcells, with increased production of pain factors and
NGF • nervous/pain system leading to vestibulitis/vulvodynia• muscular system, with defensive contraction of the
levator ani and myalgia
BertolasiBertolasi etet Al, 2004; Al, 2004; BohmeBohme--StarkeStarke etet Al, 1998, 2000, 2001;Al, 1998, 2000, 2001;BornsteinBornstein etet Al, 2001, 2004; Al, 2001, 2004; GlazerGlazer etet Al, 1995; Al, 1995; Graziottin 2001, 2004; Mc Kay Graziottin 2001, 2004; Mc Kay etet al. 1998, 2004al. 1998, 2004BertolasiBertolasi etet Al, 2008; Al, 2008; BornsteinBornstein, 2004, 2008, 2004, 2008
A.GraziottinA.Graziottin, 2010, 2010
Symptoms: Dyspareunia and Symptoms: Dyspareunia and postcoital cystitispostcoital cystitis
Signs: vulvar vestibulitis and Signs: vulvar vestibulitis and hyperactive pelvic floorhyperactive pelvic floor
A.GraziottinA.Graziottin, 2010, 2010
increased concentration of increased concentration of mastcellsmastcellshigher (p<0.001) in the superficial layers higher (p<0.001) in the superficial layers vsvs
the deep (0.05)the deep (0.05)(Bornstein et al, 2001, 2004, 2008)(Bornstein et al, 2001, 2004, 2008)
NormalNormal mucosamucosa
Increase of Mastcells Increase of Mastcells in the Vestibular mucosa in the Vestibular mucosa
MastcellsMastcellsNormalNormal mucosamucosa
Mucosa in VVSMucosa in VVS
MastMast--cell cell produceproduce NGF with NGF with proliferation of the free pain nerve proliferation of the free pain nerve
terminals = increase of nociceptorsterminals = increase of nociceptors X X 10 times 10 times
(Bohme(Bohme-- Starke et Al, 2001, Bornstein, 2004Starke et Al, 2001, Bornstein, 2004 ) ) Graziottin & Vincenti, 2004Graziottin & Vincenti, 2004
MastcellsMastcells
MastcellsMastcells and and vestibulitisvestibulitis//vulvodiniavulvodiniaConclusion 1.Conclusion 1.
HeparanaseHeparanase, which is , which is degranulateddegranulatedfrom mast cells,from mast cells,
is capable of degrading the vestibular is capable of degrading the vestibular stromastromaand epithelial basement membrane,and epithelial basement membrane,thus permitting thus permitting stromalstromal proliferation proliferation thus permitting thus permitting stromalstromal proliferation proliferation
and intraepithelial extension of nerve fibers. and intraepithelial extension of nerve fibers. The The hyperinnervationhyperinnervation
has been thought to cause has been thought to cause the vestibular hyperesthesia the vestibular hyperesthesia
distinctive of localized distinctive of localized vulvodyniavulvodyniaBornsteinBornstein etet Al, 2008Al, 2008
MastcellsMastcells and and irritableirritable bowelbowel syndromesyndrome
The colon The colon isis the the mostmost importantimportant immunitaryimmunitaryorganorgan ofof humanhuman bodybody
ColonicColonic mastcellsmastcells permanentlypermanently controlcontrol the the mucosalmucosal boundaryboundary and and “set the “set the levellevel” ” ofof the the generalgeneral immunitaryimmunitary, , inflammatoryinflammatory and and painpainresponseresponseresponseresponse
HyperactivatedHyperactivated coloniccolonic mastcellsmastcells increaseincrease painpain vulnerabilityvulnerability in colon in colon AND AND differentdifferent organsorgans, in the , in the abdomenabdomen//pelvispelvis suchsuch asas bladderbladder, , vestibulumvestibulum, and , and distantdistant, , ieie brainbrain
FoodFood allergiesallergies increaseincrease painpain vulnerabilityvulnerability in in differentdifferent painpain syndromessyndromes, , suchsuch asas endometriosisendometriosis
StanghelliniStanghellini etet Al, 2006, 2008; Barbara Al, 2006, 2008; Barbara etet Al, 2004; Al, 2004; AbarAbar etet Al, 2008Al, 2008
Barbara et al; GastroenterologyBarbara et al; Gastroenterology 2004 2004
MastcellsMastcells in the in the bladderbladder painpain syndromesyndromeBPS/IC (“BPS/IC (“interstitialinterstitial cystitiscystitis”)”)
RecurrentRecurrent bladderbladder inflammationinflammation leadsleads toto::
••HyperactivationHyperactivation ofof mastcellsmastcells in the in the bladderbladder wallwall withwith chronicchronicdetrusorialdetrusorial inflammationinflammation and progressive and progressive scarringscarring
••IncreasedIncreased production production ofof painpain signalssignals
••ProliferationProliferation ofof painpain fibersfibers
••DefensiveDefensive contractioncontraction ofof the the levatorlevator ani ani
A.Graziottin, 2010
BJU Int. 2008 :204BJU Int. 2008 :204--7 7
Question 3.
What bridges
Endometriosis & Chronic Pelvic Pain
What bridgesendometriosis, chronic inflammation and pain
to depression?
CourtesyCourtesy ofof G. Biggio, 2009G. Biggio, 2009
Somatic Symptoms of Depression
• “Unexplained” pain – CPP, Backache, Chest pain, Chronic join pain, Limb pain,
Headache, Bodily aches and Fibromyalgia
• Fatigue/loss of energy • Insomnia• Insomnia• Gastrointestinal symptoms
– Abdominal cramping, bloating, heartburn, diarrhea and/or constipation
• Change in sexual desire & Female Sexual Disorders• Weight loss or gain
– Loss or increase in of appetite • Dizziness & Palpitations
RakelRakel RERE.. DepressionDepression.. PrimPrim CareCare 19991999;;2626((22))::211211--224224,, TrivediTrivedi MHMH.. TheThe linklink betweenbetween depressiondepression andand physicalphysicalsymptomssymptoms.. PrimPrim CareCare CompanionCompanion JJ ClinClin PsychiatryPsychiatry 20042004;;66((SupplSuppl 11))::1212--1616,, BurtBurt VKVK.. PlottingPlotting thethe coursecourse toto remissionremission::thethesearchsearchforfor betterbetteroutcomesoutcomesinin thethetreatmenttreatmentofof depressiondepression.. JJ ClinClin PsychiatryPsychiatry 20042004;;6565SupplSuppl1212::2020--2525.. ©JLA’06©JLA’06
Major brain changes in depression• Down-regulation of the
* serotoninergic system:
§ in the brain
§ in the body (95% of serotonin is outside the brain!)
* dopaminergic system* dopaminergic system
1) seeking-appetitive-lust system
2) motor system (nigro-striatal)
3) logic linear thinking
* opiatergic system
A.GraziottinA.Graziottin, 2010, 2010
and and increaseincrease ofof inflammatoryinflammatory mediatorsmediators
NEW READINGS OF DEPRESSION
••asas a a systemicsystemic diseasedisease
asas anan inflammatoryinflammatory
RakelRakel RE.RE. DepressionDepression.. Prim CarePrim Care 1999;26(2):2111999;26(2):211--224, 224, TrivediTrivedi MH.MH. The link between depression and physical symptomsThe link between depression and physical symptoms.. Prim Care Companion J Prim Care Companion J ClinClin PsychiatryPsychiatry
2004;6(2004;6(SupplSuppl 1):121):12--16, 16, Burt VK.Burt VK. Plotting the course to remission: the search for better outcomes in the treatment of depressionPlotting the course to remission: the search for better outcomes in the treatment of depression.. J J ClinClin
PsychiatryPsychiatry 2004;65 2004;65 SupplSuppl 12:2012:20--25.25.Graziottin & Serafini, Graziottin & Serafini, Menop.IntMenop.Int, 2009;, 2009;
DinanDinan TG, TG, CurrCurr OpinOpin Psychiatry 22(1):32Psychiatry 22(1):32--6, 2009.6, 2009.
asas anan inflammatoryinflammatoryconditioncondition
withwith significantsignificant increaseincrease ofof inflammatoryinflammatorymoleculesmolecules producedproduced byby the the mastcellsmastcells
Inflammatory markers in depression
• Major depression is associated with a proinflammatory response, as indexed by elevation in C-reactive protein and cytokines such as interleukin 6 and tumor necrosis factor-alpha.
• Most studies support a link between depression, inflammation and cardiovascular events.
• Antidepressants suppress the inflammatory response. Whether or not the immune system is an appropriate target for antidepressant development has yet to be established.
Dinan TG, Curr Opin Psychiatry 22(1):32-6, 2009.
DepressionDepression is an is an inflammatory state inflammatory state that may increase the risk of cardiac diseasethat may increase the risk of cardiac disease. .
Inflammation & depression
.
InflammationInflammation PainPain
Depression is (also) a systemic Depression is (also) a systemic
inflammatory stateinflammatory state
A.GraziottinA.Graziottin, 2010, 2010
EstrogensEstrogens -- and testosterone!and testosterone!--havehave anan antianti--inflammatoryinflammatory activityactivity
in the in the brainbrainHalbreichHalbreich etet Al, 2001; Begliuomini Al, 2001; Begliuomini etet Al, 2007; Al, 2007; BrannBrann Al, 2007; Al, 2007; DheenDheen etet Al, 2007; Al, 2007; FoyFoyetet Al, 2007; Al, 2007; HajszanHajszan etet al, 2008; al, 2008; RazRaz etet Al, 2008; Vegeto Al, 2008; Vegeto etet Al, 2008; Al, 2008; DinanDinan, 2009 , 2009
Conclusion 3.
Depression:
• is a systemic disease
• is an inflammatory condition• is an inflammatory condition
• “somatizations” are the biological correlates of a systemic inflammatory state and of the widespread diffusion on neurotransmitters
The protagonists of the Chronic Pain scenario
ChronicChronicinflammationinflammation
PeripheralPeripheral NervousNervousPeripheralPeripheral NervousNervousSystem System
PAIN FIBERS PAIN FIBERS
MastMastcellcell
CentralCentral NervousNervousSystemSystem
PAIN CENTERSPAIN CENTERS
DepressionDepression
The The MastcellMastcell isis the the directordirectorofof painpain & & depressiondepression orchestraorchestra
“Immunologic abnormalities, especiallyindices of excess inflammation, are acommon finding in patients withdepression.
There is increasing evidence suggesting
By Leah McNally, Zubin Bhagwagar and Jonas Hannestadin Inflammation, Glutamate, and Glia in Depression: A Literature Review
2008 CNS Spectr.13(6):501-509
There is increasing evidence suggesting
that inflammation could, in a subgroup
of patients and in some medical conditions
contribute to thepathogenesis of depression.”
CRHCRH
CENTRAL CENTRAL NEUROINFLAMMATIONNEUROINFLAMMATION
DepressionDepression
PSYCHOGENICPSYCHOGENICSTIMULISTIMULI
HORMONAL STIMULIHORMONAL STIMULI
NEUROGENIC NEUROGENIC STIMULISTIMULI
vagina uterus
Peritoneum
PelvicPelvic PainPain((NeurogenicNeurogenic//NociceptiveNociceptive))
PelvicPelvic TissueTissueDamageDamage
IMMUNOGENIC IMMUNOGENIC STIMULISTIMULI
CROSSCROSS--TALKTALK
ChronicChronic (Neuropathic ?)(Neuropathic ?)PelvicPelvic Pain Pain -- CPPCPP
bladdercolon
Conclusion
CPP and comorbidities, such as Endometriosis, Vulvodynia, Bladder PainSyndrome and IBS, are characterized by
Mastcell mediated:Mastcell mediated:
• inflammation
• depression
• pain
New perspectives
Down-regulation of the hyperactive mastcells / microglia is the new frontier
• in endometriosis & chronic • in endometriosis & chronic inflammation
ImmunologicalImmunological reviewreviewJuneJune 2007 2007 volvol 217 pag 5217 pag 5--337337
•• in in chronicchronic pelvicpelvic painpain
RenRen & & DubnerDubner, Nature medicine, , Nature medicine, OctoberOctober 14, 201014, 2010
•• and in and in depressiondepression associatedassociated toto
chronicchronic diseasesdiseases A.Graziottin, 2011
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