The relationship of Chlamydophila pneumoniae with schizophrenia: The role of brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) in this relationship

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Bacilos gramnegativos." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Susana Molgatini, Eduardo Rey, Jorge Basilaki, Christian Mosca, Rafael Galante, Laura Gliosca" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Susana" "apellidos" => "Molgatini" ] 1 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Rey" ] 2 => array:2 [ "nombre" => "Jorge" "apellidos" => "Basilaki" ] 3 => array:2 [ "nombre" => "Christian" "apellidos" => "Mosca" ] 4 => array:2 [ "nombre" => "Rafael" "apellidos" => "Galante" ] 5 => array:2 [ "nombre" => "Laura" "apellidos" => "Gliosca" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0325754116301183?idApp=UINPBA00004N" "url" => "/03257541/0000004900000001/v1_201704040030/S0325754116301183/v1_201704040030/es/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Original article" "titulo" => "The relationship of Chlamydophila pneumoniae with schizophrenia: The role of brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) in this relationship" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "39" "paginaFinal" => "49" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Fatma Kalayci, Armagan Ozdemir, Suat Saribas, Pelin Yuksel, Sevgi Ergin, Ali Mert Kuskucu, Cana Aksoy Poyraz, Ibrahim Balcioglu, Nihat Alpay, Aykut Kurt, Zeynep Sezgin, Banu Tufan Kocak, Rana Sucu Icel, Gunay Can, Hrisi Bahar Tokman, Bekir Kocazeybek" "autores" => array:16 [ 0 => array:3 [ "nombre" => "Fatma" "apellidos" => "Kalayci" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "Armagan" "apellidos" => "Ozdemir" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Suat" "apellidos" => "Saribas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Pelin" "apellidos" => "Yuksel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Sevgi" "apellidos" => "Ergin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Ali Mert" "apellidos" => "Kuskucu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Cana Aksoy" "apellidos" => "Poyraz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 7 => array:3 [ "nombre" => "Ibrahim" "apellidos" => "Balcioglu" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 8 => array:3 [ "nombre" => "Nihat" "apellidos" => "Alpay" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 9 => array:3 [ "nombre" => "Aykut" "apellidos" => "Kurt" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 10 => array:3 [ "nombre" => "Zeynep" "apellidos" => "Sezgin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 11 => array:3 [ "nombre" => "Banu Tufan" "apellidos" => "Kocak" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 12 => array:3 [ "nombre" => "Rana Sucu" "apellidos" => "Icel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "f" "identificador" => "aff0030" ] ] ] 13 => array:3 [ "nombre" => "Gunay" "apellidos" => "Can" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "g" "identificador" => "aff0035" ] ] ] 14 => array:3 [ "nombre" => "Hrisi Bahar" "apellidos" => "Tokman" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 15 => array:4 [ "nombre" => "Bekir" "apellidos" => "Kocazeybek" "email" => array:1 [ 0 => "bzeybek@istanbul.edu.tr" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Istanbul University, Cerrahpasa Medical Faculty, Department of Medical Microbiology, Istanbul, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "T.C. Health Ministry Bakirkoy Mental Health and Neurology Training and Research Hospital Psychiatry Clinic, Istanbul, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Istanbul University, Cerrahpasa Medical Faculty, Department of Psychiatry, Istanbul, Turkey" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Istanbul University, Cerrahpasa Medical Faculty, Department of Medical Biochemistry, Istanbul, Turkey" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "T.C. Health Ministry Erenkoy Mental Health and Neurology Training and Research Hospital, Istanbul, Turkey" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "T.C. Health Ministry, Sisli Etfal Education and Research Hospital, Department of Blood Center, Istanbul, Turkey" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Istanbul University, Cerrahpasa Medical Faculty, Department of Public Health, Istanbul, Turkey" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Papel del factor neurotrófico de origen cerebral y de la neurotropina-3 en la relación de Chlamydophila pneumoniae con la esquizofrenia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1749 "Ancho" => 3417 "Tamanyo" => 155957 ] ] "descripcion" => array:1 [ "en" => "Side-by-side box-whisker plots of BDNF and NT3 levels of patients with past (PaCP, past C. pneumoniae), persistent (PeCP, persistent C. pneumoniae) C. pneumoniae infection and C. pneumoniae seronegativity (CPS). PaCP, past C. pneumoniae infection; PeCP, persistent C. pneumoniae infection; CPS, C. pneumoniae seronegativity." ] ] ] "textoCompleto" => "IntroductionSchizophrenia is a multi-factorial and complex neuropsychiatric disorder that affects a large number of people worldwide. In addition to genetic risk factors<a class="elsevierStyleCrossRef" href="#bib0460">33</a>, winter-spring birth<a class="elsevierStyleCrossRef" href="#bib0555">52</a>, rural or urban life<a class="elsevierStyleCrossRef" href="#bib0505">42</a>, a crowded household<a class="elsevierStyleCrossRef" href="#bib0300">1</a>, birth complications<a class="elsevierStyleCrossRef" href="#bib0420">25</a>, cat contact during the early stages of life<a class="elsevierStyleCrossRef" href="#bib0560">53</a> and migration<a class="elsevierStyleCrossRef" href="#bib0365">14</a> have been implicated in the development of schizophrenia. In studies on the etiopathogenesis of schizophrenia, some researchers have investigated the associations of this disease with Toxoplasma gondii<a class="elsevierStyleCrossRefs" href="#bib0355">12,54</a>, Treponema pallidum<a class="elsevierStyleCrossRef" href="#bib0455">32</a>, Cytomegalovirus (CMV)<a class="elsevierStyleCrossRef" href="#bib0465">34</a>, Herpes simplex viruses I and II (HSV-I, HSC-II)<a class="elsevierStyleCrossRefs" href="#bib0510">43,46</a>, West Nile virus (WNV)<a class="elsevierStyleCrossRef" href="#bib0325">6</a>, and Borna Disease virus (BDV)<a class="elsevierStyleCrossRef" href="#bib0440">29</a>, and important data have been obtained. In a meta-analysis that included 42 studies performed in 17 countries over 5 decades, Torrey et al. suggested that individuals suffering from schizophrenia have an increased prevalence of antibodies against T. gondii<a class="elsevierStyleCrossRef" href="#bib0570">55</a>. A combined odds ratio (OR) of 2.73 was reported by the authors. In another meta-analysis that included 56 studies that assessed the possible association between the detection of different infectious agents and schizophrenia, Arias et al. reported statistically significant associations between schizophrenia and infection with Human herpes virus 2 (OR=1.34), BDV (OR=2.03), Human endogenous retrovirus W family (OR=19.31), Chlamydophila pneumoniae (OR=6.3499, Chlamydophila psittaci (OR=29.05) and T. gondii (OR=2.70)<a class="elsevierStyleCrossRef" href="#bib0315">4</a>. The principal reason for focusing on these infectious agents is that these agents have the ability to settle persistently in the central nervous system (CNS); in addition, neurological and psychiatric symptoms have been observed in some genetically predisposed people<a class="elsevierStyleCrossRef" href="#bib0490">39</a>. However, in recent years, important results related to the relationship between neurotrophic and intracellular C. pneumoniae and schizophrenia have only been reported in a few studies<a class="elsevierStyleCrossRefs" href="#bib0395">20–22</a>.C. pneumoniae is a gram negative bacterium that undergoes biphasic growth within the host. The ability of C. pneumoniae elementary bodies to infect various human cells (e.g., macrophages, monocytes and lymphocytes, as well as endothelial and smooth muscle cells)<a class="elsevierStyleCrossRef" href="#bib0370">15</a> suggests that C. pneumoniae infection may result in systemic dissemination<a class="elsevierStyleCrossRef" href="#bib0345">10</a>. In addition, the detection of C. pneumoniae DNA in peripheral blood mononuclear cells (PBMCs) using molecular methods suggests that this dissemination occurs in various tissues<a class="elsevierStyleCrossRefs" href="#bib0345">10,41</a>. C. pneumoniae is primarily responsible for atypical pneumonia<a class="elsevierStyleCrossRef" href="#bib0445">30</a>; however, several recent studies have asserted that C. pneumoniae might be related to neuropsychiatric (e.g., schizophrenia) and neurodegenerative diseases (e.g., multiplesclerosis)<a class="elsevierStyleCrossRefs" href="#bib0400">21,22,49</a>, as well as other diseases, such as coronary heart disease<a class="elsevierStyleCrossRefs" href="#bib0425">26,47</a>, lung cancer<a class="elsevierStyleCrossRef" href="#bib0450">31</a>, and arthritis<a class="elsevierStyleCrossRef" href="#bib0320">5</a>. The cause of the association between Chlamydiaceae and many different clinical manifestations, especially schizophrenia, may be the ability of the organism to interact with its host by remaining in body tissues, causing chronic infection and relapse.C. pneumoniae infection has been reported to stimulate the transendothelial entry of monocytes through human brain endothelial cells (HBMECs)<a class="elsevierStyleCrossRef" href="#bib0340">9</a>, and it has been asserted that chronic inflammatory pathogenesis might arise as a result of persistent infection due to the ability of C. pneumoniae to reside in brain endothelial cells for many years<a class="elsevierStyleCrossRefs" href="#bib0395">20,21</a>. It was also proposed that proliferating immune system cells might favor the synthesis of different neurotrophins<a class="elsevierStyleCrossRef" href="#bib0400">21</a>. Brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) are responsible for prenatal neuronal differentiation and development, as well as postnatal neuronal plasticity<a class="elsevierStyleCrossRef" href="#bib0550">51</a>. These factors are essential for the regulation of synaptic activity, affect glutamatergic neurotransmission and dopamine synthesis, and are effective in transmitter synthesis in adults<a class="elsevierStyleCrossRef" href="#bib0475">36</a>. Hippocampal damage was reported to cause the upregulation of BDNF in related regions of schizophrenic patients<a class="elsevierStyleCrossRefs" href="#bib0330">7,48</a>. The influence of this factor on dopaminergic neurons may be relevant to the pathogenesis of schizophrenia, which is suggested to be related to dopaminergic dysfunction<a class="elsevierStyleCrossRef" href="#bib0535">48</a>. NT-3 enhances the survival of dopaminergic neurons suggesting a possible role of this factor in the pathophysiology of dopaminergic-related neuropsychiatric disorders (e.g., Parkinson's disease, schizophrenia, and Tourette's syndrome)<a class="elsevierStyleCrossRefs" href="#bib0360">13,24</a>. Neurotrophins may exert their effects via multiple mechanisms: decreased or increased levels of neurotrophins, imbalances between different neurotrophins, and abnormalities in the control and timing of neurotrophin production, secretion and signaling pathways<a class="elsevierStyleCrossRef" href="#bib0535">48</a>. There is a growing interest in neurotrophins and their capacity to regulate central neurotransmission and promote neuroplasticity. Recent findings are consistent with our current understanding of neurobiology and the course of schizophrenia, so that there may be a prominent role of these agents in the development of schizophrenia. NT-3 and BDNF levels have been proposed to change in response to various manifestations of infection<a class="elsevierStyleCrossRefs" href="#bib0350">11,27</a>.Here we aimed to detect the presence of C. pneumoniae infections using serological and molecular methods and to investigate the schizophrenia–C. pneumoniae relationship. We also assessed the levels of BDNF and NT-3 to evaluate the role of BDNF and NT-3 in this relationship.Materials and methodsThis study was planned as a cross-sectional and randomized case–control study between March 2013 and August 2013. The patients who were admitted to the Bakirkoy Mental Health Hospital in the Psychiatry Clinic and Department of Psychiatry of the Cerrahpasa Medical Faculty at Istanbul University were included as the patient group (PG), and healthy blood donors (who donated blood to the blood center of Sisli Etfal Training and Research Hospital) as well as healthy volunteer hospital workers were included as the healthy control group (HCG).Patient and control groupsPatient group (PG)Fifty patients who were diagnosed by two experienced psychiatrists in accordance with the Diagnostic and Statistical Manual of Mental Disorders IV-Text Revision (DSM IV-TR) criteria<a class="elsevierStyleCrossRef" href="#bib0310">3</a> and who had a disease duration of 1–10 years (mean of 3.75±0.25 years) were included as the PG. Their ages ranged from 18 to 52 years [mean±s.d. (29.9±9.26)]. The PG included 21 males (42%) and 29 females (58%). Patients suffering from any other physical illness such as brain tumors, thyroid disease, severe hepatic disease, severe cardiac disease, any other psychiatric diagnosis, organic brain disorder, or serious neurological disease, alcohol and/or drug abuse and pregnancy were excluded from the study. The study was approved by the local Ethical Committee of the Cerrahpasa Medical Faculty. A written informed consent was obtained from all participants. Following the first whole blood-collection and serum samples from the patients, the second whole blood samples were collected after 4–8 weeks to observe seroconversion, in accordance with the CDC (Centers for Disease Control and Prevention, USA) recommendations<a class="elsevierStyleCrossRef" href="#bib0375">16</a>. All patients received antipsychotic treatment [atypical antipsychotics (clozapine, risperidone, quetiapine, olanzapine, etc.) and typical antipsychotics (haloperidol)]. An informed consent form was also verbally read to all blood donors and volunteers. We also recorded information related to the participants’ age, education, marital status, medical history, family history, family ownership of pets, use of alcohol and smoking.Healthy control group (HCG)The HCG consisted of 35 healthy blood donors and volunteer hospital workers who were matched with the patient group with respect to gender and age distribution. The patients and the matched normal subjects had similar socioeconomic status and dietary patterns. The age of the participants in the HCG ranged from 19 to 57 years [mean±s.d. (32.3±10.27)], and that group included 13 males (37.1%) and 22 females (62.8%). All the participants in the HCG declared no history of schizophrenia, bipolar disorder, or major depression, had no previous antipsychotic drug use, drug use or antibiotic use in the previous two years, and had no history of alcohol consumption or smoking. An informed consent form was also verbally read to all blood donors and volunteers.Collection of serum samplesThis study was performed between March and August 2013. Two whole blood samples were collected from each individual both in the patient and control groups with an interval of 4–8 weeks to observe seroconversion. The immunofluorescence assay (IFA) of the second whole blood samples collected were repeated after 4–8 weeks. Fasting blood samples (5ml and 4ml) from the PG and the HCG were collected into sterile vacuum collection tubes with no anticoagulants and sterile collection tubes with EDTA (ethylenediaminetetracetic acid), respectively.Whole blood and serum samples from all PG and HCG cases were transferred to the Microbiology Department of the Cerrahpasa Medical Faculty under optimal conditions. The whole blood samples were divided into two portions. One portion was centrifuged at 1000rpm for 15min to obtain serum samples and was then used with a commercially available kit to determine BDNF and NT-3 concentrations. These serum samples were stored at −20°C. The remaining portion was centrifuged at 5000rpm for 5min for the detection of C. pneumoniae antibodies, and the serum samples were stored at −70°C. The 4ml blood samples with EDTA were treated with Ficoll to separate PBMCs, divided into sterile Eppendorf tubes containing 0.5ml of a saline solution and stored at −70°C.MethodsSerological methodsDetection of C. pneumoniae antibodies using the immunofluorescence antibody (IFA) methodSerum samples from the PG and HCG participants were studied for the presence of IgM, IgG and IgA antibodies against C. pneumoniae by IFA (Euroimmun Labordiagnostica, Germany). The serum samples were tested after treatment with Gullsorb (Gull Laboratories, Salt Lake City, Utah) in accordance with the manufacturer's instructions to remove interfering IgG antibodies<a class="elsevierStyleCrossRef" href="#bib0435">28</a>. Antigens prepared from C. pneumoniae elementary bodies were used as antigens. Most of this antigen consists of major outer membrane proteins (MOMPs), lipopolysaccharide (LPS), and outer membrane proteins (OMPs). A doubling dilution method, which started from 1/16 for IgM, 1/40 for IgA and 1/16 to 1/512 for IgG, was employed for antibody detection. The manufacturer's recommendations were followed for the determination of C. pneumoniae IgM. All slides were evaluated using a fluorescence microscope (Zeiss-Axioskop40)<a class="elsevierStyleCrossRefs" href="#bib0305">2,16</a>. The seropositivity criteria for the diagnosis of persistent C. pneumoniae infection were IgG ≥512 and IgA ≥40; for the study population, IgG titers of >16 were accepted as the criterion for previous infection. Our study results were evaluated in accordance with the CDC criteria<a class="elsevierStyleCrossRefs" href="#bib0305">2,16,31</a>.Determination of BDNF and NT-3 concentrations using the sandwich ELISA methodSerum BDNF and NT-3 levels were measured with the sandwich enzyme-linked immunosorbent assay (ELISA) using a commercially available kit (BOSTER Immunoleader, ABD) following the manufacturer's guidelines. In brief, in flat-bottom microtiter plates (96-well), the samples were diluted 1:2 in sample diluent, and the standard curves ranged from 31.2 to 2000pg for BDNF and from 15.6 to 1000pg for NT-3.The standards and samples (0.1ml) were added to each well. The microtiter plates were then incubated for 90min at 37°C. A biotinylated anti-human BDNF antibody and a biotinylated anti-human NT-3 antibody (0.1ml) were added to the wells and incubated for 60min at 37°C. The plates were then washed three times with wash buffer. Avidin–Biotin Peroxidase solution was then added to each well and incubated for 30min at 37°C. After washing (five times with wash buffer), the substrate was added and incubated for 20–25min at 37°C. After the addition of the stop solution, the amounts of BDNF and NT-3 were determined (absorbance set at 450nm).Molecular methodsC. pneumoniae DNA was detected in PBMCs using a quantitative real time-polymerase chain reaction (qRT-PCR) method with commercially available kits (LightMix® Kit Chlamydophila pneumoniae and LightCycler® FastStart DNA MasterHybProbe, Roche, Berlin, Germany) following the manufacturer's guidelines.Isolation of peripheral blood mononuclear cells (PBMCs)As C. pneumoniae is an obligate intracellular human pathogen, we isolated PBMCs from whole blood. The whole blood samples that were collected from each patient into EDTA-treated tubes were diluted 1:1 in PBS. The diluted blood was carefully layered over Ficoll-Paque (Wisent, St-Bruno) at a blood:Ficoll ratio of 3:1. Centrifugation (1600g, 35min) was performed to obtain a mononuclear cell fraction, which was aspirated, diluted 1:1 in PBS and centrifuged at 1600g for 10min. The PBMCs were stored at −70°C until the time of qRT-PCR analysis.DNA extraction from PBMCs and detection of C. pneumoniae DNA in PBMCs via RT- PCRA qRT-PCR method was used for the detection of C. pneumoniae in PBMCs. Nucleic acid extraction was performed using a commercial nucleic acid purification kit (High Pure PCR Template Preparation Kit, Roche Germany) according to the manufacturer's instructions. We used a LightMix®C. pneumoniae (TIB MOLBIOL GmbH, Germany) real-time PCR kit for the detection of C. pneumoniae DNA. The kit included primers that were designed to amplify a 140bp fragment of the J38 genomic region of C. pneumoniae and a hybridization probe.The mix includes an internal control system to exclude PCR amplification errors. We included a positive control, calibrators (ranging from 10 to 1000000copies), and negative controls in each test batch.Statistical analysisThe data obtained in the trial were analyzed using the SPSS (version 17.00) statistics program. The data were evaluated using a multivariate logistic regression test (forward conditional model) and the Chi-square and Fisher exact tests. The Chi-square tests were used to evaluate the relationships between chlamydial infection and the presence of schizophrenia. The Chi-square test and the Fisher's exact test were used to compare frequencies among the groups. The distribution patterns of BDNF and NT-3 were analyzed using the Chi-square test. Most of the BDNF and NT-3 values did not fit a standard distribution curve, and the data were therefore subjected to non-parametric analyses. Thus, the Mann–Whitney U test was employed to compare groups. All statistical tests were two-sided, and p values lower than 0.05 were considered to be statistically significant.ResultsWhen the PG and HCG participants were compared, primary school graduation and the presence of relatives with neuropsychiatric disorders were found to be significantly more common in the PG than in the HCG (p<0.05). However, graduation from a university was found to be significantly less common in the PG than in the HCG (p<0.05). The rate of smoking was significantly higher in the PG than in the HCG (p<0.001) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Fourteen (28%) and one (2.85%) of the PG and HCG participants, respectively, were determined to have persistent C. pneumoniae infection (the seropositivity criteria for the diagnosis of persistent C. pneumoniae infection were IgG ≥512 and IgA ≥40), based on microimmunofluorescence (MIF) IgA and IgG results of two whole blood samples tested with an interval of 4–8 weeks (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). A significant difference in persistent C. pneumoniae infection was observed between the PG and the HCG (OR=13.222, CI 95%: 1.648–106.07, χ2; 8.95; p<0.05); however, no significant difference in past C. pneumoniae infection was found between the groups (OR=1.330, CI 95%: 0.549–3.219, χ2; 0.400; p>0.05).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>When the PG and HCG participants were compared with respect to gender and age for past and persistent C. pneumoniae infection seropositivity, PG females had significantly greater rates of persistent C. pneumoniae infection than HCG females. Additionally, a significant difference in persistent C. pneumoniae infection was found between PG and HCG participants, with infection being more frequent among females in the PG (p<0.05). Persistent C. pneumoniae infection was also found more frequently in 18–29 years and 30–40 years age of both groups. However, no significant differences in past C. pneumoniae infection were found among gender- and age-matched groups from the PG and the HCG (p>0.05). When the mean serum BDNF and NT-3 levels of the PG and HCG participants were compared, serum BDNF levels were significantly lower in the PG participants than in the HCG participants (p<0.05), and serum NT-3 levels were significantly lower in the PG than in the HCG (p<0.001) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>When the PG and HCG participants were compared with respect to the mean serum BDNF and NT-3 levels based on seropositivity for past C. pneumoniae infection, the serum BDNF and NT-3 levels were found to be significantly lower in the PG than in the HCG (p<0.05). Statistical analyses were not performed to compare the mean serum BDNF and NT-3 levels between the PG and the HCG based on persistent C. pneumoniae seropositivity because only one persistent C. pneumoniae case was detected in the HCG; therefore, a standard deviation could not be determined (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).When considering PG participants with past (NT-3:594pg/ml) or persistent (NT-3:480.1pg/ml) C. pneumoniae infection seropositivity, the mean serum NT-3 levels were higher in PG patients with C. pneumoniae seropositivity than in seronegative patients (NT-3:461pg/ml); however, this difference was not statistically significant (p>0.05). In contrast, when considering serum BDNF levels in schizophrenic patients with past (BDNF: 1689.1pg/ml) or persistent (BDNF: 1560.8pg/ml) C. pneumoniae infection, the mean serum BDNF levels were lower in PG patients with C. pneumoniae seropositivity than in seronegative patients (BDNF: 1962pg/ml) (p>0.05) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>We detected no C. pneumoniae DNA in the PBMCs from 85 participants by qRT-PCR. Although we detected C. pneumoniae seropositivity in schizophrenic patients (n:10) with persistent infection, we failed to detect C. pneumoniae DNA.The results of a multivariate logistic regression analysis (following a forward conditional model) of demographic parameters (e.g., education and neuropsychiatric disorders in at least one relative), serological tests (C. pneumoniae IgG≥512+IgA≥40) and mean serum neurotrophic factor levels (BDNF/NT-3) are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Based on the results of our analysis, primary school graduation (OR:1, p<0.05), the presence of seropositivity for persistent C. pneumoniae infection (OR:39.8, p<0.05) and the presence of neuropsychiatric disorders in at least one relative (OR:9.03, p<0.05) were identified as independent risk factors for schizophrenia. In addition, the rate of university graduation (p<0.05) and the mean serum neurotrophin-3 level (p<0.001) were found to be significantly lower in the PG than in the HCG.DiscussionImportant data were recently obtained in studies that addressed the role of infectious agents in the etiopathogenesis of schizophrenia. The most interesting finding of these studies has been the presence of chronic infection caused by C. pneumoniae. Although persistently elevated IgA (or IgG) antibody levels have been proposed and used by some researchers to indicate chronic infection, there is no validated serological marker of persistent infection. In addition, it has been suggested that high IgA titers may be a better marker of chronic C. pneumoniae infection than IgG titers because serum IgA has a half-life of 5–7 days, but IgG has a half-life of weeks to months. First, we attempted to identify persistent C. pneumoniae infection in our study groups. The detection of persistent C. pneumoniae infection based on the presence of elevated titers of IgA-type C. pneumoniae antibodies for 6 months and the persistent production of IgG is generally indicative of persistent infection with C. pneumoniae rather than re-infection<a class="elsevierStyleCrossRef" href="#bib0375">16</a>.The presence of C. pneumoniae DNA in PBMCs suggests that the systemic dissemination of C. pneumoniae occurs after exposure to a respiratory infection<a class="elsevierStyleCrossRef" href="#bib0345">10</a>. To establish a link between Chlamydia and schizophrenia, we performed a search for related studies. In a study performed by Xaiver et al., a female patient with pharyngitis caused by C. pneumoniae showed excessive manifestations related to acute psychosis during a 3-day period<a class="elsevierStyleCrossRef" href="#bib0585">58</a>. Those authors suggested that this acute psychosis may have been triggered by meningoencephalitis. C. pneumoniae infection in human brain microvascular endothelial cells was demonstrated to alter the permeability of the blood–brain barrier<a class="elsevierStyleCrossRefs" href="#bib0480">37,50</a>.C. pneumoniae infection may facilitate the transmigration of monocytes through human brain endothelial cells; this observation may represent one mechanism by which the organism enters the CNS. Consequently, the organism may enter the CNS inside infected monocytes, resulting in chronic injury<a class="elsevierStyleCrossRefs" href="#bib0370">15,38</a>. The pro-inflammatory chemokines and cytokines that are produced by Chlamydia-infected cells may be involved in inflammation and tissue injury<a class="elsevierStyleCrossRefs" href="#bib0470">35,50</a>.BDNF and NT-3, which are produced by neurons, peripheral and CNS tissues, microglia, and Th1 and Th2 cells, might be altered in psychiatric disorders, such as schizophrenia. These factors were good candidates in our efforts to establish a link between Chlamydia infections and schizophrenia<a class="elsevierStyleCrossRefs" href="#bib0335">8,17</a>. Considering the above mechanisms, we evaluated the role of C. pneumoniae in the development of schizophrenia. Some researchers reported that NGF, BDNF and NT-3 are produced via in vitro and in vivo microglial expression<a class="elsevierStyleCrossRef" href="#bib0385">18</a>. Additionally, it was suggested that Th1 cells may produce NT-3 and Th2 cells may produce BDNF. Two neurotrophins may be produced via the stimulation of aTh1-orTh2-based immune response<a class="elsevierStyleCrossRefs" href="#bib0335">8,17,18,40</a>. The expression levels of neurotrophins that influence synaptic activity in the CNS by binding to the TrkA, TrkB and TrkC tropomyosin receptors may change based on the developing immune response (i.e., Th1 or Th2). This interaction between the immune system and the CNS might be triggered by infections with organisms like C. pneumoniae<a class="elsevierStyleCrossRefs" href="#bib0395">20,21</a>.Fellerhoff et al. detected 40% and 6.7% chlamydial DNA in the PBMCs of patients with schizophrenia and control subjects, respectively<a class="elsevierStyleCrossRef" href="#bib0400">21</a>. In another study performed by Fellerhoff et al., 4-times more chlamydial DNA was detected in the frontal cortex of postmortem schizophrenic and bipolar cases<a class="elsevierStyleCrossRef" href="#bib0405">22</a>. This finding led the authors to propose that neural development is likely to be impaired by the inflammation that is caused by Chlamydiaceae infections with neural and microglial involvement and might consequently cause neuropsychiatric disorders.In this study, we detected a statistically significant difference in chronic C. pneumoniae infection between PG and HCG participants (p<0.05). We also determined that chronic C. pneumoniae infection causes a 13-fold greater risk of developing schizophrenia. Moreover, persistent C. pneumoniae infection was detected as an independent risk factor in our multivariate regression analysis. Based on our results, we suggested that C. pneumoniae infections may be related to schizophrenia. Despite our positive serological results, we were unable to detect C. pneumoniae DNA in PBMCs using qRT-PCR, which has an analytic sensitivity of 10 DNA copies. This finding contrast with the results reported in the above studies; in our opinion, this difference could be related to the absence of infected monocytes in the peripheral blood or the presence of C. pneumoniae DNA at a frequency below 10 copies in peripheral blood cells. Additionally, Murray et al. reported that the treatment of schizophrenic patients with neuroleptic drugs (e.g., haloperidol and pimozide) inhibited the calmodulin-dependent process that Chlamydiaceae use to enter cells<a class="elsevierStyleCrossRef" href="#bib0515">44</a>. Thus, these drugs may prevent the uptake of Chlamydiaceae by the cell and thus prevent the detection of Chlamydiaceae DNA in those cells. Our PG individuals were diagnosed with schizophrenia and treated for approximately 3–5 years, suggesting the possibility that these drugs might affect the uptake of Chlamydiaceae by the cells.In a meta-analysis related to the epidemiology of schizophrenia, the frequency of schizophrenia was reported to be equal in both sexes, but the mean age at the onset of illness was higher for females than for males (25–35 vs. 18-25 years)<a class="elsevierStyleCrossRef" href="#bib0390">19</a>. We suggested that the detection of significantly different rates of chronic C. pneumoniae infection in female schizophrenic patients than in HCG patients and the detection of significantly more chronic C. pneumoniae infections in young and middle-aged schizophrenic patients are important demographic findings and are consistent with the available literature.Although we expected to detect high levels of neurotrophin expression because chronic infection triggers inflammatory processes during early episodic schizophrenic psychosis, we actually detected low neurotrophin serum levels in schizophrenic patients. The lower serum BDNF and NT-3 levels observed in schizophrenic patients who had been receiving long-term treatment with antipsychotic drugs were consistent with the results of Fourney et al., who reported that antipsychotic drugs (especially haloperidol) down-regulated neurotrophins and decreased hippocampal BDNF mRNA expression<a class="elsevierStyleCrossRef" href="#bib0410">23</a>. Similar findings have been reported by other groups<a class="elsevierStyleCrossRefs" href="#bib0575">56,57</a>. Most remarkably, we found that antipsychotic drug users with past or chronic C. pneumoniae infection had higher mean serum NT-3 levels than C. pneumoniae-seronegative patients with schizophrenia. We propose that this result may be related to continued NT-3 expression, which is caused by microglial or T cell activation in the presence of persistent C. pneumoniae infection, together with specific host immune responses to microglial C. pneumoniae infection, even with potential antipsychotic drug pressure in the hippocampal region.In our study, having graduated from a primary school and not having graduated from a university were identified as independent risk factors. Park et al. reported that “to have a neuropsychiatric disease in the family” was not a significant factor in the Chlamydiaceae–schizophrenia relationship<a class="elsevierStyleCrossRef" href="#bib0520">45</a>. This factor has been reported to be a significant risk factor in two other Turkish studies that addressed the T. gondii-schizophrenia and BDV–schizophrenia relationships<a class="elsevierStyleCrossRefs" href="#bib0440">29,59</a>. To have a neuropsychiatric disease “in the family” showed a significant difference between two groups in accordance with the univariate analysis in our study (p<0.05) and was also detected as an independent risk factor according to the multivariate analysis.Serologically, persistent C. pneumoniae infection was identified as an independent risk factor according to the multivariate regression analysis. The serological detection of C. pneumoniae was also found to differ significantly between patients and controls in accordance with the univariate analysis, suggesting that persistent C. pneumoniae infections may play a role in the development of schizophrenia, as has been proposed by numerous other studies<a class="elsevierStyleCrossRefs" href="#bib0400">21,22</a>. In addition, serum neurotrophin levels (especially NT-3) were lower in the PG than in the HCG, likely due to antipsychotic treatment. However, the serum NT- 3 levels of the schizophrenic patients with past or persistent C. pneumoniae seropositivity were higher than those of the schizophrenic patients with no C. pneumoniae seropositivity, although this difference was not statistically significant. We suggest that this result may be related to the expression of certain amounts of NT-3 by microglia and T cells that are activated by chronic and persistent C. pneumoniae infection and have migrated to the brain via monocytes (despite drug pressure).This study has several limitations. First, during chronic C. pneumoniae infection, the expression of the organism's own 60kDa heat shock proteins (HsP60) increases, especially when the proteins are elevated persistently. The host immune response to microbial HsP60 may cause autoimmunity to human HsP60 and the subsequent development of some chronic diseases, such as asthma, atherosclerosis, or coronary heart disease<a class="elsevierStyleCrossRef" href="#bib0370">15</a>. We did not investigate HsP60 of C. pneumoniae. Secondly, our sample size was limited. Moreover, the schizophrenic patients were in different stages of schizophrenia and received different antipsychotic treatments. Antipsychotic medication is known to influence the immune system; thus, the infectivity of the organism may be affected. Moreover, the potential confounding variables were smoking, domestic pet contact, differences in education level between the patients and the controls and the effects of different drug doses on the C. pneumoniae–schizophrenia–neurotrophin (BDNF and NT-3) relationship.In conclusion, the presence of serological C. pneumoniae positivity in the PG suggested the possible role of persistent C. pneumoniae infections in the development of schizophrenia. The presence of lower levels of serum neurotrophins (especially NT-3) in the PG than in the HCG suggested that prior antipsychotic treatment may have an effect. However, the high serum NT-3 levels of the schizophrenic patients with past or persistent C. pneumoniae seropositivity suggested that NT-3 is expressed by microglia and T cells that are activated by chronic and persistent C. pneumoniae infection and have migrated to the brain via monocytes (despite drug pressure). To define this relationship more clearly, similar, matched, broad-spectrum case–control studies should be conducted.Ethical disclosureProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of DataThe authors declare that they have followed the protocols of their work centre on the publication of patient data and that all the patients included in the study have received sufficient information and have given their informed consent in writing to participate in that study.Right to privacy and informed consentThe authors have obtained the informed consent of the patients and /or subjects mentioned in the article. The author for correspondence is in possession of this document.Conflict of interestThe authors declare that there are no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres824203" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec820697" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres824204" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec820696" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:4 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Patient and control groups" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Patient group (PG)" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Healthy control group (HCG)" ] ] ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Collection of serum samples" ] 2 => array:3 [ "identificador" => "sec0035" "titulo" => "Methods" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0040" "titulo" => "Serological methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Detection of C. pneumoniae antibodies using the immunofluorescence antibody (IFA) method" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Determination of BDNF and NT-3 concentrations using the sandwich ELISA method" ] ] ] 1 => array:3 [ "identificador" => "sec0055" "titulo" => "Molecular methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Isolation of peripheral blood mononuclear cells (PBMCs)" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "DNA extraction from PBMCs and detection of C. pneumoniae DNA in PBMCs via RT- PCR" ] ] ] ] ] 3 => array:2 [ "identificador" => "sec0070" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0075" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0085" "titulo" => "Ethical disclosure" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0090" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0095" "titulo" => "Confidentiality of Data" ] 2 => array:2 [ "identificador" => "sec0100" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0105" "titulo" => "Conflict of interest" ] 10 => array:2 [ "identificador" => "xack276421" "titulo" => "Acknowledgements" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-09-09" "fechaAceptado" => "2016-09-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec820697" "palabras" => array:4 [ 0 => "Chlamydophila pneumoniae" 1 => "Schizophrenia" 2 => "BDNF" 3 => "NT-3" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec820696" "palabras" => array:4 [ 0 => "Chlamydophila pneumoniae" 1 => "Esquizofrenia" 2 => "BDNF" 3 => "NT-3" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Several pathogens have been suspected of playing a role in the pathogenesis of schizophrenia. Chronic inflammation has been proposed to occur as a result of persistent infection caused by Chlamydophila pneumoniae cells that reside in brain endothelial cells for many years. It was recently hypothesized that brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) may play prominent roles in the development of schizophrenia. NT-3 and BDNF levels have been suggested to change in response to various manifestations of infection. Therefore, we aimed to elucidate the roles of BDNF and NT3 in the schizophrenia–C. pneumoniae infection relationship. RT-PCR, immunofluorescence and ELISA methods were used. Fifty patients suffering from schizophrenia and 35 healthy individuals were included as the patient group (PG) and the healthy control group (HCG), respectively. We detected persistent infection in 14 of the 50 individuals in the PG and in 1 of the 35 individuals in the HCG. A significant difference was found between the two groups (p<0.05). Twenty-two individuals in the PG and 13 in the HCG showed seropositivity for past C. pneumoniae infection, and no difference was observed between the groups (p>0.05). C. pneumoniae DNA was not detected in any group. A significant difference in NT-3 levels was observed between the groups, with very low levels in the PG (p<0.001). A significant difference in BDNF levels was also found, with lower levels in the PG (p<0.05). The mean serum NT-3 level was higher in the PG cases with C. pneumoniae seropositivity than in seronegative cases; however, this difference was not statistically significant (p>0.05). In conclusion, we suggest that NT-3 levels during persistent C. pneumoniae infection may play a role in this relationship." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Existe la sospecha de que algunos patógenos pueden desempeñar un papel en la patogénesis de la esquizofrenia; en ese contexto, se ha propuesto que la infección persistente causada por células de Chlamydophila pneumoniae presentes en las células endoteliales cerebrales durante muchos años lleva a la inflamación crónica. Recientemente se ha planteado la hipótesis de que el factor neurotrófico de origen cerebral (BDNF, por sus siglas en inglés) y la neurotropina-3 (NT-3) podrían estar implicados en el desarrollo de la esquizofrenia, y se ha sugerido que sus niveles se modifican en respuesta a diversas manifestaciones de la infección. En esta investigación intentamos esclarecer el papel que desempeñan el BDNF y la NT3 en la relación entre la esquizofrenia y la infección por C. pneumoniae. Se utilizaron métodos de RT-PCR, inmunofluorescencia y ELISA. Se incluyeron 50 pacientes con esquizofrenia y 35 individuos sanos como grupo de pacientes (GP) y grupo de controles sanos (GCS), respectivamente. Detectamos una infección persistente en 14 sujetos del GP y en 1 de los del GCS, lo que constituyó una diferencia significativa (p<0,05). Veinte participantes del GP y 13 del GCS fueron seropositivos para una infección pasada por C. pneumoniae, diferencia no significativa (p>0,05). No se detectó ADN de C. pneumoniae en ninguno de los dos grupos. Se observó una diferencia significativa entre los grupos en los niveles de NT-3, que fueron muy bajos en el GP (p<0,001), y de BDNF, inferiores en el GP (p<0,05). La concentración sérica media de NT-3 fue mayor en los individuos seropositivos para C. pneumoniae en comparación con los seronegativos, pero esta diferencia no alcanzó significación estadística (p>0,05). Sugerimos que los niveles de NT-3 durante una infección persistente por C. pneumoniae pueden estar implicados en la relación de Chlamydophila pneumoniae con la esquizofrenia." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1633 "Ancho" => 3417 "Tamanyo" => 140371 ] ] "descripcion" => array:1 [ "en" => "Side-by-side box-whisker plots of BDNF and NT3 levels in PG and HCG. PG, patient group; HCG, healthy control group." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1749 "Ancho" => 3417 "Tamanyo" => 155957 ] ] "descripcion" => array:1 [ "en" => "Side-by-side box-whisker plots of BDNF and NT3 levels of patients with past (PaCP, past C. pneumoniae), persistent (PeCP, persistent C. pneumoniae) C. pneumoniae infection and C. pneumoniae seronegativity (CPS). PaCP, past C. pneumoniae infection; PeCP, persistent C. pneumoniae infection; CPS, C. pneumoniae seronegativity." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Demographic parameters \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Patient group</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Healthy control group</th><th class="td" title="table-head " align="center" valign="top" scope="col">p \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Marital status</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Married \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Single \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Educational status</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Primary school \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High school \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">University \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">To have relatives with neuropsychiatric</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Present \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="char" valign="middle"><0.05</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Absence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Smoking habit</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Present \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="char" valign="middle"><0.001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Absence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">Alcohol use</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Present \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="char" valign="middle">>0.05</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Absence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1385767.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic parameters, analyzed in the patient group and healthy control group cases" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">PG<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">HCG<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">p<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Past C. pneumoniae infection (n: 35)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IgG≥16-IgG<512 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (44%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (37.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean BDNF<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> (pg/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1689.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2140.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean NT-3<a class="elsevierStyleCrossRef" href="#tblfn0025">e</a> (pg/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">594 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">903.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top">Persistent C. pneumoniae infection (n: 15)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IgG≥1/512+IgA≥1/40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 (28%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (2.8%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean BDNF<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> (pg/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1560.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2061.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">–<a class="elsevierStyleCrossRef" href="#tblfn0030">f</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean NT-3<a class="elsevierStyleCrossRef" href="#tblfn0025">e</a> (pg/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">480.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1034.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1385768.png" ] ] ] "notaPie" => array:6 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "PG, patient group." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "HCG, healthy control group." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "p values calculated with Mann–Whitney U test." ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "BDNF, brain derived neurotrophic factor." ] 4 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "e" "nota" => "NT-3, neurotrophin-3." ] 5 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "f" "nota" => "A standard deviation could not be determined." ] ] ] "descripcion" => array:1 [ "en" => "The IgG and IgA values of patient and control groups with the mean serum BDNF and NT-3 levels" ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">B<a class="elsevierStyleCrossRef" href="#tblfn0035">a</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">SE<a class="elsevierStyleCrossRef" href="#tblfn0040">b</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">d.f.<a class="elsevierStyleCrossRef" href="#tblfn0045">c</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col">OR<a class="elsevierStyleCrossRef" href="#tblfn0050">d</a> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">95.0% CI<a class="elsevierStyleCrossRef" href="#tblfn0055">e</a></th><th class="td" title="table-head " align="center" valign="top" scope="col">p \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Lower \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Upper \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NT-3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.004 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.996 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.994 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.335 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BDNF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.999 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.998 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.110 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Primary school \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.015 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High school \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−0.728 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.792 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.483 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.102 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.282 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.358 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">University \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">−2.252 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.780 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.105 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.023 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.485 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.004 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neuropsychiatric disorders at least in one relative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.201 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.446 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.036 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.531 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">153.874 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.012 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chronic C. pneumoniae infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.684 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.892 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.804 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.976 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1622.535 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.049 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Constant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.825 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.392 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">124.643 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1385769.png" ] ] ] "notaPie" => array:5 [ 0 => array:3 [ "identificador" => "tblfn0035" "etiqueta" => "a" "nota" => "B, beta regression coefficient." ] 1 => array:3 [ "identificador" => "tblfn0040" "etiqueta" => "b" "nota" => "SE, standard error." ] 2 => array:3 [ "identificador" => "tblfn0045" "etiqueta" => "c" "nota" => "d.f., degree of freedom." ] 3 => array:3 [ "identificador" => "tblfn0050" "etiqueta" => "d" "nota" => "OR, odds ratio." ] 4 => array:3 [ "identificador" => "tblfn0055" "etiqueta" => "e" "nota" => "CI, confidence interval." ] ] ] "descripcion" => array:1 [ "en" => "Multivariate logistic regression analysis of demographical parameters, serologic tests and mean serum BDNF and NT-3 levels" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:59 [ 0 => array:3 [ "identificador" => "bib0300" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Household crowding in early adulthood and schizophrenia are unrelated in Denmark: a nested case–control study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. 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Original article

Papel del factor neurotrófico de origen cerebral y de la neurotropina-3 en la relación de Chlamydophila pneumoniae con la esquizofrenia

Fatma Kalaycia, Armagan Ozdemirb, Suat Saribasa, Pelin Yuksela, Sevgi Ergina, Ali Mert Kuskucua, Cana Aksoy Poyrazc, Ibrahim Balciogluc, Nihat Alpayb, Aykut Kurta, Zeynep Sezgind, Banu Tufan Kocake, Rana Sucu Icelf, Gunay Cang, Hrisi Bahar Tokmana, Bekir Kocazeybeka,

Corresponding author

bzeybek@istanbul.edu.tr

Corresponding author.

a Istanbul University, Cerrahpasa Medical Faculty, Department of Medical Microbiology, Istanbul, Turkey

b T.C. Health Ministry Bakirkoy Mental Health and Neurology Training and Research Hospital Psychiatry Clinic, Istanbul, Turkey

c Istanbul University, Cerrahpasa Medical Faculty, Department of Psychiatry, Istanbul, Turkey

d Istanbul University, Cerrahpasa Medical Faculty, Department of Medical Biochemistry, Istanbul, Turkey

e T.C. Health Ministry Erenkoy Mental Health and Neurology Training and Research Hospital, Istanbul, Turkey

f T.C. Health Ministry, Sisli Etfal Education and Research Hospital, Department of Blood Center, Istanbul, Turkey

g Istanbul University, Cerrahpasa Medical Faculty, Department of Public Health, Istanbul, Turkey

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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Side-by-side box-whisker plots of BDNF and NT3 levels of patients with past &#40;PaCP&#44; past <span class="elsevierStyleItalic">C&#46; pneumoniae</span>&#41;&#44; persistent &#40;PeCP&#44; persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span>&#41; <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection and <span class="elsevierStyleItalic">C&#46; pneumoniae</span> seronegativity &#40;CPS&#41;&#46; PaCP&#44; past <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection&#59; PeCP&#44; persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection&#59; CPS&#44; <span class="elsevierStyleItalic">C&#46; pneumoniae</span> seronegativity&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Schizophrenia is a multi-factorial and complex neuropsychiatric disorder that affects a large number of people worldwide&#46; In addition to genetic risk factors<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">33</span></a>&#44; winter-spring birth<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">52</span></a>&#44; rural or urban life<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a>&#44; a crowded household<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">1</span></a>&#44; birth complications<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">25</span></a>&#44; cat contact during the early stages of life<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">53</span></a> and migration<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">14</span></a> have been implicated in the development of schizophrenia&#46; In studies on the etiopathogenesis of schizophrenia&#44; some researchers have investigated the associations of this disease with <span class="elsevierStyleItalic">Toxoplasma gondii</span><a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">12&#44;54</span></a>&#44; <span class="elsevierStyleItalic">Treponema pallidum</span><a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">32</span></a>&#44; <span class="elsevierStyleItalic">Cytomegalovirus</span> &#40;CMV&#41;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">34</span></a>&#44; <span class="elsevierStyleItalic">Herpes simplex viruses</span> I and II &#40;HSV-I&#44; HSC-II&#41;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">43&#44;46</span></a>&#44; <span class="elsevierStyleItalic">West Nile virus</span> &#40;WNV&#41;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">6</span></a>&#44; and <span class="elsevierStyleItalic">Borna Disease virus</span> &#40;BDV&#41;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">29</span></a>&#44; and important data have been obtained&#46; In a meta-analysis that included 42 studies performed in 17 countries over 5 decades&#44; Torrey et al&#46; suggested that individuals suffering from schizophrenia have an increased prevalence of antibodies against <span class="elsevierStyleItalic">T&#46; gondii</span><a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">55</span></a><span class="elsevierStyleItalic">&#46;</span> A combined odds ratio &#40;OR&#41; of 2&#46;73 was reported by the authors&#46; In another meta-analysis that included 56 studies that assessed the possible association between the detection of different infectious agents and schizophrenia&#44; Arias et al&#46; reported statistically significant associations between schizophrenia and infection with <span class="elsevierStyleItalic">Human herpes virus</span> 2 &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;34&#41;&#44; BDV &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;03&#41;&#44; <span class="elsevierStyleItalic">Human endogenous retrovirus</span> W family &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>19&#46;31&#41;&#44; <span class="elsevierStyleItalic">Chlamydophila pneumoniae</span> &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#46;3499&#44; <span class="elsevierStyleItalic">Chlamydophila psittaci</span> &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>29&#46;05&#41; and <span class="elsevierStyleItalic">T&#46; gondii</span> &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;70&#41;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">4</span></a>&#46; The principal reason for focusing on these infectious agents is that these agents have the ability to settle persistently in the central nervous system &#40;CNS&#41;&#59; in addition&#44; neurological and psychiatric symptoms have been observed in some genetically predisposed people<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">39</span></a>&#46; However&#44; in recent years&#44; important results related to the relationship between neurotrophic and intracellular <span class="elsevierStyleItalic">C&#46; pneumoniae</span> and schizophrenia have only been reported in a few studies<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">20&#8211;22</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">C&#46; pneumoniae</span> is a gram negative bacterium that undergoes biphasic growth within the host&#46; The ability of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> elementary bodies to infect various human cells &#40;e&#46;g&#46;&#44; macrophages&#44; monocytes and lymphocytes&#44; as well as endothelial and smooth muscle cells&#41;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">15</span></a> suggests that <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection may result in systemic dissemination<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">10</span></a>&#46; In addition&#44; the detection of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> DNA in peripheral blood mononuclear cells &#40;PBMCs&#41; using molecular methods suggests that this dissemination occurs in various tissues<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">10&#44;41</span></a>&#46; <span class="elsevierStyleItalic">C&#46; pneumoniae</span> is primarily responsible for atypical pneumonia<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">30</span></a>&#59; however&#44; several recent studies have asserted that <span class="elsevierStyleItalic">C&#46; pneumoniae</span> might be related to neuropsychiatric &#40;e&#46;g&#46;&#44; schizophrenia&#41; and neurodegenerative diseases &#40;e&#46;g&#46;&#44; multiplesclerosis&#41;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">21&#44;22&#44;49</span></a>&#44; as well as other diseases&#44; such as coronary heart disease<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">26&#44;47</span></a>&#44; lung cancer<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">31</span></a>&#44; and arthritis<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">5</span></a>&#46; The cause of the association between <span class="elsevierStyleItalic">Chlamydiaceae</span> and many different clinical manifestations&#44; especially schizophrenia&#44; may be the ability of the organism to interact with its host by remaining in body tissues&#44; causing chronic infection and relapse&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection has been reported to stimulate the transendothelial entry of monocytes through human brain endothelial cells &#40;HBMECs&#41;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">9</span></a>&#44; and it has been asserted that chronic inflammatory pathogenesis might arise as a result of persistent infection due to the ability of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> to reside in brain endothelial cells for many years<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">20&#44;21</span></a>&#46; It was also proposed that proliferating immune system cells might favor the synthesis of different neurotrophins<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">21</span></a>&#46; Brain-derived neurotrophic factor &#40;BDNF&#41; and neurotrophin-3 &#40;NT-3&#41; are responsible for prenatal neuronal differentiation and development&#44; as well as postnatal neuronal plasticity<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">51</span></a>&#46; These factors are essential for the regulation of synaptic activity&#44; affect glutamatergic neurotransmission and dopamine synthesis&#44; and are effective in transmitter synthesis in adults<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">36</span></a>&#46; Hippocampal damage was reported to cause the upregulation of BDNF in related regions of schizophrenic patients<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">7&#44;48</span></a>&#46; The influence of this factor on dopaminergic neurons may be relevant to the pathogenesis of schizophrenia&#44; which is suggested to be related to dopaminergic dysfunction<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">48</span></a>&#46; NT-3 enhances the survival of dopaminergic neurons suggesting a possible role of this factor in the pathophysiology of dopaminergic-related neuropsychiatric disorders &#40;e&#46;g&#46;&#44; Parkinson&#39;s disease&#44; schizophrenia&#44; and Tourette&#39;s syndrome&#41;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">13&#44;24</span></a>&#46; Neurotrophins may exert their effects via multiple mechanisms&#58; decreased or increased levels of neurotrophins&#44; imbalances between different neurotrophins&#44; and abnormalities in the control and timing of neurotrophin production&#44; secretion and signaling pathways<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">48</span></a>&#46; There is a growing interest in neurotrophins and their capacity to regulate central neurotransmission and promote neuroplasticity&#46; Recent findings are consistent with our current understanding of neurobiology and the course of schizophrenia&#44; so that there may be a prominent role of these agents in the development of schizophrenia&#46; NT-3 and BDNF levels have been proposed to change in response to various manifestations of infection<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">11&#44;27</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Here we aimed to detect the presence of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infections using serological and molecular methods and to investigate the schizophrenia&#8211;<span class="elsevierStyleItalic">C&#46; pneumoniae</span> relationship&#46; We also assessed the levels of BDNF and NT-3 to evaluate the role of BDNF and NT-3 in this relationship&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Materials and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This study was planned as a cross-sectional and randomized case&#8211;control study between March 2013 and August 2013&#46; The patients who were admitted to the Bakirkoy Mental Health Hospital in the Psychiatry Clinic and Department of Psychiatry of the Cerrahpasa Medical Faculty at Istanbul University were included as the patient group &#40;PG&#41;&#44; and healthy blood donors &#40;who donated blood to the blood center of Sisli Etfal Training and Research Hospital&#41; as well as healthy volunteer hospital workers were included as the healthy control group &#40;HCG&#41;&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patient and control groups</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Patient group &#40;PG&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Fifty patients who were diagnosed by two experienced psychiatrists in accordance with the Diagnostic and Statistical Manual of Mental Disorders IV-Text Revision &#40;DSM IV-TR&#41; criteria<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">3</span></a> and who had a disease duration of 1&#8211;10 years &#40;mean of 3&#46;75<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;25 years&#41; were included as the PG&#46; Their ages ranged from 18 to 52 years &#91;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>s&#46;d&#46; &#40;29&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9&#46;26&#41;&#93;&#46; The PG included 21 males &#40;42&#37;&#41; and 29 females &#40;58&#37;&#41;&#46; Patients suffering from any other physical illness such as brain tumors&#44; thyroid disease&#44; severe hepatic disease&#44; severe cardiac disease&#44; any other psychiatric diagnosis&#44; organic brain disorder&#44; or serious neurological disease&#44; alcohol and&#47;or drug abuse and pregnancy were excluded from the study&#46; The study was approved by the local Ethical Committee of the Cerrahpasa Medical Faculty&#46; A written informed consent was obtained from all participants&#46; Following the first whole blood-collection and serum samples from the patients&#44; the second whole blood samples were collected after 4&#8211;8 weeks to observe seroconversion&#44; in accordance with the CDC &#40;Centers for Disease Control and Prevention&#44; USA&#41; recommendations<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">16</span></a>&#46; All patients received antipsychotic treatment &#91;atypical antipsychotics &#40;clozapine&#44; risperidone&#44; quetiapine&#44; olanzapine&#44; etc&#46;&#41; and typical antipsychotics &#40;haloperidol&#41;&#93;&#46; An informed consent form was also verbally read to all blood donors and volunteers&#46; We also recorded information related to the participants&#8217; age&#44; education&#44; marital status&#44; medical history&#44; family history&#44; family ownership of pets&#44; use of alcohol and smoking&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Healthy control group &#40;HCG&#41;</span><p id="par0035" class="elsevierStylePara elsevierViewall">The HCG consisted of 35 healthy blood donors and volunteer hospital workers who were matched with the patient group with respect to gender and age distribution&#46; The patients and the matched normal subjects had similar socioeconomic status and dietary patterns&#46; The age of the participants in the HCG ranged from 19 to 57 years &#91;mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>s&#46;d&#46; &#40;32&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;27&#41;&#93;&#44; and that group included 13 males &#40;37&#46;1&#37;&#41; and 22 females &#40;62&#46;8&#37;&#41;&#46; All the participants in the HCG declared no history of schizophrenia&#44; bipolar disorder&#44; or major depression&#44; had no previous antipsychotic drug use&#44; drug use or antibiotic use in the previous two years&#44; and had no history of alcohol consumption or smoking&#46; An informed consent form was also verbally read to all blood donors and volunteers&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Collection of serum samples</span><p id="par0040" class="elsevierStylePara elsevierViewall">This study was performed between March and August 2013&#46; Two whole blood samples were collected from each individual both in the patient and control groups with an interval of 4&#8211;8 weeks to observe seroconversion&#46; The immunofluorescence assay &#40;IFA&#41; of the second whole blood samples collected were repeated after 4&#8211;8 weeks&#46; Fasting blood samples &#40;5<span class="elsevierStyleHsp" style=""></span>ml and 4<span class="elsevierStyleHsp" style=""></span>ml&#41; from the PG and the HCG were collected into sterile vacuum collection tubes with no anticoagulants and sterile collection tubes with EDTA &#40;ethylenediaminetetracetic acid&#41;&#44; respectively&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Whole blood and serum samples from all PG and HCG cases were transferred to the Microbiology Department of the Cerrahpasa Medical Faculty under optimal conditions&#46; The whole blood samples were divided into two portions&#46; One portion was centrifuged at 1000<span class="elsevierStyleHsp" style=""></span>rpm for 15<span class="elsevierStyleHsp" style=""></span>min to obtain serum samples and was then used with a commercially available kit to determine BDNF and NT-3 concentrations&#46; These serum samples were stored at &#8722;20<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; The remaining portion was centrifuged at 5000<span class="elsevierStyleHsp" style=""></span>rpm for 5<span class="elsevierStyleHsp" style=""></span>min for the detection of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> antibodies&#44; and the serum samples were stored at &#8722;70<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; The 4<span class="elsevierStyleHsp" style=""></span>ml blood samples with EDTA were treated with Ficoll to separate PBMCs&#44; divided into sterile Eppendorf tubes containing 0&#46;5<span class="elsevierStyleHsp" style=""></span>ml of a saline solution and stored at &#8722;70<span class="elsevierStyleHsp" style=""></span>&#176;C&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Methods</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Serological methods</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Detection of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> antibodies using the immunofluorescence antibody &#40;IFA&#41; method</span><p id="par0050" class="elsevierStylePara elsevierViewall">Serum samples from the PG and HCG participants were studied for the presence of IgM&#44; IgG and IgA antibodies against <span class="elsevierStyleItalic">C&#46; pneumoniae</span> by IFA &#40;Euroimmun Labordiagnostica&#44; Germany&#41;&#46; The serum samples were tested after treatment with Gullsorb &#40;Gull Laboratories&#44; Salt Lake City&#44; Utah&#41; in accordance with the manufacturer&#39;s instructions to remove interfering IgG antibodies<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">28</span></a>&#46; Antigens prepared from <span class="elsevierStyleItalic">C&#46; pneumoniae</span> elementary bodies were used as antigens&#46; Most of this antigen consists of major outer membrane proteins &#40;MOMPs&#41;&#44; lipopolysaccharide &#40;LPS&#41;&#44; and outer membrane proteins &#40;OMPs&#41;&#46; A doubling dilution method&#44; which started from 1&#47;16 for IgM&#44; 1&#47;40 for IgA and 1&#47;16 to 1&#47;512 for IgG&#44; was employed for antibody detection&#46; The manufacturer&#39;s recommendations were followed for the determination of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> IgM&#46; All slides were evaluated using a fluorescence microscope &#40;Zeiss-Axioskop40&#41;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">2&#44;16</span></a>&#46; The seropositivity criteria for the diagnosis of persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection were IgG &#8805;512 and IgA &#8805;40&#59; for the study population&#44; IgG titers of &#62;16 were accepted as the criterion for previous infection&#46; Our study results were evaluated in accordance with the CDC criteria<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">2&#44;16&#44;31</span></a>&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Determination of BDNF and NT-3 concentrations using the sandwich ELISA method</span><p id="par0055" class="elsevierStylePara elsevierViewall">Serum BDNF and NT-3 levels were measured with the sandwich enzyme-linked immunosorbent assay &#40;ELISA&#41; using a commercially available kit &#40;BOSTER Immunoleader&#44; ABD&#41; following the manufacturer&#39;s guidelines&#46; In brief&#44; in flat-bottom microtiter plates &#40;96-well&#41;&#44; the samples were diluted 1&#58;2 in sample diluent&#44; and the standard curves ranged from 31&#46;2 to 2000<span class="elsevierStyleHsp" style=""></span>pg for BDNF and from 15&#46;6 to 1000<span class="elsevierStyleHsp" style=""></span>pg for NT-3&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The standards and samples &#40;0&#46;1<span class="elsevierStyleHsp" style=""></span>ml&#41; were added to each well&#46; The microtiter plates were then incubated for 90<span class="elsevierStyleHsp" style=""></span>min at 37<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; A biotinylated anti-human BDNF antibody and a biotinylated anti-human NT-3 antibody &#40;0&#46;1<span class="elsevierStyleHsp" style=""></span>ml&#41; were added to the wells and incubated for 60<span class="elsevierStyleHsp" style=""></span>min at 37<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; The plates were then washed three times with wash buffer&#46; Avidin&#8211;Biotin Peroxidase solution was then added to each well and incubated for 30<span class="elsevierStyleHsp" style=""></span>min at 37<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; After washing &#40;five times with wash buffer&#41;&#44; the substrate was added and incubated for 20&#8211;25<span class="elsevierStyleHsp" style=""></span>min at 37<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; After the addition of the stop solution&#44; the amounts of BDNF and NT-3 were determined &#40;absorbance set at 450<span class="elsevierStyleHsp" style=""></span>nm&#41;&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Molecular methods</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">C&#46; pneumoniae</span> DNA was detected in PBMCs using a quantitative real time-polymerase chain reaction &#40;qRT-PCR&#41; method with commercially available kits &#40;LightMix<span class="elsevierStyleSup">&#174;</span> Kit <span class="elsevierStyleItalic">Chlamydophila pneumoniae</span> and LightCycler<span class="elsevierStyleSup">&#174;</span> FastStart DNA MasterHybProbe&#44; Roche&#44; Berlin&#44; Germany&#41; following the manufacturer&#39;s guidelines&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Isolation of peripheral blood mononuclear cells &#40;PBMCs&#41;</span><p id="par0070" class="elsevierStylePara elsevierViewall">As <span class="elsevierStyleItalic">C&#46; pneumoniae</span> is an obligate intracellular human pathogen&#44; we isolated PBMCs from whole blood&#46; The whole blood samples that were collected from each patient into EDTA-treated tubes were diluted 1&#58;1 in PBS&#46; The diluted blood was carefully layered over Ficoll-Paque &#40;Wisent&#44; St-Bruno&#41; at a blood&#58;Ficoll ratio of 3&#58;1&#46; Centrifugation &#40;1600<span class="elsevierStyleItalic">g</span>&#44; 35<span class="elsevierStyleHsp" style=""></span>min&#41; was performed to obtain a mononuclear cell fraction&#44; which was aspirated&#44; diluted 1&#58;1 in PBS and centrifuged at 1600<span class="elsevierStyleItalic">g</span> for 10<span class="elsevierStyleHsp" style=""></span>min&#46; The PBMCs were stored at &#8722;70<span class="elsevierStyleHsp" style=""></span>&#176;C until the time of qRT-PCR analysis&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">DNA extraction from PBMCs and detection of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> DNA in PBMCs via RT- PCR</span><p id="par0075" class="elsevierStylePara elsevierViewall">A qRT-PCR method was used for the detection of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> in PBMCs&#46; Nucleic acid extraction was performed using a commercial nucleic acid purification kit &#40;High Pure PCR Template Preparation Kit&#44; Roche Germany&#41; according to the manufacturer&#39;s instructions&#46; We used a LightMix<span class="elsevierStyleSup">&#174;</span><span class="elsevierStyleItalic">C&#46; pneumoniae</span> &#40;TIB MOLBIOL GmbH&#44; Germany&#41; real-time PCR kit for the detection of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> DNA&#46; The kit included primers that were designed to amplify a 140<span class="elsevierStyleHsp" style=""></span>bp fragment of the J38 genomic region of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> and a hybridization probe&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The mix includes an internal control system to exclude PCR amplification errors&#46; We included a positive control&#44; calibrators &#40;ranging from 10 to 1<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>000<span class="elsevierStyleHsp" style=""></span>copies&#41;&#44; and negative controls in each test batch&#46;</p></span></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0085" class="elsevierStylePara elsevierViewall">The data obtained in the trial were analyzed using the SPSS &#40;version 17&#46;00&#41; statistics program&#46; The data were evaluated using a multivariate logistic regression test &#40;forward conditional model&#41; and the Chi-square and Fisher exact tests&#46; The Chi-square tests were used to evaluate the relationships between chlamydial infection and the presence of schizophrenia&#46; The Chi-square test and the Fisher&#39;s exact test were used to compare frequencies among the groups&#46; The distribution patterns of BDNF and NT-3 were analyzed using the Chi-square test&#46; Most of the BDNF and NT-3 values did not fit a standard distribution curve&#44; and the data were therefore subjected to non-parametric analyses&#46; Thus&#44; the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test was employed to compare groups&#46; All statistical tests were two-sided&#44; and <span class="elsevierStyleItalic">p</span> values lower than 0&#46;05 were considered to be statistically significant&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">When the PG and HCG participants were compared&#44; primary school graduation and the presence of relatives with neuropsychiatric disorders were found to be significantly more common in the PG than in the HCG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; However&#44; graduation from a university was found to be significantly less common in the PG than in the HCG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The rate of smoking was significantly higher in the PG than in the HCG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Fourteen &#40;28&#37;&#41; and one &#40;2&#46;85&#37;&#41; of the PG and HCG participants&#44; respectively&#44; were determined to have persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection &#40;the seropositivity criteria for the diagnosis of persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection were IgG &#8805;512 and IgA &#8805;40&#41;&#44; based on microimmunofluorescence &#40;MIF&#41; IgA and IgG results of two whole blood samples tested with an interval of 4&#8211;8 weeks &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; A significant difference in persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection was observed between the PG and the HCG &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>13&#46;222&#44; CI 95&#37;&#58; 1&#46;648&#8211;106&#46;07&#44; <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#59; 8&#46;95&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#59; however&#44; no significant difference in past <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection was found between the groups &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;330&#44; CI 95&#37;&#58; 0&#46;549&#8211;3&#46;219&#44; <span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#59; 0&#46;400&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">When the PG and HCG participants were compared with respect to gender and age for past and persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection seropositivity&#44; PG females had significantly greater rates of persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection than HCG females&#46; Additionally&#44; a significant difference in persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection was found between PG and HCG participants&#44; with infection being more frequent among females in the PG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection was also found more frequently in 18&#8211;29 years and 30&#8211;40 years age of both groups&#46; However&#44; no significant differences in past <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection were found among gender- and age-matched groups from the PG and the HCG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; When the mean serum BDNF and NT-3 levels of the PG and HCG participants were compared&#44; serum BDNF levels were significantly lower in the PG participants than in the HCG participants &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; and serum NT-3 levels were significantly lower in the PG than in the HCG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">When the PG and HCG participants were compared with respect to the mean serum BDNF and NT-3 levels based on seropositivity for past <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection&#44; the serum BDNF and NT-3 levels were found to be significantly lower in the PG than in the HCG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Statistical analyses were not performed to compare the mean serum BDNF and NT-3 levels between the PG and the HCG based on persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> seropositivity because only one persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> case was detected in the HCG&#59; therefore&#44; a standard deviation could not be determined &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">When considering PG participants with past &#40;NT-3&#58;594<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#41; or persistent &#40;NT-3&#58;480&#46;1<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#41; <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection seropositivity&#44; the mean serum NT-3 levels were higher in PG patients with <span class="elsevierStyleItalic">C&#46; pneumoniae</span> seropositivity than in seronegative patients &#40;NT-3&#58;461<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#41;&#59; however&#44; this difference was not statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; In contrast&#44; when considering serum BDNF levels in schizophrenic patients with past &#40;BDNF&#58; 1689&#46;1<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#41; or persistent &#40;BDNF&#58; 1560&#46;8<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#41; <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection&#44; the mean serum BDNF levels were lower in PG patients with <span class="elsevierStyleItalic">C&#46; pneumoniae</span> seropositivity than in seronegative patients &#40;BDNF&#58; 1962<span class="elsevierStyleHsp" style=""></span>pg&#47;ml&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">We detected no <span class="elsevierStyleItalic">C&#46; pneumoniae</span> DNA in the PBMCs from 85 participants by qRT-PCR&#46; Although we detected <span class="elsevierStyleItalic">C&#46; pneumoniae</span> seropositivity in schizophrenic patients &#40;n&#58;10&#41; with persistent infection&#44; we failed to detect <span class="elsevierStyleItalic">C&#46; pneumoniae</span> DNA&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The results of a multivariate logistic regression analysis &#40;following a forward conditional model&#41; of demographic parameters &#40;e&#46;g&#46;&#44; education and neuropsychiatric disorders in at least one relative&#41;&#44; serological tests &#40;<span class="elsevierStyleItalic">C&#46; pneumoniae</span> IgG<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>512<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>IgA<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>40&#41; and mean serum neurotrophic factor levels &#40;BDNF&#47;NT-3&#41; are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Based on the results of our analysis&#44; primary school graduation &#40;OR&#58;1&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; the presence of seropositivity for persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection &#40;OR&#58;39&#46;8&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and the presence of neuropsychiatric disorders in at least one relative &#40;OR&#58;9&#46;03&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; were identified as independent risk factors for schizophrenia&#46; In addition&#44; the rate of university graduation &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and the mean serum neurotrophin-3 level &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41; were found to be significantly lower in the PG than in the HCG&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">Important data were recently obtained in studies that addressed the role of infectious agents in the etiopathogenesis of schizophrenia&#46; The most interesting finding of these studies has been the presence of chronic infection caused by <span class="elsevierStyleItalic">C&#46; pneumoniae</span>&#46; Although persistently elevated IgA &#40;or IgG&#41; antibody levels have been proposed and used by some researchers to indicate chronic infection&#44; there is no validated serological marker of persistent infection&#46; In addition&#44; it has been suggested that high IgA titers may be a better marker of chronic <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection than IgG titers because serum IgA has a half-life of 5&#8211;7 days&#44; but IgG has a half-life of weeks to months&#46; First&#44; we attempted to identify persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection in our study groups&#46; The detection of persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection based on the presence of elevated titers of IgA-type <span class="elsevierStyleItalic">C&#46; pneumoniae</span> antibodies for 6 months and the persistent production of IgG is generally indicative of persistent infection with <span class="elsevierStyleItalic">C&#46; pneumoniae</span> rather than re-infection<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">16</span></a>&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">The presence of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> DNA in PBMCs suggests that the systemic dissemination of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> occurs after exposure to a respiratory infection<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">10</span></a>&#46; To establish a link between <span class="elsevierStyleItalic">Chlamydia</span> and schizophrenia&#44; we performed a search for related studies&#46; In a study performed by Xaiver et al&#46;&#44; a female patient with pharyngitis caused by <span class="elsevierStyleItalic">C&#46; pneumoniae</span> showed excessive manifestations related to acute psychosis during a 3-day period<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">58</span></a>&#46; Those authors suggested that this acute psychosis may have been triggered by meningoencephalitis&#46; <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection in human brain microvascular endothelial cells was demonstrated to alter the permeability of the blood&#8211;brain barrier<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">37&#44;50</span></a>&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection may facilitate the transmigration of monocytes through human brain endothelial cells&#59; this observation may represent one mechanism by which the organism enters the CNS&#46; Consequently&#44; the organism may enter the CNS inside infected monocytes&#44; resulting in chronic injury<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">15&#44;38</span></a>&#46; The pro-inflammatory chemokines and cytokines that are produced by <span class="elsevierStyleItalic">Chlamydia</span>-infected cells may be involved in inflammation and tissue injury<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">35&#44;50</span></a>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">BDNF and NT-3&#44; which are produced by neurons&#44; peripheral and CNS tissues&#44; microglia&#44; and Th1 and Th2 cells&#44; might be altered in psychiatric disorders&#44; such as schizophrenia&#46; These factors were good candidates in our efforts to establish a link between <span class="elsevierStyleItalic">Chlamydia</span> infections and schizophrenia<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">8&#44;17</span></a>&#46; Considering the above mechanisms&#44; we evaluated the role of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> in the development of schizophrenia&#46; Some researchers reported that NGF&#44; BDNF and NT-3 are produced via in vitro and in vivo microglial expression<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a>&#46; Additionally&#44; it was suggested that Th1 cells may produce NT-3 and Th2 cells may produce BDNF&#46; Two neurotrophins may be produced via the stimulation of aTh1-orTh2-based immune response<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">8&#44;17&#44;18&#44;40</span></a>&#46; The expression levels of neurotrophins that influence synaptic activity in the CNS by binding to the TrkA&#44; TrkB and TrkC tropomyosin receptors may change based on the developing immune response &#40;i&#46;e&#46;&#44; Th1 or Th2&#41;&#46; This interaction between the immune system and the CNS might be triggered by infections with organisms like <span class="elsevierStyleItalic">C&#46; pneumoniae</span><a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">20&#44;21</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Fellerhoff et al&#46; detected 40&#37; and 6&#46;7&#37; chlamydial DNA in the PBMCs of patients with schizophrenia and control subjects&#44; respectively<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">21</span></a>&#46; In another study performed by Fellerhoff et al&#46;&#44; 4-times more chlamydial DNA was detected in the frontal cortex of postmortem schizophrenic and bipolar cases<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">22</span></a>&#46; This finding led the authors to propose that neural development is likely to be impaired by the inflammation that is caused by <span class="elsevierStyleItalic">Chlamydiaceae</span> infections with neural and microglial involvement and might consequently cause neuropsychiatric disorders&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In this study&#44; we detected a statistically significant difference in chronic <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection between PG and HCG participants &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; We also determined that chronic <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection causes a 13-fold greater risk of developing schizophrenia&#46; Moreover&#44; persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection was detected as an independent risk factor in our multivariate regression analysis&#46; Based on our results&#44; we suggested that <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infections may be related to schizophrenia&#46; Despite our positive serological results&#44; we were unable to detect <span class="elsevierStyleItalic">C&#46; pneumoniae</span> DNA in PBMCs using qRT-PCR&#44; which has an analytic sensitivity of 10 DNA copies&#46; This finding contrast with the results reported in the above studies&#59; in our opinion&#44; this difference could be related to the absence of infected monocytes in the peripheral blood or the presence of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> DNA at a frequency below 10 copies in peripheral blood cells&#46; Additionally&#44; Murray et al&#46; reported that the treatment of schizophrenic patients with neuroleptic drugs &#40;e&#46;g&#46;&#44; haloperidol and pimozide&#41; inhibited the calmodulin-dependent process that <span class="elsevierStyleItalic">Chlamydiaceae</span> use to enter cells<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">44</span></a>&#46; Thus&#44; these drugs may prevent the uptake of <span class="elsevierStyleItalic">Chlamydiaceae</span> by the cell and thus prevent the detection of <span class="elsevierStyleItalic">Chlamydiaceae</span> DNA in those cells&#46; Our PG individuals were diagnosed with schizophrenia and treated for approximately 3&#8211;5 years&#44; suggesting the possibility that these drugs might affect the uptake of <span class="elsevierStyleItalic">Chlamydiaceae</span> by the cells&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">In a meta-analysis related to the epidemiology of schizophrenia&#44; the frequency of schizophrenia was reported to be equal in both sexes&#44; but the mean age at the onset of illness was higher for females than for males &#40;25&#8211;35 vs&#46; 18-25 years&#41;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">19</span></a>&#46; We suggested that the detection of significantly different rates of chronic <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection in female schizophrenic patients than in HCG patients and the detection of significantly more chronic <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infections in young and middle-aged schizophrenic patients are important demographic findings and are consistent with the available literature&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Although we expected to detect high levels of neurotrophin expression because chronic infection triggers inflammatory processes during early episodic schizophrenic psychosis&#44; we actually detected low neurotrophin serum levels in schizophrenic patients&#46; The lower serum BDNF and NT-3 levels observed in schizophrenic patients who had been receiving long-term treatment with antipsychotic drugs were consistent with the results of Fourney et al&#46;&#44; who reported that antipsychotic drugs &#40;especially haloperidol&#41; down-regulated neurotrophins and decreased hippocampal BDNF mRNA expression<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">23</span></a>&#46; Similar findings have been reported by other groups<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">56&#44;57</span></a>&#46; Most remarkably&#44; we found that antipsychotic drug users with past or chronic <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection had higher mean serum NT-3 levels than <span class="elsevierStyleItalic">C&#46; pneumoniae</span>-seronegative patients with schizophrenia&#46; We propose that this result may be related to continued NT-3 expression&#44; which is caused by microglial or T cell activation in the presence of persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection&#44; together with specific host immune responses to microglial <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection&#44; even with potential antipsychotic drug pressure in the hippocampal region&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In our study&#44; having graduated from a primary school and not having graduated from a university were identified as independent risk factors&#46; Park et al&#46; reported that &#8220;to have a neuropsychiatric disease in the family&#8221; was not a significant factor in the <span class="elsevierStyleItalic">Chlamydiaceae</span>&#8211;schizophrenia relationship<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">45</span></a>&#46; This factor has been reported to be a significant risk factor in two other Turkish studies that addressed the <span class="elsevierStyleItalic">T&#46; gondii</span>-schizophrenia and BDV&#8211;schizophrenia relationships<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">29&#44;59</span></a>&#46; To have a neuropsychiatric disease &#8220;in the family&#8221; showed a significant difference between two groups in accordance with the univariate analysis in our study &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41; and was also detected as an independent risk factor according to the multivariate analysis&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Serologically&#44; persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection was identified as an independent risk factor according to the multivariate regression analysis&#46; The serological detection of <span class="elsevierStyleItalic">C&#46; pneumoniae</span> was also found to differ significantly between patients and controls in accordance with the univariate analysis&#44; suggesting that persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infections may play a role in the development of schizophrenia&#44; as has been proposed by numerous other studies<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">21&#44;22</span></a>&#46; In addition&#44; serum neurotrophin levels &#40;especially NT-3&#41; were lower in the PG than in the HCG&#44; likely due to antipsychotic treatment&#46; However&#44; the serum NT- 3 levels of the schizophrenic patients with past or persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> seropositivity were higher than those of the schizophrenic patients with no <span class="elsevierStyleItalic">C&#46; pneumoniae</span> seropositivity&#44; although this difference was not statistically significant&#46; We suggest that this result may be related to the expression of certain amounts of NT-3 by microglia and T cells that are activated by chronic and persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection and have migrated to the brain via monocytes &#40;despite drug pressure&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">This study has several limitations&#46; First&#44; during chronic <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection&#44; the expression of the organism&#39;s own 60<span class="elsevierStyleHsp" style=""></span>kDa heat shock proteins &#40;HsP60&#41; increases&#44; especially when the proteins are elevated persistently&#46; The host immune response to microbial HsP60 may cause autoimmunity to human HsP60 and the subsequent development of some chronic diseases&#44; such as asthma&#44; atherosclerosis&#44; or coronary heart disease<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">15</span></a>&#46; We did not investigate HsP60 of <span class="elsevierStyleItalic">C&#46; pneumoniae</span>&#46; Secondly&#44; our sample size was limited&#46; Moreover&#44; the schizophrenic patients were in different stages of schizophrenia and received different antipsychotic treatments&#46; Antipsychotic medication is known to influence the immune system&#59; thus&#44; the infectivity of the organism may be affected&#46; Moreover&#44; the potential confounding variables were smoking&#44; domestic pet contact&#44; differences in education level between the patients and the controls and the effects of different drug doses on the <span class="elsevierStyleItalic">C&#46; pneumoniae</span>&#8211;schizophrenia&#8211;neurotrophin &#40;BDNF and NT-3&#41; relationship&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">In conclusion&#44; the presence of serological <span class="elsevierStyleItalic">C&#46; pneumoniae</span> positivity in the PG suggested the possible role of persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infections in the development of schizophrenia&#46; The presence of lower levels of serum neurotrophins &#40;especially NT-3&#41; in the PG than in the HCG suggested that prior antipsychotic treatment may have an effect&#46; However&#44; the high serum NT-3 levels of the schizophrenic patients with past or persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> seropositivity suggested that NT-3 is expressed by microglia and T cells that are activated by chronic and persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection and have migrated to the brain via monocytes &#40;despite drug pressure&#41;&#46; To define this relationship more clearly&#44; similar&#44; matched&#44; broad-spectrum case&#8211;control studies should be conducted&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical disclosure</span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of human and animal subjects</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of Data</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work centre on the publication of patient data and that all the patients included in the study have received sufficient information and have given their informed consent in writing to participate in that study&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of the patients and &#47;or subjects mentioned in the article&#46; The author for correspondence is in possession of this document&#46;</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interest</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest&#46;</p></span></span>"
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          "identificador" => "xres824203"
          "titulo" => "Abstract"
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              "identificador" => "abst0005"
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        1 => array:2 [
          "identificador" => "xpalclavsec820697"
          "titulo" => "Keywords"
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          "titulo" => "Resumen"
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          "identificador" => "xpalclavsec820696"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Materials and methods"
          "secciones" => array:4 [
            0 => array:3 [
              "identificador" => "sec0015"
              "titulo" => "Patient and control groups"
              "secciones" => array:2 [
                0 => array:2 [
                  "identificador" => "sec0020"
                  "titulo" => "Patient group &#40;PG&#41;"
                ]
                1 => array:2 [
                  "identificador" => "sec0025"
                  "titulo" => "Healthy control group &#40;HCG&#41;"
                ]
              ]
            ]
            1 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Collection of serum samples"
            ]
            2 => array:3 [
              "identificador" => "sec0035"
              "titulo" => "Methods"
              "secciones" => array:2 [
                0 => array:3 [
                  "identificador" => "sec0040"
                  "titulo" => "Serological methods"
                  "secciones" => array:2 [
                    0 => array:2 [
                      "identificador" => "sec0045"
                      "titulo" => "Detection of C&#46; pneumoniae antibodies using the immunofluorescence antibody &#40;IFA&#41; method"
                    ]
                    1 => array:2 [
                      "identificador" => "sec0050"
                      "titulo" => "Determination of BDNF and NT-3 concentrations using the sandwich ELISA method"
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                  ]
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                1 => array:3 [
                  "identificador" => "sec0055"
                  "titulo" => "Molecular methods"
                  "secciones" => array:2 [
                    0 => array:2 [
                      "identificador" => "sec0060"
                      "titulo" => "Isolation of peripheral blood mononuclear cells &#40;PBMCs&#41;"
                    ]
                    1 => array:2 [
                      "identificador" => "sec0065"
                      "titulo" => "DNA extraction from PBMCs and detection of C&#46; pneumoniae DNA in PBMCs via RT- PCR"
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                  ]
                ]
              ]
            ]
            3 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Statistical analysis"
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        6 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Results"
        ]
        7 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Discussion"
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        8 => array:3 [
          "identificador" => "sec0085"
          "titulo" => "Ethical disclosure"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0090"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0095"
              "titulo" => "Confidentiality of Data"
            ]
            2 => array:2 [
              "identificador" => "sec0100"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0105"
          "titulo" => "Conflict of interest"
        ]
        10 => array:2 [
          "identificador" => "xack276421"
          "titulo" => "Acknowledgements"
        ]
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          "titulo" => "References"
        ]
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-09-09"
    "fechaAceptado" => "2016-09-12"
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        0 => array:4 [
          "clase" => "keyword"
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            0 => "<span class="elsevierStyleItalic">Chlamydophila pneumoniae</span>"
            1 => "Schizophrenia"
            2 => "BDNF"
            3 => "NT-3"
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        ]
      ]
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          "identificador" => "xpalclavsec820696"
          "palabras" => array:4 [
            0 => "<span class="elsevierStyleItalic">Chlamydophila pneumoniae</span>"
            1 => "Esquizofrenia"
            2 => "BDNF"
            3 => "NT-3"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Several pathogens have been suspected of playing a role in the pathogenesis of schizophrenia&#46; Chronic inflammation has been proposed to occur as a result of persistent infection caused by <span class="elsevierStyleItalic">Chlamydophila pneumoniae</span> cells that reside in brain endothelial cells for many years&#46; It was recently hypothesized that brain-derived neurotrophic factor &#40;BDNF&#41; and neurotrophin-3 &#40;NT-3&#41; may play prominent roles in the development of schizophrenia&#46; NT-3 and BDNF levels have been suggested to change in response to various manifestations of infection&#46; Therefore&#44; we aimed to elucidate the roles of BDNF and NT3 in the schizophrenia&#8211;<span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection relationship&#46; RT-PCR&#44; immunofluorescence and ELISA methods were used&#46; Fifty patients suffering from schizophrenia and 35 healthy individuals were included as the patient group &#40;PG&#41; and the healthy control group &#40;HCG&#41;&#44; respectively&#46; We detected persistent infection in 14 of the 50 individuals in the PG and in 1 of the 35 individuals in the HCG&#46; A significant difference was found between the two groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; Twenty-two individuals in the PG and 13 in the HCG showed seropositivity for past <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection&#44; and no difference was observed between the groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; <span class="elsevierStyleItalic">C&#46; pneumoniae</span> DNA was not detected in any group&#46; A significant difference in NT-3 levels was observed between the groups&#44; with very low levels in the PG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; A significant difference in BDNF levels was also found&#44; with lower levels in the PG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The mean serum NT-3 level was higher in the PG cases with <span class="elsevierStyleItalic">C&#46; pneumoniae</span> seropositivity than in seronegative cases&#59; however&#44; this difference was not statistically significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; In conclusion&#44; we suggest that NT-3 levels during persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection may play a role in this relationship&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Existe la sospecha de que algunos pat&#243;genos pueden desempe&#241;ar un papel en la patog&#233;nesis de la esquizofrenia&#59; en ese contexto&#44; se ha propuesto que la infecci&#243;n persistente causada por c&#233;lulas de <span class="elsevierStyleItalic">Chlamydophila pneumoniae</span> presentes en las c&#233;lulas endoteliales cerebrales durante muchos a&#241;os lleva a la inflamaci&#243;n cr&#243;nica&#46; Recientemente se ha planteado la hip&#243;tesis de que el factor neurotr&#243;fico de origen cerebral &#40;BDNF&#44; por sus siglas en ingl&#233;s&#41; y la neurotropina-3 &#40;NT-3&#41; podr&#237;an estar implicados en el desarrollo de la esquizofrenia&#44; y se ha sugerido que sus niveles se modifican en respuesta a diversas manifestaciones de la infecci&#243;n&#46; En esta investigaci&#243;n intentamos esclarecer el papel que desempe&#241;an el BDNF y la NT3 en la relaci&#243;n entre la esquizofrenia y la infecci&#243;n por <span class="elsevierStyleItalic">C&#46; pneumoniae</span>&#46; Se utilizaron m&#233;todos de RT-PCR&#44; inmunofluorescencia y ELISA&#46; Se incluyeron 50 pacientes con esquizofrenia y 35 individuos sanos como grupo de pacientes &#40;GP&#41; y grupo de controles sanos &#40;GCS&#41;&#44; respectivamente&#46; Detectamos una infecci&#243;n persistente en 14 sujetos del GP y en 1 de los del GCS&#44; lo que constituy&#243; una diferencia significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Veinte participantes del GP y 13 del GCS fueron seropositivos para una infecci&#243;n pasada por <span class="elsevierStyleItalic">C&#46; pneumoniae</span>&#44; diferencia no significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; No se detect&#243; ADN de <span class="elsevierStyleItalic">C&#46; pneumoniae</span> en ninguno de los dos grupos&#46; Se observ&#243; una diferencia significativa entre los grupos en los niveles de NT-3&#44; que fueron muy bajos en el GP &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#44; y de BDNF&#44; inferiores en el GP &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; La concentraci&#243;n s&#233;rica media de NT-3 fue mayor en los individuos seropositivos para <span class="elsevierStyleItalic">C&#46; pneumoniae</span> en comparaci&#243;n con los seronegativos&#44; pero esta diferencia no alcanz&#243; significaci&#243;n estad&#237;stica &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; Sugerimos que los niveles de NT-3 durante una infecci&#243;n persistente por <span class="elsevierStyleItalic">C&#46; pneumoniae</span> pueden estar implicados en la relaci&#243;n de <span class="elsevierStyleItalic">Chlamydophila pneumoniae</span> con la esquizofrenia&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Side-by-side box-whisker plots of BDNF and NT3 levels in PG and HCG&#46; PG&#44; patient group&#59; HCG&#44; healthy control group&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Side-by-side box-whisker plots of BDNF and NT3 levels of patients with past &#40;PaCP&#44; past <span class="elsevierStyleItalic">C&#46; pneumoniae</span>&#41;&#44; persistent &#40;PeCP&#44; persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span>&#41; <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection and <span class="elsevierStyleItalic">C&#46; pneumoniae</span> seronegativity &#40;CPS&#41;&#46; PaCP&#44; past <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection&#59; PeCP&#44; persistent <span class="elsevierStyleItalic">C&#46; pneumoniae</span> infection&#59; CPS&#44; <span class="elsevierStyleItalic">C&#46; pneumoniae</span> seronegativity&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">To have relatives with neuropsychiatric</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="middle">&#60;0&#46;05</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Smoking habit</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="middle">&#60;0&#46;001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">Alcohol use</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="char" valign="middle">&#62;0&#46;05</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Absence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Demographic parameters&#44; analyzed in the patient group and healthy control group cases</p>"
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">PG<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">HCG<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Past C&#46; pneumoniae infection &#40;n&#58; 35&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IgG<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>16-IgG<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>512&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;44&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;37&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean BDNF<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a> &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1689&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2140&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean NT-3<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a> &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">594&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">903&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Persistent C&#46; pneumoniae infection &#40;n&#58; 15&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IgG<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#47;512<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>IgA<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>1&#47;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;28&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#60;0&#46;05&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean BDNF<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a> &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1560&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2061&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">f</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean NT-3<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a> &#40;pg&#47;ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">480&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1034&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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            ]
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0030">A standard deviation could not be determined&#46;</p>"
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            "detalle" => "Table "
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">95&#46;0&#37; CI<a class="elsevierStyleCrossRef" href="#tblfn0055"><span class="elsevierStyleSup">e</span></a></th><th class="td" title="table-head  " align="center" valign="top" scope="col"><span class="elsevierStyleItalic">p</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Lower&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Upper&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NT-3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;996&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;994&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;335&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BDNF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8722;0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;999&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;998&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;110&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Primary school&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;015&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;049&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Constant&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;392&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">124&#46;643&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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      "titulo" => "References"
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        0 => array:2 [
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                  "host" => array:1 [
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                            1 => "A&#46; Sorlozano"
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                            6 => "A&#46; Dirican"
                            7 => "M&#46;M&#46; Torun"
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            5 => array:3 [
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                            1 => "B&#46; Kocazeybek"
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                            5 => "P&#46; Yuksel"
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                            8 => "R&#46; Caliskan"
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                  ]
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                  "contribucion" => array:1 [
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Article information

ISSN: 03257541
Original language: English

DOI:10.1016/j.ram.2016.09.009

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Year/Month	Html	Pdf	Total

2024 October	17	6	23
2024 September	21	5	26
2024 August	27	5	32
2024 July	32	1	33
2024 June	35	1	36
2024 May	27	0	27
2024 April	33	2	35
2024 March	57	5	62
2024 February	33	1	34
2024 January	18	3	21
2023 December	11	8	19
2023 November	20	2	22
2023 October	32	5	37
2023 September	13	1	14
2023 August	18	4	22
2023 July	17	4	21
2023 June	21	7	28
2023 May	36	2	38
2023 April	40	1	41
2023 March	44	4	48
2023 February	60	5	65
2023 January	12	8	20
2022 December	11	3	14
2022 November	18	6	24
2022 October	14	5	19
2022 September	16	10	26
2022 August	11	7	18
2022 July	8	6	14
2022 June	11	7	18
2022 May	7	10	17
2022 April	12	10	22
2022 March	19	5	24
2022 February	10	7	17
2022 January	11	6	17
2021 December	16	11	27
2021 November	16	11	27
2021 October	14	13	27
2021 September	13	14	27
2021 August	20	12	32
2021 July	19	7	26
2021 June	9	5	14
2021 May	9	6	15
2021 April	18	20	38
2021 March	15	3	18
2021 February	8	10	18
2021 January	9	10	19
2020 December	10	11	21
2020 November	12	10	22
2020 October	10	11	21
2020 September	9	11	20
2020 August	10	8	18
2020 July	11	3	14
2020 June	12	12	24
2020 May	11	10	21
2020 April	16	8	24
2020 March	17	8	25
2020 February	21	16	37
2020 January	11	13	24
2019 December	19	10	29
2019 November	8	5	13
2019 October	9	4	13
2019 September	8	6	14
2019 August	2	3	5
2019 July	10	12	22
2019 June	31	15	46
2019 May	57	24	81
2019 April	30	17	47
2019 March	18	6	24
2019 February	30	5	35
2019 January	35	3	38
2018 December	36	6	42
2018 November	32	12	44
2018 October	29	20	49
2018 September	48	10	58
2018 August	18	12	30
2018 July	5	2	7
2018 June	15	10	25
2018 May	6	3	9
2018 April	22	10	32
2018 March	5	8	13
2018 February	1	3	4
2018 January	5	7	12
2017 December	11	5	16
2017 November	14	9	23
2017 October	7	5	12
2017 September	4	4	8
2017 August	11	3	14
2017 July	8	3	11
2017 June	14	12	26
2017 May	35	6	41
2017 April	25	15	40
2017 March	4	31	35

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